4. A client has a tracheostomy tube in place. When the nurse suctions the client,
food particles are noted. What action by the nurse is best?
b. Measure and compare cuff pressures.
ANS: B
2. A nurse assesses a client after an open lung biopsy. Which assessment finding
is matched with the correct intervention?
c. Client has reduced breath sounds. Nurse calls physician immediately.
ANS: C
3. A nurse assesses a clients respiratory status. Which information is of highest
priority for the nurse to obtain?
d. Occupation and hobbies
ANS: D
2. A nurse assesses a client who is experiencing an acid-base imbalance. The
clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm
Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first?
a. Cardiac rate and rhythm
ANS: A
6. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial
blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What
action should the nurse take next?
a. Assess clients rate, rhythm, and depth of respiration.
7. A nurse is assessing a client who is recovering from a lung biopsy. Which
assessment finding requires immediate action?
b. Absent breath sounds
ANS: B
8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The
clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22
mEq/L. Which action should the nurse take first?
a. Apply oxygen by mask or nasal cannula.
8. A nurse is caring for a client who is scheduled to undergo a thoracentesis.
Which intervention should the nurse complete prior to the procedure?
d. Validate that informed consent has been given by the client.
ANS: D
,9. A nurse assesses a client after a thoracentesis. Which assessment finding
warrants immediate action?
d. The trachea is deviated toward the opposite side of the neck.
ANS: D
1.A nurse is caring for a client who has just had a central venous access line
inserted. Which action should the nurse take next?
b. Ensure an x-ray is completed to confirm placement.
ANS: B
3.A nurse teaches a client who is being discharged home with a peripherally
inserted central catheter (PICC). Which statement should the nurse include in
this clients teaching?
a. Avoid carrying your grandchild with the arm that has the central catheter.
ANS: A
5.A nurse is caring for a client who is receiving an epidural infusion for pain
management. Which assessment finding requires immediate intervention from
the nurse?
b. Report of headache and stiff neck
ANS: B
7.A nurse is assessing clients who have intravenous therapy prescribed. Which
assessment finding for a client with a peripherally inserted central catheter
(PICC) requires immediate attention?
d. Upper extremity swelling is noted.
ANS: D
13.A nurse teaches a client who is prescribed a central vascular access device.
Which statement should the nurse include in this clients teaching?
c. Ask all providers to vigorously clean the connections prior to accessing the device
, ANS: C
14.A nurse is caring for a client with a peripheral vascular access device who is
experiencing pain, redness, and swelling at the site. After removing the device,
which action should the nurse take to relieve pain?
b. Place warm compresses on the site.
ANS: B
17.A nurse prepares to flush a peripherally inserted central catheter (PICC) line
with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin with
a concentration of 100 units/mL. Which of the syringes shown below should the
nurse use to draw up and administer the heparin?
ANS: D (10-mL syringe picture)
2.A nurse assesses a client who has a peripherally inserted central catheter
(PICC). For which complications should the nurse assess? (Select all that
apply.)
a. Phlebitis
c. Thrombophlebitis
ANS: A, C
11. While assessing a client who has facial trauma, the nurse auscultates stridor.
The client is anxious and restless. Which action should the nurse take first?
a. Contact the provider and prepare for intubation.
ANS: A
8.A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the
site. Which action should the nurse take next?
d. Stop the infusion of intravenous fluids.
3. A nurse assesses a client who has facial trauma. Which assessment findings
require immediate intervention? (Select all that apply.)
a. Stridor
d. Ecchymosis behind the ear
ANS: A, D
food particles are noted. What action by the nurse is best?
b. Measure and compare cuff pressures.
ANS: B
2. A nurse assesses a client after an open lung biopsy. Which assessment finding
is matched with the correct intervention?
c. Client has reduced breath sounds. Nurse calls physician immediately.
ANS: C
3. A nurse assesses a clients respiratory status. Which information is of highest
priority for the nurse to obtain?
d. Occupation and hobbies
ANS: D
2. A nurse assesses a client who is experiencing an acid-base imbalance. The
clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm
Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first?
a. Cardiac rate and rhythm
ANS: A
6. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial
blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What
action should the nurse take next?
a. Assess clients rate, rhythm, and depth of respiration.
7. A nurse is assessing a client who is recovering from a lung biopsy. Which
assessment finding requires immediate action?
b. Absent breath sounds
ANS: B
8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The
clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22
mEq/L. Which action should the nurse take first?
a. Apply oxygen by mask or nasal cannula.
8. A nurse is caring for a client who is scheduled to undergo a thoracentesis.
Which intervention should the nurse complete prior to the procedure?
d. Validate that informed consent has been given by the client.
ANS: D
,9. A nurse assesses a client after a thoracentesis. Which assessment finding
warrants immediate action?
d. The trachea is deviated toward the opposite side of the neck.
ANS: D
1.A nurse is caring for a client who has just had a central venous access line
inserted. Which action should the nurse take next?
b. Ensure an x-ray is completed to confirm placement.
ANS: B
3.A nurse teaches a client who is being discharged home with a peripherally
inserted central catheter (PICC). Which statement should the nurse include in
this clients teaching?
a. Avoid carrying your grandchild with the arm that has the central catheter.
ANS: A
5.A nurse is caring for a client who is receiving an epidural infusion for pain
management. Which assessment finding requires immediate intervention from
the nurse?
b. Report of headache and stiff neck
ANS: B
7.A nurse is assessing clients who have intravenous therapy prescribed. Which
assessment finding for a client with a peripherally inserted central catheter
(PICC) requires immediate attention?
d. Upper extremity swelling is noted.
ANS: D
13.A nurse teaches a client who is prescribed a central vascular access device.
Which statement should the nurse include in this clients teaching?
c. Ask all providers to vigorously clean the connections prior to accessing the device
, ANS: C
14.A nurse is caring for a client with a peripheral vascular access device who is
experiencing pain, redness, and swelling at the site. After removing the device,
which action should the nurse take to relieve pain?
b. Place warm compresses on the site.
ANS: B
17.A nurse prepares to flush a peripherally inserted central catheter (PICC) line
with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin with
a concentration of 100 units/mL. Which of the syringes shown below should the
nurse use to draw up and administer the heparin?
ANS: D (10-mL syringe picture)
2.A nurse assesses a client who has a peripherally inserted central catheter
(PICC). For which complications should the nurse assess? (Select all that
apply.)
a. Phlebitis
c. Thrombophlebitis
ANS: A, C
11. While assessing a client who has facial trauma, the nurse auscultates stridor.
The client is anxious and restless. Which action should the nurse take first?
a. Contact the provider and prepare for intubation.
ANS: A
8.A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the
site. Which action should the nurse take next?
d. Stop the infusion of intravenous fluids.
3. A nurse assesses a client who has facial trauma. Which assessment findings
require immediate intervention? (Select all that apply.)
a. Stridor
d. Ecchymosis behind the ear
ANS: A, D
