Exam (elaborations)
MS3- FINAL EXAM QUESTIONS AND ANSWERS
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MS3- FINAL EXAM QUESTIONS AND ANSWERS
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MS3- FINAL EXAM QUESTIONS AND ANSWERSA client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse
is best?
A.Assess for other manifestations of hypoxia.
B.Change the sensor on the pulse oximeter.
C.Obtain a new oximeter from central supply.
D.Tell the client to take slow, deep breaths. - Answers- A
Pulse oximetry is not always the most accurate assessment tool for hypoxia as many
factors can interfere, producing normal or near-normal readings in the setting of
hypoxia. The nurse should conduct a more thorough assessment. The other actions are
not appropriate for a hypoxic client.
A client has been brought to the emergency department with a life-threatening chest
injury. What action by the nurse takes priority?
A.Apply oxygen at 100%.
B.Assess the respiratory rate.
C.Ensure a patent airway.
D.Start two large-bore IV lines. - Answers- C
The priority for any chest trauma client is airway, breathing, circulation. The nurse first
ensures the client has a patent airway. Assessing respiratory rate and applying oxygen
are next, followed by inserting ivs.
A client in the emergency department has several broken ribs. What care measure will
best promote comfort?
A.Allowing the client to choose the position in bed
B.Humidifying the supplemental oxygen
C.Offering frequent, small drinks of water
D.Providing warmed blankets - Answers- A
Allow the client with respiratory problems to assume a position of comfort if it does not
interfere with care. Often the client will choose a more upright position, which also
improves oxygenation. The other options are less effective comfort measures.
A client is brought to the emergency department after sustaining injuries in a severe car
crash. The client's chest wall does not appear to be moving normally with respirations,
oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the
priority?
A.Administer oxygen and reassess.
B.Auscultate the client's lung sounds.
C.Facilitate a portable chest x-ray.
D.Prepare to assist with intubation. - Answers- D
,This client has manifestations of flail chest and, with the other signs, needs to be
intubated and mechanically ventilated immediately. The nurse does not have time to
administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be
taken after the client is intubated.
A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the
nurse include in this client's teaching?
A. "Take an antibiotic each day."
B. "Contact your provider to obtain genetic screening."
C. "Eat a well-balanced, nutritious diet."
D. "Plan to exercise for 30 minutes every day - Answers- C
Clients with CF often are malnourished due to vitamin deficiency and pancreatic
malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are
not essential actions. Genetic screening would not help the client manage CF bette
While assessing a client who is 12 hours postoperative after a thoracotomy for lung
cancer, a nurse notices that the lower chest tube is dislodged. Which action should the
nurse take first?
A. Assess for drainage from the site.
B. Cover the insertion site with sterile gauze.
C. Contact the provider and obtain a suture kit.
D. Reinsert the tube using sterile technique. - Answers- B
Immediately covering the insertion site helps prevent air from entering the pleural space
and causing a pneumothorax. The area will not reseal quickly enough to prevent air
from entering the chest. The nurse should not leave the client to obtain a suture kit. An
occlusive dressing may cause a tension pneumothorax. The site should only be
assessed after the insertion site is covered. The provider should be called to reinsert the
chest tube or prescribe other treatment options.
A nurse cares for a client who is infected with Burkholderia cepacia. Which action
should the nurse take first when admitting this client to a pulmonary care unit?
A. Instruct the client to wash his or her hands after contact with other people.
B. Implement Droplet Precautions and don a surgical mask.
C. Keep the client isolated from other clients with cystic fibrosis.
D. Obtain blood, sputum, and urine culture specimens. - Answers- C
Burkholderia cepacia infection is spread through casual contact between cystic fibrosis
clients, thus the need for these clients to be separated from one another. Strict isolation
measures will not be necessary. Although the client should wash his or her hands
frequently, the most important measure that can be implemented on the unit is isolation
of the client from other clients with cystic fibrosis. There is no need to implement Droplet
Precautions or don a surgical mask when caring for this client. Obtaining blood, sputum,
and urine culture specimens will not provide information necessary to care for a client
with Burkholderia cepacia infection.
, A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take
deep breaths because of the pain. Which action should the nurse take?
A. Ambulate the client in the hallway to promote deep breathing.
B. Auscultate the client's anterior and posterior lung fields.
C. Encourage the client to take shallow breaths to help with the pain.
D. Administer pain medication and encourage the client to take deep breaths. -
Answers- D
A chest tube is placed in the pleural space and may be uncomfortable for a client. The
nurse should provide pain medication to minimize discomfort and encourage the client
to take deep breaths. The other responses do not address the client's discomfort and
need to take deep breaths to prevent complication
A nurse cares for a client who has a chest tube. When would this client be at highest
risk for developing a pneumothorax?
A. When the insertion site becomes red and warm to the touch
B. When the tube drainage decreases and becomes sanguineous
C. When the client experiences pain at the insertion site
D. When the tube becomes disconnected from the drainage system - Answers- D
Intrathoracic pressures are less than atmospheric pressures; therefore, if the chest tube
becomes disconnected from the drainage system, air can be sucked into the pleural
space and cause a pneumothorax. A red, warm, and painful insertion site does not
increase the client's risk for a pneumothorax. Tube drainage should decrease and
become serous as the client heals. Sanguineous drainage is a sign of bleeding but does
not increase the client's risk for a pneumothorax.
A nurse cares for a client who has a pleural chest tube. Which action should the nurse
take to ensure safe use of this equipment?
A. Strip the tubing to minimize clot formation and ensure patency.
B. Secure tubing junctions with clamps to prevent accidental disconnections.
C. Connect the chest tube to wall suction at the level prescribed by the provider.
D. Keep padded clamps at the bedside for use if the drainage system is interrupted. -
Answers- D
Padded clamps should be kept at the bedside for use if the drainage system becomes
dislodged or is interrupted. The nurse should never strip the tubing. Tubing junctions
should be taped, not clamped. Wall suction should be set at the level indicated by the
device's manufacturer, not the provider
A nurse cares for a female client who has a family history of cystic fibrosis. The client
asks, "Will my children have cystic fibrosis?" How should the nurse respond?
A. "Since many of your family members are carriers, your children will also be carriers of
the gene."
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