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 that informed consent has been given by the client.
ANS: D
9. A nurse assesses a client after a thoracentesis. Which assessment finding
warrants immediate action?
d. The trachea is deviated toward the opposite side of the neck.
ANS: D
1.A nurse is caring for a client who has just had a central venous access line
inserted. Which action should the nurse take next?
b. Ensure an x-ray is completed to confirm placement.
ANS: B
3.A nurse teaches a client who is being discharged home with a peripherally
inserted central catheter (PICC). Which statement should the nurse include in
this clients teaching?
a. Avoid carrying your grandchild with the arm that has the central catheter.
ANS: A
5.A nurse is caring for a client who is receiving an epidural infusion for pain
management. Which assessment finding requires immediate intervention from
the nurse?
b. Report of headache and stiff neck
ANS: B
7.A nurse is assessing clients who have intravenous therapy prescribed. Which
assessment finding for a client with a peripherally inserted central catheter
(PICC) requires immediate attention?
d. Upper extremity swelling is noted.
ANS: D
13.A nurse teaches a client who is prescribed a central vascular access device.
Which statement should the nurse include in this clients teaching?
c. Ask all providers to vigorously clean the connections prior to accessing the device.
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