Question 1. Question :
The nursing assistant reports to the nurse that an African-American client’s pulse oximetry reading is
93%. The client has no complaints. Which action by the nurse is most appropriate?
Student A
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Question 1. Question :
The nursing assistant reports to the nurse that an African-American client’s pulse oximetry reading is
93%. The client has no complaints. Which action by the nurse is most appropriate?
Student Answer: Replace the sensor probe of the oximeter.
Place the probe on another finger.
CORRECT Assess other signs of respiratory adequacy.
Prepare to obtain arterial blood gases.
Question 2. Question :
Which of the following has the highest priority when assessing a client’s respiratory status?
Student Answer: Average daily fluid intake
Neck circumference
Height and weight
CORRECT Occupation and hobbies
Question 3. Question :
Which of the following assessments obtained while auscultating breath sounds is matched with the
appropriate nursing action the nurse should take secondary to the assessment finding?
Student Answer: Hollow sounds are heard over the trachea. – The nurse increases the
oxygen flow rate.
INCORRECT Crackles are heard in bases. – The nurse encourages the client to cough
forcefully.
CORRECT Wheezes are heard in central areas. – The nurse administers an inhaled
bronchodilator.
Vesicular sounds are heard over the periphery. – The nurse has the
client breathe deeply.
Question 4. Question :
What nursing action is appropriate to implement when a client reports waking up feeling very tired even
after 8 hours of good sleep?
Student Answer: CORRECT Ask the client if he or she has ever been evaluated for sleep
apnea.
Contact the provider for a prescription for sleep medication.
Educate the client to sleep upright in a reclining chair.
Tell the client not to drink beverages with caffeine before bed.
Question 5. Question :
What should the nurse suggest to help a client’s self-esteem if he is being discharged home after having
a tracheostomy placed? (Select all that apply.)
Student Answer: CORRECT Have some type of communication system with you at all times.
CORRECT Always have someone with you so they can talk for you.
CORRECT It is better to stay home and find hobbies to enjoy at home.
CORRECT Try loose-fitting shirts with collars.
CORRECT Wear fashionable scarves.
Question 6. Question :
Which of the following procedures is an incorrect method of suctioning a tracheostomy and should be
adjusted?
Student Answer: CORRECT Applying suction while inserting the catheter
Preoxygenating the client prior to suctioning
Suctioning for a total of three times if needed
Suctioning for only 10 to 15 seconds each time
Question 7. Question :
What should be included in client teaching when providing information to the client who uses oxygen in
the home? (Select all that apply.)
Student Answer: CORRECT The client should not allow smoking in the house.
CORRECT Electrical cords should be in good working order and have no
bare wires.
CORRECT Flammable liquids must be stored in the garage.
INCORRECT Household light bulbs should be the fluorescent type.
CORRECT The client should not allow pets inside the home.
Question 8. Question :
What should be the priority nursing action for a client who is experiencing epistaxis?
Student Answer: Apply direct pressure.
CORRECT Initiate Standard Precautions.
INCORRECT Loosely pack the nares with gauze.
Sit the client upright.
Question 9. Question :
A client, with a new tracheostomy. is being seen in the oncology clinic. What finding by the nurse best
indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?
Student Answer: INCORRECT The client demonstrates good understanding of stoma care.
CORRECT The client has joined a book club that meets at the library.
Family members take turns assisting with stoma care.
Skin around the stoma is intact without signs of infection.
Question 10. Question :
What would be the first action the nurse should take after finding stridor in a client who has facial
trauma is restless and anxious?
Student Answer: Administer prescribed albuterol nebulizer therapy.
Ask the client to perform deep-breathing exercises.
CORRECT Contact the provider and prepare for intubation.
Place the client in High-Fowler’s position.
Question 11. Question :
Which intervention should be added to a client’s plan of care for a client who is experiencing dyspnea
and must stop multiple times when climbing a flight of stairs?
Student Answer: CORRECT Assistance with activities of daily living
Physical therapy activities every day
INCORRECT Oxygen therapy at 2 liters per nasal cannula
Complete bed rest with frequent repositioning
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