MS3- Final Exam Questions With Correct
Answers
A client appears dyspneic, but the oxygen saturation is 97%. What action by the
| | | | | | | | | | | | | |
nurse is best?
| |
a.Assess for other manifestations of hypoxia.
| | | | |
b.Change the sensor on the pulse oximeter.
| | | | | |
c.Obtain a new oximeter from central supply.
| | | | | |
d.Tell the client to take slow, deep breaths. - CORRECT ANSWER✔✔-A
| | | | | | | | | |
Pulse oximetry is not always the most accurate assessment tool for hypoxia as
| | | | | | | | | | | | |
many factors can interfere, producing normal or near-normal readings in the
| | | | | | | | | | |
setting of hypoxia. The nurse should conduct a more thorough assessment. The
| | | | | | | | | | | |
other actions are not appropriate for a hypoxic client.
| | | | | | | |
A client has been brought to the emergency department with a life-threatening
| | | | | | | | | | | |
chest injury. What action by the nurse takes priority?
| | | | | | | |
a.Apply oxygen at 100%.
| | |
b.Assess the respiratory rate.
| | |
c.Ensure a patent airway.
| | |
d.Start two large-bore IV lines. - CORRECT ANSWER✔✔-C
| | | | | | |
,The priority for any chest trauma client is airway, breathing, circulation. The nurse
| | | | | | | | | | | |
first ensures the client has a patent airway. Assessing respiratory rate and
| | | | | | | | | | | | |
applying oxygen are next, followed by inserting IVs.
| | | | | | |
A client in the emergency department has several broken ribs. What care
| | | | | | | | | | | |
measure will best promote comfort?
| | | |
a.Allowing the client to choose the position in bed
| | | | | | | |
b.Humidifying the supplemental oxygen | | |
c.Offering frequent, small drinks of water
| | | | |
d.Providing warmed blankets - CORRECT ANSWER✔✔-A | | | | |
Allow the client with respiratory problems to assume a position of comfort if it
| | | | | | | | | | | | | |
does not interfere with care. Often the client will choose a more upright position,
| | | | | | | | | | | | | |
which also improves oxygenation. The other options are less effective comfort
| | | | | | | | | | |
measures.
A client is brought to the emergency department after sustaining injuries in a
| | | | | | | | | | | | |
severe car crash. The client's chest wall does not appear to be moving normally
| | | | | | | | | | | | | |
with respirations, oxygen saturation is 82%, and the client is cyanotic. What
| | | | | | | | | | | |
action by the nurse is the priority?
| | | | | |
a.Administer oxygen and reassess. | | |
b.Auscultate the client's lung sounds. | | | |
c.Facilitate a portable chest x-ray. | | | |
d.Prepare to assist with intubation. - CORRECT ANSWER✔✔-D
| | | | | | |
,This client has manifestations of flail chest and, with the other signs, needs to be
| | | | | | | | | | | | | | |
intubated and mechanically ventilated immediately. The nurse does not have
| | | | | | | | | |
time to administer oxygen and wait to reassess, or to listen to lung sounds. A
| | | | | | | | | | | | | | |
chest x-ray will be taken after the client is intubated.
| | | | | | | | |
A nurse is teaching a client who has cystic fibrosis (CF). Which statement should
| | | | | | | | | | | | | |
the nurse include in this client's teaching?
| | | | | |
a. "Take an antibiotic each day."
| | | | |
b. "Contact your provider to obtain genetic screening."
| | | | | | |
c. "Eat a well-balanced, nutritious diet."
| | | | |
d. "Plan to exercise for 30 minutes every day - CORRECT ANSWER✔✔-C
| | | | | | | | | | |
Clients with CF often are malnourished due to vitamin deficiency and pancreatic
| | | | | | | | | | | |
malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise
| | | | | | | | | |
are not essential actions. Genetic screening would not help the client manage CF
| | | | | | | | | | | | |
bette
While assessing a client who is 12 hours postoperative after a thoracotomy for
| | | | | | | | | | | | |
lung cancer, a nurse notices that the lower chest tube is dislodged. Which action
| | | | | | | | | | | | | |
should the nurse take first? | | | |
a. Assess for drainage from the site.
| | | | | |
b. Cover the insertion site with sterile gauze.
| | | | | | |
c. Contact the provider and obtain a suture kit.
| | | | | | | |
d. Reinsert the tube using sterile technique. - CORRECT ANSWER✔✔-B
| | | | | | | | |
, Immediately covering the insertion site helps prevent air from entering the
| | | | | | | | | | |
pleural space and causing a pneumothorax. The area will not reseal quickly
| | | | | | | | | | | |
enough to prevent air from entering the chest. The nurse should not leave the
| | | | | | | | | | | | | |
client to obtain a suture kit. An occlusive dressing may cause a tension
| | | | | | | | | | | | |
pneumothorax. The site should only be assessed after the insertion site is
| | | | | | | | | | | |
covered. The provider should be called to reinsert the chest tube or prescribe
| | | | | | | | | | | | |
other treatment options.
| |
A nurse cares for a client who is infected with Burkholderia cepacia. Which action
| | | | | | | | | | | | |
should the nurse take first when admitting this client to a pulmonary care unit?
| | | | | | | | | | | | | |
a. Instruct the client to wash his or her hands after contact with other people.
| | | | | | | | | | | | | |
b. Implement Droplet Precautions and don a surgical mask.
| | | | | | | |
c. Keep the client isolated from other clients with cystic fibrosis.
| | | | | | | | | |
d. Obtain blood, sputum, and urine culture specimens. - CORRECT ANSWER✔✔-C
| | | | | | | | | |
Burkholderia cepacia infection is spread through casual contact between cystic
| | | | | | | | | |
fibrosis clients, thus the need for these clients to be separated from one another.
| | | | | | | | | | | | | |
Strict isolation measures will not be necessary. Although the client should wash
| | | | | | | | | | | |
his or her hands frequently, the most important measure that can be
| | | | | | | | | | | |
implemented on the unit is isolation of the client from other clients with cystic
| | | | | | | | | | | | | |
fibrosis. There is no need to implement Droplet Precautions or don a surgical
| | | | | | | | | | | | |
mask when caring for this client. Obtaining blood, sputum, and urine culture
| | | | | | | | | | | |
specimens will not provide information necessary to care for a client with
| | | | | | | | | | | |
Burkholderia cepacia infection. | |
A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to
| | | | | | | | | | | | | | | | | |
take deep breaths because of the pain. Which action should the nurse take?
| | | | | | | | | | | |
a. Ambulate the client in the hallway to promote deep breathing.
| | | | | | | | | |
Answers
A client appears dyspneic, but the oxygen saturation is 97%. What action by the
| | | | | | | | | | | | | |
nurse is best?
| |
a.Assess for other manifestations of hypoxia.
| | | | |
b.Change the sensor on the pulse oximeter.
| | | | | |
c.Obtain a new oximeter from central supply.
| | | | | |
d.Tell the client to take slow, deep breaths. - CORRECT ANSWER✔✔-A
| | | | | | | | | |
Pulse oximetry is not always the most accurate assessment tool for hypoxia as
| | | | | | | | | | | | |
many factors can interfere, producing normal or near-normal readings in the
| | | | | | | | | | |
setting of hypoxia. The nurse should conduct a more thorough assessment. The
| | | | | | | | | | | |
other actions are not appropriate for a hypoxic client.
| | | | | | | |
A client has been brought to the emergency department with a life-threatening
| | | | | | | | | | | |
chest injury. What action by the nurse takes priority?
| | | | | | | |
a.Apply oxygen at 100%.
| | |
b.Assess the respiratory rate.
| | |
c.Ensure a patent airway.
| | |
d.Start two large-bore IV lines. - CORRECT ANSWER✔✔-C
| | | | | | |
,The priority for any chest trauma client is airway, breathing, circulation. The nurse
| | | | | | | | | | | |
first ensures the client has a patent airway. Assessing respiratory rate and
| | | | | | | | | | | | |
applying oxygen are next, followed by inserting IVs.
| | | | | | |
A client in the emergency department has several broken ribs. What care
| | | | | | | | | | | |
measure will best promote comfort?
| | | |
a.Allowing the client to choose the position in bed
| | | | | | | |
b.Humidifying the supplemental oxygen | | |
c.Offering frequent, small drinks of water
| | | | |
d.Providing warmed blankets - CORRECT ANSWER✔✔-A | | | | |
Allow the client with respiratory problems to assume a position of comfort if it
| | | | | | | | | | | | | |
does not interfere with care. Often the client will choose a more upright position,
| | | | | | | | | | | | | |
which also improves oxygenation. The other options are less effective comfort
| | | | | | | | | | |
measures.
A client is brought to the emergency department after sustaining injuries in a
| | | | | | | | | | | | |
severe car crash. The client's chest wall does not appear to be moving normally
| | | | | | | | | | | | | |
with respirations, oxygen saturation is 82%, and the client is cyanotic. What
| | | | | | | | | | | |
action by the nurse is the priority?
| | | | | |
a.Administer oxygen and reassess. | | |
b.Auscultate the client's lung sounds. | | | |
c.Facilitate a portable chest x-ray. | | | |
d.Prepare to assist with intubation. - CORRECT ANSWER✔✔-D
| | | | | | |
,This client has manifestations of flail chest and, with the other signs, needs to be
| | | | | | | | | | | | | | |
intubated and mechanically ventilated immediately. The nurse does not have
| | | | | | | | | |
time to administer oxygen and wait to reassess, or to listen to lung sounds. A
| | | | | | | | | | | | | | |
chest x-ray will be taken after the client is intubated.
| | | | | | | | |
A nurse is teaching a client who has cystic fibrosis (CF). Which statement should
| | | | | | | | | | | | | |
the nurse include in this client's teaching?
| | | | | |
a. "Take an antibiotic each day."
| | | | |
b. "Contact your provider to obtain genetic screening."
| | | | | | |
c. "Eat a well-balanced, nutritious diet."
| | | | |
d. "Plan to exercise for 30 minutes every day - CORRECT ANSWER✔✔-C
| | | | | | | | | | |
Clients with CF often are malnourished due to vitamin deficiency and pancreatic
| | | | | | | | | | | |
malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise
| | | | | | | | | |
are not essential actions. Genetic screening would not help the client manage CF
| | | | | | | | | | | | |
bette
While assessing a client who is 12 hours postoperative after a thoracotomy for
| | | | | | | | | | | | |
lung cancer, a nurse notices that the lower chest tube is dislodged. Which action
| | | | | | | | | | | | | |
should the nurse take first? | | | |
a. Assess for drainage from the site.
| | | | | |
b. Cover the insertion site with sterile gauze.
| | | | | | |
c. Contact the provider and obtain a suture kit.
| | | | | | | |
d. Reinsert the tube using sterile technique. - CORRECT ANSWER✔✔-B
| | | | | | | | |
, Immediately covering the insertion site helps prevent air from entering the
| | | | | | | | | | |
pleural space and causing a pneumothorax. The area will not reseal quickly
| | | | | | | | | | | |
enough to prevent air from entering the chest. The nurse should not leave the
| | | | | | | | | | | | | |
client to obtain a suture kit. An occlusive dressing may cause a tension
| | | | | | | | | | | | |
pneumothorax. The site should only be assessed after the insertion site is
| | | | | | | | | | | |
covered. The provider should be called to reinsert the chest tube or prescribe
| | | | | | | | | | | | |
other treatment options.
| |
A nurse cares for a client who is infected with Burkholderia cepacia. Which action
| | | | | | | | | | | | |
should the nurse take first when admitting this client to a pulmonary care unit?
| | | | | | | | | | | | | |
a. Instruct the client to wash his or her hands after contact with other people.
| | | | | | | | | | | | | |
b. Implement Droplet Precautions and don a surgical mask.
| | | | | | | |
c. Keep the client isolated from other clients with cystic fibrosis.
| | | | | | | | | |
d. Obtain blood, sputum, and urine culture specimens. - CORRECT ANSWER✔✔-C
| | | | | | | | | |
Burkholderia cepacia infection is spread through casual contact between cystic
| | | | | | | | | |
fibrosis clients, thus the need for these clients to be separated from one another.
| | | | | | | | | | | | | |
Strict isolation measures will not be necessary. Although the client should wash
| | | | | | | | | | | |
his or her hands frequently, the most important measure that can be
| | | | | | | | | | | |
implemented on the unit is isolation of the client from other clients with cystic
| | | | | | | | | | | | | |
fibrosis. There is no need to implement Droplet Precautions or don a surgical
| | | | | | | | | | | | |
mask when caring for this client. Obtaining blood, sputum, and urine culture
| | | | | | | | | | | |
specimens will not provide information necessary to care for a client with
| | | | | | | | | | | |
Burkholderia cepacia infection. | |
A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to
| | | | | | | | | | | | | | | | | |
take deep breaths because of the pain. Which action should the nurse take?
| | | | | | | | | | | |
a. Ambulate the client in the hallway to promote deep breathing.
| | | | | | | | | |
