Test A N211 (771) for course 492
1. Which finding in a chest tube drainage system connected to suction requires nursing
action?
a. continuous bubbling in the waterseal chamber
b. tidaling in the waterseal chamber
c. fluctuation in the waterseal chamber
d. presence of small clots in the tubing
2. What is the expected outcome of administering cromolyn sodium (Intal) to a patient
with asthma?
a. to cause bronchodilation
b. to decrease airway inflammation
c. to prevent the allergic reaction
d. to relax smooth muscles
3. A patient who has chest tubes attached to a Pleurevac waterseal drainage system
is being transported to X ray. Which is the most appropriate action for the nurse to
take during transit?
a. clamping the tubes during transport
b. clamping the tubes during transport
c. maintain the patency of the chest tubes and hang the Pleurevac from an IV pole
d. maintain the patency of the chest tubes and keep the Pleurevac below the
chest level
4. A threeyearold child who has Hodgkin’s disease is administered a Mantoux TB skin
test. After 72 hrs, a red raised area approximately 11 mm in diameter develops at the
test site. What is the nurse’s best interpretation of this result?
a. the presence of active tuberculosis has been confirmed
b. the skin reaction is negative for tuberculosis
c. there is sensitivity to the tuberculosis bacillus
d. the patient is experiencing an allergic reaction
5. Which assessment finding is most indicative of cardiac tamponade in the patient after
cardiac surgery?
a. a temperature of 100 degrees Farenheit
b. an increased pulmonary artery wedge pressure (PAWP)
c. cessation of chest tube drainage
d. altered level of consciousness
6. After completing chest physiotherapy for a patient with chronic obstructive pulmonary
disease (COPD), the nurse auscultates diminished breath sounds in all lung fields.
Which nursing action is appropriate?
a. encourage deep breathing
b. apply nasal oxygen at 2L/min.
,Test A N211 (771) for course 492
c. document the finding
d. repeat the treatment
7. Which data is most suggestive that the patient is beginning to experience hypoxia?
a. shortness of breath
b. complaint of weakness
c. increased sputum
d. mental confusion
8. What is necessary for continuous positive airway pressure (CPAP) to be most effec
tive for an infant with respiratory distress?
The infant must be:
a. able to breath spontaneously without assistance
b. frequently stimulated to maintain respirations
c. intubated
d. suctioned frequently to maintain alveolar ventilation
9. The physician orders gentamicin sulfate (Garamycin) 60 mg IV every 8 hours to treat
an upper respiratory infection in an older adult patient. The nurse should assess the
patient for toxic effects to which body system?
a. hepatic
b. integumentary
c. neurological
d. renal
10. A patient has been admitted to the hospital for removal of a malignancy in the lar
ynx. A permeant tracheostomy will be inserted and the nurse will provide suctioning
when secretions are present. Which action is appropriate when suctioning a tra
cheostomy?
a. applies suction while inserting the catheter to stimulate the cough reflex
b. applies suction for no longer than 10 seconds while withdrawing the catheter
c. does not need to use sterile technique
d. rinses the catheter with water
11 Asthma is associate with airway obstruction caused by which physiological factors?
a. loss of lung elasticity and changes in the structure of the alveoli
b. swelling of the bronchial lining and filling of the bronchi with mucus
c. superimposed infection and development of lung cancer
d. pulmonary hypertension and depression
12. Which acidbase disturbance is indicated by a PaCO2 of 52 mm/Hg and a pH of
7.30?
a. metabolic acidosis
, Test A N211 (771) for course 492
b. metabolic alkalosis
c. respiratory acidosis
d. respiratory alkalosis
13. Which patient should have priority in receiving pneumococcal vaccine during a vac
cine shortage?
a. a 60 year old patient in good health
b. a 55 year old patient with repeated upper respiratory infection
c. a 37 year old patient recently diagnosed with bronchitis
d. a 23 year old patient with cystic fibrosis
14. A patient with chronic obstructive pulmonary disease (COPD) has just started oxy
gen therapy via nasal cannula. Which nursing action should be included in the pa
tient’s care plan?
a. periodically check the oxygen humidity
b. closely monitor the respiratory rate for bradypnea
c. increase the flow rate to 4 L/min
d. apply petroleum jelly to the nasal area
15. Which assessment data should lead the nurse to suspect that a patient is develop
ing pneumonia?
a. fever, tachypnea, cough, and crackles
b. chronic cough, purulent secretions, hemoptypsis, and clubbing
c. dyspnea, fatigue, anorexia, and weight loss
d. shortness of breath, cough, edema, and headache
16. In which position should the nurse place patient with orthopnea to reduce fatigue
and dyspnea?
a. dorsal recumbent, with both feet elevated
b. semiFowler’s, with the knees gatched
c. highFowler’s, with the arms supported on pillows
d. sitting on the side of the bed with feet on the floor
17. The home health nurse monitors a child using a peak expiratory flow meter. Which
action by the patient indicates that the patient needs additional teaching?
a. sits up straight for the test
b. places the lips closely and tightly around the mouthpiece
c. blow out as hard and quickly as possible
d. records the highest of three readings
18. Which dietary recommendation should the nurse include in a teaching plan for a pa
tient with sleep apnea?
a. avoid alcohol before sleep
1. Which finding in a chest tube drainage system connected to suction requires nursing
action?
a. continuous bubbling in the waterseal chamber
b. tidaling in the waterseal chamber
c. fluctuation in the waterseal chamber
d. presence of small clots in the tubing
2. What is the expected outcome of administering cromolyn sodium (Intal) to a patient
with asthma?
a. to cause bronchodilation
b. to decrease airway inflammation
c. to prevent the allergic reaction
d. to relax smooth muscles
3. A patient who has chest tubes attached to a Pleurevac waterseal drainage system
is being transported to X ray. Which is the most appropriate action for the nurse to
take during transit?
a. clamping the tubes during transport
b. clamping the tubes during transport
c. maintain the patency of the chest tubes and hang the Pleurevac from an IV pole
d. maintain the patency of the chest tubes and keep the Pleurevac below the
chest level
4. A threeyearold child who has Hodgkin’s disease is administered a Mantoux TB skin
test. After 72 hrs, a red raised area approximately 11 mm in diameter develops at the
test site. What is the nurse’s best interpretation of this result?
a. the presence of active tuberculosis has been confirmed
b. the skin reaction is negative for tuberculosis
c. there is sensitivity to the tuberculosis bacillus
d. the patient is experiencing an allergic reaction
5. Which assessment finding is most indicative of cardiac tamponade in the patient after
cardiac surgery?
a. a temperature of 100 degrees Farenheit
b. an increased pulmonary artery wedge pressure (PAWP)
c. cessation of chest tube drainage
d. altered level of consciousness
6. After completing chest physiotherapy for a patient with chronic obstructive pulmonary
disease (COPD), the nurse auscultates diminished breath sounds in all lung fields.
Which nursing action is appropriate?
a. encourage deep breathing
b. apply nasal oxygen at 2L/min.
,Test A N211 (771) for course 492
c. document the finding
d. repeat the treatment
7. Which data is most suggestive that the patient is beginning to experience hypoxia?
a. shortness of breath
b. complaint of weakness
c. increased sputum
d. mental confusion
8. What is necessary for continuous positive airway pressure (CPAP) to be most effec
tive for an infant with respiratory distress?
The infant must be:
a. able to breath spontaneously without assistance
b. frequently stimulated to maintain respirations
c. intubated
d. suctioned frequently to maintain alveolar ventilation
9. The physician orders gentamicin sulfate (Garamycin) 60 mg IV every 8 hours to treat
an upper respiratory infection in an older adult patient. The nurse should assess the
patient for toxic effects to which body system?
a. hepatic
b. integumentary
c. neurological
d. renal
10. A patient has been admitted to the hospital for removal of a malignancy in the lar
ynx. A permeant tracheostomy will be inserted and the nurse will provide suctioning
when secretions are present. Which action is appropriate when suctioning a tra
cheostomy?
a. applies suction while inserting the catheter to stimulate the cough reflex
b. applies suction for no longer than 10 seconds while withdrawing the catheter
c. does not need to use sterile technique
d. rinses the catheter with water
11 Asthma is associate with airway obstruction caused by which physiological factors?
a. loss of lung elasticity and changes in the structure of the alveoli
b. swelling of the bronchial lining and filling of the bronchi with mucus
c. superimposed infection and development of lung cancer
d. pulmonary hypertension and depression
12. Which acidbase disturbance is indicated by a PaCO2 of 52 mm/Hg and a pH of
7.30?
a. metabolic acidosis
, Test A N211 (771) for course 492
b. metabolic alkalosis
c. respiratory acidosis
d. respiratory alkalosis
13. Which patient should have priority in receiving pneumococcal vaccine during a vac
cine shortage?
a. a 60 year old patient in good health
b. a 55 year old patient with repeated upper respiratory infection
c. a 37 year old patient recently diagnosed with bronchitis
d. a 23 year old patient with cystic fibrosis
14. A patient with chronic obstructive pulmonary disease (COPD) has just started oxy
gen therapy via nasal cannula. Which nursing action should be included in the pa
tient’s care plan?
a. periodically check the oxygen humidity
b. closely monitor the respiratory rate for bradypnea
c. increase the flow rate to 4 L/min
d. apply petroleum jelly to the nasal area
15. Which assessment data should lead the nurse to suspect that a patient is develop
ing pneumonia?
a. fever, tachypnea, cough, and crackles
b. chronic cough, purulent secretions, hemoptypsis, and clubbing
c. dyspnea, fatigue, anorexia, and weight loss
d. shortness of breath, cough, edema, and headache
16. In which position should the nurse place patient with orthopnea to reduce fatigue
and dyspnea?
a. dorsal recumbent, with both feet elevated
b. semiFowler’s, with the knees gatched
c. highFowler’s, with the arms supported on pillows
d. sitting on the side of the bed with feet on the floor
17. The home health nurse monitors a child using a peak expiratory flow meter. Which
action by the patient indicates that the patient needs additional teaching?
a. sits up straight for the test
b. places the lips closely and tightly around the mouthpiece
c. blow out as hard and quickly as possible
d. records the highest of three readings
18. Which dietary recommendation should the nurse include in a teaching plan for a pa
tient with sleep apnea?
a. avoid alcohol before sleep
