Oxygenation g
1-A nurse is conducting a primary survey of a client who has sustained life-
g g g g g g g g g g g g g
threatening injuries due to a motor-
g g g g g g
vehicle crash. Identify the sequence of actions the nurse should take. (Move the acti
g g g g g g gg g g g g g g
ons into the box on the right, placing them in the selected order of performance. Use
g g g g g g g g g gg g g g g g g
all the steps.) g g
ANSWERS - Ordered Response g g g
Correct
1) Open the airway using a jaw-thrust maneuver. g g g g g g
2) Determine effectiveness of ventilator efforts. g g g g
3) Establish IV access. g g
4) Perform a Glasgow Coma Scale assessment. g g g g g
5) Remove clothing for a thorough assessment. g g g g g
2-
A nurse is caring for a client who has emphysema. Which of the following findings s
g g g g g g g g g g g g g g g
hould the nurse expect to assess in this client? (Select all that apply.) ANSWERS -
g g g g g g g g g g g g g g
gMultiple Response Select All That Apply g g g g g
1) Dyspnea
2) Bradycardia
3) Barrel chest g
4) Clubbing of the fingers g g g
5) Deep respirations g
Answer Rationale: g
Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli
g g g g g g g g g g g g
in which they become weakened and collapse. Dyspnea is seen in clients with
g g g g g g g g g g g g
emphysema as the lungs try to increase the amount of oxygen available to the tissues
g g g g g g g g g g g g g gg
.Bradycardia is incorrect. With emphysema, the heart rate will increase as the hear
g g g g g g g g g g gg g
t tries to compensate for less oxygen to the tissues. Barrel chest is correct. Clients
g g g g g g g g g g g g gg g g
with emphysema lose lung elasticity; the diaphragm becomes permanently flattened
g g g g g g g gg g
gby hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs
g g g g g g g g g g gg g g g g
gflare outward. This produces the barrel chest typical of emphysema clients.Clubbi
g g g g g g g g gg g
ng of the fingers is correct. Clubbing results from chronic low arterial-
g g g g g g g g gg g g
oxygen levels. The tips of the fingers enlarge and the nails become extremely curve
g g g g g g g g g g gg g g
d from front to back.Deep respirations is
g g g g g g g
,incorrect. Clients with emphysema lose lung elasticity and have muscle fatigue; conseq
g g g g g g g g g g gg
uently, respirations become increasingly shallow.
g g g g
3-
A nurse is caring for a client who has returned from the surgical suite following surg
g g g g g g g g g g g g g g g gg
ery for a fractured mandible. The client had intermaxillary fixation to repair and stab
g g g g g g g g g g g gg g
ilize the fracture. Which of the following actions is the priority for the nurse to take?
g g g g g g g g g g g g gg g g
ANSWERS - Multiple Choice g g g
1) Prevent aspiration. g
Answer Rationale: g
When using the airway, breathing, circulation approach to client care, the nurse shou
g g g g g g g g g g g gg
ld determine that the priority goal is to prevent the client from aspirating. Because th
g g g g g g g g g g g g gg g
e client's jaws are wired together, aspiration of emesis is a possibility. Therefore, the
g g g g g g g g g g g gg g g
client should be given medication for nausea, and wire cutters should be kept at the b
g g g g g g g g g gg g g g g g
edside in case of vomiting. g g g g
4-
A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of
g g g g g g g g g g g g g g g gg g
the following manifestations should the nurse monitor?
g g g g g g g
2) Weakness
Answer Rationale: Generalized weakness of the diaphragmatic and intercostal mus
g g g g g g g g gg
cles may produce respiratory distress or predispose the client to respiratory infectio
g g g g g g g g g g gg
ns.
5-
A nurse is assessing a client who has a long history of smoking and is suspected
g g g g g g g g g g g g g g gg g
of having laryngeal cancer. The nurse should anticipate that the client will repo
g g g g g g g g g gg g g
rt that her earliest manifestation was
g g g g g
2) hoarseness.
Answer Rationale: g
Laryngeal cancer, a malignant tumor of the larynx, is most often caused by lon
g g g g g g g g g g g g gg
g exposure to tobacco and alcohol. Hoarseness that does not resolve for several
g g g g g g g g g g g gg g
weeks is the earliest manifestation of cancer of the larynx because the tumor im
g g g g g g g g g g g gg g
pedes the action of the vocal cords during speech. The voice may sound harsh a
g g g g g g g g g g g gg g g
nd lower in pitch than normal.
g g g g g
,6- A nurse in the emergency department is caring for a client who has extensive par
g g g g g g g g g g g g g gg
tial and full-
g g
thickness burns of the head, neck, and chest. While planning the client's care, the n
g g g g g g g g g g gg g g g
urse should identify which of the following risks as the priority for assessment and i
g g g g g g g g g g gg g g g
ntervention?
1) Airway obstruction
g g
Answer Rationale: g
When using the airway, breathing, circulation approach to client care, the nurse
g g g g g g g g g g g g
determines that the priority risk is airway obstruction. Burns of the head, neck, and c
g g g g g g g g g g g g g g
hest often involve damage to the pulmonary tree due to heat as well as smoke and soo
g g g g g g g g g g g g g g g g
t inhalation. This can result in severe respiratory difficulty. Nursing measures to
g g g g g g g g g g g
maintain a patent airway should take priority in this client's care.
g g g g g g g g g g
7- A nurse is caring for a client who has chronic obstructive pulmonary disea
g g g g g g g g g g g gg
se (COPD). The client tells the nurse, "I can feel the congestion in my lungs, a
g g g g g g g g g g g g g gg g
nd I certainly cough a lot, but I can't seem to bring anything up." Which of th
g g g g g g g g g g g g g gg g g
e following actions should the nurse take to help this client with tenacious bro
g g g g g g g g g g g gg g
nchial secretions? g
Encouraging the client to drink 2 to 3 L of water daily g g g g g g g g g g g
Answer Rationale: g
COPD is a term for two diseases of the respiratory system: chronic bronchitis and em
g g g g g g g g g g g g g gg
physema. Maintaining hydration through the consumption of adequate fluids will he
g g g g g g g g gg g
lp liquefy thick secretions and facilitate their expectoration.
g g g g g g g
8- A nurse is observing the closed chest drainage system of a client who is 24 hr po
g g g g g g g g g g g g g g g gg
st thoracotomy. The nurse notes slow, steady bubbling in the suction control cham
g g g g g g g g g g g gg
ber. Which of the following actions should the nurse take?
g g g g g g g g g
gContinue to monitor the client's respiratory status.
g g g g g g
Answer Rationale: g
Slow, steady bubbling in the suction control chamber is an expected finding. Therefore,
g g g g g g g g g g g gg g
the nurse should continue to monitor the client's respiratory status.
g g g g g g g g g
9- A nurse is caring for a client who is in the immediate postoperative period follo
g g g g g g g g g g g g g gg
wing a partial laryngectomy. Which of the following parameters should the nurse
g g g g g g g g g g gg g
assess first? g
4) Airway patency g
, Answer Rationale: g
When using the airway, breathing, circulation approach to client care, the nurs
g g g g g g g g g g gg
e determines that the priority assessment is airway patency. After head and nec
g g g g g g g g g g gg g
k surgery, a major, life-
g g g g
threatening complication is airway obstruction. The priority actions involve ai
g g g gg g g g g g
rway maintenance and gas exchange.
g g g gg
10- A nurse is caring for a client with a tracheostomy. The client’s partner has been ta
g g g g g g g g g g g g g g gg
ught to perform suctioning. Which of the following actions by the partner should indi
g g g g g g g g g g g g gg
cate to the nurse a readiness for the client’s discharge?
g g g g g g g g g
Performing the procedure independently g g g
Answer Rationale: g
The nurse should recognize that the client is ready for discharge when the spou
g g g g g g g g g g g g gg
se demonstrates an ability to perform the procedure that will need to be perfor
g g g g g g g g g g g g gg
med independently at home.
g g g
11- A nurse is reviewing the laboratory findings for a client who developed fat embol
g g g g g g g g g g g g gg
ism syndrome (FES) following a fracture. Which of the following laboratory
g g g g g g g g g g g
findings should the nurse expect? g g g g
Decreased serum calcium level g g g
Answer Rationale: g
A decreased serum calcium level is an expected finding for FES, although the reaso
g g g g g g g g g g g g gg
n for this finding is unknown.
g g g g g
12-
A nurse is caring for a client who is unconscious and has a breathing pattern charact
g g g g g g g g g g g g g g g g
erized by alternating periods of hyperventilation and apnea. The nurse should docu
g g g g g g g g g g g
ment that the client has which of the following respiratory alterations?
g g g g g g g g g g
3) Cheyne-Stokes respirations g
Answer Rationale: g
Cheyne-
Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of h
g g g g g g g g g g gg g g
yperventilation) and decrease (to the point of apnea) in the rate and depth of respirati
g g g g g g g g g g g g gg g
on. CSR are common respiratory alterations seen in clients who are unconscious, co
g g g g g g g g g g gg g
matose, or moribund (approaching death). g g g g
1-A nurse is conducting a primary survey of a client who has sustained life-
g g g g g g g g g g g g g
threatening injuries due to a motor-
g g g g g g
vehicle crash. Identify the sequence of actions the nurse should take. (Move the acti
g g g g g g gg g g g g g g
ons into the box on the right, placing them in the selected order of performance. Use
g g g g g g g g g gg g g g g g g
all the steps.) g g
ANSWERS - Ordered Response g g g
Correct
1) Open the airway using a jaw-thrust maneuver. g g g g g g
2) Determine effectiveness of ventilator efforts. g g g g
3) Establish IV access. g g
4) Perform a Glasgow Coma Scale assessment. g g g g g
5) Remove clothing for a thorough assessment. g g g g g
2-
A nurse is caring for a client who has emphysema. Which of the following findings s
g g g g g g g g g g g g g g g
hould the nurse expect to assess in this client? (Select all that apply.) ANSWERS -
g g g g g g g g g g g g g g
gMultiple Response Select All That Apply g g g g g
1) Dyspnea
2) Bradycardia
3) Barrel chest g
4) Clubbing of the fingers g g g
5) Deep respirations g
Answer Rationale: g
Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli
g g g g g g g g g g g g
in which they become weakened and collapse. Dyspnea is seen in clients with
g g g g g g g g g g g g
emphysema as the lungs try to increase the amount of oxygen available to the tissues
g g g g g g g g g g g g g gg
.Bradycardia is incorrect. With emphysema, the heart rate will increase as the hear
g g g g g g g g g g gg g
t tries to compensate for less oxygen to the tissues. Barrel chest is correct. Clients
g g g g g g g g g g g g gg g g
with emphysema lose lung elasticity; the diaphragm becomes permanently flattened
g g g g g g g gg g
gby hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs
g g g g g g g g g g gg g g g g
gflare outward. This produces the barrel chest typical of emphysema clients.Clubbi
g g g g g g g g gg g
ng of the fingers is correct. Clubbing results from chronic low arterial-
g g g g g g g g gg g g
oxygen levels. The tips of the fingers enlarge and the nails become extremely curve
g g g g g g g g g g gg g g
d from front to back.Deep respirations is
g g g g g g g
,incorrect. Clients with emphysema lose lung elasticity and have muscle fatigue; conseq
g g g g g g g g g g gg
uently, respirations become increasingly shallow.
g g g g
3-
A nurse is caring for a client who has returned from the surgical suite following surg
g g g g g g g g g g g g g g g gg
ery for a fractured mandible. The client had intermaxillary fixation to repair and stab
g g g g g g g g g g g gg g
ilize the fracture. Which of the following actions is the priority for the nurse to take?
g g g g g g g g g g g g gg g g
ANSWERS - Multiple Choice g g g
1) Prevent aspiration. g
Answer Rationale: g
When using the airway, breathing, circulation approach to client care, the nurse shou
g g g g g g g g g g g gg
ld determine that the priority goal is to prevent the client from aspirating. Because th
g g g g g g g g g g g g gg g
e client's jaws are wired together, aspiration of emesis is a possibility. Therefore, the
g g g g g g g g g g g gg g g
client should be given medication for nausea, and wire cutters should be kept at the b
g g g g g g g g g gg g g g g g
edside in case of vomiting. g g g g
4-
A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of
g g g g g g g g g g g g g g g gg g
the following manifestations should the nurse monitor?
g g g g g g g
2) Weakness
Answer Rationale: Generalized weakness of the diaphragmatic and intercostal mus
g g g g g g g g gg
cles may produce respiratory distress or predispose the client to respiratory infectio
g g g g g g g g g g gg
ns.
5-
A nurse is assessing a client who has a long history of smoking and is suspected
g g g g g g g g g g g g g g gg g
of having laryngeal cancer. The nurse should anticipate that the client will repo
g g g g g g g g g gg g g
rt that her earliest manifestation was
g g g g g
2) hoarseness.
Answer Rationale: g
Laryngeal cancer, a malignant tumor of the larynx, is most often caused by lon
g g g g g g g g g g g g gg
g exposure to tobacco and alcohol. Hoarseness that does not resolve for several
g g g g g g g g g g g gg g
weeks is the earliest manifestation of cancer of the larynx because the tumor im
g g g g g g g g g g g gg g
pedes the action of the vocal cords during speech. The voice may sound harsh a
g g g g g g g g g g g gg g g
nd lower in pitch than normal.
g g g g g
,6- A nurse in the emergency department is caring for a client who has extensive par
g g g g g g g g g g g g g gg
tial and full-
g g
thickness burns of the head, neck, and chest. While planning the client's care, the n
g g g g g g g g g g gg g g g
urse should identify which of the following risks as the priority for assessment and i
g g g g g g g g g g gg g g g
ntervention?
1) Airway obstruction
g g
Answer Rationale: g
When using the airway, breathing, circulation approach to client care, the nurse
g g g g g g g g g g g g
determines that the priority risk is airway obstruction. Burns of the head, neck, and c
g g g g g g g g g g g g g g
hest often involve damage to the pulmonary tree due to heat as well as smoke and soo
g g g g g g g g g g g g g g g g
t inhalation. This can result in severe respiratory difficulty. Nursing measures to
g g g g g g g g g g g
maintain a patent airway should take priority in this client's care.
g g g g g g g g g g
7- A nurse is caring for a client who has chronic obstructive pulmonary disea
g g g g g g g g g g g gg
se (COPD). The client tells the nurse, "I can feel the congestion in my lungs, a
g g g g g g g g g g g g g gg g
nd I certainly cough a lot, but I can't seem to bring anything up." Which of th
g g g g g g g g g g g g g gg g g
e following actions should the nurse take to help this client with tenacious bro
g g g g g g g g g g g gg g
nchial secretions? g
Encouraging the client to drink 2 to 3 L of water daily g g g g g g g g g g g
Answer Rationale: g
COPD is a term for two diseases of the respiratory system: chronic bronchitis and em
g g g g g g g g g g g g g gg
physema. Maintaining hydration through the consumption of adequate fluids will he
g g g g g g g g gg g
lp liquefy thick secretions and facilitate their expectoration.
g g g g g g g
8- A nurse is observing the closed chest drainage system of a client who is 24 hr po
g g g g g g g g g g g g g g g gg
st thoracotomy. The nurse notes slow, steady bubbling in the suction control cham
g g g g g g g g g g g gg
ber. Which of the following actions should the nurse take?
g g g g g g g g g
gContinue to monitor the client's respiratory status.
g g g g g g
Answer Rationale: g
Slow, steady bubbling in the suction control chamber is an expected finding. Therefore,
g g g g g g g g g g g gg g
the nurse should continue to monitor the client's respiratory status.
g g g g g g g g g
9- A nurse is caring for a client who is in the immediate postoperative period follo
g g g g g g g g g g g g g gg
wing a partial laryngectomy. Which of the following parameters should the nurse
g g g g g g g g g g gg g
assess first? g
4) Airway patency g
, Answer Rationale: g
When using the airway, breathing, circulation approach to client care, the nurs
g g g g g g g g g g gg
e determines that the priority assessment is airway patency. After head and nec
g g g g g g g g g g gg g
k surgery, a major, life-
g g g g
threatening complication is airway obstruction. The priority actions involve ai
g g g gg g g g g g
rway maintenance and gas exchange.
g g g gg
10- A nurse is caring for a client with a tracheostomy. The client’s partner has been ta
g g g g g g g g g g g g g g gg
ught to perform suctioning. Which of the following actions by the partner should indi
g g g g g g g g g g g g gg
cate to the nurse a readiness for the client’s discharge?
g g g g g g g g g
Performing the procedure independently g g g
Answer Rationale: g
The nurse should recognize that the client is ready for discharge when the spou
g g g g g g g g g g g g gg
se demonstrates an ability to perform the procedure that will need to be perfor
g g g g g g g g g g g g gg
med independently at home.
g g g
11- A nurse is reviewing the laboratory findings for a client who developed fat embol
g g g g g g g g g g g g gg
ism syndrome (FES) following a fracture. Which of the following laboratory
g g g g g g g g g g g
findings should the nurse expect? g g g g
Decreased serum calcium level g g g
Answer Rationale: g
A decreased serum calcium level is an expected finding for FES, although the reaso
g g g g g g g g g g g g gg
n for this finding is unknown.
g g g g g
12-
A nurse is caring for a client who is unconscious and has a breathing pattern charact
g g g g g g g g g g g g g g g g
erized by alternating periods of hyperventilation and apnea. The nurse should docu
g g g g g g g g g g g
ment that the client has which of the following respiratory alterations?
g g g g g g g g g g
3) Cheyne-Stokes respirations g
Answer Rationale: g
Cheyne-
Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of h
g g g g g g g g g g gg g g
yperventilation) and decrease (to the point of apnea) in the rate and depth of respirati
g g g g g g g g g g g g gg g
on. CSR are common respiratory alterations seen in clients who are unconscious, co
g g g g g g g g g g gg g
matose, or moribund (approaching death). g g g g
