Select All That Apply NCLEX Practice
#2
NURSESLABS-SATA-2-001
A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The
nurse collects data from the client and notes which of the following signs
supports this diagnosis? Select all that apply.
A. Scant mucus
B. Early onset cough
C. Marked weight loss
D. Purulent mucus production
E. Mild episodes of dyspnea
Correct Answer: B, D, & E.
Key features of pulmonary emphysema include dyspnea that is often marked, late
cough (after the onset of dyspnea), scant mucus production, and marked weight
loss. By contrast, chronic bronchitis is characterized by an early onset of cough
(before dyspnea), copious purulent mucus production, minimal weight loss, and
milder severity of dyspnea.
Option A: Most patients with emphysema present with very nonspecific
symptoms of chronic shortness of breath and cough with or without
sputum production. As the disease process advances, the shortness of
breath and cough progressively get worse.
Option B: The most common symptom of patients with chronic bronchitis
is a cough. The history of a cough typical of chronic bronchitis is
characterized to be present for most days in a month lasting for 3 months
with at least 2 such episodes occurring for 2 years in a row. The
characteristic cough of bronchitis is caused by the copious secretion of
mucus in chronic bronchitis.
Option C: As COPD advances, patients can lose significant body weight
due to systemic inflammation and increased energy spent in the work of
, breathing. Also, there are frequent intermittent exacerbations as the
obstruction of the airways increases.
Option D: The airways become clogged by debris and this further
increases the irritation. A productive cough with sputum is present in about
50% of patients. The sputum color may vary from clear, yellow, green, or at
times blood-tinged. The color of the sputum may be dependent on the
presence of secondary bacterial infection.
Option E: During an acute exacerbation of chronic bronchitis, the bronchial
mucous membrane becomes hyperemic and edematous with diminished
bronchial mucociliary function. This, in turn, leads to airflow impediment
because of luminal obstruction to small airways.
NURSESLABS-SATA-2-002
A nurse, assigned to a client with emphysema, is providing a shift report. Which
nursing interventions would be appropriate to include? Select all that apply.
A. The nurse should reduce fluid intake to less than 850 ml per shift.
B. The nurse should teach diaphragmatic, pursed-lip breathing.
C. The nurse should administer low-flow oxygen.
D. The nurse should keep the client in a supine position as much as
possible.
E. The nurse should encourage alternating activity with rest periods.
F. The nurse should teach the use of postural drainage and chest
physiotherapy.
Correct Answer: B, C, E, & F.
Emphysema is the most severe form of COPD, characterized by recurrent
inflammation that damages and eventually destroys alveolar walls to create large
blebs or bullae (air spaces) and collapsed bronchioles on expiration (air-trapping).
Option A: Fluid intake should be increased to 3,000 ml/day, if not
contraindicated, to liquefy secretions and facilitate their removal. Provide
warm or tepid liquids. Recommend the intake of fluids between, instead of
during, meals. Using warm liquids may decrease bronchospasm. Fluids
, during meals can increase gastric distension and pressure on the
diaphragm.
Option B: Diaphragmatic, pursed-lip breathing strengthens respiratory
muscles and enhances oxygenation in clients with emphysema. This
provides the client with some means to cope with or control dyspnea and
reduce air-trapping.
Option C: Low-flow oxygen should be administered because a client with
emphysema has chronic hypercapnia and a hypoxic respiratory drive.
Administering humidified oxygen prevents drying out the airways,
decreases convective moisture losses, and improves compliance.
Option D: The client should be placed in high Fowler’s position to improve
ventilation. Elevation of the head of the bed facilitates respiratory function
by use of gravity; however, the client in severe distress will seek the
position that most eases breathing.
Option E: Alternating activity with rest allows to perform activities without
excessive distress. During severe, acute or refractory respiratory distress,
the patient may be totally unable to perform basic self-care activities
because of hypoxemia and dyspnea. Rest interspersed with care activities
remains an important part of the treatment regimen.
Option F: If the client has difficulty mobilizing copious secretions, the
nurse should teach the client and family members how to perform postural
drainage and chest physiotherapy. These techniques will prevent possible
aspirations and prevent any untoward complications.
NURSESLABS-SATA-2-003
A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is
providing hygiene care to the client and would avoid which of the following while
changing the client’s hospital gown?
A. Using a hospital gown with snaps at the sleeves
B. Disconnecting the IV tubing from the catheter in the vein
C. Checking the IV flow rate immediately after changing the hospital gown
, D. Putting the bag and tubing through the sleeve, followed by the client’s arm
E. Keeping splint soiled by blood or fluid leakage
Correct Answer: B & E.
Changing a patient’s hospital gown is needed to maintain their cleanliness and
the feeling of freshness.
Option A: A kimono-inspired gown opens in the front and uses a system
of ties and snaps at essential access points for easy treatment and
monitoring.Top snaps offer upper back access. Wide sleeves and side
snaps provide easy access for an I.V., and are MRI-compatible.
Option B: The tubing should not be removed from the IV catheter. With
each break in the system, there is an increased chance of introducing
bacteria into the system, which can lead to infection.
Option C: The flow rate should be checked immediately after changing the
hospital gown, because the position of the roller clamp may have been
affected during the change. Count the rate of flow of the infusion to make
sure it is correct before leaving the bedside.
Option D: Holding the container above the client’s arm, slide the sleeve up
over the container to remove the used gown. Place the clean gown sleeve
for the arm with the infusion over the container as if it were an extension of
the client’s arm, from the inside of the gown to the sleeve cuff.
Option E: IV board/splints are recommended to secure PIVC placed in or
adjacent to areas of flexion. This will adequately immobilize the joint and
minimize the risk of venous damage resulting from flexion. Splints should
be Inspected at least daily and change if soiled by blood or fluid leakage.
NURSESLABS-SATA-2-004
A nurse is caring for a client who underwent surgical repair of a detached retina
in the right eye. Which nursing interventions should the nurse perform? Select all
that apply.
A. Place the client in a prone position.
#2
NURSESLABS-SATA-2-001
A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The
nurse collects data from the client and notes which of the following signs
supports this diagnosis? Select all that apply.
A. Scant mucus
B. Early onset cough
C. Marked weight loss
D. Purulent mucus production
E. Mild episodes of dyspnea
Correct Answer: B, D, & E.
Key features of pulmonary emphysema include dyspnea that is often marked, late
cough (after the onset of dyspnea), scant mucus production, and marked weight
loss. By contrast, chronic bronchitis is characterized by an early onset of cough
(before dyspnea), copious purulent mucus production, minimal weight loss, and
milder severity of dyspnea.
Option A: Most patients with emphysema present with very nonspecific
symptoms of chronic shortness of breath and cough with or without
sputum production. As the disease process advances, the shortness of
breath and cough progressively get worse.
Option B: The most common symptom of patients with chronic bronchitis
is a cough. The history of a cough typical of chronic bronchitis is
characterized to be present for most days in a month lasting for 3 months
with at least 2 such episodes occurring for 2 years in a row. The
characteristic cough of bronchitis is caused by the copious secretion of
mucus in chronic bronchitis.
Option C: As COPD advances, patients can lose significant body weight
due to systemic inflammation and increased energy spent in the work of
, breathing. Also, there are frequent intermittent exacerbations as the
obstruction of the airways increases.
Option D: The airways become clogged by debris and this further
increases the irritation. A productive cough with sputum is present in about
50% of patients. The sputum color may vary from clear, yellow, green, or at
times blood-tinged. The color of the sputum may be dependent on the
presence of secondary bacterial infection.
Option E: During an acute exacerbation of chronic bronchitis, the bronchial
mucous membrane becomes hyperemic and edematous with diminished
bronchial mucociliary function. This, in turn, leads to airflow impediment
because of luminal obstruction to small airways.
NURSESLABS-SATA-2-002
A nurse, assigned to a client with emphysema, is providing a shift report. Which
nursing interventions would be appropriate to include? Select all that apply.
A. The nurse should reduce fluid intake to less than 850 ml per shift.
B. The nurse should teach diaphragmatic, pursed-lip breathing.
C. The nurse should administer low-flow oxygen.
D. The nurse should keep the client in a supine position as much as
possible.
E. The nurse should encourage alternating activity with rest periods.
F. The nurse should teach the use of postural drainage and chest
physiotherapy.
Correct Answer: B, C, E, & F.
Emphysema is the most severe form of COPD, characterized by recurrent
inflammation that damages and eventually destroys alveolar walls to create large
blebs or bullae (air spaces) and collapsed bronchioles on expiration (air-trapping).
Option A: Fluid intake should be increased to 3,000 ml/day, if not
contraindicated, to liquefy secretions and facilitate their removal. Provide
warm or tepid liquids. Recommend the intake of fluids between, instead of
during, meals. Using warm liquids may decrease bronchospasm. Fluids
, during meals can increase gastric distension and pressure on the
diaphragm.
Option B: Diaphragmatic, pursed-lip breathing strengthens respiratory
muscles and enhances oxygenation in clients with emphysema. This
provides the client with some means to cope with or control dyspnea and
reduce air-trapping.
Option C: Low-flow oxygen should be administered because a client with
emphysema has chronic hypercapnia and a hypoxic respiratory drive.
Administering humidified oxygen prevents drying out the airways,
decreases convective moisture losses, and improves compliance.
Option D: The client should be placed in high Fowler’s position to improve
ventilation. Elevation of the head of the bed facilitates respiratory function
by use of gravity; however, the client in severe distress will seek the
position that most eases breathing.
Option E: Alternating activity with rest allows to perform activities without
excessive distress. During severe, acute or refractory respiratory distress,
the patient may be totally unable to perform basic self-care activities
because of hypoxemia and dyspnea. Rest interspersed with care activities
remains an important part of the treatment regimen.
Option F: If the client has difficulty mobilizing copious secretions, the
nurse should teach the client and family members how to perform postural
drainage and chest physiotherapy. These techniques will prevent possible
aspirations and prevent any untoward complications.
NURSESLABS-SATA-2-003
A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is
providing hygiene care to the client and would avoid which of the following while
changing the client’s hospital gown?
A. Using a hospital gown with snaps at the sleeves
B. Disconnecting the IV tubing from the catheter in the vein
C. Checking the IV flow rate immediately after changing the hospital gown
, D. Putting the bag and tubing through the sleeve, followed by the client’s arm
E. Keeping splint soiled by blood or fluid leakage
Correct Answer: B & E.
Changing a patient’s hospital gown is needed to maintain their cleanliness and
the feeling of freshness.
Option A: A kimono-inspired gown opens in the front and uses a system
of ties and snaps at essential access points for easy treatment and
monitoring.Top snaps offer upper back access. Wide sleeves and side
snaps provide easy access for an I.V., and are MRI-compatible.
Option B: The tubing should not be removed from the IV catheter. With
each break in the system, there is an increased chance of introducing
bacteria into the system, which can lead to infection.
Option C: The flow rate should be checked immediately after changing the
hospital gown, because the position of the roller clamp may have been
affected during the change. Count the rate of flow of the infusion to make
sure it is correct before leaving the bedside.
Option D: Holding the container above the client’s arm, slide the sleeve up
over the container to remove the used gown. Place the clean gown sleeve
for the arm with the infusion over the container as if it were an extension of
the client’s arm, from the inside of the gown to the sleeve cuff.
Option E: IV board/splints are recommended to secure PIVC placed in or
adjacent to areas of flexion. This will adequately immobilize the joint and
minimize the risk of venous damage resulting from flexion. Splints should
be Inspected at least daily and change if soiled by blood or fluid leakage.
NURSESLABS-SATA-2-004
A nurse is caring for a client who underwent surgical repair of a detached retina
in the right eye. Which nursing interventions should the nurse perform? Select all
that apply.
A. Place the client in a prone position.
