N455 EXAM 2 QUESTIONS WITH ANSWERS
100% VERIFIED
A client is scheduled for a thoracentesis. What statement indicates further education is
necessary?
A. "This will be an invasive surgical process into my chest."
B. "I will take a deep breath when the large-bore needle is inserted."
C. "I will be leaning over a bedside table for the procedure."
D. "This procedure will require local anesthetic rather than general anesthetic." -
ANSWER B. "I will take a deep breath when the large-bore needle is inserted."
A nurse is caring for a client who has a chest tube connected to a closed drainage
system and needs to be transported to the x-ray department. Which of the following
actions should the nurse take?
A. Clamp the chest tube prior to transferring the client to a wheelchair.
B. Disconnect the chest tube from the drainage system during transport.
C. Keep the drainage system below the level of the client's chest at all times.
D. Empty the collection chamber prior to transport. - ANSWER C. Keep the drainage
system below the level of the client's chest at all times.
A nurse is caring for a client who develops a pulmonary embolism. Which of the
following interventions should the nurse implement first?
A. Give morphine IV.
B. Administer oxygen therapy.
C. Start an IV infusion of lactated Ringer's.
D. Initiate cardiac monitoring. - ANSWER B. Administer oxygen therapy.
A nurse is reviewing the laboratory data on a client who has a new prescription for
heparin for treatment of a pulmonary embolism. Which of the following data should the
nurse report to the provider?
, A. Hematocrit 45%
B. Partial thromboplastin time (PTT) 65 seconds
C. Platelets 74,000/mm3
D. White blood cell count 8,000/mm3 - ANSWER Platelets 74,000/mm3
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For
which of the following findings should the nurse notify the provider?
A. Eyelets are not visible
B. Movement of the trachea toward the unaffected side
C. Crepitus in the area above and surrounding the insertion site
D. Bubbling of the water in the water seal chamber with exhalation - ANSWER B.
Movement of the trachea toward the unaffected side
The nurse is caring for a postoperative client who has a chest tube connected to suction
and a water seal drainage system. Which of the following indicates to the nurse that the
chest tube is functioning properly?
A. Absence of fluid in the drainage tubing
B. Continuous bubbling within the water seal chamber
C. Equal amounts of fluid drainage in each collection chamber
D. Fluctuation of the fluid level within the water seal chamber - ANSWER D. Fluctuation
of the fluid level within the water seal chamber
A nurse is caring for a client who has a chest tube in place to a closed chest drainage
system. Which of the following findings should indicate to the nurse that the client's lung
has re-expanded?
A. Oxygen saturation of 95%
B. No fluctuations in the water seal chamber
C. No reports of pleuritic chest pain
D. Occasional bubbling in the water-seal chamber - ANSWER B. No fluctuations in the
water seal chamber
, A nurse is planning care for a client who has quadriplegia. Which of the following
actions should the nurse take to prevent a pulmonary embolism (PE)?
A. Assess legs for pallor.
B. Perform passive range of motion exercises.
C. Place pillows under the client's knees when in bed.
D. Massage the calves every shift. - ANSWER B. Perform passive range of motion
exercises.
A nurse is caring for a client who has a traumatic brain injury. Which of the following
findings should the nurse identify as an indication of increased intracranial pressure
(ICP)?
A. Tachycardia
B. Amnesia
C. Hypotension
D. Restlessness - ANSWER D. Restlessness
A nurse is caring for a client following surgical treatment for a brain tumor. Which of the
following interventions should the nurse take?
A. Elevate the head of the bed to 30°.
B. Notify the provider for drainage greater than 80 mL/8hr.
C. Place the client in a flat, lateral position.
D. Provide passive range-of-motion exercises to the neck. - ANSWER A. Elevate the
head of the bed to 30°.Feedback: The client who has surgery to treat a supratentorial
brain tumor is at risk for increased intracranial pressure (ICP). Elevation of the head of
the bed to 30° assists in promoting venous and CNS fluid drainage from the head to
prevent increased ICP.
A nurse is planning care for a client who had a traumatic brain injury and is emerging
restlessly from a coma. Which of the following interventions should the nurse include in
the plan?
100% VERIFIED
A client is scheduled for a thoracentesis. What statement indicates further education is
necessary?
A. "This will be an invasive surgical process into my chest."
B. "I will take a deep breath when the large-bore needle is inserted."
C. "I will be leaning over a bedside table for the procedure."
D. "This procedure will require local anesthetic rather than general anesthetic." -
ANSWER B. "I will take a deep breath when the large-bore needle is inserted."
A nurse is caring for a client who has a chest tube connected to a closed drainage
system and needs to be transported to the x-ray department. Which of the following
actions should the nurse take?
A. Clamp the chest tube prior to transferring the client to a wheelchair.
B. Disconnect the chest tube from the drainage system during transport.
C. Keep the drainage system below the level of the client's chest at all times.
D. Empty the collection chamber prior to transport. - ANSWER C. Keep the drainage
system below the level of the client's chest at all times.
A nurse is caring for a client who develops a pulmonary embolism. Which of the
following interventions should the nurse implement first?
A. Give morphine IV.
B. Administer oxygen therapy.
C. Start an IV infusion of lactated Ringer's.
D. Initiate cardiac monitoring. - ANSWER B. Administer oxygen therapy.
A nurse is reviewing the laboratory data on a client who has a new prescription for
heparin for treatment of a pulmonary embolism. Which of the following data should the
nurse report to the provider?
, A. Hematocrit 45%
B. Partial thromboplastin time (PTT) 65 seconds
C. Platelets 74,000/mm3
D. White blood cell count 8,000/mm3 - ANSWER Platelets 74,000/mm3
A nurse is assessing a client who has a pneumothorax with a chest tube in place. For
which of the following findings should the nurse notify the provider?
A. Eyelets are not visible
B. Movement of the trachea toward the unaffected side
C. Crepitus in the area above and surrounding the insertion site
D. Bubbling of the water in the water seal chamber with exhalation - ANSWER B.
Movement of the trachea toward the unaffected side
The nurse is caring for a postoperative client who has a chest tube connected to suction
and a water seal drainage system. Which of the following indicates to the nurse that the
chest tube is functioning properly?
A. Absence of fluid in the drainage tubing
B. Continuous bubbling within the water seal chamber
C. Equal amounts of fluid drainage in each collection chamber
D. Fluctuation of the fluid level within the water seal chamber - ANSWER D. Fluctuation
of the fluid level within the water seal chamber
A nurse is caring for a client who has a chest tube in place to a closed chest drainage
system. Which of the following findings should indicate to the nurse that the client's lung
has re-expanded?
A. Oxygen saturation of 95%
B. No fluctuations in the water seal chamber
C. No reports of pleuritic chest pain
D. Occasional bubbling in the water-seal chamber - ANSWER B. No fluctuations in the
water seal chamber
, A nurse is planning care for a client who has quadriplegia. Which of the following
actions should the nurse take to prevent a pulmonary embolism (PE)?
A. Assess legs for pallor.
B. Perform passive range of motion exercises.
C. Place pillows under the client's knees when in bed.
D. Massage the calves every shift. - ANSWER B. Perform passive range of motion
exercises.
A nurse is caring for a client who has a traumatic brain injury. Which of the following
findings should the nurse identify as an indication of increased intracranial pressure
(ICP)?
A. Tachycardia
B. Amnesia
C. Hypotension
D. Restlessness - ANSWER D. Restlessness
A nurse is caring for a client following surgical treatment for a brain tumor. Which of the
following interventions should the nurse take?
A. Elevate the head of the bed to 30°.
B. Notify the provider for drainage greater than 80 mL/8hr.
C. Place the client in a flat, lateral position.
D. Provide passive range-of-motion exercises to the neck. - ANSWER A. Elevate the
head of the bed to 30°.Feedback: The client who has surgery to treat a supratentorial
brain tumor is at risk for increased intracranial pressure (ICP). Elevation of the head of
the bed to 30° assists in promoting venous and CNS fluid drainage from the head to
prevent increased ICP.
A nurse is planning care for a client who had a traumatic brain injury and is emerging
restlessly from a coma. Which of the following interventions should the nurse include in
the plan?
