—General George S. Patton
1. 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.
2. 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. 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.
4. 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.
QUESTIONS
5. 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.
6. 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.
7. 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.
8. 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.
9. 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).
10. 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.
11. 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, PaCO255, HCO324.
2. The client with Adult Respiratory Distress Syndrome who has a pH 7.35, PaO275, PaCO250, HCO326.
3. The client with reactive airway disease with a pH 7.48, PaO280, PaCO230, HCO323.
4. The client with a pneumothorax with a pH 7.41, PaO298, PaCO243, HCO325.
78 PRIORITIZATION, DELEGATION, ANDMANAGEMENT OFCARE FOR THENCLEX-RN®EXAM
12. 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.
13. 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.
14. 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.
15. 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.
16. 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.
17. 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.
18. 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.
QUESTIONS
19. 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, PaO298, PaCO236, HCO328. 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.
20. 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.
21. The client has arterial blood gas values of pH 7.38, PaO277, PaCO240, 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.
22. 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.
23. 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?”
24. 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.
25. 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.”
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26. 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.
27. 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.
28. 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.
29. 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.”
30. 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).
31. 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.
32. 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.
QUESTIONS
33. 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.
34. 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.
35. The home health nurse is visiting the client diagnosed with end-stage chronic obstruc-tive pulmonary disease (COPD) while the unlicensed assisobstruc-tive 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.
36. 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.
37. 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.
38. 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.”
39. 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.
82 PRIORITIZATION, DELEGATION, ANDMANAGEMENT OFCARE FOR THENCLEX-RN®EXAM
40. 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?”
41. 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.
42. 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.”
43. 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.
44. 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.
45. 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.
46. 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.
QUESTIONS
47. The nurse is caring for a client who has a chest tube. What should the nurse do?
47. The nurse is caring for a client who has a chest tube. What should the nurse do?