4. A client has a tracheostomy tube in place. When the nurse suctions the client,
food particles are noted. What action by the nurse is best?
b. Measure and compare cuff pressures.
ANS: B
2. A nurse assesses a client
...
4. A client has a tracheostomy tube in place. When the nurse suctions the client,
food particles are noted. What action by the nurse is best?
b. Measure and compare cuff pressures.
ANS: B
2. A nurse assesses a client after an open lung biopsy. Which assessment finding
is matched with the correct intervention?
c. Client has reduced breath sounds. Nurse calls physician immediately.
ANS: C
3. A nurse assesses a clients respiratory status. Which information is of highest
priority for the nurse to obtain?
d. Occupation and hobbies
ANS: D
2. A nurse assesses a client who is experiencing an acid-base imbalance. The
clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm
Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first?
a. Cardiac rate and rhythm
ANS: A
6. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial
blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What
action should the nurse take next?
a. Assess clients rate, rhythm, and depth of respiration.
7. A nurse is assessing a client who is recovering from a lung biopsy. Which
assessment finding requires immediate action?
b. Absent breath sounds
ANS: B
8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The
clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22
mEq/L. Which action should the nurse take first?
a. Apply oxygen by mask or nasal cannula.
8. A nurse is caring for a client who is scheduled to undergo a thoracentesis.
Which intervention should the nurse complete prior to the procedure?
d. Validate
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