GNRS 555 Exam 2 Review Questions
and Answers : Ace Your Test with
Confidence
The home health nurse is assigned to visit these clients when a change in agency
staffing requires that one of the clients be rescheduled for a visit on the following
day. Which client will be best to reschedule?
1. Client with emphysema who has been on home oxygen for a month and has
SpO2 levels of 91% to 93%
2. Client with history of a cough, weight loss, and night sweats who has just had a
positive Mantoux test
3. Client with newly diagnosed pleural effusion who needs an admission visit and an
initial intake assessment
4. Client with percutaneous lung biopsy yesterday who called in to report increased
dyspnea - 1. Client with emphysema who has been on home oxygen for a month and
has SpO2 levels of 91% to 93%
Rationale: The best client for the nurse to reschedule for a home visit is the client
with chronic emphysema who is on home oxygen and who has an appropriate SpO2
level. A SpO2 level of between 89% and 92% is appropriate and satisfactory.The
client with a positive Mantoux test, in addition to a history of cough, weight loss, and
night sweats, is highly suspicious for tuberculosis and needs to be seen that day.
The nurse needs to perform follow-up assessment and coordinate follow up testing.
The nurse may need to provide reporting to the public health department and to
develop a plan for close personal contacts. A client with a newly diagnosed pleural
effusion needs a complete and thorough admission and intake assessment to ensure
that oxygenation and underlying needs are addressed. A percutaneous lung biopsy
may be performed as an outpatient procedure. The client who had a percutaneous
lung biopsy and is experiencing increased dyspnea needs to be assessed that day to
determine whether a life-threatening pneumothorax or hemothorax has developed.
A client is admitted to the medical floor with a new diagnosis of lung cancer. How will
the nurse initially assist the client in managing the anxiety associated with the new
diagnosis?
1. Encourage the client to ask questions and verbalize concerns.
2. Provide privacy for the client to be alone to deal with his or her own feelings.
3. Medicate the client with diazepam for anxiety every 8 hours.
4. Provide journals about cancer treatment. - 1. Encourage the client to ask
questions and verbalize concerns.
Rationale: The best way for the nurse to initially assist the client in managing anxiety
related to a new diagnosis of cancer is to encourage the client to ask questions and
voice concerns. The availability of the nurse to answer questions and listen to the
client's concerns will help to decrease anxiety.The client may choose to be alone,
although this may be a maladaptive coping behavior. Diazepam every 8 hours will
reduce the client's anxiety but not help to manage its cause such as fear of the
,unknown or fear of death. It is more important to work with the client to assist him or
her in dealing with those issues first. Knowledge about cancer diagnosis and
treatment may help relieve anxiety but the nurse must first assess the client's needs
as well as the plan of care.
When caring for a client who has just undergone thoracentesis, which of these
interventions does the nurse perform first?
1. Encourage coughing and deep breathing.
2. Schedule an immediate chest x-ray.
3. Document the volume of removed fluid in the medical record.
4. Set up a water seal drainage unit. - 2. Schedule an immediate chest x-ray.
Rationale: After thoracentesis, the nurse first makes sure a chest x-ray is performed
to rule out possible pneumothorax and mediastinal shift (shift of central thoracic
structures toward one side).Coughing and deep breathing is done to promote lung
expansion as part of the treatment for the underlying disorder. This can wait until a
chest x-ray is completed. The volume of fluid will be recorded in the medical record,
after the nurse schedules the x-ray to ensure a pneumothorax did not occur. Pigtail
drain catheters may be left in place to a waterseal drainage system, rather than
performing thoracentesis aspiration on a recurring basis, but this action is not
standard.
A client has returned to the medical surgical unit after a bronchoscopy. Which
nursing task is best for the charge nurse to delegate to the experienced unlicensed
assistive personnel (UAP)?
1. Assess breath sounds.
2. Offer clear liquids when gag reflex returns.
3. Determine level of consciousness.
4. Monitor blood pressure and pulse. - 4. Monitor blood pressure and pulse.
Rationale: The best nursing task for the charge nurse to delegate to the experienced
unlicensed assistive personnel (UAP) is monitoring blood pressure and pulse. An
experienced UAP would have experience in taking client vital signs after procedures
requiring conscious sedation or anesthesia.Evaluating breath sounds, gag reflex,
and determining level of consciousness are considered nursing assessments and
require the skill and knowledge of a higher-level provider or professional nurse.
The nurse is preparing the client for a diagnostic bronchoscopy. Which nursing
intervention is essential for the nurse to perform prior to the procedure?
1. Obtain informed consent.
2. Ensure the client has had nothing by mouth.
3. Review dietary and medication allergies.
4. Perform aggressive chest physiotherapy. - 2. Ensure the client has had nothing by
mouth.
Rationale: When preparing a client for a diagnostic bronchoscopy, it is essential for
the nurse to make sure the client is NPO for 4 to 8 hours before the procedure to
,reduce the risk for aspiration.It is important to verify allergies, however ensuring NPO
status is maintained is essential to prevent aspiration, which can be life threatening.
The nurse will verify that consent for the procedure was obtained. Until the client has
a gag reflex and is fully alert, he or she should be maintained on NPO status to
prevent aspiration. Aggressive chest physiotherapy is not indicated in a client who
has had a bronchoscopy and may cause bleeding if biopsies have been obtained.
The RN has received report about four clients. Which client needs the most
immediate assessment?
1. Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry
2. Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes
3. Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours
ago
4. Client with pleural effusion who has decreased breath sounds at the right base - 1.
Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry
Rationale: The client in need of the most immediate assessment is the one with
acute asthma with an oxygen saturation of 89% by pulse oximetry. An oxygen
saturation level less than 91% indicates hypoxemia and instability requiring
immediate assessment and intervention to improve blood and tissue
oxygenation.The client who is scheduled for a thoracentesis will be able to receive
teaching and will have the opportunity to ask questions and have them answered
before the procedure is performed. There is no evidence the client who had a
bronchoscopy 3 hours ago is unstable and therefore does not require attention at
this moment. It would not be unusual to have diminished breath sounds at the base
of the lung of the client with pleural effusion.
Which assessment finding in the client with exacerbation of emphysema requires
intervention by the nurse?
1. Barrel-shaped chest
2. Bronchial breath sounds heard at the bases
3. Hyperresonance to percussion of the chest
4. Ribs lying horizontal - 2. Bronchial breath sounds heard at the bases
Rationale: The client with bronchial breath sounds needs intervention by the nurse.
These sounds are not normally heard in the periphery and may indicate atelectasis
or increased lung density, as might present with a tumor or an infectious process
such as pneumonia.The anteroposterior diameter is the same as the lateral-to-lateral
or side-to-side diameter in a client with emphysema, so the client will generally have
a barrel-shaped chest. Air-filled cavities, such as the lung, are hyperresonant to
percussion. Air trapping causes the ribs in a client with emphysema to lie in a more
horizontal direction.
A client with asthma reports shortness of breath. Which of these findings does the
nurse anticipate when assessing this client's chest?
1. Expiratory wheezing not cleared by coughing
2. Bronchial breath sounds over the trachea
, 3. Crackles throughout the lung fields
4. Bronchovesicular breath sounds in the lung bases - 1. Expiratory wheezing not
cleared by coughing
Rationale: In a client with asthma and shortness of breath, the nurse expects to hear
expiratory wheezing not cleared by coughing. Wheezes are squeaky, musical,
continuous sounds associated with bronchospasm, typical with asthma. They may
be heard without a stethoscope and usually do not clear with coughing.Bronchial
breath sounds are normal breath sounds, heard over the trachea and larynx.
Crackles, an adventitious breath sound, will sound like popping, discontinuous
sounds caused by air moving into previously deflated airways or coarse rattling
sounds caused by fluid. Bronchovesicular breath sounds are normal breath sounds
heard over major bronchi where fewer alveoli are located. They are best heard
between the scapula and anterior chest.
The RN and the LPN/LVN are working together to provide care for a group of clients
on a medical surgical unit. Which of these actions is most appropriate for the RN to
perform?
1. Administer purified protein derivative (PPD) for tuberculosis testing.
2. Assess vital signs and the puncture site one day post thoracentesis.
3. Monitor oxygen saturation using pulse oximetry every 4 hours.
4. Plan client and family teaching regarding upcoming pulmonary function testing. -
4. Plan client and family teaching regarding upcoming pulmonary function testing.
Rationale: The most appropriate action for the RN to perform is developing the
teaching plan for upcoming pulmonary function test. These skills are complex,
requiring use of the nursing process, and are not in the scope of practice of the
LPN/LVN.Medication administration and monitoring of vital signs and client status
after procedures can be accomplished by the LPN/LVN. Monitoring of oxygen
saturation by pulse oximetry can also be included in the vital signs assessment.
The nurse is assessing a client with chronic bronchitis who smoked 3 packs of
cigarettes daily for 32 years. How does the nurse document pack-year history of
smoking in the medical record?
1. Client has a 32 pack-year history
2. Client has a 96 pack-year history
3. Client smoked 3 packs for years
4. Client was a passive smoker for 32 years - 2. Client has a 96 pack-year history
Rationale: This client has a 96-year pack history. Pack-year history refers to the
number of packs per day multiplied by the number of years the client smoked.
The nurse is caring for a client with heart failure and acute kidney injury. For which of
these breath sounds will the nurse assess?
1. Crackles
2. Rhonchi
3. Pleural friction rub
and Answers : Ace Your Test with
Confidence
The home health nurse is assigned to visit these clients when a change in agency
staffing requires that one of the clients be rescheduled for a visit on the following
day. Which client will be best to reschedule?
1. Client with emphysema who has been on home oxygen for a month and has
SpO2 levels of 91% to 93%
2. Client with history of a cough, weight loss, and night sweats who has just had a
positive Mantoux test
3. Client with newly diagnosed pleural effusion who needs an admission visit and an
initial intake assessment
4. Client with percutaneous lung biopsy yesterday who called in to report increased
dyspnea - 1. Client with emphysema who has been on home oxygen for a month and
has SpO2 levels of 91% to 93%
Rationale: The best client for the nurse to reschedule for a home visit is the client
with chronic emphysema who is on home oxygen and who has an appropriate SpO2
level. A SpO2 level of between 89% and 92% is appropriate and satisfactory.The
client with a positive Mantoux test, in addition to a history of cough, weight loss, and
night sweats, is highly suspicious for tuberculosis and needs to be seen that day.
The nurse needs to perform follow-up assessment and coordinate follow up testing.
The nurse may need to provide reporting to the public health department and to
develop a plan for close personal contacts. A client with a newly diagnosed pleural
effusion needs a complete and thorough admission and intake assessment to ensure
that oxygenation and underlying needs are addressed. A percutaneous lung biopsy
may be performed as an outpatient procedure. The client who had a percutaneous
lung biopsy and is experiencing increased dyspnea needs to be assessed that day to
determine whether a life-threatening pneumothorax or hemothorax has developed.
A client is admitted to the medical floor with a new diagnosis of lung cancer. How will
the nurse initially assist the client in managing the anxiety associated with the new
diagnosis?
1. Encourage the client to ask questions and verbalize concerns.
2. Provide privacy for the client to be alone to deal with his or her own feelings.
3. Medicate the client with diazepam for anxiety every 8 hours.
4. Provide journals about cancer treatment. - 1. Encourage the client to ask
questions and verbalize concerns.
Rationale: The best way for the nurse to initially assist the client in managing anxiety
related to a new diagnosis of cancer is to encourage the client to ask questions and
voice concerns. The availability of the nurse to answer questions and listen to the
client's concerns will help to decrease anxiety.The client may choose to be alone,
although this may be a maladaptive coping behavior. Diazepam every 8 hours will
reduce the client's anxiety but not help to manage its cause such as fear of the
,unknown or fear of death. It is more important to work with the client to assist him or
her in dealing with those issues first. Knowledge about cancer diagnosis and
treatment may help relieve anxiety but the nurse must first assess the client's needs
as well as the plan of care.
When caring for a client who has just undergone thoracentesis, which of these
interventions does the nurse perform first?
1. Encourage coughing and deep breathing.
2. Schedule an immediate chest x-ray.
3. Document the volume of removed fluid in the medical record.
4. Set up a water seal drainage unit. - 2. Schedule an immediate chest x-ray.
Rationale: After thoracentesis, the nurse first makes sure a chest x-ray is performed
to rule out possible pneumothorax and mediastinal shift (shift of central thoracic
structures toward one side).Coughing and deep breathing is done to promote lung
expansion as part of the treatment for the underlying disorder. This can wait until a
chest x-ray is completed. The volume of fluid will be recorded in the medical record,
after the nurse schedules the x-ray to ensure a pneumothorax did not occur. Pigtail
drain catheters may be left in place to a waterseal drainage system, rather than
performing thoracentesis aspiration on a recurring basis, but this action is not
standard.
A client has returned to the medical surgical unit after a bronchoscopy. Which
nursing task is best for the charge nurse to delegate to the experienced unlicensed
assistive personnel (UAP)?
1. Assess breath sounds.
2. Offer clear liquids when gag reflex returns.
3. Determine level of consciousness.
4. Monitor blood pressure and pulse. - 4. Monitor blood pressure and pulse.
Rationale: The best nursing task for the charge nurse to delegate to the experienced
unlicensed assistive personnel (UAP) is monitoring blood pressure and pulse. An
experienced UAP would have experience in taking client vital signs after procedures
requiring conscious sedation or anesthesia.Evaluating breath sounds, gag reflex,
and determining level of consciousness are considered nursing assessments and
require the skill and knowledge of a higher-level provider or professional nurse.
The nurse is preparing the client for a diagnostic bronchoscopy. Which nursing
intervention is essential for the nurse to perform prior to the procedure?
1. Obtain informed consent.
2. Ensure the client has had nothing by mouth.
3. Review dietary and medication allergies.
4. Perform aggressive chest physiotherapy. - 2. Ensure the client has had nothing by
mouth.
Rationale: When preparing a client for a diagnostic bronchoscopy, it is essential for
the nurse to make sure the client is NPO for 4 to 8 hours before the procedure to
,reduce the risk for aspiration.It is important to verify allergies, however ensuring NPO
status is maintained is essential to prevent aspiration, which can be life threatening.
The nurse will verify that consent for the procedure was obtained. Until the client has
a gag reflex and is fully alert, he or she should be maintained on NPO status to
prevent aspiration. Aggressive chest physiotherapy is not indicated in a client who
has had a bronchoscopy and may cause bleeding if biopsies have been obtained.
The RN has received report about four clients. Which client needs the most
immediate assessment?
1. Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry
2. Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes
3. Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours
ago
4. Client with pleural effusion who has decreased breath sounds at the right base - 1.
Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry
Rationale: The client in need of the most immediate assessment is the one with
acute asthma with an oxygen saturation of 89% by pulse oximetry. An oxygen
saturation level less than 91% indicates hypoxemia and instability requiring
immediate assessment and intervention to improve blood and tissue
oxygenation.The client who is scheduled for a thoracentesis will be able to receive
teaching and will have the opportunity to ask questions and have them answered
before the procedure is performed. There is no evidence the client who had a
bronchoscopy 3 hours ago is unstable and therefore does not require attention at
this moment. It would not be unusual to have diminished breath sounds at the base
of the lung of the client with pleural effusion.
Which assessment finding in the client with exacerbation of emphysema requires
intervention by the nurse?
1. Barrel-shaped chest
2. Bronchial breath sounds heard at the bases
3. Hyperresonance to percussion of the chest
4. Ribs lying horizontal - 2. Bronchial breath sounds heard at the bases
Rationale: The client with bronchial breath sounds needs intervention by the nurse.
These sounds are not normally heard in the periphery and may indicate atelectasis
or increased lung density, as might present with a tumor or an infectious process
such as pneumonia.The anteroposterior diameter is the same as the lateral-to-lateral
or side-to-side diameter in a client with emphysema, so the client will generally have
a barrel-shaped chest. Air-filled cavities, such as the lung, are hyperresonant to
percussion. Air trapping causes the ribs in a client with emphysema to lie in a more
horizontal direction.
A client with asthma reports shortness of breath. Which of these findings does the
nurse anticipate when assessing this client's chest?
1. Expiratory wheezing not cleared by coughing
2. Bronchial breath sounds over the trachea
, 3. Crackles throughout the lung fields
4. Bronchovesicular breath sounds in the lung bases - 1. Expiratory wheezing not
cleared by coughing
Rationale: In a client with asthma and shortness of breath, the nurse expects to hear
expiratory wheezing not cleared by coughing. Wheezes are squeaky, musical,
continuous sounds associated with bronchospasm, typical with asthma. They may
be heard without a stethoscope and usually do not clear with coughing.Bronchial
breath sounds are normal breath sounds, heard over the trachea and larynx.
Crackles, an adventitious breath sound, will sound like popping, discontinuous
sounds caused by air moving into previously deflated airways or coarse rattling
sounds caused by fluid. Bronchovesicular breath sounds are normal breath sounds
heard over major bronchi where fewer alveoli are located. They are best heard
between the scapula and anterior chest.
The RN and the LPN/LVN are working together to provide care for a group of clients
on a medical surgical unit. Which of these actions is most appropriate for the RN to
perform?
1. Administer purified protein derivative (PPD) for tuberculosis testing.
2. Assess vital signs and the puncture site one day post thoracentesis.
3. Monitor oxygen saturation using pulse oximetry every 4 hours.
4. Plan client and family teaching regarding upcoming pulmonary function testing. -
4. Plan client and family teaching regarding upcoming pulmonary function testing.
Rationale: The most appropriate action for the RN to perform is developing the
teaching plan for upcoming pulmonary function test. These skills are complex,
requiring use of the nursing process, and are not in the scope of practice of the
LPN/LVN.Medication administration and monitoring of vital signs and client status
after procedures can be accomplished by the LPN/LVN. Monitoring of oxygen
saturation by pulse oximetry can also be included in the vital signs assessment.
The nurse is assessing a client with chronic bronchitis who smoked 3 packs of
cigarettes daily for 32 years. How does the nurse document pack-year history of
smoking in the medical record?
1. Client has a 32 pack-year history
2. Client has a 96 pack-year history
3. Client smoked 3 packs for years
4. Client was a passive smoker for 32 years - 2. Client has a 96 pack-year history
Rationale: This client has a 96-year pack history. Pack-year history refers to the
number of packs per day multiplied by the number of years the client smoked.
The nurse is caring for a client with heart failure and acute kidney injury. For which of
these breath sounds will the nurse assess?
1. Crackles
2. Rhonchi
3. Pleural friction rub
