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review questions
| Question | Answer |
|---|---|
| A nurse is reviewing information with a client who is scheduled for pulmonary function tests. Which of the following statements should the nurse make? a “Do not use inhaler medications for 6 hr following the test.” b “Do not smoke tobacco for 6 | b “Do not smoke tobacco for 6 to 8 hr prior to the test.” |
| A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? a Non-rebreather mask b Nasal cannula c Ventur | c Venturi mask |
| A nurse is caring for a client who is experiencing respiratory distress. Sort the following manifestations of hypoxemia by whether it is an early or late manifestation of hypoxemia. Cyanosis Tachycardia Tachypnea Anxiety and restlessness brad | Early: Tachycardia Tachypnea Anxiety and restlessness Late: cyanosis, bradycardia |
| A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? Select all that apply. a Client who has dysphagia b Client who has AIDS c Client wh | a Client who has dysphagia b Client who has AIDS e Client who has a closed head injury and is receiving mechanical ventilation f Client who has myasthenia gravis |
| A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8° C (100° F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SpO2 91% on room air. Prioritize the following nursing interventions. -adminis | 1. oxygen 2. sputum 3. antibiotics 4. flu vaccine |
| A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? a Males (sex assigned at birth) b Environmental allergies c Alcohol use d History of diabetes | environmental allergies |
| A nurse in the emergency department is caring for a client who is experiencing an acute asthma attack. Which of the following findings indicates that the client’s respiratory status is declining? Select all that apply. a SpO2 95% b Wheezing | b Wheezing c Retraction of sternal muscles e Tachycardia |
| A nurse is assessing a client who has an SpO2 of 91%, audible wheezes and is using accessory muscles when breathing. Which of the following classes of medications should the nurse anticipate a provider prescription? a Third-generation cephalosporin | d Short-acting beta 2 agonist |
| A nurse is providing discharge teaching to a client who has asthma and received a new prescription for prednisone. Which of the following client statements indicates understanding? a “I will decrease my fluid intake while taking this medication.” b | c “I will take my medication with meals.” |
| A nurse is providing teaching with a client who has asthma about the purpose of taking a long-acting bronchodilator. Which of the following client statements indicates understanding? a “This medication can decrease my immune response.” b “I take t | b “I take this medication to prevent asthma attacks.” |
| A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following statements should the nurse include? a “Take quick breaths upon inhalation.” b “Place your hand over your stomach.” c “Take a deep breath i | c “Take a deep breath in through your nose.” |
| A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? a “I will place the adapter on my finger to read my blood oxygen saturation level.” b | d “I will take in a deep breath and hold it before exhaling.” |
| A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates an understanding of the teaching? a “This medication can increase my blood sugar levels.” | c “I can have an increase in my heart rate while taking this medication.” |
| A nurse is preparing to administer an initial dose of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication? Select all that apply. a Hypokalemia b Tachycardia c Fluid re | a Hypokalemia c Fluid retention e Black, tarry stools |
| A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonary embolism? Select all that apply. a A client who has a BMI of 30 b A client who is postmenopausal c A client who has a fractured femur d | a A client who has a BMI of 30 c A client who has a fractured femur e A client who has chronic atrial fibrillation |
| A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect? Select all that apply. a Bradypnea b Pleural friction rub c Hypertension d Petechiae e Tachycardia | b Pleural friction rub d Petechiae e Tachycardia |
| A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states, “I am anxious and unable to get enough air.” Vital signs are heart rate 117/min, respirations 38/min, temperature 38.4° C (101.2° F), and blood press | c Administer oxygen therapy. |
| A nurse in a clinic is caring for a client who has suspected anemia. Which of the following laboratory test results should the nurse review? a Iron 90 mcg/dL b RBC 6.5 mm3 c WBC 4,800 mm³ d Hgb 10 g/dL | d Hgb 10 g/dL |
| A nurse is providing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching? a “You should make an ap | c “You can donate blood each week if your hemoglobin is stable.” |
| A charge nurse is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? a Inser | d Obtains vital signs every 15 min throughout the procedure. |
| A nurse is preparing to administer packed RBCs to a client who has a Hgb of 6 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion? a Obtain consent from the client for the transfusion. b As | b Assess for an acute hemolytic reaction. |
| A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? Select all that apply. a Temperature change from 37° | c Heart rate change from 88/min pretransfusion to 120/min e Client appears flushed |
| A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take if the client develops manifestations of an allergic transfusion reaction? Select all that apply. a Stop the transfusion. b | a Stop the transfusion. c Maintain an IV infusion with 0.9% sodium chloride. e Administer diphenhydramine. |
| A nurse is planning care for a client who has Hgb 7.5 g/dL and Hct 21.5%. Which of the following actions should the nurse include in the plan of care? Select all that apply. a Provide assistance with ambulation. b Monitor oxygen saturation. | a Provide assistance with ambulation. b Monitor oxygen saturation. d Obtain stool specimen for occult blood. e Schedule daily rest periods. |
| nurse in a clinic receives a phone call from a client seeking information about a new prescription for erythropoietin. Which of the following information should the nurse review with the client? a The client needs an erythrocyte sedimentation rate (E | b The client should have their hemoglobin checked weekly until stable. |
| A nurse is caring for a client who has idiopathic thrombocytopenic purpura (ITP). The nurse should notify the provider and report possible small-vessel clotting when which of the following is assessed? a Petechiae on the upper chest b Hypotension | c Cyanotic nail beds |
| A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take? Select all that apply. a Encourage the client to ambulate b Administer analgesic for pain c Encourage increased | b Administer analgesic for pain c Encourage increased fluid intake e Monitor the puncture site for drainage |
| A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect? Select all the apply. a Bradycardia b Headache c Nuchal rigidity d Seizures e Photophobia | b Headache c Nuchal rigidity d Seizures e Photophobia |
| A nurse is assessing for the presence of Brudzinski’s sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? Select all that apply. a Place client in supine position. b | a Place client in supine position. c Place hands behind the client’s neck. d Bend client’s head toward chest. |
| A nurse is caring for a client who has meningitis and is at risk for SIADH. Which of the following findings should the nurse monitor for? Select all that apply. a Dilute urine b Bounding pulse c Change in level of consciousness d Weight | b Bounding pulse c Change in level of consciousness |
| A nurse in a neurology clinic is caring for clients who have seizure disorders. Match each manifestation the nurse observes with the type of seizure each client is experiencing. The client repeatedly experienced loss of consciousness with no motor acti | absence seizure tonic-clonic atonic myoclonic simple partial |
| A nurse is providing discharge instructions to a client who has a prescription for phenytoin. Which of the following information should the nurse include? a Discontinue the medication if there is no seizure activity for 6 months. b Watch for reced | c Take the medication at the same time every day. |
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