Question 1 pts
The nurse notes each time the mechanical ventilator delivers a breath to a client with acute respiratory
distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the nurse’s best
intervention?
a) Suction the client.
b) Perform chest physiotherapy.
c) Assess the airway.
d) Raise the head of bed to high Fowlers.
Question 2 pts
A client has a new tracheostomy, on a mechanical ventilator with the following settings: SIMV, rate of
12, TV 800, FIo2 80% and PEEP of 5 cmH20. Which assessment finding requires immediate action by the
nurse?
a) Blood-tinged sputum
b) Rhonchi in upper lobes
c) Dry mucous membranes
d) Constant, nonproductive coughing
Question 3 pts
The nurse palpates the posterior chest while the client says “99” and notes absent fremitus. Which
action should the nurse take next?
a) Encourage the client to turn, cough, and deep breathe.
b) Review the chest x-ray report for evidence of pneumonia.
c) Auscultate anterior and posterior breath sounds bilaterally.
d) Palpate the anterior chest and observe for barrel chest.
Question 4 pts
The nurse is caring for a client with a pulmonary embolus, also has right-sided heart failure. Which
clinical findings requires immediate follow up?
a) Heart rate of 115 beats/min
b) Respiratory rate of 28 breaths/min
c) +2 dependent edema to bilateral extremities
d) Urinary output of 25 mL/hr
, Question 5 pts
The nurse has been made aware of the arterial blood gas (ABG) results on four clients. Which result is
most important for the nurse to report immediately to the health care provider?
a) pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%
b) pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%
c) pH 7.31, PaO2 81mm Hg, PaCO2 50 mm Hg, and O2 sat 94%
d) pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
Question 6 pts
The nurse monitors a client immediately following a chest tube insertion for a hemopneumothorax.
Which of the following assessment findings requires immediate follow up?
a) 400 mL of blood in the collection chamber
b) Tidaling in the water-seal chamber
c) Platelet count 151,000/micro/L
d) Subcutaneous emphysema at the insertion site
Question 7 pts
When assessing a client who has just arrived after an automobile accident, the emergency department
nurse notes heart rate of 125 bpm and absent breath sounds over the right lung. Which of the following
actions is priority?
a) Administration of an inhaled bronchodilator
b) Insertion of a chest tube with a chest drainage system
c) Prepare for oral intubation with mechanical ventilation
d) Send client for a stat CT scan of the thorax
Question 8 pts
A nurse assesses a client who is experiencing an acid–base imbalance. The client’s arterial blood gas
values are: pH 7.33, PaO 88 mm Hg, PaCO 38 mm Hg, and HCO 17 mEq/L. Which assessment would the
nurse perform first?
a) Cardiac rate and rhythm
b) Musculoskeletal strength
c) Level of orientation
d) Skin and mucous membranes
The nurse notes each time the mechanical ventilator delivers a breath to a client with acute respiratory
distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the nurse’s best
intervention?
a) Suction the client.
b) Perform chest physiotherapy.
c) Assess the airway.
d) Raise the head of bed to high Fowlers.
Question 2 pts
A client has a new tracheostomy, on a mechanical ventilator with the following settings: SIMV, rate of
12, TV 800, FIo2 80% and PEEP of 5 cmH20. Which assessment finding requires immediate action by the
nurse?
a) Blood-tinged sputum
b) Rhonchi in upper lobes
c) Dry mucous membranes
d) Constant, nonproductive coughing
Question 3 pts
The nurse palpates the posterior chest while the client says “99” and notes absent fremitus. Which
action should the nurse take next?
a) Encourage the client to turn, cough, and deep breathe.
b) Review the chest x-ray report for evidence of pneumonia.
c) Auscultate anterior and posterior breath sounds bilaterally.
d) Palpate the anterior chest and observe for barrel chest.
Question 4 pts
The nurse is caring for a client with a pulmonary embolus, also has right-sided heart failure. Which
clinical findings requires immediate follow up?
a) Heart rate of 115 beats/min
b) Respiratory rate of 28 breaths/min
c) +2 dependent edema to bilateral extremities
d) Urinary output of 25 mL/hr
, Question 5 pts
The nurse has been made aware of the arterial blood gas (ABG) results on four clients. Which result is
most important for the nurse to report immediately to the health care provider?
a) pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%
b) pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%
c) pH 7.31, PaO2 81mm Hg, PaCO2 50 mm Hg, and O2 sat 94%
d) pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
Question 6 pts
The nurse monitors a client immediately following a chest tube insertion for a hemopneumothorax.
Which of the following assessment findings requires immediate follow up?
a) 400 mL of blood in the collection chamber
b) Tidaling in the water-seal chamber
c) Platelet count 151,000/micro/L
d) Subcutaneous emphysema at the insertion site
Question 7 pts
When assessing a client who has just arrived after an automobile accident, the emergency department
nurse notes heart rate of 125 bpm and absent breath sounds over the right lung. Which of the following
actions is priority?
a) Administration of an inhaled bronchodilator
b) Insertion of a chest tube with a chest drainage system
c) Prepare for oral intubation with mechanical ventilation
d) Send client for a stat CT scan of the thorax
Question 8 pts
A nurse assesses a client who is experiencing an acid–base imbalance. The client’s arterial blood gas
values are: pH 7.33, PaO 88 mm Hg, PaCO 38 mm Hg, and HCO 17 mEq/L. Which assessment would the
nurse perform first?
a) Cardiac rate and rhythm
b) Musculoskeletal strength
c) Level of orientation
d) Skin and mucous membranes
