Question: A client presents with acute shortness of breath. Continuous wheezes are heard on auscultation during both inspiration and expiration. What condition is most likely?
Answer Options:
A. Asthma
B. Pleurisy
C. Pneumonia
D. Emphysema
Answer: A — Asthma
Question: A postoperative client is reluctant to ambulate and cough. This increases their risk for what complication?
Answer Options:
A. Atelectasis
B. Pulmonary embolism
C. Aspiration
D. Acute respiratory distress syndrome (ARDS)
Answer: A — Atelectasis
Question: The walls of the _____ are lined with squamous epithelial cells.
Answer Options:
terminal bronchioles
respiratory bronchioles
bronchi
pulmonary vessels
Answer: pulmonary vessels
Question: A client has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation?
Answer Options:
A. Rhonchi
B. Expiratory wheezes
C. Inspiratory wheezes
D. Crackles
Answer: D — Crackles
Question: The nurse is caring for an adult client who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina?
Answer Options:
A. Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)
B. Impaired skin integrity related to CAD
C. Ineffective breathing pattern related to decreased cardiac output
D. Anxiety related to fear of death
Answer: A — Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)
Question: A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse’s assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do?
Answer Options:
A. Lie in a low Fowler or supine position
B. Call the nurse for oral suctioning, as needed
C. Increase oral fluids unless contraindicated
D. Increase activity
Answer: C — Increase oral fluids unless contraindicated
Question: The _____ respiratory tract includes the nasal cavity, pharynx, and larynx.
Answer Options:
upper
lower
ventral
dorsal
Answer: upper
Question: In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a client’s arterial oxygen saturation (SaO2). What procedure will best accomplish this?
Answer Options:
A. Arterial blood gas (ABG) measurement
B. Peak flow measurement
C. Pulse oximetry
D. Incentive spirometry
Answer: C — Pulse oximetry
Question: A client’s most recent diagnostic imaging has revealed that lung cancer has metastasized to the bones and liver. What is the most likely mechanism by which the client’s cancer cells spread?
Answer Options:
A. Angiogenesis
B. Lymphatic circulation
C. Apoptosis
D. Invasion
Answer: B — Lymphatic circulation
Question: During a routine mammogram, a client asks the nurse whether breast cancer causes the most deaths. Which type of cancer is the leading cause of death in the United States?
Answer Options:
A. Lung
B. Breast
C. Prostate
D. Colorectal
Answer: A — Lung
Question: A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse’s immediate, priority concern when planning this client’s care?
Answer Options:
A. Risk of infection
B. Fluid status
C. Psychosocial coping
D. Nutritional status
Answer: B — Fluid status
Question: A client admitted with an acute exacerbation of chronic obstructive pulmonary disease is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the client’s blood?
Answer Options:
A. Pulse oximetry
B. A capillary blood sample
C. An arterial blood gas (ABG) study
D. A complete blood count (CBC)
Answer: C — An arterial blood gas (ABG) study
Question: A nurse is working with a 10-year-old client who is undergoing a diagnostic workup for suspected asthma. Which signs and symptoms are consistent with a diagnosis of asthma?
Answer Options:
A. Wheezing
B. Chest tightness
C. Crackles
D. Cough
E. Bradypnea
Answer: A, B, D — Wheezing, Chest tightness, Cough
Question: An 87-year-old client has been hospitalized with pneumonia. Which nursing action would be a priority in this client’s plan of care?
Answer Options:
A. Administration of probiotic supplements
B. Bed rest
C. Nasogastric intubation
D. Cautious hydration
Answer: D — Cautious hydration
Question: A client is refusing to wear external pneumatic compression stockings postoperatively. What complication does this increase the risk for?
Answer Options:
A. Sepsis
B. Hematoma
C. Infection
D. Pulmonary embolism
Answer: D — Pulmonary embolism
Question: A nurse coming on shift on the medical unit is taking a report on four clients. What client does the nurse know is at the greatest risk of developing ESKD?
Answer Options:
A. A client with a history of polycystic kidney disease
B. A client with severe chronic obstructive pulmonary disease
C. A client who is morbidly obese with a history of vascular disorders
D. A client with diabetes mellitus and poorly controlled hypertension
Answer: D — A client with diabetes mellitus and poorly controlled hypertension
Question: The _____ of the trachea function to move foreign particles toward the mouth.
Answer Options:
cartilaginous rings
ciliated cells
alveoli
pulmonary vessels
Answer: ciliated cells
Question: The inside of the trachea is lined by small, hair-like projections called _____.
Answer Options:
cartilage
alveoli
cilia
surfactant
Answer: cilia
Question: The nurse is admitting a client to the medical-surgical unit from the PACU. In order to help the client clear secretions and help prevent pneumonia, the nurse should encourage the client to:
Answer Options:
A. Use the incentive spirometer every 2 hours
B. Limit activity for the first 72 hours
C. Eat a balanced diet that is high in protein
D. Take medications as prescribed
Answer: A — Use the incentive spirometer every 2 hours
Question: Muscles used for inspiration include the _____.
Answer Options:
sternocleidomastoids
external intercostal muscles
diaphragm
All of the above
Answer: All of the above
Question: A client diagnosed with acute sinusitis asks how to promote drainage. What should the nurse recommend?
Answer Options:
A. Apply heat to the forehead
B. Increase fluid intake
C. Apply a cold pack to the affected area
D. Perform postural drainage
Answer: B — Increase fluid intake
Question: The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client’s risk of developing pulmonary emboli (PE)?
Answer Options:
A. Maintaining the client in a supine position
B. Early ambulation
C. Increased dietary intake of protein
D. Administering aspirin with warfarin
Answer: B — Early ambulation
Question: A critical care nurse is planning assessments in the knowledge that clients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the client?
Answer Options:
A. Difficulty breathing
B. Pulmonary edema
C. Cardiovascular overload
D. Hypovolemia
E. Hyponatremia
Answer: A, B, C, E — Difficulty breathing, Pulmonary edema, Cardiovascular overload, Hyponatremia
Question: A nurse is developing a teaching plan for an adult client with asthma. Which teaching point should have the highest priority in the plan of care that the nurse is developing?
Answer Options:
A. Change filters on heaters and air conditioners frequently
B. Gradually increase levels of physical exertion
C. Take prescribed medications as scheduled
D. Avoid goose-down pillows
Answer: C — Take prescribed medications as scheduled
Question: The larynx contains the vocal cords.
Answer Options:
True
False
Answer: True
Question: Constant bubbling is observed in the water-seal chamber of a client’s chest-drainage system. What does this indicate?
Answer Options:
A. The system has an air leak
B. The system is functioning normally
C. The chest tube is obstructed
D. The client has a pneumothorax
Answer: A — The system has an air leak
Question: An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that what vessel is most commonly used as source for a CABG?
Answer Options:
A. Femoral artery
B. Greater saphenous vein
C. Brachial vein
D. Brachial artery
Answer: B — Greater saphenous vein