SOLUTION TESTED QUESTIONS
● Major respiratory problems related to pathophysiology of ARDS
include: Answer: pulmonary edema caused by increased membrane
permeability.
● A client is admitted with a medical diagnosis of Addisonian crisis.
When completing the admission assessment, the nurse expects this client
to exhibit which clinical manifestations? Answer: Hypotension, rapid
weak pulse, and rapid respiratory rate.
● A client is on mechanical ventilation. When condensation collects in
the ventilator tubing, the nurse should: Answer: Drain the fluid away
from the endotracheal tube
● A client who just returned from surgery reports shortness of breath and
chest pain. O2 saturation 90%. Which should be the nurse's initial
action? Answer: Administer supplemental oxygen
● A female client taking oral contraceptives reports to the nurse that she
is experiencing calf pain. What action should the nurse implement first?
Answer: Make the client rest in bed and measure both leg
circumferences.
,● A nurse assesses several clients who have a history of respiratory
problems. Which client should the nurse assess first? Answer: A 27-year-
old client with pneumonia and a heart rate of 125 beats/min
● Calculate the flow rate in drops/minute for the following IV order:
1000 mL of NS over 12 hours using a 60 gtt/mL infusion set. Answer: 83
gtt/min
● In preparing a discharge plan for a 22-year-old male client diagnosed
with Buerger's disease (thromboangiitis obliterans), which referral is
most important? Answer: Smoking cessation program.
● Physical examination of a comatose client reveals decorticate
posturing. Which statement is accurate regarding this client's status
based upon this finding? Answer: Severe dysfunction of the cerebral
cortex has occurred.
● The elevated pulmonary capillary wedge pressure (PCWP) is related
to the presence of Answer: left heart failure
● The nurse assesses a client with advanced cirrhosis of the liver for
signs of hepatic
encephalopathy. Which finding should the nurse consider an indication
of progressive hepatic encephalopathy? Answer: Difficulty in
handwriting.
, ● The nurse documented the client had pupils equal, round, reactive to
light and accommodation (PERLA). To assess a client's pupillary
response to accommodation, a nurse should perform which activity?
Answer: Ask the client to look at a distant object and then at an object
held 10 cm from the nose.
● The nurse is making room assignments for four newly admitted
clients. Which client should be placed closest to the nurse's station?
Answer: A 47-year-old with hepatic cirrhosis an esophageal balloon
tamponade
● The nurse is making several room assignments. Which client should
be placed in the private room near the nurse's station? Answer: The 60-
year-old who is one day post thyroidectomy
● The nurse obtains a heart rate of 98 and a blood pressure of 110/76
prior to administering a scheduled dose of verapamil (treat HBP) for a
client with atrial flutter. Which action should the nurse implement?
Answer: Administer the dose as prescribed.
● The RN is assigned to care for four surgical clients. After receiving a
report, which client should the nurse see first? The client who is Answer:
three days postoperative colon resection receiving transfusion of packed
RBCs.