Situation 1: Suctioning is the mechanical aspiration of mucous secretions from the tracheobronchial tree by application of negative pressure. Nurses should be knowledgeable when performing such procedure.
1. The nurse is suctioning a client through an endotracheal tube. During the suctioning procedure the nurse notes cardiac irregularities on the monitor. Which of the following is the most appropriate nursing intervention?
a. Continue to suction
b. Ensure that the suction is limited to 15 seconds
c. Stop the procedure and reoxygenate the client
d. Notify the physician immediately
2. A nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which of the following observations, if made by the instructor, would indicate an inappropriate action?
a. Hyperventilating the client with 100% oxygen before suctioning
b. Instilling 3 to 5 ml normal saline in the tracheostomy tube to loosen secretions
c. Applying suction during insertion of the catheter
d. Applying suction during withdrawal of the catheter
3. A nurse is suctioning a client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning to a maximum of:
a. 5 seconds c. 30 seconds
b. 15 seconds d. 1 minute
4. A nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which of the following observations is made?
a. Secretions are becoming bloody
b. Heart rate decreases from 78 to 54 beats per minute
c. Coughing occurs with suctioning
d. Skin color becomes cyanotic
5. A client with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, the nurse should:
a. Apply suction while inserting the catheter
b. Hyperoxygenate with 100% oxygen before and after suctioning
c. Use short, jabbing movements of the catheter to loosen secretions
d. Suction 2 to 3 times in quick succession to remove secretions
Situation 2. The nurse is caring for a client with a chest tube drainage system following a traumatic open chest injury.
6. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber on the chest tube system. Which nursing action is most appropriate?
a. No action is necessary
b. Encourage coughing and deep breathing
c. Suction the client
d. Increase the suction
7. During the first 36 hours after the insertion of the chest tube, the nurse assess the function of the three-chamber, closed-chest drainage system and notes that the water in the underwater seal tube is not fluctuating. The initial nursing intervention should be to
a. Inform the physician
b. Take the client's vital signs
c. Check whether the tube is kinked
d. Turn the client to the unaffected side
8. The client's chest tube was attached to a Pleurevac drainage system. As part of routine nursing care, the nurse would ensure that:
a. The connection between the chest tube and the drainage system is taped, and that an occlusive dressing is maintained at the insertion site
b. The amount of chest tube drainage is noted and recorded every 24 hours in the client's record.
c. The suction control chamber has sterile water added every shift and that the system is kept below waist level
d. The water seal chamber has continuous bubbling and that monitoring for crepitus is done once a shift.
9. When the nurse enters the room of the client, she notices that the chest tube is dislodged from the chest. The most appropriate nursing intervention is to:
a. Notify the physician
b. Insert a new chest tube
c. Cover the insertion site with petroleum gauze
d. Instruct the client to breathe deeply until help arrives
10. The client who has chest tube drainage is to be transported to the X-Ray department in order to assess the degree of lung reexpansion. To safely transport the client, the nurse would:
a. Remove the chest tubes, immediately covering the incision site with a sterile petrolatum gauze to prevent air from entering the chest.
b. Disconnect the drainage bottles from the chest tubes, covering the catheter tip with a sterile dressing to prevent contamination.
c. Send the client to x-ray with the chest tube clamped but still attached to the drainage system to prevent air from entering the chest wall if the bottles are accidentally broken
d. Send the client to x-ray with the chest tube attached to the drainage system, taking precautions to prevent interruption in the system.
Situation 3. Nurse Gemma is caring for Mr. Kyle, a 30 years old man diagnosed with emphysema. Oxygen therapy was prescribed by his physician.
11. An oxygen delivery system is prescribed for Mr. Kyle in order to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed?
a. Venturi mask c. Face tent
b. Aerosol mask d. Tracheostomy collar
12. When caring for Mr. Kyle, the nurse checks the oxygen flow rate to ensure that it does not exceed:
a. 1 liter per minute
b. 3 liters per minute
c. 6 liters per minute
d. 10 liters per minute
13. Supplemental low-flow oxygen therapy was prescribed to Mr. Kyle by his physician. Which is the most essential action for the nurse to initiate?
a. Anticipate the need for humidification
b. Notify the physician that this order is contraindicated
c. Place the client in High-Fowler's position
d. Schedule nursing care to allow frequent observations of the client
14. Nurse Gemma explains to Mr. Kyle's family that humidification is given with oxygen administration because:
a. Oxygen is highly permeable in water, thereby increasing gaseous diffusion
b. Oxygen is very drying to the mucous membranes
c. The partial pressures of oxygen are increased by water dilution, allowing more oxygen to reach the alveoli.
d. Water acts as a carrier substance facilitating movement of oxygen across the respiratory membrane
15. Mr. Kyle's arterial blood gases reveal: pH - 7.38; PO2 - 65; PCO2 - 55; HCO3 - 32. The nurse's interpretation of this clients blood gases is that he has:
a. Uncompensated respiratory acidosis
b. Compensated respiratory acidosis
c. Uncompensated metabolic alkalosis
d. Compensated metabolic alkalosis
Situation 4. Mr. Ginga, a 25 year old male client, is scheduled for a temporary colostomy due to severe diverticulitis.
16. Mr. Ginga's physician ordered neomycin SO4. The purpose of preoperative administration of neomycin SO4 is to:
a. Reduce the risk of postoperative wound infection
b. Decrease bacterial count of the colon
c. Reduce the size of a possible tumor before surgery
d. Stimulate peristalsis and facilitate action of cleansing enemas
17. The nurse knows that a colostomy begins functioning:
b. 2 to 3 days postoperatively
c. 1 week postoperatively
d. 2 weeks postoperatively
18. Nurse Sagiri is performing a colostomy irrigation on Mr. Ginga. During the irrigation, the client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action?
a. Notify the physician immediately
b. Increase the height of the irrigation
c. Stop the irrigation temporarily
d. Medicate for pain and resume irrigation
19. The nurse is monitoring for stoma prolapse, she would observe which of the following appearances in the stoma if prolapse occurred?
a. Sunken and hidden
b. Dark and bluish in color
c. Narrowed and flattened
d. Protruding and swollen
20. Mr. Ginga is concerned about the odor of the stool in the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor?
a. Yogurt c. Cucumbers
b. Broccoli d. Eggs
Situation 5. A nasogastric tube has been inserted into Mr. Hugh, a 30 year old gangster boss, who was admitted due to brain attack (CVA).
21. The physician prescribes that the tube be attached to intermittent suction. The nurse attaches the suction noting that the pressure should not exceed:
a. 10 mm Hg c. 25 mm Hg
b. 20 mm Hg d. 30 mm Hg
22. When caring for a client with a nasogastric tube attached to suction, the nurse should:
a. Irrigate the tube with normal saline
b. Use sterile technique when irrigating the tube
c. Withdraw the tube quickly when decompression is terminated
d. Allow the client to have small chips of ice or sips of water unless nauseated
relieve discomfort in the nostril with a nasogastric tube in place?
a. Remove any tape and loosely pin the tube to his gown
b. Lubricate the nasogastric tube with viscous xylocaine
c. Loop the nasogastric tube to avoid pressure on the nares
d. Replace the nasogastric tube with a smaller diameter tube
24. Nurse Naj has aspirated 40 ml of undigested formula from Mr. Hugh's nasogastric tube before administering an intermittent tube feeding. The nurse understands that before administering the tube feeding, the 40 ml of gastric aspirate should be:
a. Discarded properly and recorded as output on the client's I&O record
b. Poured into the nasogastric tube through a syringe with the plunger removed
c. Mixed with the formula and poured into the nasogastric tube through a syringe without a plunger
d. Diluted with water and injected into the nasogastric tube by putting pressure on the plunger
25. To best evaluate whether a prior feeding has been absorbed, the nurse should:
a. Evaluate the intake in relation to the output
b. Instill air into the stomach while auscultating
c. Aspirate for a residual volume and reinstill it
d. Compare the client's body weight with the baseline data
Situation 6. Nurse Gelie is taking care of Christopher, 22 years old, who is scheduled for cleansing enema.
26. Nurse Gelie is preparing to administer a high cleansing enema to Christopher. She positions the client in the:
a. Left lateral position with the right leg acutely flexed
b. Right Sims' position
c. Dorsal recumbent position
d. Right lateral position with the left leg acutely flexed
27. The maximum height at which the container of fluid should be held when administering a high cleansing enema is:
a. 30 cm (12 inches)
b. 37 cm (15 inches)
c. 45 cm (20 inches)
d. 66 cm (26 inches)
23. Answer: C Rationale: Looping the nasogastric tube inserted is:
a. 2 inches c. 6 inches
b. 4 inches d. 8 inches
29. Nurse Gelie has administered approximately half of a high cleansing enema when the client complains of pain and cramping. Which of the following nursing actions is the most appropriate?
a. Raise the enema bag so that the solution can be administered quickly
b. Clamp the tubing for 30 seconds and restart the flow at a slower rate
c. Reassure the client and continue the flow
d. Discontinue the enema and notify the physician
30. With the knowledge that Christopher is accustomed to taking enemas periodically to avoid constipation, the nurse should:
a. Arrange to have enemas ordered
b. Have the physician order a daily laxative
c. Offer the client a large glass of prune juice and warm water each morning
d. Realize that enemas will be necessary because the normal conditioned reflex has been lost
Situation 7. Ash, 15 years old, is admitted to the burn unit in serious condition with deep partial-thickness burns over the head, face, neck and anterior chest. There are also second degree burns on the left leg and thigh.
31. On the first night in the hospital, nurse Misty enters the room and finds Ash crying softly and moaning in pain. Recognizing the extent of the injuries, the nurse should:
a. Do nothing at this time
b. Offer two acetaminophen (Tylenol) pills as ordered and a glass of warm milk
c. Give an IM injection of 40 mg of meperidine HCl (Demerol) as ordered
d. Inject 25 mg of meperidine HCl (Demerol) as ordered via central IV line
32. Nurse Misty plans to help prevent contractures in the burned leg by:
a. Maintaining abduction of the left leg, extension of the left knee, and flexion of the left ankle
b. maintaining adduction of the left leg and extension of the left knee and ankle
c. Maintaining abduction of the left leg and flexion of the left knee and ankle
d. Maintaining adduction of the left leg, flexion of the left knee, and extension of the left ankle
33. Hyponatremia may develop in clients with burns due to:
a. Displacement of sodium in edema fluids and loss through denuded areas of the skin
b. Increased aldosterone secretion
c. Inadequate fluid replacement
d. Metabolic acidosis
34. Ash is to receive fluid replacement therapy. Besides assessing size and depth of the burn, which physical parameters are also important baseline data for fluid replacement therapy?
a. Age, sex and vital signs
b. Age, weight, vital signs and skin turgor
c. Vital signs, level of mentation and urine output
d. Vital signs and quantity and specific gravity of urine
35. Which behavior is least likely to be included in the nursing assessment of a client with burns during the recovery period?
a. Anxiety with mild confusion
b. Desperation and panic
c. Withdrawal and depression
d. Dependency and regression
Situation 8. The first phase of the nursing process is the Assessment. It requires the nurse to obtain objective and subjective data from primary and secondary sources, to identify and group significant data, as well as to communicate this information to other members of the health team. The information necessary from making nursing decisions is obtained through assessment.
36. The best place to assess for dehydration by checking skin turgor in older adults is on the:
a. Dorsal aspect of the forearm
b. Anterior chest, below the clavicle
c. Back of the hand
37. When auscultating heart sounds, the nurse knows that the first heart sound (S1) is best heard:
a. Using the bell of the stethoscope
b. With the client lying on the right side
c. At the second intercostal space, right sternal border
d. At the fifth intercostal space, left sternal border
38. Objective assessment data indicating circulatory overload in a client who has chronic renal failure would include:
a. Neck vein distention, apprehension, soft eyeballs
b. Periorbital edema, distended neck veins, moist crackles
c. Increased blood pressure, flattened neck veins, shock
d. Decreased pulse pressure, cool, dry skin, decreased skin turgor
39. Based on the primary cause for skin changes in older adults, the initial nursing assessment of an elderly client with dry skin would include:
a. Presence of age spots
b. A diet history
c. History of prior sun exposure
d. Medications taken as a younger adult
40. Which nursing assessment would identify the earliest indication of increasing intracranial pressure?
a. Temperature over 102°F
b. Change in level of consciousness
c. Widening pulse pressure
d. Unequal pupils
Situation 9.Nurses should develop the skills on how to prioritize in order to properly allocate the appropriate care to different clients.
41. During report from the night shift, the day nurse receive information on four clients. Which client should the nurse assess first?
a. Gary, 78 year old, 3 days after knee surgery whose pain level at 6:00 AM was 3 out of 10
b. May, 45 year old, with diverticulosis who is scheduled for bowel surgery at 8:00 AM
c. Jessie, 18 years old, with multiple fractures whose Hct is 32, which is down from 32.5 of the previous day
d. Kira, 62 year old, 2 days following bladder surgery whose WBC is 11,000
42. A school bus is involved in a traffic accident at 7:30 AM en route to delivering a group of children with “special needs” to school. A pediatric emergency team is dispatched to the scene of the accident. The registered nurse will give greatest priority to:
a. The child with epilepsy who is complaining of headache
b. The child with diabetes mellitus who is complaining of feeling scared and shaky
c. The child with rheumatoid arthritis who is complaining of feeling stiff and sore
d. The child with scoliosis who is wearing a Milwaukee brace and complaining of shoulder level pain
43. A registered nurse returns to the pediatric unit from dinner break and receives the following report from the LVN/LPN. Which child should the registered nurse attend to first?
a. A child with epiglottitis and a tracheostomy with a neck dressing that is wet and soiled
b. A child with acute glomerulonephritis whose urine is bloody
c. A child with sickle cell anemia whose PCA (patient-controlled analgesia) medication cassette is empty
d. A child with pyloric stenosis who has vomited
44. The nurse finds the client's IV bag empty at change of shift. The RN on the previous shift reported that a new 1000 ml bag would be hung. The client is in no apparent distress. What is the first priority?
a. Maintain patency of the IV site with a new bag of solution
b. Check the IV record to see if a new bag was charted
c. Assess heart and lungs for signs of fluid overload
d. Complete an incident report and notify physician of error
45. The nurse triages clients in the emergency department. Which client should the nurse treat first?
a. Norman, 27 years old, with right-side chest pain, shortness of breath and unequal chest excursion who was in a motor vehicle accident
b. Mikki, 7 years old, who sustained a scalp laceration in a soccer game. The child is awake and crying
c. Oak, 82 years old, with chest pain who is pale and diaphoretic
d. Diana, 35 years old, with a compound tibial fracture
Situation 10. James, a 17 years old male, is admitted with a flail chest following an automobile accident. He is very anxious, dyspneic and in severe pain. He is intubated with an endotracheal tube and is placed on a mechanical ventilator (control mode, positive pressure).
46. Which physical finding alerts the nurse to an additional problem in respiratory function?
a. Dullness to percussion in the third to fifth intercostal space, midclavicular line
b. Decreased paradoxical motion
c. Louder breath sounds on the right chest
d. pH of 7.36 in arterial blood gases
47. The high-pressure alarm sounds on the mechanical ventilator. The nurse prepares to perform which of the following most appropriate nursing intervention?
a. Check for a disconnection
b. Evaluate the tube cuff for a leak
c. Notify the respiratory therapist
d. Suction the client
48. James has had a cuffed endotracheal tube for 3 days. When the nurse goes to the bedside, the nurse hears the client say “good morning.” This indicates:
a. James is feeling better, is more alert, and is appropriately responsive
b. The cuff on the endotracheal tube is deflated, or the tube is misplaced and the nurse should act immediately
c. The endotracheal tube needs to be replaced immediately
d. The endotracheal tube has migrated to the right main stem bronchus and the nurse should obtain a STAT chest x-ray
49. To maintain correct placement of an endotracheal tube, the nurse should:
a. Check for cuff pressure periodically
b. Suction the client PRN
c. X-ray the tube every day
d. Mark the tube at its insertion point into the client's mouth or nose
50. Nurse Joy is preparing for the removal of the endotracheal tube (ET) from James. In preparing to assist the physician in this procedure, which initial nursing action is most appropriate?
a. Suction the ET tube
b. Deflate the cuff
c. Turn the ventilator to the off position
d. Obtain a code cart and place it at the bedside