Respiratory/Neuro
1. A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a
motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the
box on the right, placing them in the selected order of performance. Use all the steps.)
A. Perform a Glasgow Coma Scale assessment.
B. Establish IV access.
C. Open the airway using a jaw-thrust maneuver.
D. Determine effectiveness of ventilator efforts.
E. Remove clothing for a thorough assessment.
2. A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by
intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports that the IV
site itches and that he feels dizzy and short of breath. Which of the following actions should the
nurse take first?
A. Stop the infusion.
B. Call the client's provider.
C. Elevate the head of the bed.
D. Auscultate the client's breath sounds.
3. A nurse is caring for a client who is in the immediate postoperative period following a partial
laryngectomy. Which of the following parameters should the nurse assess first?
A. Pain severity
B. Wound drainage
C. Tissue integrity
D. Airway patency
4. A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the
following findings should the nurse notify the provider?
A. Movement of the trachea toward the unaffected side
B. Bubbling of the water in the water seal chamber with exhalation
C. Crepitus in the area above and surrounding the insertion site
Created Page 1
on:02/15/2022
, Respiratory/Neuro
D. Eyelets are not visible
5. A nurse in an emergency department is caring for a client who has a sucking chest wound resulting
from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and
a respiratory rate of 40/min. Which of the following actions should the nurse take?
A. Raise the foot of the bed to a 90° angle.
B. Remove the dressing to inspect the wound.
C. Prepare to insert a central line.
D. Administer oxygen via nasal cannula.
6. A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases
(ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs?
pH 7.22
PaCO2 68 mm
Hg Base excess
-2 PaO2 78 mm
Hg Saturation
80%
Bicarbonate 26 mEq/L
A. Respiratory acidosis
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
7. A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on
admission and again in 2 hours. Which of the following changes in assessment should indicate to the
nurse that the client could be developing a serious complication?
A. Increased respiratory rate from 18 to 44/min.
B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F).
C. Increased blood pressure from 112/68 to 120/72 mm Hg.
D. Increased heart rate from 68 to 72/min.
8. A nurse is caring for a client who is immobile. Which of the following actions is the priority for the
nurse to include in
Created Page 2
on:02/15/2022
, Respiratory/Neuro
the client's plan of care?
A. Auscultate breath sounds at least every 2 hr.
B. Perform range-of-motion (ROM) exercises at least two to three times daily.
C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day.
D. Apply antiembolic stockings.
9. A nurse is caring for a child who is experiencing status asthmaticus. Which of the following
interventions is the priority for the nurse to take?
A. Administer a short-acting ß2 –agonist (SABA).
B. Obtain a peak flow reading.
C. Administer an inhaled glucocorticoid.
D. Determine the cause of the acute exacerbation.
10. A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation.
Which of the following actions is the nurse’s highest priority?
A. Initiating oxygen therapy
B. Providing immediate rest for the client
C. Positioning the client in high-Fowler’s
D. Administering a nebulized beta-adrenergic
11. A nurse is caring for a female client in the emergency department who reports shortness of breath
and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that
she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg.
Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2
86%. Which of the following is the priority nursing intervention?
A. Prepare for mechanical ventilation.
B. Administer oxygen via face mask.
C. Prepare to administer a sedative.
D. Assess for indications of pulmonary embolism.
Created Page 3
on:02/15/2022
1. A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a
motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the
box on the right, placing them in the selected order of performance. Use all the steps.)
A. Perform a Glasgow Coma Scale assessment.
B. Establish IV access.
C. Open the airway using a jaw-thrust maneuver.
D. Determine effectiveness of ventilator efforts.
E. Remove clothing for a thorough assessment.
2. A nurse is caring for a client who has streptococcal pneumonia and a prescription for penicillin G by
intermittent IV bolus. 10 minutes into the infusion of the third dose, the client reports that the IV
site itches and that he feels dizzy and short of breath. Which of the following actions should the
nurse take first?
A. Stop the infusion.
B. Call the client's provider.
C. Elevate the head of the bed.
D. Auscultate the client's breath sounds.
3. A nurse is caring for a client who is in the immediate postoperative period following a partial
laryngectomy. Which of the following parameters should the nurse assess first?
A. Pain severity
B. Wound drainage
C. Tissue integrity
D. Airway patency
4. A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the
following findings should the nurse notify the provider?
A. Movement of the trachea toward the unaffected side
B. Bubbling of the water in the water seal chamber with exhalation
C. Crepitus in the area above and surrounding the insertion site
Created Page 1
on:02/15/2022
, Respiratory/Neuro
D. Eyelets are not visible
5. A nurse in an emergency department is caring for a client who has a sucking chest wound resulting
from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and
a respiratory rate of 40/min. Which of the following actions should the nurse take?
A. Raise the foot of the bed to a 90° angle.
B. Remove the dressing to inspect the wound.
C. Prepare to insert a central line.
D. Administer oxygen via nasal cannula.
6. A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases
(ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs?
pH 7.22
PaCO2 68 mm
Hg Base excess
-2 PaO2 78 mm
Hg Saturation
80%
Bicarbonate 26 mEq/L
A. Respiratory acidosis
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
7. A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on
admission and again in 2 hours. Which of the following changes in assessment should indicate to the
nurse that the client could be developing a serious complication?
A. Increased respiratory rate from 18 to 44/min.
B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F).
C. Increased blood pressure from 112/68 to 120/72 mm Hg.
D. Increased heart rate from 68 to 72/min.
8. A nurse is caring for a client who is immobile. Which of the following actions is the priority for the
nurse to include in
Created Page 2
on:02/15/2022
, Respiratory/Neuro
the client's plan of care?
A. Auscultate breath sounds at least every 2 hr.
B. Perform range-of-motion (ROM) exercises at least two to three times daily.
C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day.
D. Apply antiembolic stockings.
9. A nurse is caring for a child who is experiencing status asthmaticus. Which of the following
interventions is the priority for the nurse to take?
A. Administer a short-acting ß2 –agonist (SABA).
B. Obtain a peak flow reading.
C. Administer an inhaled glucocorticoid.
D. Determine the cause of the acute exacerbation.
10. A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation.
Which of the following actions is the nurse’s highest priority?
A. Initiating oxygen therapy
B. Providing immediate rest for the client
C. Positioning the client in high-Fowler’s
D. Administering a nebulized beta-adrenergic
11. A nurse is caring for a female client in the emergency department who reports shortness of breath
and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that
she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg.
Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2
86%. Which of the following is the priority nursing intervention?
A. Prepare for mechanical ventilation.
B. Administer oxygen via face mask.
C. Prepare to administer a sedative.
D. Assess for indications of pulmonary embolism.
Created Page 3
on:02/15/2022
