PN2 Exam 1 {UPDATED} – Rasmussen College | Professional Nursing 2

PN2 Exam 1 {UPDATED} – Rasmussen College 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 press ...

PN2 Exam 1 {UPDATED} – Rasmussen College 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. ANS: C - - - - - - - - - - - - - - - - - - -- - - - - - -- - - - - - - - - - - - - -- 4. A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity d. Range of motion e. Vision ANS: A, B, D, E 1.The nurse is aware that which factors are related to the development of gastroesophageal reflux disease (GERD)? (Select all that apply.) a. Delayed gastric emptying b. Eating large meals c. Hiatal hernia d. Obesity ANS: A, B, C, D 21.A nurse admits a client from the emergency department. Client data are listed below: History/70 years of age/ History of diabetes/ On insulin twice a day/ Reports new-onset dyspnea and productive cough/ What action by the nurse is the priority? a. Administer oxygen at 4 liters per nasal cannula. 3. A client with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The clients blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate? c. Start a large-bore IV with normal saline. 12. A nurse assesses a client with Crohns disease and colonic strictures. Which clinical manifestation should alert the nurse to urgently contact the health care provider? a. Distended abdomen 13. A nurse reviews the chart of a client who has Crohns disease and a draining fistula. Which documentation should alert the nurse to urgently contact the provider for additional prescriptions? a. Serum potassium of 2.6 mEq/L 19. A nurse plans care for a client with Crohns disease who has a heavily draining fistula. Which intervention should the nurse indicate as the priority action in this clients plan of care? b. Skin protection