Name: Score:
40 Multiple choice questions
,Term 1 of 40
Which action would the nurse take first when a client with acute bronchitis and emphysema
reports feeling anxious and short of breath?
1
Obtain the oxygen saturation.
2
Provide oxygen at 2 L per minute.
3
Offer the prescribed rescue inhaler.
4
Suggest use of pursed-lip breathing
2
Pulse oximetry will assess for adequate oxygen saturation and would be done first because
a low saturation would indicate the need for rapid implementation of actions such as
oxygen administration and notification of the health care provider. Weighing the client
would help in determining fluid overload but would be done after assuring adequate
oxygen saturation. The lung sounds would be auscultated to see if the client has fluid
overload or whether the dialysate infusion is decreasing room for lung expansion, but can
be done after checking oxygen saturation. If the lung sounds indicate that the dialysate is
decreasing the ability of the lungs to expand, the client can be repositioned to allow better
lung expansion.
1
With a nasogastric (NG) tube for decompression in place, nausea may indicate tube
displacement or obstruction. Checking its placement can determine whether it is in the
stomach; once placement is verified, fluid then can be instilled to ensure patency. The
antiemetic may relieve the discomfort, but it will not determine the cause.
3
The client is too busy keeping active during the manic part of a bipolar disorder. This stage's
characteristics include elation, activity, restlessness, and increased energy. Although the
client may be using more calories than usual during this period, food is not a priority, and
the client will not spend the time to eat. The nurse would need to suggest finger foods and
high-calorie snacks.
1
More assessment is needed before further actions are taken; the nurse would check the
client's oxygen saturation as the initial action. If oxygen saturation is low, then oxygen
administration would be needed. The rescue inhaler may be needed if the client has
,wheezes or decreased breath sounds. Pursed-lip breathing may be helpful if anxiety is
causing hyperventilation, but the first action would be to assure that the client is not
hypoxemic.
, Term 2 of 40
Which action would the nurse plan for a client during the early postoperative period after a
prostatectomy?
1
Have the client stand to void.
2
Discourage straining for a bowel movement.
3
Use a bulb syringe to aspirate urine from the retention catheter.
4
Notify the primary health care provider if the client does not void by bedtime.
4
Increased intra-abdominal pressure associated with lifting, coughing, or laughing, in
conjunction with a relaxed pelvic musculature and a bladder displaced into the vagina, may
result in stress incontinence.
3
Deficient ADH from the posterior pituitary results in diabetes insipidus. This can be caused
by head trauma; water is not conserved by the body, and excess amounts of urine are
produced.
2
Straining applies pressure to the operative site, which can precipitate bleeding and should
be avoided. A retention catheter is routinely put into place, so standing to void and not
voiding by bedtime are not applicable. To prevent trauma, negative pressure should not be
exerted on the bladder by using a bulb syringe to aspirate.
2
Pulse oximetry will assess for adequate oxygen saturation and would be done first because
a low saturation would indicate the need for rapid implementation of actions such as
oxygen administration and notification of the health care provider. Weighing the client
would help in determining fluid overload but would be done after assuring adequate
oxygen saturation. The lung sounds would be auscultated to see if the client has fluid
overload or whether the dialysate infusion is decreasing room for lung expansion, but can
be done after checking oxygen saturation. If the lung sounds indicate that the dialysate is
decreasing the ability of the lungs to expand, the client can be repositioned to allow better
lung expansion.
40 Multiple choice questions
,Term 1 of 40
Which action would the nurse take first when a client with acute bronchitis and emphysema
reports feeling anxious and short of breath?
1
Obtain the oxygen saturation.
2
Provide oxygen at 2 L per minute.
3
Offer the prescribed rescue inhaler.
4
Suggest use of pursed-lip breathing
2
Pulse oximetry will assess for adequate oxygen saturation and would be done first because
a low saturation would indicate the need for rapid implementation of actions such as
oxygen administration and notification of the health care provider. Weighing the client
would help in determining fluid overload but would be done after assuring adequate
oxygen saturation. The lung sounds would be auscultated to see if the client has fluid
overload or whether the dialysate infusion is decreasing room for lung expansion, but can
be done after checking oxygen saturation. If the lung sounds indicate that the dialysate is
decreasing the ability of the lungs to expand, the client can be repositioned to allow better
lung expansion.
1
With a nasogastric (NG) tube for decompression in place, nausea may indicate tube
displacement or obstruction. Checking its placement can determine whether it is in the
stomach; once placement is verified, fluid then can be instilled to ensure patency. The
antiemetic may relieve the discomfort, but it will not determine the cause.
3
The client is too busy keeping active during the manic part of a bipolar disorder. This stage's
characteristics include elation, activity, restlessness, and increased energy. Although the
client may be using more calories than usual during this period, food is not a priority, and
the client will not spend the time to eat. The nurse would need to suggest finger foods and
high-calorie snacks.
1
More assessment is needed before further actions are taken; the nurse would check the
client's oxygen saturation as the initial action. If oxygen saturation is low, then oxygen
administration would be needed. The rescue inhaler may be needed if the client has
,wheezes or decreased breath sounds. Pursed-lip breathing may be helpful if anxiety is
causing hyperventilation, but the first action would be to assure that the client is not
hypoxemic.
, Term 2 of 40
Which action would the nurse plan for a client during the early postoperative period after a
prostatectomy?
1
Have the client stand to void.
2
Discourage straining for a bowel movement.
3
Use a bulb syringe to aspirate urine from the retention catheter.
4
Notify the primary health care provider if the client does not void by bedtime.
4
Increased intra-abdominal pressure associated with lifting, coughing, or laughing, in
conjunction with a relaxed pelvic musculature and a bladder displaced into the vagina, may
result in stress incontinence.
3
Deficient ADH from the posterior pituitary results in diabetes insipidus. This can be caused
by head trauma; water is not conserved by the body, and excess amounts of urine are
produced.
2
Straining applies pressure to the operative site, which can precipitate bleeding and should
be avoided. A retention catheter is routinely put into place, so standing to void and not
voiding by bedtime are not applicable. To prevent trauma, negative pressure should not be
exerted on the bladder by using a bulb syringe to aspirate.
2
Pulse oximetry will assess for adequate oxygen saturation and would be done first because
a low saturation would indicate the need for rapid implementation of actions such as
oxygen administration and notification of the health care provider. Weighing the client
would help in determining fluid overload but would be done after assuring adequate
oxygen saturation. The lung sounds would be auscultated to see if the client has fluid
overload or whether the dialysate infusion is decreasing room for lung expansion, but can
be done after checking oxygen saturation. If the lung sounds indicate that the dialysate is
decreasing the ability of the lungs to expand, the client can be repositioned to allow better
lung expansion.
