Detailed Answer Key
Complex Oyxgenation ATI Practice
1. 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.)
A. Perform a Glasgow Coma Scale assessment.
B. Establish IV access.
C. Open the airway using a jaw-thrust maneuver.
D. Determine effectiveness of ventilator efforts.
E. Remove clothing for a thorough assessment.
Answer: 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.
Rationale:
A. Perform a Glasgow Coma Scale assessment.
Assessing neurological status (Disability) using the GCS helps determine the level of
consciousness and identify potential brain injuries or other neurological deficits.
B. Establish IV access.
Securing IV access is essential for fluid resuscitation and medication administration to manage
shock and maintain circulation, especially in life-threatening injuries.
C. Open the airway using a jaw-thrust maneuver.
Airway management is the first priority in trauma care to ensure oxygen delivery to the body.
The jaw-thrust maneuver is used when a cervical spine injury is suspected, as it prevents further
spinal damage while opening the airway.
D. Determine effectiveness of ventilator efforts.
After establishing a patent airway, assess the client's breathing and ventilatory effectiveness to
ensure adequate oxygenation and carbon dioxide exchange. This involves checking for chest rise,
respiratory rate, and auscultating breath sounds.
E. Remove clothing for a thorough assessment.
Exposing the patient allows for a complete visual inspection for hidden injuries, burns, or
deformities (Exposure). This step is critical but must be performed after ensuring the client's
airway, breathing, circulation, and neurological status are stabilized.
2. 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
B. Black colored stools
C. Staining of teeth
D. Body secretions turning a red-orange color
Answer: D. Body secretions turning a red-orange color
Rationale:
A. Constipation
Rifampin does not cause constipation. More common gastrointestinal effects are diarrhea and
nausea.
B. Black colored stools
It is most commonly iron supplements that cause stools to turn black, not rifampin.
C. Staining of teeth
Teeth may be stained from taking liquid iron preparations, not from taking rifampin.
D. Body secretions turning a red-orange color
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.
3. 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.
B. Ensure adequate nutrition.
C. Promote oral hygiene
D. Relieve the client's pain.
Answer: A. Prevent aspiration.
Rationale:
A. Prevent aspiration.
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.
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
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.
While the client may be in pain and will need to be medicated, this is not the priority at this time.
4. 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
B. Glaucoma
C. Depression
D. Migraines
Answer: A. Asthma
Rationale:
A. Asthma
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
Beta-blockers are contraindicated in clients who have cardiogenic shock, but are not
contraindicated in a client who has glaucoma.
C. Depression
Beta-blockers are contraindicated in clients who have AV heart block, but are not contraindicated
in clients who have depression.
D. Migraines
Beta-blockers are used for prophylactic treatment of migraine headaches.
5. 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
B. Suppress respiratory effort
C. Induce sedation
D. Decrease respiratory secretions
Answer: B. Suppress respiratory effort
Rationale:
A. Decrease chest wall compliance
Neuromuscular blocking agents, such as pancuronium, induce paralysis by relaxing skeletal
muscles, which improves chest wall compliance.
B. Suppress respiratory effort
Neuromuscular blocking agents, such as pancuronium, induce paralysis and suppress the client's
respiratory efforts to the point of apnea, allowing the mechanical ventilator to take over the work
of breathing for the client. This therapy is especially helpful for a client who has ARDS and poor
lung compliance.
C. Induce sedation
Neuromuscular blocking agents, such as pancuronium, induce paralysis and have no sedative
effect at all. A sedative or analgesic should be prescribed as an adjunct to the pancuronium.
D. Decrease respiratory secretions
Neuromuscular blocking agents, such as pancuronium, induce paralysis. An adverse effect of this
medication is increased production of respiratory secretions.
6. A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for
several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The
nurse should realize that this finding is most likely an indication of which of the following
conditions?
A. An upper respiratory infection
B. Pulmonary edema
C. Atelectasis
D. Delayed gastric emptying
Answer: C. Atelectasis
Rationale:
A. An upper respiratory infection
Although the spleen plays a role in immunity against bacterial infections, the nurse would be
more concerned about the risk of an upper respiratory infection in a client who has undergone
splenectomy, or removal of the spleen.
B. Pulmonary edema
Pulmonary edema may develop in a client who is on bedrest following trauma, but this is not the
most likely cause of decreased breath sounds in this client.
C. Atelectasis
Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or
bronchioles) or by hypoventilation. Prolonged bedrest with few changes in position, ineffective
coughing, and underlying lung disease are risk factors for the development of atelectasis.
D. Delayed gastric emptying
Although delayed gastric emptying may result in ineffective coughing, this is not the most likely
cause of decreased breath sounds in this client.
7. 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.
B. Check the suction control outlet on the wall.
C. Clamp the chest tube.
D. Continue to monitor the client's respiratory status.
Answer: D. Continue to monitor the client's respiratory status.
Rationale:
A. Check the tubing connections for leaks.
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.
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.
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.
Slow, steady bubbling in the suction control chamber is an expected finding. Therefore, the nurse
should continue to monitor the client's respiratory status.
8. 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
B. Decreased level of serum lipids
C. Decreased erythrocyte sedimentation rate (ESR)
D. Increased platelet count
Answer: A. Decreased serum calcium level
Rationale:
A. Decreased serum calcium level
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
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)
An increased ESR is an expected finding for FES, although the reason for this finding is
unknown.
D. Increased platelet count
A decreased platelet count is an expected finding for FES, although the reason for this finding is
unknown.
9. 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
B. Apneustic respirations
C. Cheyne-Stokes respirations
D. Stridor
Answer: C. Cheyne-Stokes respirations
Rationale:
A. Kussmaul respirations
Kussmaul respirations are deep, rapid, regular respirations and are commonly seen in clients who
are experiencing metabolic acidosis.
B. Apneustic respirations
Apneustic respirations are characterized by a prolonged inspiratory phase alternating with
expiratory pauses.
C. Cheyne-Stokes respirations
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
Stridor is a continuous, high-pitched sound heard on inspiration in clients who have partial
airway obstruction of the larynx or trachea.
10. 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."
B. "I'll sleep better if I take a sleeping pill at night."
C. "I'll get a humidifier to run at my bedside at night."
D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."
Answer: D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."
Rationale:
A. "It might help if I tried sleeping only on my back."
The flat, supine position increases the chance of obstructing the airway.
B. "I'll sleep better if I take a sleeping pill at night."
ypnotics (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."
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."
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.
11. A nurse is caring for a client who has a chest tube connected to a closed drainage system and
needs to be transported to the x-ray department. Which of the following actions should the nurse
take?
A. Clamp the chest tube prior to transferring the client to a wheelchair.
B. Disconnect the chest tube from the drainage system during transport.
C. Keep the drainage system below the level of the client's chest at all times.
D. Empty the collection chamber prior to transport.
Answer: C. Keep the drainage system below the level of the client's chest at all times.
Rationale:
A. Clamp the chest tube prior to transferring the client to a wheelchair.
Clamping the tube can lead to a tension pneumothorax (collapse of the lung) due to increased
intrathoracic pressure from gas and fluid that cannot be drained from the pleural space.
B. Disconnect the chest tube from the drainage system during transport.
The chest tube should not be disconnected from the drainage system.
C. Keep the drainage system below the level of the client's chest at all times.
During transport, the drainage system should be kept below the level of the client's chest to
prevent air and drainage fluid from re-entering the thoracic cavity.
D. Empty the collection chamber prior to transport.
Emptying the collection chamber prior to transport is unnecessary.
12. A nurse is providing teaching to a client who is postoperative following coronary artery
bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside
from managing pain, which of the following desired effects of medications should the nurse
identify as most important for the client’s recovery?
A. It decreases the client's level of anxiety.
B. It facilitates the client's deep breathing.
C. It enhances the client's ability to sleep.
D. It reduces the client's blood pressure.
Answer: B. It facilitates the client's deep breathing.
Rationale:
A. It decreases the client's level of anxiety.
The nurse should assess for and manage the client’s anxiety, as this can result in postoperative
delirium. Following the administration of an opioid medication, the nurse should assess the client
for relief of pain and apprehension. Even though opioid analgesics may decrease the client's level
of anxiety (partially from pain reduction alone), there is another effect that is more important.
B. It facilitates the client's deep breathing.
When using the airway, breathing, circulation approach to client care, the nurse should identify
facilitation of deep breathing as the most important desired effect of opioids aside from pain
relief. Following thoracic type surgeries, the client’s has increased pain with moving, deep
breathing and coughing. Opioid medications help minimize the discomfort experienced with
deep breathing and coughing which prevents the development of postoperative pneumonia. The
nurse should also encourage the client to splint his incision to help minimize pain.
C. It enhances the client's ability to sleep.
The nurse should take measures to facilitate sleep in the postoperative client such as providing
quiet time that is undisturbed, dimming lights, and ensuring the client is comfortable and not in
pain. Even though opioid analgesics may increase the client’s ability to relax and sleep, another
effect is more important.
D. It reduces the client's blood pressure.
The nurse should closely monitor the cardiac status of the client who is postoperative. The client
who is experiencing pain releases catecholamines which produce vasoconstriction and increase
blood pressure. Even though opioid analgesics may assist in reducing a client’s blood pressure,
another effect is more important.
13. 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
B. Bubbling of the water in the water seal chamber with exhalation
C. Crepitus in the area above and surrounding the insertion site
D. Eyelets are not visible
Answer: A. Movement of the trachea toward the unaffected side
Rationale:
A. Movement of the trachea toward the unaffected side
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
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
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
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 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.
B. Remove the dressing to inspect the wound.
C. Prepare to insert a central line.
D. Administer oxygen via nasal cannula.
Answer: D. Administer oxygen via nasal cannula.
Rationale:
A. Raise the foot of the bed to a 90° angle.
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.
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.
Although the client may need IV access, a central line is not usually needed in this situation.
D. Administer oxygen via nasal cannula.
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 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.
B. Suction the client less frequently.
C. Administer an antidysrhythmic medication.
D. Perform pre-oxygenation prior to suctioning.
Answer: D. Perform pre-oxygenation prior to suctioning.
Rationale:
A. Obtain a cardiology consult.
These manifestations are not related to a cardiac condition in this situation.
B. Suction the client less frequently.
These manifestations are not the result of suctioning too frequently.
C. Administer an antidysrhythmic medication.
These manifestations cannot be corrected with the use of an antidysrhythmic medication.
D. Perform pre-oxygenation prior to suctioning.
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 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.
B. Add more water to the suction control chamber of the drainage system.
C. Verify that the suction regulator is on and check the tubing for leaks.
D. Milk the chest tube and dislodge any clots in the tubing that are occluding it.
Answer: C. Verify that the suction regulator is on and check the tubing for leaks.
Rationale:
A. Continue to monitor the client as this is an expected finding.
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.
More water should not be added to the closed system.
C. Verify that the suction regulator is on and check the tubing for leaks.
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.
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.
17. A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a
thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse
give highest priority to?
A. Arterial blood gases
B. Urinary output
C. Chest tube drainage
D. Pain level
Answer: A. Arterial blood gases
Rationale:
A. Arterial blood gases
According to the ABC priority-setting framework, the postoperative surgical client may need
supplemental oxygen in order to maintain normal blood oxygen levels. The effectiveness of
oxygenation is monitored using pulse oximetry and arterial blood gases.
B. Urinary output
The nurse should monitor the client’s urinary output in order to monitor fluid status and cardiac
output of the client who is postoperative; however, there is another assessment that would take
priority.
C. Chest tube drainage
The nurse should monitor the amount and characteristics of chest tube drainage because drainage
in excess of 70 mL/hr may indicate acute bleeding or require that administration of blood
products. While this is an appropriate intervention, there is another intervention that would take
priority.
D. Pain level
The nurse should monitor for and treat pain in the client who is postoperative following a
thoracotomy to provide comfort and to enhance the client’s ability to deep breathe. However,
there is another assessment that would take priority.
18. A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood
gases (ABG) reveal the following values. Which of the following is an appropriate analysis of
the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80%
Bicarbonate 26 mEq/L
A. Respiratory acidosis
B. Metabolic acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis
Answer: A. Respiratory acidosis
Rationale:
A. Respiratory acidosis
Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory
function. It can be the result of respiratory depression, seen with anesthesia or opioid
administration; inadequate chest expansion, due to a weakness of the respiratory muscles or
constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction,
or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O 2 and CO2),
resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli.
Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 – 7.45)
and a CO2 level that is higher than the normal reference range (35 – 45 mm Hg).
B. Metabolic acidosis
Metabolic acidosis occurs when there is an alteration in the level of hydrogen ions or a reduction
in the amount of bicarbonate available. It can be the result of diabetic ketoacidosis, 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 (HCO3) level that is
lower than the normal reference range (21 – 28 mEq/mL).
C. Metabolic alkalosis
Metabolic alkalosis occurs when there is an alteration in the level of HCO3 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 HCO3 level that is higher than the normal
reference range (35 – 45 mm Hg).
D. Respiratory alkalosis
Respiratory alkalosis occurs when there is an excessive loss of CO2 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 CO2 level that is lower than the normal reference range (35 – 45 mm Hg).
19. 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.
B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of
600 pg/mL.
C. The client who has end-stage renal failure and is scheduled for dialysis today.
D. The client who has gastroenteritis and is febrile.
Answer: D. The client who has gastroenteritis and is febrile.
Rationale:
A. The client who has been NPO since midnight for endoscopy.
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.
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.
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.
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.
20. 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.
B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F).
C. Increased blood pressure from 112/68 to 120/72 mm Hg.
D. Increased heart rate from 68 to 72/min.
Answer: A. Increased respiratory rate from 18 to 44/min.
Rationale:
A. Increased respiratory rate from 18 to 44/min.
This change in respiratory rate is significant, as the first value is within the expected reference
range, but the second value is very elevated for an adult client. Increased respiratory rate could
be a manifestation of a possible fat embolism, a serious complication that may follow the type of
fracture sustained by the client. Fat emboli can be trapped in lung tissue, leading to respiratory
symptoms and mental disturbances.
B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F).
This change in temperature is not significant, as both values are within the expected reference
range. A client who has a fat embolism may develop a high temperature, usually 39.5º C (103
Fº).
C. Increased blood pressure from 112/68 to 120/72 mm Hg.
This change in blood pressure is not significant, as both values are within the expected reference
range.
D. Increased heart rate from 68 to 72/min.
This change in heart rate is not significant, as both values are within the expected reference
range.
21. A nurse is developing a plan of care for a client who is postoperative. Which of the following
interventions should the nurse include in the plan to prevent pulmonary complications?
A. Perform range-of-motion exercises
B. Place suction equipment at the bedside
C. Encourage the use of an incentive spirometer
D. Administer an expectorant
Answer: C. Encourage the use of an incentive spirometer
Rationale:
A. Perform range-of-motion exercises
This is not indicated to prevent pulmonary complications, but early ambulation is helpful to
promote lung expansion and remove secretions.
B. Place suction equipment at the bedside
Suction equipment should be readily available if needed, but its presence does not prevent
pulmonary complications.
C. Encourage the use of an incentive spirometer
Incentive spirometry expands the lungs and promotes gas exchange after surgery which can help
prevent pulmonary complications.
D. Administer an expectorant
Administering an expectorant is not indicated to prevent pulmonary complications, but the nurse
should encourage the client to cough and deep breathe.
22. 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
B. Continuous bubbling in the water-seal chamber
C. Bloody drainage in the collection chamber
D. Fluid-level fluctuations in the water-seal chamber
Answer: B. Continuous bubbling in the water-seal chamber
Rationale:
A. Constant bubbling in the suction-control chamber
Constant, gentle bubbling in the suction control chamber indicates that the suction is functioning.
B. Continuous bubbling in the water-seal chamber
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
For the first few hours after surgery, the drainage is likely to be bloody, transitioning to bloodtinged 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
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 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.
B. Administer oxygen via face mask.
C. Prepare to administer a sedative.
D. Assess for indications of pulmonary embolism.
Answer: B. Administer oxygen via face mask.
Rationale:
A. Prepare for mechanical ventilation.
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.
The pH reflects alkalosis, and the low PaCO2 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.
In many cases, the cause of this acid-base disorder is extreme anxiety with hyperventilation and
loss of CO2, as evidenced by the client’s respiratory rate of 40/min and her PaCO2 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.
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 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
B. Discomfort at the puncture site
C. Increased heart rate
D. Decreased temperature
Answer: C. Increased heart rate
Rationale:
A. Serosanguineous drainage from the puncture site
A small amount of serosanguineous drainage at the puncture site is expected after a
thoracentesis.
B. Discomfort at the puncture site
Mild discomfort at the puncture site is expected after a thoracentesis.
C. Increased heart rate
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
Infection is possible after any invasive procedure; however, it takes time to develop and
increases the body temperature.
25. A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO 2
of 50 mm Hg. The nurse should identify that the client is experiencing which of the following
acid-base imbalances?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answer: C. Respiratory acidosis
Rationale:
A. Metabolic acidosis
With uncompensated metabolic acidosis, the pH is less than 7.35 and the PaCO2 is less than 35
mm Hg or within the expected reference range.
B. Metabolic alkalosis
With uncompensated metabolic alkalosis, the pH is greater than 7.45 and the PaCO2 is greater
than 45 mm Hg or within the expected reference range.
C. Respiratory acidosis
With uncompensated respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than
45 mm Hg.
D. Respiratory alkalosis
With uncompensated respiratory alkalosis, the pH is greater than 7.45 and the PaCO 2 is less than
45 mm Hg.
26. A A nurse is caring for a client who has a chest tube in place to a closed chest drainage
system. Which of the following findings should indicate to the nurse that the client's lung has reexpanded?
A. Oxygen saturation of 95%
B. No fluctuations in the water seal chamber
C. No reports of pleuritic chest pain
D. Occasional bubbling in the water-seal chamber
Answer: B. No fluctuations in the water seal chamber
Rationale:
A. Oxygen saturation of 95%
A client can have an oxygen saturation of 95% with or without lung re-expansion.
B. No fluctuations in the water seal chamber
Fluctuation stops when the lung has re-expanded, but the nurse should check for other
indications of re-expansion, such as equal breath sounds bilaterally, because fluctuation can also
stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or the
suction source is not functioning.
C. No reports of pleuritic chest pain
The client might not report pain if his pain management is effective, not because his lung has reexpanded.
D. Occasional bubbling in the water-seal chamber
Occasional bubbling indicates the removal of air from the pleural space, indicating that the lung
is not fully re-expanded.
27. 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.
B. Strip the client’s chest tube.
C. Clamp the client’s chest tube.
D. Reposition the client.
Answer: D. Reposition the client.
Rationale:
A. Increase the client’s wall suction.
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.
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.
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.
The nurse repositioning the client is an appropriate action to relieve chest burning from the chest
tube.
28. 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.
B. Administer prescribed analgesic medication.
C. Encourage coughing and deep breathing.
D. Raise the head of the bed.
Answer: D. Raise the head of the bed.
Rationale:
A. Administer oxygen at 2 L/min.
The nurse should assess the client further and implement less invasive interventions before
applying oxygen at 2 L/min.
B. Administer prescribed analgesic medication.
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.
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.
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 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. 5Finger
B. Earlobe
C. Toe
D. Skin fold
Answer: B. Earlobe
Rationale:
A. 5Finger
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
The earlobe is rarely edematous, is the least affected by decreased blood flow, and has greater
accuracy when measuring oxygen saturation.
C. Toe
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
A skin fold may not have adequate capillary circulation of hemoglobin molecules to provide an
accurate oxygen saturation reading.
30. 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.
B. Encourage coughing and deep breathing.
C. Encourage the client to increase fluid intake.
D. Encourage regular use of the incentive spirometer.
Answer: C. Encourage the client to increase fluid intake.
Rationale:
A. Encourage the client to ambulate frequently.
Ambulation prevents the accumulation of respiratory secretions, but not their thinning.
B. Encourage coughing and deep breathing.
Coughing and deep breathing promotes expectoration, not thinning of respiratory secretions.
C. Encourage the client to increase fluid intake.
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.
Using an incentive spirometer promotes expectoration, not thinning of respiratory secretions.
31. A nurse is caring for a client who has a central venous catheter and develops acute shortness
of breath. Which of the following actions should the nurse take first?
A. Clamp the catheter.
B. Position the client in left lateral Trendelenburg.
C. Initiate oxygen therapy.
D. Auscultate breath sounds.
Answer: A. Clamp the catheter.
Rationale:
A. Clamp the catheter.
The greatest risk to this client is injury from further air entering the central venous catheter;
therefore, the first action the nurse should take is to clamp the catheter.
B. Position the client in left lateral Trendelenburg.
The nurse should position the client in the left lateral Trendelenburg to prevent the air from
entering the coronary arteries; however, the nurse should take another action first.
C. Initiate oxygen therapy.
The nurse should initiate oxygen therapy to treat any hypoxia the client may be experiencing;
however, the nurse should take another action first.
D. Auscultate breath sounds.
The nurse should auscultate breath sounds to determine if there is air movement within the lungs;
however, the nurse should take another action first.
32. A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which
of the following findings should indicate to the nurse that the client is experiencing a
complication?
A. Continuous bubbling in the water-seal chamber
B. Occasional bubbling in the water-seal chamber
C. Constant bubbling in the suction-control chamber
D. Fluctuations in the fluid level in the water-seal chamber
Answer: A. Continuous bubbling in the water-seal chamber
Rationale:
A. Continuous bubbling in the water-seal chamber
Excessive and continuous bubbling in the water-seal chamber indicates an air leak in the
drainage system.
B. Occasional bubbling in the water-seal chamber
The nurse should expect continuous bubbling in the water-seal chamber initially and occasional
bubbling after that. The bubbles indicate the removal of air from the pleural space, which is the
expected result.
C. Constant bubbling in the suction-control chamber
The nurse should expect constant, gentle bubbling in the suction control chamber.
D. Fluctuations in the fluid level in the water-seal chamber
The nurse should expect to see fluctuation with inspiration and exhalation, as this reflects the
expected pressure changes in the pleural space during respiration.
33. 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
B. A client who has a prescription for discharge
C. A client who received oral pain medication 30 min ago
D. A client who told an assistive personnel he is short of breath
Answer: D. A client who told an assistive personnel he is short of breath
Rationale:
A. A client who is scheduled for an abdominal x-ray and is awaiting transport
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
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
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
A client who has shortness of breath is unstable; therefore, this is the client the nurse should plan
to see first.
34. 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."
B. "Keep wire cutters with you at all times."
C. "Use a water pick device to keep your teeth clean."
D. "Consume a high-protein, liquid diet."
Answer: B. "Keep wire cutters with you at all times."
Rationale:
A. "We can teach you some relaxation techniques to minimize your pain."
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."
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."
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.
D. "Consume a high-protein, liquid diet."
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.
35. 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 high-flow oxygen.
B. Check the client for a positive Chvostek's sign.
C. Administer an IV vasopressor medication.
D. Monitor the client for headache.
Answer: A. Provide high-flow oxygen.
Rationale:
A. Provide high-flow oxygen.
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.
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.
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.
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 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
B. Passage of the ET tube into the esophagus
C. Movement of the ET tube into the right main bronchus
D. Infection of the vocal cords
Answer: C. Movement of the ET tube into the right main bronchus
Rationale:
A. Blockage of the ET tube by the client's tongue
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
The nurse should suspect passage of the ET tube into the esophagus if the client's breath sounds
are heard over the abdomen and the abdomen becomes distended.
C. Movement of the ET tube into the right main bronchus
During intubation, the staff can misplace the ET tube in the right mainstem bronchus. The nurse
should identify absence of chest wall movement or breath sounds on a single side as indicating
ET tube displacement, and should notify appropriate personnel to reposition the tube.
D. Infection of the vocal cords
The nurse should suspect infection if the client exhibits findings such as hyperthermia and
increased WBC.
37. A nurse is caring for a client who is postoperative and whose respirations are shallow and
9/min. Which of the following acid-based imbalances should the nurse identify the client as
being at risk for developing initially?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
Answer: A. Respiratory acidosis
Rationale:
A. Respiratory acidosis
Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to
inadequate excretion of it, and an increase in the hydrogen ion concentration (decreased pH) of
the arterial blood. A major cause of this imbalance is hypoventilation from anesthetics or opioids.
B. Respiratory alkalosis
Alkalosis occurs when there is an imbalance in the amount or strength of the bases. In cases of
respiratory alkalosis, this occurs because of an excessive loss of carbon dioxide through
hyperventilation. It can occur in clients as a response to fear, anxiety or pain, from a fever or
salicylate (aspirin) overdose.
C. Metabolic acidosis
Metabolic acidosis results due to an increase in the amount of acid or a decrease in the amount of
base available. It is seen in starvation, diabetic ketoacidosis, renal failure, dehydration, and
diarrhea.
D. Metabolic alkalosis
Metabolic alkalosis results from an increase in the amount of bases seen in massive blood
transfusion, or the administration of sodium bicarbonate, or a bicarbonate containing antacid. It
can also occur related to an acid deficit, seen with prolonged vomiting, the use of thiazide
diuretics, or prolonged gastric suctioning.
38. A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS).
Which of the following interventions should the nurse include in the plan?
A. Administer low-flow oxygen continuously via nasal cannula.
B. Encourage oral intake of at least 3,000 mL of fluids per day.
C. Offer high-protein and high-carbohydrate foods frequently.
D. Place in a prone position.
Answer: D. Place in a prone position.
Rationale:
A. Administer low-flow oxygen continuously via nasal cannula.
ARDS is an acute respiratory failure in which the client remains hypoxic despite the
administration of 100% oxygen. Clients who have ARDS require high concentrations of oxygen,
usually by mask or ventilator.
B. Encourage oral intake of at least 3,000 mL of fluids per day.
Diuretics and fluid restrictions help minimize pulmonary edema, which is part of ARDS.
C. Offer high-protein and high-carbohydrate foods frequently.
Clients who have ARDS are at high risk for malnutrition. The client is often sedated and
paralyzed to provide mechanical ventilation and decrease oxygen needs. The nutritional needs of
the client will be met through enteral or parenteral means.
D. Place in a prone position.
Oxygenation in clients who have ARDS is improved when placed in the prone position. Frequent
and consistent turning of the client is also beneficial and can be accomplished by the use of
specialty beds.
39. A nurse is assessing a client who has developed atelectasis postoperatively. Which of the
following findings should the nurse expect?
A. Facial flushing
B. Increasing dyspnea
C. Decreasing respiratory rate
D. Friction rub
Answer: B. Increasing dyspnea
Rationale:
A. Facial flushing
Atelectasis refers to the closure or collapse of the alveoli resulting in hypoxia. A client may
develop cyanosis as a result.
B. Increasing dyspnea
The postoperative client is at increased risk for developing atelectasis because of a blunted cough
reflex or shallow breathing due to anesthesia, opioids or pain medication. Common
manifestations include shortness of breath and pleural pain.
C. Decreasing respiratory rate
Because of the decreased oxygen exchange caused by the atelectasis, the client will be
tachypneic in an effort to meet the body's oxygen needs.
D. Friction rub
A friction rub is a grating or creaking sound heard when a client has inflammation of the pleura.
For the client who has atelectasis, auscultation may reveal decreased breath sounds and crackles.
40. A nurse is caring for a client who has just developed a pulmonary embolism. Which of the
following medications should the nurse anticipate administering?
A. Furosemide
B. Dexamethasone
C. Heparin
D. Atropine
Answer: C. Heparin
Rationale:
A. Furosemide
Furosemide, a diuretic, is often used in the treatment of pulmonary edema; however, it is not
used for the client who has a pulmonary embolism.
B. Dexamethasone
Glucocorticoids such as dexamethasone decrease inflammation and is used to treat a wide variety
of disorders, including inflammatory bowel disease and cerebral edema. It is not, however, useful
in treating a pulmonary emboli.
C. Heparin
A pulmonary emboli is a condition in which the pulmonary blood flow is obstructed, resulting in
hypoxia and possible death. Most often caused by a blood clot, treatment such as heparin, an
anticoagulant, is used to prevent the enlargement of the existing clot or formation of new clots.
D. Atropine
Atropine, an anticholinergic, is used in the treatment of bradycardia. The client who has a
pulmonary embolism will be tachycardic.
41. A nurse is caring for a client who develops a pulmonary embolism. Which of the following
interventions should the nurse implement first?
A. Give morphine IV.
B. Administer oxygen therapy.
C. Start an IV infusion of lactated Ringer's.
D. Initiate cardiac monitoring.
Answer: B. Administer oxygen therapy.
Rationale:
A. Give morphine IV.
It is important to manage the client's pain because this can reduce oxygen consumption and limit
the harmful effects of catecholamines, which are released when the client experiences pain;
however, another intervention should be implemented by the nurse first.
B. Administer oxygen therapy.
The greatest risk to the safety of a client who has a pulmonary embolism is hypoxemia with
respiratory distress and cyanosis. Oxygen therapy should be applied by the nurse using a nasal
cannula or mask. Pulse oximetry should be initiated to monitor oxygen saturation.
C. Start an IV infusion of lactated Ringer's.
Crystalloids are administered via continuous IV bolus to maintain cardiac output and prevent
shock; however, another intervention is the priority action for the nurse to take.
D. Initiate cardiac monitoring.
The client who develops a pulmonary embolism is likely to have cardiac manifestation as a result
of decreased tissue perfusion. It will be important to monitor the client's cardiac rhythm for Twave and ST-segment changes as well as right ventricular failure or myocardial infarction. There
is, however, another intervention that is the priority.
42. A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the
following manifestations should the nurse expect?
A. Bradycardia
B. Bradypnea
C. Lethargy
D. Intercostal retractions
Answer: D. Intercostal retractions
Rationale:
A. Bradycardia
A client who is hypoxic is more likely to have tachycardia than bradycardia.
B. Bradypnea
Clients who have hypoxia generally have rapid, shallow respirations and are dyspneic.
C. Lethargy
The client who is hypoxic is increasingly restless and may state feeling light-headed.
D. Intercostal retractions
Hypoxia is a condition in which the tissues of the body are oxygen-starved. It follows hypoxemia
(low oxygen in the blood) and is manifested as substernal or intercostal retractions as the body
works harder to draw more oxygen into the lungs.
43. A nurse is assessing a client immediately after the provider removed the client's endotracheal
tube. Which of the following findings should the nurse report to the provider?
A. Stridor
B. Copious oral secretions
C. Hoarseness
D. Sore throat
Answer: A. Stridor
Rationale:
A. Stridor
Stridor, or a high-pitched crowing sound heard during inspiration, is a result of laryngeal edema.
This finding indicates possible obstruction of the client's airway. Therefore, the nurse should
report it to the provider immediately.
B. Copious oral secretions
Copious oral secretions following extubation is an expected finding. The nurse should remind the
client to cough to facilitate removal of secretions in the throat.
C. Hoarseness
Hoarseness is an expected finding following extubation.
D. Sore throat
Sore throat is an expected finding following extubation.
44. A nurse in the emergency department is caring for a client who was injured in a motorvehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest
moves inward during inspiration and bulges out during expiration. The nurse should identify this
finding as which of the following?
A. Atelectasis
B. Flail chest
C. Hemothorax
D. Pneumothorax
Answer: B. Flail chest
Rationale:
A. Atelectasis
Atelectasis is a collapse of the alveoli. With atelectasis, the exchange of oxygen and carbon
dioxide is diminished. Crackles, fever and productive cough are manifestations of atelectasis.
B. Flail chest
Flail chest is the result of multiple rib fractures that cause instability. During inspiration, the
thorax moves inward and during expiration it bulges out.
C. Hemothorax
Hemothorax is blood in the pleural space and involves decreased movement of the involved
chest wall. Manifestations of a large hemothorax include diminished breath sounds and dull
percussion sounds.
D. Pneumothorax
Pneumothorax is air in the pleural space and involves decreased movement of the involved chest
wall. Manifestations of pneumothorax include diminished breath sounds and hyperresonance
upon percussion.
45. A nurse is auscultating the lungs of a client who has pleurisy. Which of the following
adventitious breath sounds should the nurse expect to hear?
A. Loud, scratchy sounds
B. Squeaky, musical sounds
C. Popping sounds
D. Snoring sounds
Answer: A. Loud, scratchy sounds
Rationale:
A. Loud, scratchy sounds
Loud, scratchy sounds caused by inflammation of the pleura are a manifestation of pleurisy.
B. Squeaky, musical sounds
Squeaky, musical sounds caused by air whoosh through narrowed airways are a manifestation of
bronchospasms.
C. Popping sounds
Popping sounds caused by moving into deflated airways are a manifestation of atelectasis and
pneumonia.
D. Snoring sounds
Snoring sounds, known as rhonchi, are heard when a client has thick, tenacious secretions.
46. A nurse in the emergency department is caring for a client who has pulmonary edema, reports
dyspnea, and appears anxious. The client's blood pressure is 108/79 and his apical pulse is 112.
Which of the following interventions is the nurse's priority?
A. Administer high-flow oxygen at 5 L/min by facemask to the client.
B. Place the client in high-Fowler's position with legs dependent.
C. Give the client sublingual nitroglycerin.
D. Reassure the client.
Answer: A. Administer high-flow oxygen at 5 L/min by facemask to the client.
Rationale:
A. Administer high-flow oxygen at 5 L/min by facemask to the client.
A client who has pulmonary edema is critically ill and is hypoxic. The first action the nurse
should take when using the airway, breathing, circulation approach to client care is to administer
high-flow oxygen at 5 L/min by facemask to the client.
B. Place the client in high-Fowler's position with legs dependent.
The nurse should place the client in high-Fowler's position with legs dependent to decrease
venous return to the heart. However, there is another intervention that is the nurse's priority.
C. Give the client sublingual nitroglycerin.
The nurse should administer sublingual nitroglycerin to decrease preload and afterload.
However, there is another intervention that is the nurse's priority.
D. Reassure the client.
The nurse should reassure the client that his dyspnea will diminish with treatment. However,
there is another intervention that is the nurse's priority.
47. A nurse is monitoring an older adult client immediately following a bronchoscopy. The
nurse's priority is to monitor the client for which of the following?
A. Observing for confusion
B. Auscultating breath sounds
C. Confirming the gag reflex
D. Measuring blood pressure
Answer: C. Confirming the gag reflex
Rationale:
A. Observing for confusion
Following a bronchoscopy, an older adult client is at risk for confusion due to medications use
for sedation. However, there is another assessment that is the nurse's priority.
B. Auscultating breath sounds
The client is at risk for hypoxia following a bronchoscopy and the nurse should auscultate the
client's breath sounds. However, there is another assessment that is the nurse's priority.
C. Confirming the gag reflex
When using the airway, breathing, circulation approach to client care, the nurse should first
assess the client's gag reflex to ensure that the client has an open airway.
D. Measuring blood pressure
The client is at risk for hypotension due to the medications used for sedation during the
procedure. However, there is another assessment that is the nurse's priority.
48. A nurse in the emergency department is assessing an older adult client who has communityacquired pneumonia. Which of the following findings should the nurse expect?
A. Unequal pupils
B. Hypertension
C. Tympany upon chest percussion
D. Confusion
Answer: D. Confusion
Rationale:
A. Unequal pupils
Unequal pupils are an expected finding for a client who has increased intracranial pressure.
B. Hypertension
Hypotension is an expected finding for a client who has pneumonia.
C. Tympany upon chest percussion
Dull sounds upon chest percussion is an expected finding for a client who has pneumonia.
D. Confusion
Confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia.
49. A nurse in the intensive care unit is providing teaching for a client prior to removal of an
endotracheal tube. Which of the following instructions should the nurse include in the teaching?
A. "Rest in a side-lying position after the tube is removed."
B. "Use the incentive spirometer every 4 hr after the tube is removed."
C. "Avoid speaking for long periods."
D. "A nurse will monitor your vital signs every 15 minutes in the first hour after the tube is
removed."
Answer: C. "Avoid speaking for long periods."
Rationale:
A. "Rest in a side-lying position after the tube is removed."
To promote ventilation, the client should sit upright in a semi-Fowler's position after the tube is
removed.
B. "Use the incentive spirometer every 4 hr after the tube is removed."
To promote ventilation the client should use the incentive spirometer every 2 hr after the tube is
removed.
C. "Avoid speaking for long periods."
The client should avoid speaking for long periods to promote gas exchange.
D. "A nurse will monitor your vital signs every 15 minutes in the first hour after the tube is
removed."
To reduce the risk of respiratory distress after the tube is removed, the nurse will monitor the
client's vital signs every 5 min after the tube is removed.
50. A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight
of 60 kg. The nurse should expect the tidal volume to be set at which of the following?
A. 300 mL
B. 480 mL
C. 800 mL
D. 950 mL
Answer: B. 480 mL
Rationale:
A. 300 mL
The average tidal volume is 7 to 9 mL/kg of body weight. Therefore, this setting is below the
average range.
B. 480 mL
The average tidal volume is 7 to 9 mL/kg. 60 kg x 8 mL/kg = 480. Therefore, this setting is
within the average range.
C. 800 mL
The average tidal volume is 7 to 9 mL/kg of body weight. Therefore, this setting exceeds the
average range.
D. 950 mL
The average tidal volume is 7 to 9 mL/kg of body weight. Therefore, this setting exceeds the
average range.
51. A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should
monitor the client for which of the following manifestations of this condition? (Select all that
apply.)
A. Severe dyspnea
B. Nausea
C. Decreased level of consciousness
D. Headache
E. Hypotension
Answer: A. Severe dyspnea
C. Decreased level of consciousness
D. Headache
E. Hypotension
Rationale:
A. Severe dyspnea
Severe dyspnea is correct. Severe dyspnea is a manifestation of ARF that occurs as a result of
hypoxemia.
B. Nausea
Nausea is incorrect. Gastrointestinal manifestations are not manifestations of ARF.
C. Decreased level of consciousness
Decreased level of consciousness is correct. Decreased level of consciousness is a manifestation
of ARF that occurs due to hypercapnia.
D. Headache
Headache is correct. Headache is a manifestation of ARF that occurs due to hypercapnia.
E. Hypotension
Hypotension is correct. Hypotension is a manifestation of ARF that occurs due to acidosis.
52. A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client
trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper
airway, the client remains apneic. Which of the following actions should the nurse take?
A. Start CPR.
B. Place a red tag on the client's upper body and obtain immediate help from other personnel.
C. Place a black tag on the client's upper body and attempt to help the next client in need.
D. Reposition the client's upper airway a second time before assessing his respirations.
Answer: C. Place a black tag on the client's upper body and attempt to help the next client in
need.
Rationale:
A. Start CPR.
Clients in need of CPR are not immediately treated when multiple victims are present.
Furthermore, CPR will not be effective if the client is trapped under a vehicle.
B. Place a red tag on the client's upper body and obtain immediate help from other personnel.
A red triage tag is not appropriate for a client who has apnea. This client's condition is
imminently terminal. Therefore, the client should place a black tag on the client.
C. Place a black tag on the client's upper body and attempt to help the next client in need.
When assessing an apneic adult casualty in a disaster situation, a nurse should attempt to
reposition the upper airway on time. If the client still does not breathe, a black tag should be
placed on the upper body and the nurse should move on to the next client in need.
D. Reposition the client's upper airway a second time before assessing his respirations.
After attempting to reposition the airway one time, the nurse should triage the client and move
on to the next client in need.
53. A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the
following clients should the nurse identify as requiring airborne precautions?
A. A client who has scabies
B. A client who has pertussis
C. A client who has streptococcal pharyngitis
D. A client who has measles
Answer: D. A client who has measles
Rationale:
A. A client who has scabies
A client who has scabies requires contact precautions.
B. A client who has pertussis
A client who has pertussis requires droplet precautions.
C. A client who has streptococcal pharyngitis
A client who has streptococcal pharyngitis requires droplet precautions.
D. A client who has measles
A client who has measles requires airborne precautions as well as a negative pressure room.
54. A nurse is monitoring a client who received epinephrine for angioedema after a first dose of
losartan. Which of the following data indicates a therapeutic response to the epinephrine?
A. Respirations are unlabored.
B. Client reports decreased groin pain of 3 on a 1 to 10 scale.
C. The client's blood pressure when arising from resting position is at premedication levels.
D. The client tolerates a second dose of medication with no greater than 1+ peripheral edema.
Answer: A. Respirations are unlabored.
Rationale:
A. Respirations are unlabored.
Losartan is an angiotensin receptor blocker (ARB). Both ARBs and angiotensin converting
enzyme (ACE) inhibitors have the adverse effect of angioedema. The primary symptom of
angioedema is swelling of the tongue, glottis, and pharynx. This results in limitation or blockage
of the airway. Angioedema causes the capillaries to become more permeable, resulting in fluid
shifting into the subcutaneous tissues. Although the mouth and throat are most often affected,
any area may be involved in the process. Untreated, angioedema can result in death.
Improvement of respiratory effort following the administration of epinephrine is the most
important therapeutic indicator.
B. Client reports decreased groin pain of 3 on a 1 to 10 scale.
Although edema can occur in any area, the groin is not affected specifically by the disorder.
Angioplasty and angiograms most often utilize the femoral vessels, but the prefix "angio" is a
general term for blood vessel rather than a reference to the femoral area.
C. The client's blood pressure when arising from resting position is at premedication levels.
Hypotension is a common side effect of angiotensin II receptor blockers (ARBs) such as
losartan. For this side effect, the nurse should monitor blood pressure when the client changes
position. However, angioedema is an adverse reaction that can result in swelling of the lips,
tongue, and glottis. The client experiences extreme respiratory distress.
D. The client tolerates a second dose of medication with no greater than 1+ peripheral edema.
Peripheral edema is not usually associated with angioedema. The edema that is significant in this
client occurs in the lips, mouth, and throat, causing airway obstruction. Once the client has this
response, the client must know to never take any medication in the angiotensin II receptor
blocker classification.
55. A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney
failure and determines the client has respiratory acidosis. Which of the following findings should
the nurse expect?
A. Widened QRS complexes
B. Hyperactive deep tendon reflexes
C. Bounding peripheral pulses
D. Warm, flushed skin
Answer: A. Widened QRS complexes
Rationale:
A. Widened QRS complexes
A client who has respiratory acidosis is likely to cardiac changes from delayed electrical
conduction through the heart, such as widened QRS complexes, tall T waves, prolonged PR
intervals, and a heart rate that ranges from bradycardia to heart block.
B. Hyperactive deep tendon reflexes
A client who has respiratory acidosis is more likely to have reduced muscle tone and hypoactive
deep tendon reflexes due to hyperkalemia.
C. Bounding peripheral pulses
A client who has respiratory acidosis is more likely to have thready peripheral pulses which are
difficult to palpate.
D. Warm, flushed skin
A client who has respiratory acidosis is more likely to have pale to cyanotic, dry skin. A client
who has metabolic acidosis is likely to have warm, flushed dry skin.
56. A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the
following actions should the nurse take after noticing a rise in the water seal chamber with client
inspiration?
A. Continue to monitor the client.
B. Immediately notify the provider.
C. Reposition the client toward the left side.
D. Clamp the chest tube near the water seal.
Answer: A. Continue to monitor the client.
Rationale:
A. Continue to monitor the client.
The fluid in the water seal chamber rises 2 to 4 inches during inhalation and falls during
exhalation. This is a process called tidaling. An absence of tidaling might indicate a fully
expanded lung or an obstruction in the chest tube.
B. Immediately notify the provider.
The nurse does not need to contact the provider at this time. The fluid in the water seal chamber
is expected to rise during inhalation and fall during exhalation.
C. Reposition the client toward the left side.
Repositioning the client can aid in comfort and prevention of pressure ulcers; however,
repositioning is not indicated in this situation.
D. Clamp the chest tube near the water seal.
Chest tube manipulation should be kept at a minimum. Clamping the chest tube is not
recommended. It should be clamped only for brief periods to check for an air leak or change the
drainage system.
57. A nurse is caring for a client who is receiving positive-pressure mechanical ventilation.
Which of the following interventions should the nurse implement to prevent complications?
(Select all that apply.)
A. Elevate the head of the bed to at least 30°.
B. Verify the prescribed ventilator settings daily.
C. Apply restraints if the client becomes agitated.
D. Administer pantoprazole as prescribed.
E. Reposition the endotracheal tube to the opposite side of the mouth daily.
Answer: A. Elevate the head of the bed to at least 30°.
D. Administer pantoprazole as prescribed.
E. Reposition the endotracheal tube to the opposite side of the mouth daily.
Rationale:
A. Elevate the head of the bed to at least 30°.
Elevate the head of the bed to at least 30° is correct. A client who is intubated is at risk for
aspiration and ventilator-associated pneumonia. To minimize these risks, the nurse should
maintain the head of the bed at 30° or higher.
B. Verify the prescribed ventilator settings daily.
Verify the prescribed ventilator settings daily is incorrect. The nurse should perform and
document ventilator checks at least every 8 hr to ensure the ventilator settings are as prescribed.
C. Apply restraints if the client becomes agitated
Apply restraints if the client becomes agitated is incorrect. A client who becomes agitated or
restless might be experiencing air hunger. The nurse should assess the flow settings. If the client
continues to be restless or agitated, a chemical restraint, such as midazolam, may be
administered. Physical restraints are a last resort and only applied to prevent accidental
dislodgement of the endotracheal tube.
D. Administer pantoprazole as prescribed.
Administer pantoprazole as prescribed is correct. Stress ulcers occur in many patients receiving
mechanical ventilation. Antacids, histamine blockers, or proton-pump inhibitors are often
prescribed as soon as a client is intubated.
E. Reposition the endotracheal tube to the opposite side of the mouth daily.
Reposition the endotracheal tube to the opposite side of the mouth daily is correct. The nurse
should assess the area around the endotracheal tube frequently for color, tenderness, skin
irritation, and drainage. The nurse should perform oral care every 2 hr. To prevent skin
breakdown, the oral endotracheal tube should be moved to the opposite side on the mouth once
daily.
58. A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a
chest tube drainage system in place. Which of the following findings by the nurse indicates a
need for intervention?
A. Chest tube eyelets not visible
B. Continuous bubbling in the suction control chamber
C. Presence of tidal fluctuation in the water seal chamber
D. Development of subcutaneous emphysema
Answer: D. Development of subcutaneous emphysema
Rationale:
A. Chest tube eyelets not visible
Eyelets allow for drainage from the pleural space. The eyelets should not be visible when
inspecting the insertion site.
B. Continuous bubbling in the suction control chamber
The suction control chamber regulates the amount of negative pressure being applied to the
pleural space. When suction is applied, the water in this chamber should bubble continuously.
C. Presence of tidal fluctuation in the water seal chamber
The water contained in the water seal chamber prevents air from re-entering the pleural space.
The water level in this chamber rises with inhalation and falls with exhalation, which referred to
as tidaling and is an expected finding
D. Development of subcutaneous emphysema
Subcutaneous emphysema is an indication that air is trapped in and under the skin, which be the
result of a pneumothorax and should be reported to the provider.
59. A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of
the following findings should the nurse expect?
A. HCO3- 30 mEq/L
B. PaCO2 50 mm Hg
C. pH 7.45
D. Potassium 3.3 mEq/L
Answer: B. PaCO2 50 mm Hg
Rationale:
A. HCO3- 30 mEq/L
This laboratory value is expected for a client who has metabolic alkalosis.
B. PaCO2 50 mm Hg
This laboratory value is an expected finding for a client who has respiratory acidosis.
C. pH 7.45
This laboratory value is within the expected reference range.
D. Potassium 3.3 mEq/L
This laboratory value is expected for a client who has metabolic alkalosis.
60. A nurse is caring for a client who has an endotracheal tube and is receiving mechanical
ventilation. Which of the following interventions should the nurse take to reduce the risk for
ventilator-associated pneumonia?
A. Position the head of the client's bed in the flat position.
B. Turn the client every 4 hr.
C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
D. Perform hand hygiene prior to suctioning the client's endotracheal tube.
Answer: C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
Rationale:
A. Position the head of the client's bed in the flat position.
The nurse should elevate the head of the client’s bed 30° to reduce the risk for aspiration and
pneumonia.
B. Turn the client every 4 hr.
The nurse should turn the client every 2 hr to promote lung expansion and reduce the risk for
pneumonia.
C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
The nurse should brush the client’s teeth every 8 hr and rinse the client’s mouth with an
antimicrobial rinse every 2 hr to reduce the growth of bacteria.
D. Perform hand hygiene prior to suctioning the client's endotracheal tube.
The nurse should perform hand hygiene prior to suctioning the client’s endotracheal tube to
reduce the risk of introducing bacteria.
61. A nurse is caring for a client who has an endotracheal tube and is receiving mechanical
ventilation. The client pulls out his endotracheal tube. Which of the following actions should the
nurse take first?
A. Prepare the client for reintubation.
B. Assess the client’s airway.
C. Suction the client’s mouth.
D. Elevate the client’s head of bed.
Answer: B. Assess the client’s airway.
Rationale:
A. Prepare the client for reintubation.
The nurse should prepare the client for reintubation to promote ventilation and improve
oxygenation; however, there is another action the nurse should take first.
B. Assess the client’s airway.
The first action the nurse should take using the nursing process is to assess the client’s airway for
obstruction, listen to the client’s lungs for air movement, and provide mechanical ventilation
with a bag-valve-mask device to reduce the risk for hypoxia.
C. Suction the client’s mouth.
The nurse should suction the client’s oral airway as needed to remove secretions and improve
oxygenation; however, there is another action the nurse should take first.
D. Elevate the client’s head of bed.
The nurse should elevate the client’s head of bed to promote ventilation; however, there is
another action the nurse should take first.
62. A nurse is caring for a child who is experiencing status asthmaticus. Which of the following
interventions is the priority for the nurse to take?
A. Administer a short-acting ß2 –agonist (SABA).
B. Obtain a peak flow reading.
C. Administer an inhaled glucocorticoid.
D. Determine the cause of the acute exacerbation.
Answer: A. Administer a short-acting ß2 –agonist (SABA).
Rationale:
A. Administer a short-acting ß2 –agonist (SABA).
When using the urgent versus non-urgent approach to client care, the nurse should determine that
the priority action is to administer a nebulized high-dose SABA to relieve bronchoconstriction
and improve ventilation.
B. Obtain a peak flow reading.
Obtaining a peak flow reading is non-urgent while the client is in distress. Although a peak flow
reading will assist with determining the severity of the bronchospasms and assist with
management of medications to prevent further exacerbations, there is another action that is the
priority.
C. Administer an inhaled glucocorticoid.
Administering an inhaled glucocorticoid is non-urgent while the client is in distress. Although an
inhaled glucocorticoid should be used for long-term therapy to prevent future exacerbations,
there is another action that is the priority. The nurse should administer a systemic glucocorticoid
for immediate relief of airway inflammation.
D. Determine the cause of the acute exacerbation.
Determining the cause of the acute exacerbation is non-urgent while the client is in distress.
Although the nurse should determine the trigger for the asthma exacerbation to prevent future
attacks, there is another action that is the priority.
63. A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following
manifestations should the nurse expect?
A. Nausea
B. Dysphagia
C. Agitation
D. Hypotension
Answer: C. Agitation
Rationale:
A. Nausea
The nurse would not expect the client to be nauseated during an asthma attack.
B. Dysphagia
The nurse should expect the client to display dyspnea, not dysphagia, during an asthma attack.
C. Agitation
The nurse should expect agitation due to neurological changes from poor oxygen exchange.
D. Hypotension
The nurse should expect hypertension due to increased work load of the heart from decreased
oxygenation.
64. A nurse is teaching a client about taking diphenhydramine. The nurse should explain to the
client that which of the following is an adverse effect of this medication?
A. Sedation
B. Constipation
C. Hypertension
D. Bradycardia.
Answer: A. Sedation
Rationale:
A. Sedation
Diphenhydramine can cause sedation. It is used to treat rhinitis, allergies, and insomnia.
B. Constipation
Diphenhydramine can cause diarrhea.
C. Hypertension
Diphenhydramine can cause hypotension.
D. Bradycardia.
Diphenhydramine can cause palpitations.
65. A nurse is performing chest physiotherapy on a client who has a respiratory infection. To
increase the velocity and turbulence of the air the client exhales, which of the following
techniques should the nurse use?
A. Postural drainage
B. Nebulization
C. Percussion
D. Vibration
Answer: D. Vibration
Rationale:
A. Postural drainage
Postural drainage allows secretions to drain by gravity. It does not increase air turbulence.
B. Nebulization
Nebulizer therapy can help loosen secretions prior to chest physiotherapy, but it does not
increase air turbulence.
C. Percussion
To perform percussion, the nurse strikes the skin over congested lung fields to loosen secretions.
It does not increase air turbulence.
D. Vibration
Vibration after percussion, or alternately with percussion, increases the velocity and turbulence
of the air the client exhales, while loosening secretions and triggering coughing.
