Block 10 Assessment 1.docx Roseman University of Health Sciences NURSING BLOCK 10
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Course
NURSING BLOCK 10
Institution
NURSING BLOCK 10
1. The nurse is caring for a client receiving enteral tube feedings who suddenly begins
coughing with a sudden drop in oxygen saturation. The nurse suspects aspiration and is
concerned that the client is at risk for the development of complications. Which s/s would
the nurse assess for? (SATA)
...
1. The nurse is caring for a client receiving enteral tube feedings who suddenly begins
coughing with a sudden drop in oxygen saturation. The nurse suspects aspiration and is
concerned that the client is at risk for the development of complications. Which s/s would
the nurse assess for? (SATA)
A. Dyspnea, tachypnea, and subcostal retractions
B. SaO2 level at 85% on a non-rebreather mask
C. Wheezes upon expiration and PaCO2 40
D. BP 150/100 mmHg and PaO2 80 mmHg
E. A PaO2 of 50 mmHg and infiltrates on x-ray
2. The nurse is caring for a client on a ventilator with an endotracheal tube in place. What
assessment findings would be the priority for the nurse to report to the healthcare
provider?
A. Increased crackles bilaterally in the lower lobes
B. A high pressure alarm is sounding on the ventilator
C. Decreased or absent breath sounds on the left side
D. An oxygen saturation of 88% on the monitor
3. The nurse is caring for a client who is intubated and on mechanical ventilation. The client
appears anxious and has a oxygen saturation rate of 80%. What action(s) does the
nurse plan to implement prior to and during endotracheal suctioning? (SATA)
A. Ensures that the suction equipment is working adequately
B. Applies suction continuously while inserting the catheter
C. Administer 100% oxygen prior to suctioning
D. Inserts the catheter while applying suction up to 5 times
E. Conducting a thorough respiratory assessment
4. The nurse is caring for a client in the ED with sudden onset of dyspnea. The client
recently had a total hip replacement, has an INR of 0.5, and an elevated D-Dimer. Based
on these findings, what diagnostic test will the nurse prepare the client for?
A. Bronchoscopy with sedation
B. Pulmonary angiography
C. Pulmonary function test (PFT)
D. Polysomnography test
5. The nurse is caring for a client with a chest tube being used to treat a left lower lobe
injury. Upon assessment, the nurse notes that there is no bubbling in the suction
chamber. What is the priority action?
A. Contact the HCP immediately
B. Raise the chest tube to the level of the chest
C. Check the tubing for kinks or occlusions
D. Instruct the client to use an incentive spirometer
6. The nurse responds to a client whose ventilator is alarming low pressure and the client’s
oxygen saturation has dropped to 86%. What is the priority nursing action?
A. Assess tubing for disconnections
B. Silence the alarm and assess SaO2
C. Ventilate the client with a bag and mask
D. Suction the client to clear secretions
, 7. The nurse is caring for a client on mechanical ventilation. The morning’s ABG results
are: pH: 7.46, PaCO2: 33, PaO2: 92, HCO3: 24. Based on these ABG results, the nurse
will anticipate which ventilator setting change?
A. Increase the amount of oxygen delivered
B. Decrease the rate being used for ventilation
C. Increase the number of breaths delivered
D. Discontinue ventilation and assess breath sounds
8. The nurse is caring for a client in the ED with fractured ribs and a pulmonary contusion.
Which of the following orders will the nurse question?
A. Application of oxygen via non-rebreather
B. Regular monitoring of CBC
C. Rapid infusion of 1L of IV NS
D. Frequent assessment of breath sounds
9. The nurse has finished assisting the healthcare provider with a thoracentesis for a client
with recurrent left pleural effusion. The physician removed 1800 mL of fluid during the
procedure. Which assessment finding is the priority to identify and report?
A. The patient reports sharp, stabbing pain, 5/10 upon inspiration
B. The dressing site has a small amount of bloody drainage
C. Blood pressure 90/58 mmHg and heart rate 110 bpm
D. The patient feels fatigued and would like to rest
10. The nurse is caring for an older adult client admitted to the cardiac unit five days after
coronary artery bypass graft. Which findings indicate to the nurse that the client may be
experiencing a complication of the surgery? (SATA)
A. BP 125/75 mmHg
B. Swelling at the harvest site
C. New onset confusion
D. BP 80/40 mmHg
E. Urine output 300 mL in 5 hours
11. The nurse enters a client’s room and notices the following rhythm on the monitor. What
is the priority action by the nurse? (Ventricular tachycardia ECG)
A. Begin cardiopulmonary resuscitation
B. Administer cardioversion with 150 joules
C. Administer nitroglycerin sublingual
D. Check the client’s pulse
12. The nurse is assessing a client on a cardiac unit and notes the following rhythm. The
client reports feeling dizzy and faint. Which prescription will the nurse perform first?
(Bradycardia)
A. Prepare for pacemaker insertion
B. Administer diltiazem (Cardizem) 25 mg IV push
C. Administer atropine sulfate 0.5 mg IV push
D. Monitor blood pressure hourly
13. The nurse is educating a client on a newly implanted permanent pacemaker inserted in
the left subclavian vein. Which response from the client shows an understanding of the
discharge instructions?
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