Nur 265
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1. The nurse notes each time the mechanical ventilator delivers a breath to a
client with acute respiratory distress syndrome ( ARDS ) , the peak inspiratory
pressure alarm sounds . What is the nurse's best intervention ?
a ) Suction the client .
b ) Perform chest physiotherapy
c ) Assess the airway .
d ) Raise the head of bed to high Fowlers .: c ) Assess the airway .
2. A client has a new tracheostomy , on a mechanical ventilator with the follow-
ing settings : SIMV , rate of 12 TV 800 , Flo2 80 % and PEEP of 5 cmH20 Which
assessment finding requires immediate action by the nurse ?
a ) Blood - tinged sputum
b ) Rhonchi in upper lobes
c ) Dry mucous membranes
d ) Constant , nonproductive coughing: d ) Constant , nonproductive coughing
3. The nurse palpates the posterior chest while the client says " 99 " and notes
absent fremitus . Which action should the nurse take next ?
a ) Encourage the client to turn , cough , and deep breathe
. b ) Review the chest x - ray report for evidence of pneumonia .
c ) Auscultate anterior and posterior breath sounds bilaterally
. d ) Palpate the anterior chest and observe for barrel chest .: c ) Auscultate anterior and
posterior breath sounds bilaterally .
4. The nurse is caring for a client with a pulmonary embolus , also has right -
sided heart failure . Which clinical findings requires immediate follow up ?
a ) Heart rate of 115 beats / min
b ) Respiratory rate of 28 breaths / min
c ) +2 dependent edema to bilateral extremities
d ) Urinary output of 25 mL / hr: d ) Urinary output of 25 mL / hr
5. The nurse has been made aware of the arterial blood gas ( ABG ) results on
four clients . Which result is most important for the nurse to report immediately
to the health care provider ?
a ) pH 7.46 , PaO2 90 mm Hg , PaCO2 32 mm Hg , and O2 sat 98 %
b ) pH 7.35 , PaO2 85 mm Hg , PaCO2 45 mm Hg , and O2 sat 95 %
, Nur 265
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c ) pH 7.31 , PaO2 81mm Hg , PaCO2 50 mm Hg , and 02 sat 94 %
d ) pH 7.34 , PaO2 82 mm Hg , PaCO2 40 mm Hg , and O2 sat 97 %: c ) pH 7.31 , PaO2
81mm Hg , PaCO2 50 mm Hg , and 02 sat 94 %
6. The nurse monitors a client immediately following a chest tube insertion for
a hemopneumothorax . Which of the following assessment findings requires
immediate follow up ?
a ) 400 ml of blood in the collection chamber
b ) Tidaling in the water - seal chamber
c ) Platelet count 151,000 / micro / L
d ) Subcutaneous emphysema at the insertion site: a ) 400 ml of blood in the collection
chamber
7. When assessing a client who has just arrived after an automobile accident
, the emergency department nurse notes heart rate of 125 bpm and absent
breath sounds over the right lung . Which of the following actions is priority ?
a ) Administration of an inhaled bronchodilator
b ) Insertion of a chest tube with a chest drainage system
c ) Prepare for oral intubation with mechanical ventilation
d ) Send client for a stat CT scan of the thorax: b ) Insertion of a chest tube with a chest drainage
system
8. A nurse assesses a client who is experiencing an acid - base imbalance . The
client's arterial blood gas values are : pH 7.33 , PaO 88 mm Hg , PaCO 38 mm
Hg , and HCO 17 mEq / L . Which assessment would the nurse perform first ?
a ) Cardiac rate and rhythm
b ) Musculoskeletal strength
c ) Level of orientation
d ) Skin and mucous membranes: a ) Cardiac rate and rhythm
9. A client admitted to the emergency department tells the nurse " I was struck
in the chest with a baseball bat " Which of the following clinical assessments
requires immediate follow up ?
a ) Heart rate of 112 beats / minute
b ) Decreased tactile fremitus
Study online at https://quizlet.com/_hntebl
1. The nurse notes each time the mechanical ventilator delivers a breath to a
client with acute respiratory distress syndrome ( ARDS ) , the peak inspiratory
pressure alarm sounds . What is the nurse's best intervention ?
a ) Suction the client .
b ) Perform chest physiotherapy
c ) Assess the airway .
d ) Raise the head of bed to high Fowlers .: c ) Assess the airway .
2. A client has a new tracheostomy , on a mechanical ventilator with the follow-
ing settings : SIMV , rate of 12 TV 800 , Flo2 80 % and PEEP of 5 cmH20 Which
assessment finding requires immediate action by the nurse ?
a ) Blood - tinged sputum
b ) Rhonchi in upper lobes
c ) Dry mucous membranes
d ) Constant , nonproductive coughing: d ) Constant , nonproductive coughing
3. The nurse palpates the posterior chest while the client says " 99 " and notes
absent fremitus . Which action should the nurse take next ?
a ) Encourage the client to turn , cough , and deep breathe
. b ) Review the chest x - ray report for evidence of pneumonia .
c ) Auscultate anterior and posterior breath sounds bilaterally
. d ) Palpate the anterior chest and observe for barrel chest .: c ) Auscultate anterior and
posterior breath sounds bilaterally .
4. The nurse is caring for a client with a pulmonary embolus , also has right -
sided heart failure . Which clinical findings requires immediate follow up ?
a ) Heart rate of 115 beats / min
b ) Respiratory rate of 28 breaths / min
c ) +2 dependent edema to bilateral extremities
d ) Urinary output of 25 mL / hr: d ) Urinary output of 25 mL / hr
5. The nurse has been made aware of the arterial blood gas ( ABG ) results on
four clients . Which result is most important for the nurse to report immediately
to the health care provider ?
a ) pH 7.46 , PaO2 90 mm Hg , PaCO2 32 mm Hg , and O2 sat 98 %
b ) pH 7.35 , PaO2 85 mm Hg , PaCO2 45 mm Hg , and O2 sat 95 %
, Nur 265
Study online at https://quizlet.com/_hntebl
c ) pH 7.31 , PaO2 81mm Hg , PaCO2 50 mm Hg , and 02 sat 94 %
d ) pH 7.34 , PaO2 82 mm Hg , PaCO2 40 mm Hg , and O2 sat 97 %: c ) pH 7.31 , PaO2
81mm Hg , PaCO2 50 mm Hg , and 02 sat 94 %
6. The nurse monitors a client immediately following a chest tube insertion for
a hemopneumothorax . Which of the following assessment findings requires
immediate follow up ?
a ) 400 ml of blood in the collection chamber
b ) Tidaling in the water - seal chamber
c ) Platelet count 151,000 / micro / L
d ) Subcutaneous emphysema at the insertion site: a ) 400 ml of blood in the collection
chamber
7. When assessing a client who has just arrived after an automobile accident
, the emergency department nurse notes heart rate of 125 bpm and absent
breath sounds over the right lung . Which of the following actions is priority ?
a ) Administration of an inhaled bronchodilator
b ) Insertion of a chest tube with a chest drainage system
c ) Prepare for oral intubation with mechanical ventilation
d ) Send client for a stat CT scan of the thorax: b ) Insertion of a chest tube with a chest drainage
system
8. A nurse assesses a client who is experiencing an acid - base imbalance . The
client's arterial blood gas values are : pH 7.33 , PaO 88 mm Hg , PaCO 38 mm
Hg , and HCO 17 mEq / L . Which assessment would the nurse perform first ?
a ) Cardiac rate and rhythm
b ) Musculoskeletal strength
c ) Level of orientation
d ) Skin and mucous membranes: a ) Cardiac rate and rhythm
9. A client admitted to the emergency department tells the nurse " I was struck
in the chest with a baseball bat " Which of the following clinical assessments
requires immediate follow up ?
a ) Heart rate of 112 beats / minute
b ) Decreased tactile fremitus
