PDM: Chapter 4

The nurse is caring for a client who has a chest tube. What should the nurse do? Prioritize the nurse's actions from first (1) to last (5). 1. Assess the client's lung sounds. 2. Note the amount of suction being used. 3. Check the chest tube dressing for drainage. 4. Make sure that the chest tube is securely taped. 5. Place a bottle of sterile saline at the bedside

1, 4, 3, 2, 5

The 92-year-old client has a hospital bed in the home and is on strict bed rest. The unlicensed assistive personnel (UAP) cares for the client in the morning 5 days a week. Which statement indicates that the UAP needs additional education by the nurse? 1. "I do not give her a lot of fluids so she won't wet the bed." 2. "I perform passive range-of-motion exercises every morning." 3. "I put her on her side so that there will be no pressure on her butt." 4. "I do not pull her across the sheets when I am moving her in bed."

1. "I do not give her a lot of fluids so she won't wet the bed."

The client involved in a motor vehicle accident is being prepped for surgery when the client asks the emergency department nurse, "What happened to my child?" The nurse knows the child is dead. Which statement is an example of the ethical principle of nonmalfeasance? 1. "I will find out for you and let you know after surgery." 2. "I am sorry but your child died at the scene of the accident." 3. "You should concentrate on your surgery right now." 4. "You are concerned about your child. Would you like to talk?"

1. "I will find out for you and let you know after surgery."

The client has arterial blood gas values of pH 7.38, PaO2 77, PaCO2 40, HCO3 24. Which intervention should the critical care nurse implement? 1. Administer oxygen 6 L/min via nasal cannula. 2. Encourage the client to take deep breaths. 3. Administer intravenous sodium bicarbonate. 4. Assess the client's respiratory status.

1. Administer oxygen 6 L/min via nasal cannula.

At 1700, the HCP is yelling at the nursing staff because the early morning lab work is not available for a client's chart. Which is the most appropriate response by the charge nurse? 1. Call the lab and have the lab supervisor talk with the HCP. 2. Discuss the HCP's complaints with the nursing supervisor. 3. Form a committee of lab and nursing personnel to fix the problem. 4. Tell the HCP to stop yelling and calm down.

1. Call the lab and have the lab supervisor talk with the HCP.

The client in the intensive care unit is on a ventilator. Which interventions should the nurse implement? Select all that apply. 1. Ensure there is a manual resuscitation bag at the bedside. 2. Monitor the client's pulse oximeter reading every shift. 3. Assess the client's respiratory status every 2 hours. 4. Check the ventilator settings every 4 hours. 5. Collaborate with the respiratory therapist.

1. Ensure there is a manual resuscitation bag at the bedside. 3. Assess the client's respiratory status every 2 hours. 4. Check the ventilator settings every 4 hours. 5. Collaborate with the respiratory therapist

The emergency department nurse is preparing to assist the surgeon to insert chest tubes in a client with a right hemothorax. Which position is appropriate for the procedure? 1. Have the client sit upright and bend over the over bed table. 2. Place the client in the left lateral recumbent position. 3. Have the client sit on the side of the bed with the back arched like a Halloween cat. 4. Place the client lying on the back with the head of the bed up 45 degrees.

1. Have the client sit upright and bend over the over bed table.

The client's arterial blood gas (ABG) results are pH 7.34, PaCO2 50, HCO3 24, PaO2 87. Which intervention should the nurse implement first? 1. Have the client turn, cough, and deep breathe. 2. Place the client on oxygen via nasal cannula. 3. Check the client's pulse oximeter reading. 4. Notify the HCP of the ABG results.

1. Have the client turn, cough, and deep breathe.

The home health nurse is visiting the client diagnosed with end-stage chronic obstructive pulmonary disease (COPD) while the unlicensed assistive personnel (UAP) is providing care. Which action by the UAP would warrant intervention by the nurse? 1. Keeping the bedroom at a warm temperature. 2. Maintaining the client's oxygen rate at 2 L/min. 3. Helping the client sit in the orthopneic position. 4. Allowing the client to sleep in the recliner.

1. Keeping the bedroom at a warm temperature.

The husband of a client diagnosed with a terminal lung cancer asks the nurse, "How am I going to take care of my wife when we go home?" Which action by the nurse is most appropriate? 1. Notify the social worker about the husband's concerns. 2. Contact the hospital chaplain to talk to the husband. 3. Leave a note on the chart for the HCP to talk to the husband. 4. Reassure the husband that everything will be all right.

1. Notify the social worker about the husband's concerns.

Which tasks are appropriate to assign to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Perform mouth care on the client with pneumonia. 2. Apply oxygen via nasal cannula to the client. 3. Empty the trashcans in the clients' rooms. 4. Take the empty blood bag back to the laboratory. 5. Show the client how to ambulate on the walker.

1. Perform mouth care on the client with pneumonia. 4. Take the empty blood bag back to the laboratory.

The client diagnosed with acute respiratory distress syndrome (ARDS) is having increased difficulty breathing. The arterial blood gas indicates an arterial oxygen level of 54% on O2 at 10 LPM. Which intervention should the intensive care unit nurse implement first? 1. Prepare the client for intubation. 2. Bag the client with a bag/mask device. 3. Call a Code Blue and initiate cardiopulmonary resuscitation (CPR). 4. Start an IV with an 18-gauge catheter.

1. Prepare the client for intubation.

While the nurse is caring for a client on a ventilator the ventilator alarm sounds. What is the first action taken by the nurse? 1. Silence the ventilator alarm. 2. Notify the respiratory therapist. 3. Assess the client's respiratory status. 4. Ventilate the client using a manual resuscitation bag

1. Silence the ventilator alarm.

The client in a critical care unit died. What action should the nurse implement first? 1. Stay with the significant other. 2. Gather the client's belongings. 3. Perform post-mortem care. 4. Ask about organ donation.

1. Stay with the significant other.

Which client should the medical unit nurse assess first after receiving the shift report? 1. The 84-year-old client diagnosed with pneumonia who is afebrile but getting restless. 2. The 25-year-old client diagnosed with influenza who is febrile and has a headache. 3. The 56-year-old client diagnosed with a left-sided hemothorax with tidaling in the water-seal compartment of the Pleurvac. 4. The 38-year-old client diagnosed with a sinus infection who has green drainage from the nose.

1. The 84-year-old client diagnosed with pneumonia who is afebrile but getting restless.

The new graduate has accepted a position at a facility that is accredited by the Joint Commission. Which statement describes the purpose of this organization? 1. The Commission reviews facilities for compliance with standards of care. 2. Accreditation by the Commission guarantees the facility will be reimbursed for care provided. 3. Accreditation by the Commission reduces liability in a legal action against the facility. 4. The Commission eliminates the need for Medicare to survey a hospital.

1. The Commission reviews facilities for compliance with standards of care.

Which client should the charge nurse on the respiratory unit assign to the graduate nurse who just completed orientation? 1. The client diagnosed with bronchiolitis who has a wheezy cough and rapid breathing. 2. The client diagnosed with pneumonia who has dull percussion and vocal fremitus. 3. The client diagnosed with a flail chest who has paradoxical movement of the chest wall. 4. The client diagnosed with reactive airway disease who has bilateral wheezing.

1. The client diagnosed with bronchiolitis who has a wheezy cough and rapid breathing.

The clinic nurse is reviewing laboratory results for clients seen in the clinic. Which client requires additional assessment by the nurse? 1. The client who has a hemoglobin of 9 g/dL and a hematocrit of 29%. 2. The client who has a WBC count of 9.0 mm3. 3. The client who has a serum potassium level of 4.8 mEq/L. 4. The client who has a serum sodium level of 137 mEq/L.

1. The client who has a hemoglobin of 9 g/dL and a hematocrit of 29%.

The clinic nurse is returning phone messages from clients. Which phone message should the nurse return first? 1. The elderly client with pneumonia who reports being dizzy when getting up. 2. The client with cystic fibrosis who needs a prescription for pancreatic enzymes. 3. The client with lung cancer on chemotherapy who reports nausea. 4. The client with pertussis who reports coughing spells so severe that they cause vomiting.

1. The elderly client with pneumonia who reports being dizzy when getting up.

The nurse has been made the chairperson of a quality improvement committee. Which statement is an example of effective group process? 1. The nurse involves all committee members in the discussion. 2. The nurse makes sure all members of the group agree with the decisions. 3. The nurse asks two of the committee members to do the work. 4. The nurse does not allow deviation from the agenda to occur.

1. The nurse involves all committee members in the discussion.

The client diagnosed with active tuberculosis tells the public health nurse, "I am not going to take any more medications. I am tired of them." Which statement is the nurse's best response? 1. "You are tired of taking your tuberculosis medications." 2. "You must take your TB medications. It is not an option." 3. "You must discuss this with your healthcare provider." 4. "As long as you wear a mask, you do not have to take the meds."

2. "You must take your TB medications. It is not an option."

The female charge nurse on the respiratory unit tells the male nurse, "You are really cute and have a great body. Do you work out?" Which action should be taken by the male nurse if he thinks he is being sexually harassed? 1. Document the comment in writing and tell another staff nurse. 2. Ask the charge nurse to stop making comments like this. 3. Notify the clinical manager of the sexual harassment. 4. Report this to the corporate headquarters office.

2. Ask the charge nurse to stop making comments like this.

. In the local restaurant, the nurse overhears another hospital staff member talking to a friend about a client. The staff member discloses that the client was just diagnosed with lung cancer. What is the most appropriate action by the nurse? 1. Do not approach the staff member in the restaurant. 2. Ask the staff member not to discuss anything about the client. 3. Contact the staff member's clinical manager and report the behavior. 4. Tell the client that the staff member was discussing confidential information.

2. Ask the staff member not to discuss anything about the client.

The nurse is caring for a client diagnosed with flail chest who has had a chest tube for 3 days. The nurse notes there is no tidaling in the water-seal compartment. Which initial action should be taken by the nurse? 1. Check the tubing for any dependent loops. 2. Auscultate the client's posterior breath sounds. 3. Prepare to remove the client's chest tubes. 4. Notify the HCP that the lungs have re-expanded.

2. Auscultate the client's posterior breath sounds.

The client with a right-sided pneumothorax had chest tubes inserted 2 hours ago. There is no fluctuation in the water-seal chamber of the Pleurovac. Which intervention should the nurse implement first? 1. Assess the client's lung sounds. 2. Check for any kinks in the tubing. 3. Ask the client to take deep breaths. 4. Turn the client from side to side.

2. Check for any kinks in the tubing.

The newly hired nurse manager has identified that whenever a specific staff member is unhappy with an assignment, the entire unit has a bad day. Which action should the unit manager take to correct this problem? 1. Determine why the staff member is unhappy. 2. Discuss the staff member's attitude and the way it affects the unit. 3. Place the staff member on a counseling record for the behavior. 4. Suspend the staff member until the behavior improves.

2. Discuss the staff member's attitude and the way it affects the unit.

The nurse is accidentally stuck with a needle used to administer an intradermal injection for a PPD. Which intervention should the nurse implement first? 1. Complete the accident/occurrence report. 2. Immediately wash the area with soap and water. 3. Ask the client whether he or she has AIDS or hepatitis. 4. Place an antibiotic ointment and bandage on the site.

2. Immediately wash the area with soap and water.

In the intensive care unit (ICU), the critical care nurse assesses a client diagnosed with an asthma attack who has a respiration rate of 10 and an oxygen saturation of 88%. Which intervention should the nurse implement first? 1. Call a Rapid Response Team (RRT). 2. Increase the oxygen to 10 LPM. 3. Check the client's ABG results. 4. Administer the fast-acting inhaler

2. Increase the oxygen to 10 LPM.

The female nurse manager is discussing the yearly performance evaluation with a male nurse. Which information regarding communication styles should the nurse manager employ when talking with the employee? 1. Men tend to see the work from a global perspective centering on feelings. 2. Men often see the work environment from a logical, focused perspective. 3. Men ask many more questions than women and require specific answers. 4. Men and women communicate similarly in a nursing environment.

2. Men often see the work environment from a logical, focused perspective.

The client who is 1 day postoperative following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first? 1. Assess the client's pulse oximeter reading. 2. Notify the Rapid Response Team. 3. Place the client in the Trendelenburg position. 4. Check the client's surgical dressing.

2. Notify the Rapid Response Team.

The primary nurse in the critical care respiratory unit is very busy. Which nursing task should be the nurse's priority? 1. Assist the HCP with a sterile dressing change for a client with a left pneumonectomy. 2. Obtain a tracheostomy tray for a client who is exhibiting air hunger. 3. Transcribe orders for a client with cystic fibrosis who was transferred from the ED. 4. Assess the client diagnosed with mesothelioma who is upset, angry, and crying.

2. Obtain a tracheostomy tray for a client who is exhibiting air hunger.

The nurse is admitting a patient diagnosed with pneumonia. Which healthcare provider's order should be implemented first? 1. 1,000 mL normal saline at 125 mL/hour. 2. Obtain sputum for Gram stain and culture. 3. Ceftriaxone (Rocephin) 1,000 mg IVPB every 12 hours. 4. Ultrasonic nebulization treatment every 6 hours.

2. Obtain sputum for Gram stain and culture.

The client is admitted to the emergency department with an apical pulse rate of 134, respiration rate of 28, and BP of 92/56, and the skin is pale and clammy. What action should the nurse perform first? 1. Type and crossmatch the client for PRBCs. 2. Start two IVs with large-bore catheters. 3. Obtain the client's history and physical. 4. Check the client's allergies to medications.

2. Start two IVs with large-bore catheters.

The day surgery admission nurse is obtaining operative permits for clients having surgery. Which client should the nurse question signing the consent form? 1. The 16-year-old married client who is diagnosed with an ectopic pregnancy. 2. The 39-year-old client diagnosed with paranoid schizophrenia. 3. The 50-year-old client who admits to being a recovering alcoholic. 4. The 84-year-old client diagnosed with chronic obstructive pulmonary disease (COPD).

2. The 39-year-old client diagnosed with paranoid schizophrenia.

The nurse assists with the insertion of a chest tube in a client diagnosed with a spontaneous pneumothorax. Which data indicates that the treatment has been effective? 1. The chest x-ray indicates consolidation. 2. The client has bilateral breath sounds. 3. The suction chamber has vigorous bubbling. 4. The client has crepitus around the insertion site.

2. The client has bilateral breath sounds.

Which client requires the immediate attention of the intensive care unit nurse? 1. The client with histoplasmosis who is having excessive diaphoresis and neck stiffness. 2. The client with acute respiratory distress syndrome (ARDS) who has difficulty breathing. 3. The client with pulmonary sarcoidosis who has a dry cough and mild chest pain. 4. The client with asbestosis who has a productive cough and chest tightness.

2. The client with acute respiratory distress syndrome (ARDS) who has difficulty breathing.

The nurse is preparing to make rounds after receiving shift report. Which client should the nurse assess first? 1. The patient diagnosed with end-stage COPD complaining of shortness of breath after ambulating to the bathroom. 2. The patient diagnosed with a deep vein thrombosis who is requesting an anti-anxiety medication. 3. The patient diagnosed with cystic fibrosis who has a sputum specimen to be taken to the laboratory. 4. The patient diagnosed with an empyema who has a temperature of 100.8°F, pulse of 118, respiration rate of 26, and BP of 148/64.

2. The patient diagnosed with a deep vein thrombosis who is requesting an anti-anxiety medication

The home health client is diagnosed with chronic obstructive disease. The unlicensed assistive personnel (UAP) tells the home health nurse that the client has trouble breathing when the client lies in a supine position. Which priority instruction should the nurse provide to the UAP? 1. To ensure the client's oxygen is in place correctly. 2. To allow the client to sleep in a recliner. 3. To allow a fan to blow on the client when lying in bed. 4. To have the client take slow, deep breaths.

2. To allow the client to sleep in a recliner.

The clinic nurse encounters a client who does not respond to verbal stimuli and initiates cardiopulmonary resuscitation (CPR). What should the nurse do? Prioritize the nurse's actions from first (1) to last (5). 1. Open the client's airway. 2. Check the client's carotid pulse. 3. Assess the client for unresponsiveness. 4. Perform compressions at a 30:2 rate. 5. Pinch the nose and give two breaths.

3, 4, 1, 5, 2

The client calls the clinic nurse and asks, "What is the best way to prevent getting influenza?" Which statement is the nurse's best response? 1. "Take prophylactic antibiotics for 10 days after being exposed to influenza." 2. "Stay away for large crowds and wear a scarf over your mouth during cold weather." 3. "The best way to prevent getting influenza is to get a yearly flu vaccine." 4. "You must eat three well-balanced meals a day and exercise daily to prevent influenza."

3. "The best way to prevent getting influenza is to get a yearly flu vaccine."

The wife of a client diagnosed as terminal is concerned that the client is not eating or drinking. Which is the home health nurse's best response? 1. "I will start an IV if your husband continues to refuse to eat or drink." 2. "You should discuss placing a PEG feeding tube in your husband with the HCP." 3. "This is normal at the end of life; the dehydration produces a type of euphoria." 4. "You are right to be concerned. Would you like to talk about your worry?"

3. "This is normal at the end of life; the dehydration produces a type of euphoria."

The hospice client asks the nurse, "What should I do about my house? My son and daughter are fighting over it." Which statement is the nurse's best response? 1. "I think you should tell your children that you will leave the house to a charity." 2. "I would sell the house and go on an extended vacation and spend the money." 3. "What do you want to happen to your house? It is your decision." 4. "Wait and let your children fight over the house after you are gone."

3. "What do you want to happen to your house? It is your decision."

The client has just been told a medical condition cannot be treated successfully and the client has a life expectancy of about 6 months. To whom should the nurse refer the client at this time? 1. A home health nurse. 2. The client's pastor. 3. A hospice agency. 4. The social worker.

3. A hospice agency.

The client diagnosed with abdominal pain of unknown etiology has a nasogastric tube draining green bile and reports abdominal pain of 8 on a scale of 1 to 10. The client's arterial blood gas values are pH 7.48, PaO2 98, PaCO2 36, HCO3 28. Which intervention should the nurse implement based on the client's ABGs? 1. Assess the client to rule out any complications secondary to the client's pain. 2. Determine the last time the client was medicated for abdominal pain. 3. Check the amount of suction on the client's nasogastric tube. 4. Administer intravenous sodium bicarbonate to the client.

3. Check the amount of suction on the client's nasogastric tube.

The intensive care unit (ICU) nurse is caring for a client on a ventilator who is exhibiting respiratory distress. The ventilator alarms are going off. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Ventilate with a manual resuscitation bag. 3. Check the ventilator to resolve the problem. 4. Auscultate the client's lung sounds.

3. Check the ventilator to resolve the problem.

The Hispanic female client diagnosed with bacterial pneumonia is being admitted to the medical unit. The Hispanic husband answers questions even though the nurse directly asks the client. Which action should the nurse take? 1. Ask the husband to allow his wife to answer the questions. 2. Request the husband to leave the examination room. 3. Continue to allow the husband to answer the wife's questions. 4. Do not ask any further questions until the client starts answering.

3. Continue to allow the husband to answer the wife's questions.

The nurse is working with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) to care for a group of clients. Which nursing task should not be delegated or assigned? 1. The routine oral medications for the clients. 2. The bed baths and oral care. 3. Evaluating the client's progress. 4. Transporting a client to dialysis.

3. Evaluating the client's progress.

The nurse is teaching the parents of a child diagnosed with cystic fibrosis. Which information is priority to teach the parents? 1. Explain that the child's skin tastes salty. 2. Observe the consistency of the stools daily. 3. Give pancreatic enzymes with every meal. 4. Increase the intake of salt in the child's diet

3. Give pancreatic enzymes with every meal.

The unlicensed assistive personnel (UAP) tells the clinic nurse that the male client in Room 1 is "really breathing hard and can't seem to catch his breath." Which instruction should the nurse give to the UAP? 1. Put 4 mL oxygen on the client. 2. Sit the client upright in a chair. 3. Go with the nurse to the client's room. 4. Take the client's vital signs.

3. Go with the nurse to the client's room.

The nurse is developing a nursing care plan for a client diagnosed with chronic obstructive pulmonary disease (COPD). What should be the client's priority nursing diagnosis? 1. Activity intolerance. 2. Altered coping. 3. Impaired gas exchange. 4. Self-care deficit.

3. Impaired gas exchange.

The UAP enters the elderly female client's room to give the bath, but the client is watching her favorite soap opera. Which instructions should the nurse give to the UAP? 1. Tell the UAP to complete the bath at this time. 2. Have the UAP skip the client's bath for the day. 3. Instruct the UAP to give the bath after the program. 4. Document the attempt to give the bath as refused.

3. Instruct the UAP to give the bath after the program.

The clinic nurse is evaluating vital signs for clients being seen in the outpatient clinic. Which client would require nursing intervention? 1. The 10-month-old infant who has a pulse rate of 140 beats per minute. 2. The 3-year-old toddler who has a respiratory rate of 28 breaths per minute. 3. The 24-week gestational woman who has a BP of 142/96 mm Hg. 4. The 42-year-old client who has a temperature of 100.2°F (37.8ºC).

3. The 24-week gestational woman who has a BP of 142/96 mm Hg.

The healthcare provider ordered the loop diuretic, bumetanide (Bumex), to be administered STAT to a client diagnosed with pulmonary edema. After 4 hours, which of the following assessment data indicates the client may be experiencing a complication of the medication? 1. The client develops jugular vein distention. 2. The client has bilateral rales and rhonchi. 3. The client complains of painful leg cramps. 4. The client's output is greater than the intake.

3. The client complains of painful leg cramps.

The nurse is assessing clients on a respiratory unit. Which client should be the nurse's first priority? 1. The client diagnosed with bronchiectasis who has clubbing of the fingernails. 2. The client diagnosed with byssinosis who reports chest tightness. 3. The client diagnosed with cystic fibrosis who has a pulse oximeter reading of 91%. 4. The client diagnosed with pneumoconiosis who has shortness of breath.

3. The client diagnosed with cystic fibrosis who has a pulse oximeter reading of 91%.

Which client should the charge nurse assign to the new graduate on the respiratory unit? 1. The client diagnosed with lung cancer who has rust-colored sputum and chest pain of 10 on a scale of 1 to 10. 2. The client diagnosed with atelectasis who is having shortness of breath and difficulty breathing. 3. The client diagnosed with tuberculosis who has a non-productive cough and orange colored urine. 4. The client diagnosed with pneumonia who has a pulse oximeter reading of 91% and has a CRT >3 seconds.

3. The client diagnosed with tuberculosis who has a non-productive cough and orange colored urine.

The charge nurse in the intensive care unit asks a nurse to float from the medical/ surgical unit to the ICU. Which client should the charge nurse assign to the float nurse? 1. The client who is 3 hours postoperative lung transplant. 2. The client who has a central venous pressure of 13 cm H2O. 3. The client who is diagnosed with bacterial pneumonia. 4. The client who is diagnosed with Hantavirus pulmonary syndrome.

3. The client who is diagnosed with bacterial pneumonia.

The charge nurse of the respiratory care unit is making assignments. Which clients should be assigned to the intensive care nurse who is working on the respiratory care unit for the day? Select the patient/patients that apply. 1. The client who had four coronary artery bypass grafts 3 days ago. 2. The client who has anterior and posterior chest tubes after a motor vehicle accident. 3. The client who will be moved to the intensive care unit when a bed is available. 4. The client who has a do not resuscitate order and is requesting to see a chaplain. 5. The client who is on multiple intravenous drip medications needed to be titrated.

3. The client who will be moved to the intensive care unit when a bed is available. 5. The client who is on multiple intravenous drip medications needed to be titrated.

The nurse is working in an outpatient clinic along with a licensed practical nurse (LPN). Which client should the nurse assign to the LPN? 1. The client whose purified protein derivative (PPD) induration of the left arm is 14 mm. 2. The client diagnosed with pneumonia whose pulse oximeter reading is 90%. 3. The client with acute bronchitis who has a chronic clear mucous cough and low fever. 4. The client with reactive airway disease who has bilateral wheezing.

3. The client with acute bronchitis who has a chronic clear mucous cough and low fever.

The charge nurse on the critical care respiratory unit is evaluating arterial blood gas (ABG) values of several clients. Which client would require an immediate intervention by the charge nurse? 1. The client with chronic obstructive pulmonary disease who has a pH 7.34, PaO2 70, PaCO2 55, HCO3 24. 2. The client with Adult Respiratory Distress Syndrome who has a pH 7.35, PaO2 75, PaCO2 50, HCO3 26. 3. The client with reactive airway disease with a pH 7.48, PaO2 80, PaCO2 30, HCO3 23. 4. The client with a pneumothorax with a pH 7.41, PaO2 98, PaCO2 43, HCO3 25.

3. The client with reactive airway disease with a pH 7.48, PaO2 80, PaCO2 30, HCO3 23.

The nurse on a medical unit has a client with adventitious breath sounds, but the nurse is unable to determine the exact nature of the situation. Which multidisciplinary team member should the nurse consult first? 1. The healthcare provider. 2. The unit manager. 3. The respiratory therapist. 4. The case manager.

3. The respiratory therapist.

The client in the post-anesthesia care unit (PACU) has noisy and irregular respirations (Rs) with a pulse oximeter reading of 89%. Which intervention should the PACU nurse implement first? 1. Increase the client's oxygen rate via nasal cannula. 2. Notify the respiratory therapist to draw arterial blood gases. 3. Tilt the head back and push forward on the angle of the lower jaw. 4. Obtain an intubation tray and prepare for emergency intubation.

3. Tilt the head back and push forward on the angle of the lower jaw.

The clinic nurse is scheduling a chest x-ray for a female client who may have pneumonia. Which question is most important for the nurse to ask the client? 1. "Have you ever had a chest x-ray before?" 2. "Can you hold your breath for a minute?" 3. "Do you smoke or have you ever smoked cigarettes?" 4. "Is there any chance you may be pregnant?"

4. "Is there any chance you may be pregnant?"

Which task is most appropriate for the home health nurse to delegate to unlicensed assistive personnel (UAP)? 1. Changing the client's subclavian dressing. 2. Reinserting the client's Foley catheter. 3. Demonstrating ambulation with a walker. 4. Getting the client up in a chair three times a day.

4. Getting the client up in a chair three times a day.

The unlicensed assistive personnel (UAP) is bathing the client diagnosed with adult acute respiratory distress syndrome (ARDS) who is on a ventilator. The bed is in the high position with the opposite side rail elevated. Which action should the ICU nurse take? 1. Demonstrate the correct technique when giving a bed bath. 2. Encourage the UAP to put the bed in the lowest position. 3. Explain that the client on a ventilator should not be bathed. 4. Give the UAP praise for performing the bath safely

4. Give the UAP praise for performing the bath safely

The client who is 2 days postoperative following a left pneumonectomy has an apical pulse (AP) rate of 128 beats per minute and a blood pressure (BP) of 80/50 mm Hg. Which intervention should the nurse implement first? 1. Notify the healthcare provider (HCP) immediately. 2. Assess the client's incisional wound. 3. Prepare to administer dopamine, a vasopressor. 4. Increase the client's intravenous (IV) rate.

4. Increase the client's intravenous (IV) rate.

The healthcare facility where the nurse works uses e-mail to notify the staff of in-services and mandatory requirements. Which is important information for the nurse manager to remember when using e-mail to disseminate information? 1. Give as much information as possible in each e-mail. 2. Use e-mail for all communications with the staff. 3. Use capital letters to get a point across with emphasis. 4. Make the e-mail notices quick and easy to read.

4. Make the e-mail notices quick and easy to read

The client in the intensive care unit (ICU) has been on a ventilator for 2 weeks with an endotracheal tube in place. Which intervention should the nurse prepare the client for next? 1. Transfer to a long-term care facility. 2. Daily arterial blood gases. 3. Removal of life support. 4. Placement of a tracheostomy.

4. Placement of a tracheostomy.

The clinic nurse is scheduling a 14-year-old client for a tonsillectomy. Which intervention should the clinic nurse implement? 1. Obtain informed consent from the client. 2. Send a throat culture to the laboratory. 3. Discuss the need to cough and deep breathe. 4. Request the laboratory to draw a PT and a PTT.

4. Request the laboratory to draw a PT and a PTT.

The respiratory unit nurse is calculating the shift intake and output for a client diagnosed with right-sided chest tube. The client has received 1,500 mL of D5W, IVPB of 100 mL of 0.9% NS, 12 ounces of water, 6 ounces of milk, and 4 ounces of chicken broth. The client has had a urinary output of 800 mL and chest drainage of 125 mL. What is the total intake and output for this client?

Intake: 2160 mL Output: 925 mL