Question

1. A nurse is caring for a client who is intubated and receiving mechanical ventilation. Which of the following findings should indicate to the nurse that the client's airway requires suctioning?

a. Pulse ox saturation of 94%

b. Rhonchi noted upon auscultation

c. decreased peak airway inspiratory pressure

d. low pressure alarm sounding on the ventilator

2. The nurse is teaching a client about PICC line. Which of the following statements by the nurse is correct?

a. The procedure will be done in the surgical unit

b. The PICC line will be inserted in a small blood vessell

c. Blood for diagnostic tests can be drawn out of the PICC line

d. Exercise activities can be performed without restriction

3. A nurse is providing teaching on managing chest pain at home to a client who had a recent MI. The client is prescribed nitroglycerin tablets. Who of the following client statements indicated teaching has been effective?

a. I should sit down after taking the tablets

b. I should wait 20 minutes between taking the tablets

c. I should call 911 as soon as I feel the chest pain

d. I should swallow the tablets

4. A client is diagnosed with a pneumothorax has a chest tube inserted and connected to a closed water-seal drainage system. To help maintain this system, the nurse should

a. empty the system at least every 8 hrs

b. change the chest tube site dressing every 24 hrs

c. refill the water chamber if the fluid level is low

d. strip or clear the chest tube every 8 hr

5. A female client is scheduled for a colonoscopy and will require moderate sedation. Which of the following statements by the client’s family member indicated an understanding of the conscious sedation?

a. I should not let her eat or drink for several hours after the procedure

b. she will be on the ventilator for a short time

c. I will be here after the procedure to drive her home

d. The doctor will discuss the discharge instructions with her after the procedure

6. A nurse is caring for a client who is experiencing angina. Five mins after giving the client nitroglycerin pill, the nurse reassess the client. Assessment findings include blood pressure 132/68 mm Hg, respiratory rate 20/min, pain level of 6, and diaphoresis, which of the following should the nurse take next?

a. Notify the provider

b. Lower the head of the bed

c. give the client a second dose of nitroglycerin

d. Administer oxygen to maintain oxygen saturation about 94%

7. A nurse is caring for a client who has chronic renal failure. The client received hemodialysis one hour ago. Which of the following clinical manifestations indicated a complication related to the procedure?

a. decrease in weight

b. elevated temperature

c. altered mental status

d. decreased blood pressure

Answer 1

1. Answer ; B) Ronchi noted upon auscultation
Rationale ; It is the situation that the nurse needs to act on and provide proper suction to this client. This Sound indicate that there is some kind of secretion or particles situated in that area needs to evacuated soon. The other option given in this question doesn't need to do this procedure by the nurse.

2. Answer ; C) Blood for diagnostic can be drawn out of the PICC line.
Rationale ; From the given option this one would be the most relevance, it can be used for the above mentioned purpose, but this is not the main aim for having this line. In terms of exercise there are some limits and follow up. It was not placed in the small vessels. Obviously its not a major procedure to do in the surgical set up.

3. Answer ; A) I should sit down after taking the tablet.
Rationale ; From the given statement the above mentioned statement said by the person has correct knowledge. The other statement are not needed and irrelevant to the use of NTG.

4. Answer ; D) Strip or clear the chest tube every 8 hours

5. Asnwer ; C) I will be here after the procedure to drive her home.

6. Answer ; C) give client a second dose of nitroglycerine

7.Answer ; D) decreased blood pressure.