EXAM PRACTICE

Answer Key
Question 1 See full question

Which practice should a nurse recommend to a client who has had a cesarean birth?
You Selected:

 Coughing and deep-breathing exercises

Correct response:

 Coughing and deep-breathing exercises

Explanation:
Remediation:

Question 2 See full question

A neonate born at 40 weeks' gestation admitted to the nursery is found to be
hypoglycemic. At 4 hours of age, the neonate appears pale and his pulse oximeter is
reading 75% on room air. The nurse should:
You Selected:

 provide supplemental oxygen

Correct response:

 provide supplemental oxygen

Explanation:
Remediation:

Question 3 See full question

During the first feeding, the nurse observes that the neonate becomes cyanotic after
gagging on mucus. What should the nurse do first?
You Selected:

 Raise the neonate's head and pat the back gently.

Correct response:

 Clear the neonate's airway with suction or gravity.

Explanation:

, Remediation:

Question 4 See full question

A preschool child immobilized in a hip spica cast has trouble breathing after meals.
Which action would be best?
You Selected:

 Encourage the child to drink more between meals.

Correct response:

 Offer the child small feedings several times a day.

Explanation:
Remediation:

Question 5 See full question

A client hospitalized for treatment of a pulmonary embolism develops respiratory
alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
You Selected:

 Light-headedness or paresthesia

Correct response:

 Light-headedness or paresthesia

Explanation:
Remediation:

Question 6 See full question

A young adult is admitted to the emergency department after an automobile accident.
The client has severe pain in the right chest from contact with the steering wheel. What
should the nurse do first?
You Selected:

 Reduce the client's anxiety.

Correct response:

 Maintain adequate oxygenation.

Explanation:
Remediation:

,Question 7 See full question

The nurse is caring for a client receiving morphine in an intravenous infusion using a
patient-controlled anesthesia pump (PCA) for relief of postoperative pain. On
assessment, the client’s vital signs are as follows: heart rate, 84 bpm; respirations, 8
breaths/min; blood pressure 104/56 mm Hg; and oxygen saturation of 88% on room air.
What should the nurse do first
You Selected:

 Stop the infusion of morphine.

Correct response:

 Assist the client to sit and stimulate coughing/deep breathing.

Explanation:
Remediation:

Question 8 See full question

A client has had a left chest tube in place for several days. The nurse assesses the
client and notes that there is no bubbling in the water seal chamber. Auscultation of the
left lower lung reveals vesicular breath sounds. What is the most appropriate action by
the nurse?
You Selected:

 Further assess the client for reinflation of the lung.

Correct response:

 Further assess the client for reinflation of the lung.

Explanation:
Remediation:

Question 9 See full question

A client with septic shock has continued to deteriorate and has become unresponsive.
The nurse has inserted an intravenous line and an oral airway. Which of the following is
the highest priority for the nurse at this time?
You Selected:

 Confirm the placement of the oral airway.

Correct response:

 Confirm the placement of the oral airway.

, Explanation:
Remediation:

Question 10 See full question

A child is being seen in the emergency department for reports of severe sore throat,
trouble swallowing, and fever. The child has swollen cervical lymph nodes and a fiery
red pharynx on examination. Which of the following assessment findings below should
be reported immediately to the healthcare provider?
You Selected:

 Drooling and not swallowing

Correct response:

 Drooling and not swallowing

Explanation:
Remediation:




Answer Key
Question 1 See full question

A client is breathing 40 breaths/minute. He is diaphoretic and confused. Which nursing
diagnosis should be the priority for the client at this time?
You Selected:

 Impaired gas exchange

Correct response:

 Impaired gas exchange

Explanation:
Remediation:

Question 2 See full question

A client brought by ambulance to the emergency department after taking an overdose of
barbiturates is comatose. The nurse should assess the client for:
You Selected: