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Comprehensive Medical-Surgical Nursing Exam Guide: In-Depth Analysis, Patient Care, and 600+ Verified Questions and Answers for Mastery WITH RATIONALES FOR GUARANTEED SUCCESS GRADED A+ $27.99
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Comprehensive Medical-Surgical Nursing Exam Guide: In-Depth Analysis, Patient Care, and 600+ Verified Questions and Answers for Mastery WITH RATIONALES FOR GUARANTEED SUCCESS GRADED A+
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Course
Medical surgical nursing
Institution
Medical Surgical Nursing
Comprehensive Medical-Surgical Nursing Exam Guide: In-Depth Analysis, Patient Care, and 600+ Verified Questions and Answers for Mastery WITH RATIONALES FOR GUARANTEED SUCCESS GRADED A+
Comprehensive Medical-Surgical Nursing Exam Guide: In-Depth Analysis, Patient Care, and 600+ Verifie...
Comprehensive Medical-Surgical Nursing Exam Guide: In-Depth
Analysis, Patient Care, and 600+ Verified Questions and Answers for
Mastery WITH RATIONALES FOR GUARANTEED SUCCESS GRADED A+
A nurse is caring for a client who is in respiratory distress and requires endotracheal suctioning. Which
of the following actions should the nurse take?
A. Use clean technique when suctioning the client's endotracheal tube.
B. Use a rotating motion when removing the suction catheter.
C. Suction the oropharyngeal cavity prior to suctioning the endotracheal tube.
D. Suction the client's endotracheal tube every 2 hr.
B. Use a rotating motion when removing the suction catheter.
Rationale: The nurse should rotate the suction catheter during withdrawal to reduce the risk of tissue
trauma.
A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the client in
which of the following positions to promote effective breathing?
A. Lateral position with a pillow at the back and over the chest to support the arm
,B. High-Fowler's position with the arms supported on the over-bed table
C. Semi-Fowler's position with pillows supporting both arms
D. Supine position with the head of the bed elevated to 15°
B. High-Fowler's position with the arms supported on the over-bed table
Rationale: The nurse should place the client in a position that allows for greater expansion of the chest,
such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort
on the over-bed table.
A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery
devices should the nurse use to provide the client with the highest level of oxygen?
A. Nasal cannula
B. Nonrebreather mask
C. Simple face mask
D. Partial rebreather mask
B. Nonrebreather mask
Rationale: The nurse should use a non-rebreather mask for a client in respiratory distress to provide the
highest oxygen level. A non-rebreather mask is made up of a reservoir bag from which the client obtains
the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation
,ports with flaps that prevent room air from entering the mask. This device delivers greater than 90%
FiO2.
A nurse is admitting a client who has active tuberculosis. Which of the following isolation precautions
should the nurse implement?
A. Airborne
B. Neutropenic
C. Contact
D. Droplet
A. Airborne
Rationale: The nurse should initiate airborne precautions for the client who has tuberculosis because
tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a
room with negative airflow pressure filtered through a high-efficiency particulate air (HEPA) filter.
Members of the healthcare team should not enter the client's room without wearing an N95 respirator
mask.
A nurse is assessing a client who is 4 hr postoperative following a total laryngectomy. Which of the
following findings is the priority for the nurse to report to the provider?
A. Bleeding at the surgical site
B. Decreased oxygen saturation
C. Urinary retention
, D. Increased pain level
B. Decreased oxygen saturation
Rationale: Using the airway, breathing, circulation approach to client care, the nurse should identify
decreased oxygen saturation as the priority finding to address and report to the provider. A client who is
postoperative following a total laryngectomy is at higher risk for hypoxia due to airway obstruction.
A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary
embolism?
A. A client who is 48 hr postoperative following a total hip arthroplasty
B. A client who is 8 hr postoperative following an open surgical appendectomy
C. A client who is 2 hr postoperative following an open reduction external fixation of the right radius
D. A client who is 4 hr postoperative following a laparoscopic cholecystectomy
A. A client who is 48 hr postoperative following a total hip arthroplasty
Rationale: The nurse should identify that the client who has undergone a total hip replacement surgery
is at greatest risk for a pulmonary embolus due to decreased mobility of the affected extremity and an
increased amount of blood clots form in the veins of the thigh following hip surgery. DVTs are most
likely to occur 48-72 hours following the arthroplasty. The nurse should intervene to reduce the risk by
applying sequential compression devises or antiembolic stockings and by administering anticoagulant
medications.
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