The position of a conscious client during suctioning is:

Response: Fowler's

Correct answer: Fowler's

Score: 1 out of 1 Y

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Question 3
 A client is receiving isoetharine hydrochloride (Bronkosol) via a nebulizer. The nurse monitors the
client for which side effect of this medication?

Response: Tachycardia

Feedback: Side effects that can occur from a beta 2 agonist include tremors, nausea, nervousness,
palpitations, tachycardia, peripheral vasodilation, and dryness of the mouth or throat. Due to the
vasodilatory effect of peripheral vasculature and subsequent decrease in cardiac venous return,
compensatory mechanisms manifest as tachycardia are relatively common, especially within the first
weeks of usage.

Correct answer: Tachycardia

Score: 1 out of 1 Y

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Question 4
 A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the
oxygen flow rate to ensure that it does not exceed:

Response: 2 L/min

Feedback: Oxygen is used cautiously and should not exceed 2 L/min.

Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered
by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory
system.
Correct answer: 2 L/min

Score: 1 out of 1 Y

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Question 5
 A nurse is caring for a male client immediately after the removal of the endotracheal tube. The nurse
reports which of the following signs immediately if experienced by the client?

Response: Stridor

Feedback: The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound
that is heard with the stethoscope over the trachea.

Stridor indicates airway edema and places the client at risk for airway obstruction

Correct answer: Stridor

Score: 1 out of 1 Y

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Question 6
 Which of the following pathophysiological mechanisms that occur in the lung parenchyma allows
pneumonia to develop?

Response: Inflammation

Feedback: The most common feature of all types of pneumonia is an inflammatory pulmonary response
to the offending organism or agent. The resident macrophages serve to protect the lung from foreign
pathogens. Ironically, the inflammatory reaction triggered by these very macrophages is what is
responsible for the histopathological and clinical findings seen in pneumonia.

Correct answer: Inflammation

Score: 1 out of 1 Y

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Question 7
 Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following nursing
actions will facilitate obtaining the specimen?

Response: Having the clients take three deep breaths

Feedback: To obtain a sputum specimen, the client should rinse the mouth to reduce contamination,
breathe deeply, and then cough into a sputum specimen container.

The client should be encouraged to cough and not spit so as to obtain sputum.

Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or
water. The optimal time to obtain a specimen is on arising in the morning

Correct answer: Having the clients take three deep breaths

Score: 1 out of 1 Y

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Question 8
 The most important action the nurse should do before and after suctioning a client is:

Response: Hyperventilating the client with 100% oxygen

Correct answer: Hyperventilating the client with 100% oxygen

Score: 1 out of 1 Y

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Question 9
 Aminophylline (theophylline) is prescribed for a client with acute bronchitis. A nurse administers the
medication, knowing that the primary action of this medication is to:

Response: Relax smooth muscles of the bronchial airway.

Feedback: Aminophylline is a bronchodilator that directly relaxes the smooth muscles of the bronchial
airway. Theophylline causes non-selective inhibition of type III and type IV isoenzymes of
phosphodiesterase, which leads to increased tissue cyclic adenosine monophosphate (cAMP) and cyclic
3?,5? guanosine monophosphate concentrations, resulting in smooth muscle relaxation in lungs and
pulmonary vessels, diuresis, CNS and cardiac stimulation.

Correct answer: Relax smooth muscles of the bronchial airway.

Score: 1 out of 1 Y

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Question 10
 An emergency room nurse is assessing a female client who has sustained a blunt injury to the chest
wall. Which of these signs would indicate the presence of a pneumothorax in this client?

Response: Diminished breathe sounds

Feedback: This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed
pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea,
cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on
the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

Correct answer: Diminished breathe sounds

Score: 1 out of 1 
 Which of the following terms is used to describe removal of the breast tissue and an axillary lymph
node dissection leaving muscular structure intact as surgical treatment of breast cancer?

Response: Modified radical mastectomy

Correct answer: Modified radical mastectomy

Score: 1 out of 1 Y

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Question 3
 The laboratory of a male patient with Peptic ulcer revealed an elevated titer of Helicobacter pylori.
Which of the following statements indicate an understanding of this data?

Response: Treatment will include Ranitidine and Antibiotics

Correct answer: Treatment will include Ranitidine and Antibiotics

Score: 1 out of 1 Y
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Question 4
 The client had undergone external radiation treatment. The most common systemic side effects of the
treatment include the following EXCEPT”

Response: Fatigue

Correct answer: Dry desquamation of the skin

Score: 0 out of 1 N

o

Question 5
 The nurse is conducting an education session for a group of smokers in a “stop smoking” class. Which
finding would the nurse state as a common symptom of lung cancer? :

Response: Cough or change in a chronic cough

Correct answer: Cough or change in a chronic cough

Score: 1 out of 1 Y

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Question 6
 A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected lung cancer. Which
of the following is a contraindication to the study for this patient?

Response: The patient has a pacemaker.

Correct answer: The patient has a pacemaker.

Score: 1 out of 1 Y

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Question 7
 A client hospitalized with chronic dyspepsia is diagnosed with gastric cancer. Which of the following
is associated with an increased incidence of gastric cancer?
Response: Luncheon meats

Correct answer: Luncheon meats

Score: 1 out of 1 Y

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Question 8
 Nurse Meredith is instructing a premenopausal woman about breast self-examination. The nurse
should tell the client to do her self-examination:

Response: immediately after her menstrual period.

Correct answer: immediately after her menstrual period.

Score: 1 out of 1 Y

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Question 9
 A client with breast cancer is returned to the room following a right total mastectomy. The nurse
should:

Response: Elevate the client’s right arm on pillows

Correct answer: Elevate the client’s right arm on pillows

Score: 1 out of 1 Y

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Question 10
 Chemotherapy may be used in combination with surgery in the treatment of lung cancer. Special
nursing considerations with chemotherapy include all but which of the following?

Response: Explaining that the reactions to chemotherapy are minimal

Correct answer: Explaining that the reactions to chemotherapy are minimal

Score: 1 out of 1 Y

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Question 11
 A 64-year-old woman returns to your clinic for continued evaluation of a chronic cough, which she has
been experiencing for the past 2 months. A chest x-ray obtained yesterday shows a spiculated right
middle lobe mass with mediastinal lymphadenopathy. In addition, today the patient reports right leg
pain of new onset. You are concerned about metastatic disease.

For this patient, which of the following approaches to diagnostic imaging would be most appropriate
for the evaluation of possible metastatic disease?

Response: CT scan of the chest, head, and adrenal glands, and a bone scan

Correct answer: CT scan of the chest, head, and adrenal glands, and a bone scan

Score: 1 out of 1 Y

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Question 12
 Nurse April is teaching a client who suspects that she has a lump in her breast. The nurse instructs the
client that a diagnosis of breast cancer is confirmed by:

Response: fine needle aspiration.

Correct answer: fine needle aspiration.

Score: 1 out of 1 Y

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Question 13
 A female client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a
fluid and electrolyte imbalance induced by chemotherapy?

Response: Dry oral mucous membranes and cracked lips

Correct answer: Dry oral mucous membranes and cracked lips

Score: 1 out of 1 Y

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Question 14
 A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse
assesses the client, which finding should you instruct the student to report immediately?

Response: Respiratory rate of 8 to 10 per minute

Correct answer: Respiratory rate of 8 to 10 per minute

Score: 1 out of 1 Y

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Question 15
 What are the early symptoms of stomach cancer?

Response: All of the above

Correct answer: All of the above

Score: 1 out of 1 
Question 1

 A client has developed atrial fibrillation, which has a ventricular rate of 150 beats per minute. A nurse
assesses the client for:

Response: Hypotension and dizziness

Feedback: The client with uncontrolled atrial fibrillation with a ventricular rate more than 150 beats a
minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for
palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope,
shortness of breath, and distended neck veins. A physical exam should always begin with the
assessment of airway breathing and circulation as it is going to affect the decision making regarding
management. On general physical examination, patients may have tachycardia with an irregularly
irregular pulse.

Correct answer: Hypotension and dizziness

Score: 1 out of 1 Y

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Question 2
 A client with myocardial infarction has been transferred from a coronary care unit to a general medical
unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client
activities?

Response: Bathroom privileges and self-care activities.

Feedback: On transfer from the CCU, the client is allowed self-care activities and bathroom privileges.
Supervised ambulation for brief distances is encouraged, with distances gradually increased (50, 100,
200 feet). A patient on telemetry should be visualized hourly. With every ECG alarm, the patient should
be visualized and assessed (refer to Nursing Assessment Clinical Guideline). It is the responsibility of
nursing staff to know the whereabouts of their patient at all times – toilet doors should not be locked –
however, laminated signs may be used on doors instead

Correct answer: Bathroom privileges and self-care activities.

Score: 1 out of 1 Y

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Question 3
 The adaptations of a client with complete heart block would most likely include:

Response: Syncope and slow ventricular rate

Feedback: In complete atrioventricular block, the ventricles take over the pacemaker function in the
heart but at a much slower rate than that of the SA node. As a result, there is decreased cerebral
circulation, causing syncope. Patients with third-degree blocks can have varying clinical presentations.
Rarely, patients are asymptomatic. Usually, they may present with generalized fatigue, tiredness, chest
pain, shortness of breath, presyncope, or syncope. They may have significant hemodynamic instability
and can be obtunded.

Correct answer: Syncope and slow ventricular rate

Score: 1 out of 1 Y

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Question 4
 A 60-year-old male client comes into the emergency department with complaints of crushing chest
pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction.
Immediate admission orders include oxygen by NC at 4L/minute, blood work, chest X-ray, an ECG,
and two (2) mg of morphine given intravenously. The nurse should first:

Response: Administer the morphine.

Feedback: Although obtaining the ECG, chest x-ray, and blood work are all important, the nurse’s
priority action would be to relieve the crushing chest pain. Opioids may be used for pain control in
addition to sublingual nitroglycerin if the blood pressure is adequate. All patients with STEMI and
NSTEMI require immediately chewed aspirin 160 mg to 325 mg. Furthermore, the patient should have
intravenous access and oxygen supplementation if oxygen saturation is less than 91%.

Correct answer: Administer the morphine.

Score: 1 out of 1 Y

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Question 5
 While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the
cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse’s
first course of action should be to:

Response: Notify the physician promptly.

Feedback: PVCs are often a precursor of life-threatening dysrhythmias, including ventricular

tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs
occur at a rate greater than 5 or 6 per minute in the post-MI client, the physician should be notified
immediately. More than 6 PVCs per minute is considered serious and usually calls for decreasing
ventricular irritability by administering medications such as lidocaine.

Correct answer: Notify the physician promptly.

Score: 1 out of 1 Y

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Question 6
 A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. Does the
nurse ensure accurate measurement by avoiding which of the following?

Response: Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.

Feedback: BP should be taken with the client seated with the arm bared, positioned with support, and at
heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the
recording. The client should not have smoked tobacco or taken in caffeine in the 30 minutes preceding
the measurement. First, the patient should be questioned regarding recent caffeine consumption,
exercise, or smoking. If any of these activities have occurred within the last 30 minutes, blood pressure
measurement should be postponed until this period has passed.

Correct answer: Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion.

Score: 1 out of 1 Y

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Question 7
 IV heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of
the following medications is available in the nursing unit?

Response: Protamine sulfate

Feedback: The antidote to heparin is protamine sulfate and should be readily available for use if
excessive bleeding or hemorrhage should occur. Protamine is a medication used to reverse and
neutralize the anticoagulant effects of heparin. Protamine is the specific antagonist that neutralizes
heparin-induced anticoagulation. Protamine is a strongly alkaline (nearly two-thirds of the amino acid
composition is arginine) polycationic low-molecular-weight protein found in salmon sperm that is also
currently available in a recombinant form.

Correct answer: Protamine sulfate

Score: 1 out of 1 Y

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Question 8
 A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P
waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse
determines that the client is experiencing:

Response: Ventricular tachycardia

Feedback: Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes
(usually greater than 0.14 second), and a rate between 100 and 250 impulses per minute. The rhythm is
usually regular. Ventricular tachycardia is characterized as a wide complex (QRS duration greater than
120 milliseconds) tachyarrhythmia at a heart rate greater than 100 beats per minute. It is classified by
duration as non-sustained or sustained. Non-sustained ventricular tachycardia is defined as more than 3
beats of ventricular origin at a rate greater than 100 beats per minute that lasts less than 30 seconds in
duration.

Correct answer: Ventricular tachycardia

Score: 1 out of 1 Y

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Question 9
 A client with no history of cardiovascular disease comes into the ambulatory clinic with flu-like
symptoms. The client suddenly complains of chest pain. Which of the following questions would best
help a nurse to discriminate pain caused by a non-cardiac problem?

Response: “Does the pain get worse when you breathe in?”

Feedback: Chest pain is assessed by using the standard pain assessment parameters. It is very important
to find out what makes the pain worse. Is there an exertional component, is it associated with eating or
breathing? Is there a positional component? Don’t forget to ask about new workout routines, sports, and
lifting. Ask what medications they have tried.

Correct answer: “Does the pain get worse when you breathe in?”

Score: 1 out of 1 Y

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Question 10
 A nurse is viewing the cardiac monitor in a client’s room and notes that the client has just gone into
ventricular tachycardia. The client is awake and alert and has a good skin color. The nurse would
prepare to do which of the following?

Response: Immediately defibrillate.

Correct answer: Administer amiodarone (Cordarone) intravenously.

Score: 0 out of 1