PN2 EXAM 1

4. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? b. Measure and compare cuff pressures. ANS: B 2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? c. Client has reduced breath sounds. Nurse calls physician immediately. ANS: C 3. A nurse assesses a clients respiratory status. Which information is of highest priority for the nurse to obtain? d. Occupation and hobbies ANS: D 2. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first? a. Cardiac rate and rhythm ANS: A 6. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next? a. Assess clients rate, rhythm, and depth of respiration. 7. A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action? b. Absent breath sounds ANS: B 8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first? a. Apply oxygen by mask or nasal cannula. 8. A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure? d. Validate that informed consent has been given by the client. ANS: D 9. A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? d. The trachea is deviated toward the opposite side of the neck. ANS: D 1.A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next? b. Ensure an x-ray is completed to confirm placement. ANS: B 3.A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients teaching?