ANSWER; 100% CORRECT; 2026- 2027 UPDATE
1. A nurse in the emergency department is assessing a client
who was in a motor vehicle crash. Findings include absent
breath sounds in the left lower lobe with dyspnea, blood
pressure 118/68 mm Hg, heart rate 124/min, respirations
38/min, temperature 38.6° C (101.4° F), and SaO, 92% on room
air. Which of the following actions should the nurse take first?
A. Obtain a chest x-ray.
B. Prepare for chest tube insertion.
C. Administer oxygen via a high-flow mask.
D. Initiate IV access. - correct answer- c
1. A nurse is assessing a client following a gunshot wound to the
chest. For which of the following findings should the nurse
monitor to detect a pneumothorax? (Select all that apply.)
A. Tachypnea
B. Deviation of the trachea
C. Bradycardia
D. Decreased use of accessory muscles
E. Pleuritic pain - correct answer- a, b, e
,1. A nurse is caring for a group of clients. Which of the following
clients are at risk for a pulmonary embolism? (Select all that
apply.)
A. A client who has a BMI of 30
B. A female client who is postmenopausal
C. A client who has a fractured femur
D. A client who is a marathon runner
E. A client who has chronic atrial fibrillation - correct answer-
a, c, e
1. A nurse is monitoring a group of clients for increased risk for
developing pneumonia. Which of the following clients should
the nurse expect to be at risk? (Select all that apply.)
A. Client who has dysphagia
B. Client who has AIDS
C. Client who was vaccinated for pneumococcus and influenza 6
months ago
D. Client who is postoperative and has received local anesthesia
E. Client who has a closed head injury and is receiving ventilation
F. Client who has myasthenia gravis - correct answer- a, b, e,
f
,1. A nurse is orienting a newly licensed nurse who is caring for a
client who is receiving mechanical ventilation and is on pressure
support ventilation (PSV) mode. Which of the following
statements by the newly licensed nurse indicates an
understanding of PSV?
A. "It keeps the alveoli open and prevents atelectasis."
B. "It allows preset pressure delivered during spontaneous
ventilation."
C. "It guarantees minimal minute ventilator."
D. "It delivers a preset ventilatory rate and tidal volume to the
client." - correct answer- b
1. A nurse is preparing to care for a client following a chest tube
placement. Which of the following items should be available in
the client's room? (Select all that apply.)
A. Oxygen
B. Sterile water
C. Enclosed hemostat clamps
D. Indwelling urinary catheter
E. Occlusive dressing - correct answer- a, b, c, e
, 2. A nurse in a clinic is caring for a client whose partner states
the client woke up this morning, did not recognize him, and did
not know where she was. The client reports chills and chest pain
that is worse upon inspiration. Which of the following actions is
the nursing priority?
A. Obtain baseline vital signs and oxygen saturation.
B. Obtain a sputum culture.
C. Obtain a complete history from the client.
D. Provide a pneumococcal vaccine. - correct answer- a
2. A nurse is assessing a client who has a pulmonary embolism.
Which of the following manifestations should the nurse expect
to find? (Select all that apply.)
A. Bradypnea
B. Pleural friction rub
C. Hypertension
D. Petechiae
E. Tachycardia - correct answer- b, d, e
2. A nurse is caring for a client who has a chest tube and
drainage system in place. The nurse observes that the chest tube
was accidentally removed. Which of the following actions should
the nurse take first?