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- A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.) C. Open the airway using a jaw-thrust maneuver. D. Determine effectiveness of ventilator efforts.
B. Establish IV access.
A. Perform a Glasgow Coma Scale assessment. E. Remove clothing for a thorough assessment.
- A nurse is caring for a client who has active pulmonary tuberculosis (TB) and is to be started on intravenous rifampin therapy. The nurse should instruct the client that this medication can cause which of the following adverse effects?
A. Constipation
Rationale: Rifampin does not cause constipation. More common gastrointestinal effects are diarrhea and nausea. B. Black colored stools
Rationale: It is most commonly iron supplements that cause stools to turn black, not rifampin. C. Staining of teeth Rationale: Teeth may be stained from taking liquid iron preparations, not from taking rifampin.
D. Body secretions turning a red-orange color
Rationale: Rifampin is used in combination with other medicines to treat TB. Rifampin will cause the urine, stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-brown.
- A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?
A. Prevent aspiration. Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority goal is to prevent the client from aspirating. Because the client's jaws are wired together, aspiration of emesis is a possibility. Therefore, the client should be given medication for nausea, and wire cutters should be kept at the bedside in case of vomiting. B. Ensure adequate nutrition.
Rationale:
The client should be NPO initially after surgery until the gag reflex has returned. Once the client is able to eat, the client may advance to a calorie-appropriate, high-protein liquid diet. However, this is not the priority at this time.
C. Promote oral hygiene
Rationale: The client will have an incision inside the mouth. While it is important that the client receive frequent mouth cleaning, this is not the priority at this time. D. Relieve the client's pain.
Rationale: While the client may be in pain and will need to be medicated, this is not the priority at this time.
- A nurse caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions?
A. Asthma Rationale: Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can cause bronchospasms. Propranolol blocks the sympathetic stimulation, which prevents smooth muscle relaxation.
B. Glaucoma
Rationale: Beta-blockers are contraindicated in clients who have cardiogenic shock, but are not contraindicated in a client who has glaucoma.
C. Depression
Rationale: Beta-blockers are contraindicated in clients who have AV heart block, but are not contraindicated in clients who have depression.
D. Migraines Rationale: Beta-blockers are used for prophylactic treatment of migraine headaches.
- A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?
A. Decrease chest wall compliance
- A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Check the tubing connections for leaks.
Rationale: This action is used to determine why a water seal chamber has continuous bubbling, not slow, steady bubbling.
B. Check the suction control outlet on the wall. Rationale: This action is used to determine why a suction control chamber that is hooked to wall suction has little or no bubbling.
C. Clamp the chest tube. Rationale: The nurse should briefly clamp the chest tube to check for air leaks or to change the drainage
system. This is not an appropriate action for the nurse to take at this time. D. Continue to monitor the client's respiratory status. Rationale: Slow, steady bubbling in the suction control chamber is an expected finding. Therefore, the nurse should continue to monitor the client's respiratory status.
- A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?
A. Decreased serum calcium level
Rationale: A decreased serum calcium level is an expected finding for FES, although the reason for this finding is unknown.
B. Decreased level of serum lipids Rationale: An increase serum lipid level is an expected finding for FES, although the reason for this finding is unknown.
C. Decreased erythrocyte sedimentation rate (ESR) Rationale: An increased ESR is an expected finding for FES, although the reason for this finding is unknown.
D. Increased platelet count Rationale: A decreased platelet count is an expected finding for FES, although the reason for this finding is unknown.
- A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
A. Kussmaul respirations Rationale: Kussmaul respirations are deep, rapid, regular respirations and are commonly seen in clients who are experiencing metabolic acidosis.
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B. Apneustic respirations
Rationale: Apneustic respirations are characterized by a prolonged inspiratory phase alternating with expiratory pauses.
C. Cheyne-Stokes respirations
Rationale: Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR
are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death).
D. Stridor Rationale: Stridor is a continuous, high-pitched sound heard on inspiration in clients who have partial airway obstruction of the larynx or trachea.
10.A A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching?
A. "It might help if I tried sleeping only on my back." Rationale: The flat, supine position increases the chance of obstructing the airway.
B. "I'll sleep better if I take a sleeping pill at night." Rationale: Hypnotics (sleeping pills) aggravate sleep apnea and can also cause increased daytime somnolence (sleepiness).
C. "I'll get a humidifier to run at my bedside at night."
Rationale: Bedside humidifiers are an effective way to help clients who have thick pulmonary secretions, but they do not help sleep apnea.
D. "If I could lose about 50 pounds, I might stop having so many apneic episodes." Rationale: Sleep apnea is a disorder in which breathing stops during sleep for at least 10 seconds at least five times per hour. Excessive weight is one of the three major risk factors associated with sleep apnea and is the only one the client can modify (gender and age are the other two). Weight loss and maintenance are the primary interventions for the treatment of sleep apnea.
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- A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?
A. Movement of the trachea toward the unaffected side
Rationale: A chest tube inserted for a spontaneous pneumothorax may result in the development of a tension pneumothorax, a medical emergency. This results from air in the pleural space compressing the blood vessels of the thorax and limiting blood return to the heart. An assessment of tracheal deviation, or movement of the trachea toward the unaffected side, is indicative of tension pneumothorax and should be reported to the provider immediately.
B. Bubbling of the water in the water seal chamber with exhalation
Rationale: The water seal chamber prevents air from re-entering the pleural space. Bubbling in this
chamber indicates air is being removed from the client’s pleural space, allowing re-expansion of the lung. It should occur during exhalation, coughing, and sneezing. When the air from the pleural space is removed, the bubbling will stop. Excessive bubbling in this chamber may indicate an air leak and should be further investigated by the nurse.
C. Crepitus in the area above and surrounding the insertion site Rationale: Crepitus, or subcutaneous emphysema, sounds like a crackling noise when palpated. It can be an expected finding in the client who has a pneumothorax and will persist for several hours (or longer, depending on how long it takes the air to be reabsorbed) following evacuation of the pneumothorax.
D. Eyelets are not visible
Rationale: The observation of eyelets would indicate to the nurse that the chest tube has been become dislodged from the pleural space and would necessitate reporting to the provider.
14.A A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? A. Raise the foot of the bed to a 90° angle. Rationale: Trendelenburg position increases pressure on the heart and lungs and is contraindicated for a client who has an open chest wound. The nurse should place the client in a moderate to highFowler’s position.
B. Remove the dressing to inspect the wound. Rationale: A dressing should not be removed from a sucking chest wound until immediately prior to chest tube insertion. Removal of the dressing will cause an increase in size of the pneumothorax and increased respiratory difficulty. C. Prepare to insert a central line.
Rationale: Although the client may need IV access, a central line is not usually needed in this situation.
D. Administer oxygen via nasal cannula. Rationale: The client has an increased respiratory rate and heart rate, indicating that she is having respiratory difficulty. The sucking chest wound indicates the client has a pneumothorax and/or a hemothorax. Administering oxygen will increase the oxygen exchange in the lungs and the oxygen available to the tissues.
15.A A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? A. Obtain a cardiology consult.
Rationale: These manifestations are not related to a cardiac condition in this situation.
B. Suction the client less frequently.
Rationale: These manifestations are not the result of suctioning too frequently.
C. Administer an antidysrhythmic medication.
Rationale: These manifestations cannot be corrected with the use of an antidysrhythmic medication.
D. Perform pre-oxygenation prior to suctioning. Rationale: Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury.. In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual resuscitator bag set at 100% oxygen.
16.A A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Continue to monitor the client as this is an expected finding.
Rationale: The expected finding would be a gentle bubbling of the water in the suction control chamber. B. Add more water to the suction control chamber of the drainage system. Rationale: More water should not be added to the closed system.
C. Verify that the suction regulator is on and check the tubing for leaks. Rationale: A lack of bubbling may indicate that either the suction regulator is turned off or that there is a leak in the tubing.
D. Milk the chest tube and dislodge any clots in the tubing that are occluding it. Rationale: Stripping, or milking, can pull too hard on the chest cavity and may cause a tissue injury to the lung. Stripping is only done when specifically indicated.
starvation, hypoxia, renal or liver failure, dehydration, or diarrhea. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 – 7.45) and a bicarbonate (HCO 3 ) level that is lower than the normal reference range (21 – 28 mEq/mL).
C. Metabolic alkalosis
Rationale: Metabolic alkalosis occurs when there is an alteration in the level of HCO 3 along with an increase in the pH of the blood. It can be the result when a client ingests too much antacid from
blood transfusions or total parenteral nutrition. It can also occur if the client has prolonged vomiting or NG suction, takes thiazide diuretics, or has a metabolic disorder such as hypercortisolism or hyper aldosteronism. Arterial blood gases will reveal a pH that is higher than the normal reference range (7.35 – 7.45) and an HCO 3 level that is higher than the normal reference range (35 – 45 mm Hg).
D. Respiratory alkalosis Rationale: Respiratory alkalosis occurs when there is an excessive loss of CO 2 through hyperventilation, mechanical ventilation, fever, overdose of salicylates, or lesions to the central nervous system. Arterial blood gases will reveal a pH that is higher than the normal reference range (7.35 – 7.45) and a CO 2 level that is lower than the normal reference range (35 – 45 mm Hg).
19.A A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
A. The client who has been NPO since midnight for endoscopy.
Rationale: Most clients with a baseline normal fluid status can tolerate being NPO overnight without risk of fluid volume deficit.
B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL.
Rationale: The client who has heart failure has ventricular impairment which prevents adequate filling or emptying of blood, resulting in fluid overload or inadequate tissue perfusion. An elevated BNP level is indicative of increased blood volume, thus fluid volume excess. C. The client who has end-stage renal failure and is scheduled for dialysis today. Rationale: The client who has end-stage renal failure is unable to appropriately filter blood and excrete waste products, including fluid. This client is likely to have a fluid excess that is managed with dialysis.
D. The client who has gastroenteritis and is febrile. Rationale: This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit.
- A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?
A. Increased respiratory rate from 18 to 44/min.
Rationale: Administering an expectorant is not indicated to prevent pulmonary complications, but the nurse should encourage the client to cough and deep breathe.
22.A A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?
A. Constant bubbling in the suction-control chamber Rationale: Constant, gentle bubbling in the suction control chamber indicates that the suction is functioning.
B. Continuous bubbling in the water-seal chamber Rationale: Continuous or excessive bubbling in the water-seal chamber indicates an air leak between the water seal and the client’s chest. However, gentle bubbling on forceful exhalation or coughing is normal.
C. Bloody drainage in the collection chamber Rationale: For the first few hours after surgery, the drainage is likely to be bloody, transitioning to blood-tinged after that. Since the nurse doesn’t empty a disposable system but replaces it when it is full, bloody drainage in the collection chamber at 12 hr is an expected finding.
D. Fluid-level fluctuations in the water-seal chamber Rationale: Fluid in the water-seal chamber should fluctuate with inspiration and exhalation, a process called tidaling, because pressure in the pleural space changes during respiration.
23.A A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention?
A. Prepare for mechanical ventilation. Rationale: If the client cannot compensate for this acid-base imbalance and conservative treatment does not help, mechanical ventilation might become necessary; however, it is not the first step in managing this
client’s imbalance. B. Administer oxygen via face mask.
Rationale: The pH reflects alkalosis, and the low PaCO 2 indicates that the lungs are involved, so the client has respiratory alkalosis. The client’s oxygen saturation is low, so one priority is to administer oxygen via mask attempting to achieve an oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus the priority is to restore oxygenation. C. Prepare to administer a sedative. Rationale: In many cases, the cause of this acid-base disorder is extreme anxiety with hyperventilation
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and loss of CO 2 , as evidenced by the client’s respiratory rate of 40/min and her PaCO 2 of 29. A sedative will help relieve anxiety and slow her breathing enough to correct the acid-base imbalance. However, the greatest risk to the client is hypoxia, so administering a sedative is not the priority action.
D. Assess for indications of pulmonary embolism.
Rationale: Pulmonary embolism is a possible cause of this type of acid-base imbalance, particularly with the client’s history of birth control pills and smoking, so the nurse should be alert for manifestations of this disorder. However, this is part of ongoing client monitoring and not the first step in managing the imbalance.
24.A A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately?
A. Serosanguineous drainage from the puncture site Rationale: A small amount of serosanguineous drainage at the puncture site is expected after a thoracentesis.
B. Discomfort at the puncture site
Rationale: Mild discomfort at the puncture site is expected after a thoracentesis.
C. Increased heart rate Rationale: Clients are at risk for developing pulmonary edema or cardiovascular distress due mediastinal content shift after the aspiration of a large amount of fluid from the client's pleural space. Therefore, the client may experience an increase in heart and respiratory rate, along with coughing with blood-tinged frothy sputum, and tightness in the chest. These findings require
notification of the provider immediately.
D. Decreased temperature Rationale: Infection is possible after any invasive procedure; however, it takes time to develop and increases the body temperature.
25.A A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
A. Metabolic acidosis
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27.A A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?
A. Increase the client’s wall suction.
Rationale: The nurse increasing the wall suction does not affect the amount of negative pressure of the chest tube and would not relieve the client’s chest burning.
B. Strip the client’s chest tube.
Rationale: The nurse stripping the chest tube increases negative pressure and may damage lung tissue and would not resolve the client’s chest burning.
C. Clamp the client’s chest tube. Rationale: The nurse clamping the chest tube briefly to change the chamber or check for an air leak is
recommended but would not resolve the client’s chest burning. D. Reposition the client. Rationale: The nurse repositioning the client is an appropriate action to relieve chest burning from the chest tube.
28.A A nurse is caring for a client who has returned to the unit following a surgical procedure. The client’s oxygen saturation is 85%. Which of the following actions should the nurse take first? A. Administer oxygen at 2 L/min. Rationale: The nurse should assess the client further and implement less invasive interventions before applying oxygen at 2 L/min.
B. Administer prescribed analgesic medication. Rationale: Pain management promotes increased participation by the client in coughing and deep breathing, frequent position changes and use of the incentive spirometer, but this is not the first action the nurse should take. C. Encourage coughing and deep breathing.
Rationale: Coughing and deep breathing promotes lung expansion and prevents respiratory infection, but these actions are not effective immediately in increasing oxygen saturation. D. Raise the head of the bed.
Rationale: Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway. This is the first action the nurse should take and is the least invasive.
29.A A nurse is preparing to measure a client’s level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations?
A. Finger Rationale: Edema of the hands and fingers interferes with blood circulation in the capillary bed. The oximeter probe may not be able to adequately detect hemoglobin molecules to provide an accurate oxygen saturation reading.
B. Earlobe
Rationale: The earlobe is rarely edematous, is the least affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation.
C. Toe
Rationale: Thickening of nails interferes with blood circulation in the capillary bed. The oximeter probe may not be able to adequately detect hemoglobin molecules to provide an accurate oxygen saturation reading.
D. Skin fold Rationale: A skin fold may not have adequate capillary circulation of hemoglobin molecules to provide an accurate oxygen saturation reading.
30.A A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?
A. Encourage the client to ambulate frequently. Rationale: Ambulation prevents the accumulation of respiratory secretions, but not their thinning.
B. Encourage coughing and deep breathing.
Rationale: Coughing and deep breathing promotes expectoration, not thinning of respiratory secretions.
C. Encourage the client to increase fluid intake. Rationale: Increasing fluid intake to1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client’s ability to cough and remove the secretions. D. Encourage regular use of the incentive spirometer.
Rationale: Using an incentive spirometer promotes expectoration, not thinning of respiratory secretions.
33.A A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?
A. A client who is scheduled for an abdominal x-ray and is awaiting transport Rationale: A client who is scheduled for an abdominal x-ray and is awaiting transport is stable. The nurse should see the client before allowing her to leave the unit; however, there is another client the nurse should see first.
B. A client who has a prescription for discharge Rationale:
A client who has a prescription for discharge is stable; therefore, there is another client the nurse should see first.
C. A client who received oral pain medication 30 min ago
Rationale: A client who received oral pain medication 30 minutes ago is stable; therefore, there is another client the nurse should see first. The nurse should expect oral analgesia to reach peak effect after 1 hr.
D. A client who told an assistive personnel he is short of breath Rationale: A client who has shortness of breath is unstable; therefore, this is the client the nurse should plan to see first.
34.A A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make?
A. "We can teach you some relaxation techniques to minimize your pain." Rationale: The nurse should manage the client's pain by including pharmacological and nonpharmacological relief interventions; however, there is another statement that the nurse should identify as the priority.
B. "Keep wire cutters with you at all times." Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to include is to tell the client to keep wire cutters available at all times. When the jaw is wired shut, the client is likely to aspirate if vomiting occurs. The client should use the wire cutters to clip the wires to keep the mouth clear of emesis, and should notify the provider so the jaw can be re-wired.
C. "Use a water pick device to keep your teeth clean." Rationale: The nurse should teach the client about appropriate oral hygiene to prevent infection in the mouth, which could complicate healing. However, there is another statement that the nurse should identify as the priority.
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D. "Consume a high-protein, liquid diet."
Rationale: The nurse should tell the client to consume a liquid diet that includes protein and other nutrients necessary for wound healing; however, there is another statement that the nurse should identify as the priority.
- A nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first? A. Provide highflow oxygen. Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to client care is to provide the client with high-flow oxygen. The client is experiencing fat embolism syndrome as a complication of a long bone fracture. The lungs are affected first, causing a drop
in the level of arterial oxygen, and the client can require mechanical ventilation. B.
Check the client for a positive Chvostek's sign. Rationale: The nurse should check the client for a positive Chvostek's sign to monitor for hypocalcemia secondary to fat embolism syndrome; however, there is another action the nurse should take first.
C. Administer an IV vasopressor medication. Rationale: The nurse should administer an IV vasopressor medication to prevent hypotension secondary to fat embolism syndrome; however, there is another action the nurse should take first. D. Monitor the client for headache.
Rationale: The nurse should monitor the client for headache secondary to fat embolism syndrome to provide appropriate pain relief; however, there is another action the nurse should take first.
36.A A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?
A. Blockage of the ET tube by the client's tongue
Rationale: The ET tube is positioned over the client's tongue, so the tongue cannot obstruct it. The nurse should expect decreased SaO2 if the ET tube is obstructed.
B. Passage of the ET tube into the esophagus
