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STUDY) Exam Reviews | Questions and
Verified Answers | 100% Correct | Grade A
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Restless client who is biting the endotracheal tube. - -1-While caring for a client who is
being mechanically ventilated, the nurse responds to a high-pressure alarm on the ventilator.
Which assessment finding warrants immediate intervention by the nurse? Endotracheal cuff
pressure greater than 25 cm H20.
Decreased lung compliance during ventilation.
Bilateral crackles with increased secretions.
Restless client who is biting the endotracheal tube.
Administer a nebulizer treatment. -✅✅ -2-While making rounds, the charge nurse notices that
a young adult client with asthma who was admitted yesterday is sitting on the side of the bed
and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute
via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention
should the nurse implement?
Administer a nebulizer treatment.
Increase oxygen to 6 liters/minute.
Assist the client to lie back in bed.
Call for an Ambu resuscitating bag.
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Initiate intravenous fluids as prescribed. - -3-After placement of a left subclavian central
venous catheter (CVC), the nurse receives report of the X- ray findings that indicate the CVC tip
is in the client's superior vena cava. Which action should the nurse implement?
Remove the catheter and apply direct pressure for 5 minutes.
Initiate intravenous fluids as prescribed.
Secure the catheter using aseptic technique.
Notify the healthcare provider of the need to reposition the catheter.
Request a culture and sensitivity of the wound. -✅✅ -4-While caring for a client's
postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound
was inflamed and tender but without drainage. Which is the most important action for the nurse
to take?
Determine if the drainage has an unpleasant odor.
Monitor the client's white blood cell count (WBC).
Request a culture and sensitivity of the wound.
Cleanse the wound with a sterile saline solution.
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Increase wall suction to eliminate fluctuation in water seal. - -5-A client who fell 20 feet
from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes
were inserted in the emergency department prior to his transfer tothe intensive care unit (ICU).
The nurse observes that the suction control chamber is bubbling at the -10 cm H20 mark, with
fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the
collection chamber. Which intervention should the nurse implement?
Increase wall suction to eliminate fluctuation in water seal.
Give blood from the collection chamber as autotransfusion.
Add sterile water to the suction control chamber.
Manipulate blood in tubing to drain into chamber.
Portosystemic shunting. - ✅✅ -6-A client admitted to the hospital with advanced liver failure
related to chronic alcoholism is exhibiting ascites and edema. Which pathophysiological
mechanisms should the nurse identify as responsible for the third spacing symptoms? (Select
all that apply.)
Portal hypertension.
Sodium and water retention.
Decreased serum albumin.
Abnormal protein metabolism
Portosystemic shunting.
Administer prescribed antibiotics. -✅✅ -7-The nurse is providing care for a client with a
draining postoperative wound infected with methicillin- resistant Staphylococcus aureus
(MRSA). Which is the most important action for the nurse to take? Encourage increased oral
fluids.
Provide high-protein snacks.
Change the wound dressing.
Administer prescribed antibiotics.
Raisin bran muffins.
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Bowl of oatmeal.
Cup of raspberries. - -8-A client with hemorrhoids asks for information about a high fiber
diet. Which breakfast menu items should the nurse suggest? (Select all that apply.)
Raisin bran muffins.
Bowl of oatmeal.
Cup of raspberries.
Scrambled eggs.
Bacon slices.
Wear long sleeves and pants. - ✅✅ -9-When teaching a group of school-aged children how to
reduce the risk for Lyme disease, which instruction should the camp nurse include?Wash hands
frequently.
Avoid drinking lake water.
Do not share personal products.
,Wear long sleeves and pants.
The client who is immobile on prescribed bedrest. - ✅✅
-10-Which client will benefit most from
the application of pneumatic compression devices to the lower extremities?
The client who is immobile on prescribed bedrest.
has pressure ulcers on several toes.
has diminished pedal pulse volume.
is confused and tries to climb out of bed
Use sunblock or protective clothing when outdoors - ✅✅
-11-A 4-year-old with acute
lymphocytic leukemia (ALL) is receiving chemotherapy protocol that includes methotrexate, an
antimetabolite. Which information should the nurse provide the parents about caring for their
child?
Use sunblock or protective clothing when outdoors
Include the child on regular outings with the family
Obtain any childhood vaccination that is not up-to-date
Use diluted commercial mouthwash with mouth care
Place a wedge under the client's hip. - ✅✅ -12-After placing a client at 26-weeks gestation in
the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic.
What action should the nurse implement?Instruct the client to take deep breaths.
Place a wedge under the client's hip.
Place the client in the Trendelenburg position.
Remove the client's legs from the stirrups.
Place a new pad and weigh the pad removed to determine blood loss. - ✅✅ -13-A grand
multiparous client had a precipitous delivery in the emergency room 6 hours ago. The client was
given oxytocin intramuscularly after birth. The nurse examines the client and observes the pad
under her buttocks is full of blood. Which action should the nurse take first?
Place a new pad and weigh the pad removed to determine blood loss.
Massage the fundus and express clots.
Start an IV and begin an oxytocin infusion.
Clean the perineal area and encourage her to breastfeed.
67 -✅✅ -14-A 9-year-old is receiving vancomycin 400 mg IV every 6 hours for a
methicillin-resistant (Beta- lactam-resistant) Staphylococci aureus (MRSA) infection. The
medication is diluted in a100 mL bag of saline with instructions to infuse over one and a half
hours. How many mL/hour should the nurse program the infusion pump? (Enter numeric value
only. If rounding is required, round to the nearest whole number.)
Institute contact precautions for staff and visitors.
Use standard precautions and wear a mask
Monitor the client's white blood cell count.
, Send wound drainage for culture and sensitivity. - ✅✅ -15-A client with foul-smelling drainage
from an incision on the upper left arm is admitted with a suspected methicillin-resistant
Staphylococcus aureus (MRSA). Which nursing interventions should the nurse include in the
plan of care? (Select all that apply.)
Explain the purpose of a low bacteria diet.
Institute contact precautions for staff and visitors.
Use standard precautions and wear a mask
Monitor the client's white blood cell count.
Send wound drainage for culture and sensitivity.
Renal and liver function tests. -✅✅ -16-Which laboratory values are critical for the nurse to
monitor for a client who is experiencing a thyrotoxic crisis?
Glucose and calcium levels.
Blood and urine cultures.
Electrolytes and hemoglobin.
Renal and liver function tests.
Begin manual ventilation immediately. - ✅✅ -17-An unconscious client is admitted to the
intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the
client's oxygen saturation level is 62%. Which
action should the nurse take first?Silence the alarm and call the technician.
Monitor oxygen saturation levels every 5 minutes.
Begin manual ventilation immediately.
Call respiratory therapy.
Muscle fiber degeneration. - ✅✅ -18-A 5-year-old child with a history of a waddling gait and
frequent falls is brought into the hospital for diagnostic testing. When explaining the diagnostic
testing to the parents, the nurseshould provide information based on which understanding of the
underlying disease pathology?Systemic autoimmune vasculopathy.
Muscle fiber degeneration.
Impaired neuron function.
Autonomic neuropathy.
Facilitate a consultation for speech therapy. -✅✅ -19-An older client is referred to a
rehabilitation facility following a cerebrovascular accident (CVA). The client is aphasic with
left-side paresis and is having difficulty swallowing. Which intervention is most important for the
nurse to include in the client's plan of care? Multiple-Choice Single-AnswerSelect your answer
from the options on
Initiate passive range of motion exercises.
Use pictures and gestures to communicate.
Facilitate a consultation for speech therapy.
Arrange for daily home care assistance.
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