Sparks, S., & Taylor, C. (2020). Nursing Diagnosis Reference Manual 11th ed.
Lippincott Williams &
Wilkins.
1) A nurse has developed a nursing diagnosis of
ineffective airway clearance for a client who
sustained an inhalation burn injury. Which of
the following nursing intervention should
include in the plan of care for this client?
a. Monitor oxygen saturation every 4 hrs.
b. Encourage coughing and deep breathing
every 4 hrs.
c. Elevate the head of bed
d. Asses respiratory rate and breath sounds
every 4 hrs.
2) A client who is involved in a motor vehicle
crash presents to the emergency department
with severe internal bleeding. The client is
severely hypotensive and unresponsive. The
nurse anticipates which intravenous solution
will most likely be prescribed to increase
intravascular volume, replace immediate blood
loss and increase blood pressure?
a. 5%D in lactated Ringer’s solution
b. 0.33%normal saline
c. 0.225%normal saline
d. 0.45%normal saline
3) A nurse in the telemetry unit is monitoring a
client for cardiac changes indicative of
hypokalemia. Which of the following if noted in
cardiac monitor, would indicate the presence of
hypokalemia?
a. Tall, peaked T wave
b. ST segment depression
c. Widening QRS complex
d. Prolonged PR interval
4) A nurse is performing cardiopulmonary
resuscitation (CPR)on a client who has had a
cardiac arrest. An automatic external
defibrillator is available to treat the client.
Which of the following activities will allow the
nurse to assess the client’s cardiac rhythm?
a. Hold the defibrillator paddles firmly against
the chest
b. Apply adhesive patch electrodes to the chest
and move away from the client
c. Apply standard ECG monitoring leads to the
client and observe the rhythm
d. Connect standard ECG electrodes to a trans
telephonic monitor
5) A client who sustained an inhalation injury
arrives in ER. On initial assessment the nurse
notes that the client is very confused and
combative. The nurse determines that the client
is most likely experiencing?
a. Anxiety
b. Fear
c. Pain
d. Hypoxia
6) A nurse attempts to relieve an airway
obstruction on a 3year old conscious child. The
nurse performs this maneuver correctly by
standing behind the child, placing her arms
under the client’s axillae and around the client
and positioning her hands to deliver thrusts
between.
a. Groin and the abdomen
b. Umbilicus and the groin
c. Lower abdomen and the chest
d. Umbilicus and the xiphoid process
7) The ER nurse is monitoring a client who
received treatment for a severe asthma attack.
The nurse determines that the client’s
respiratory status had worsened if which of the
following is noted on assessment?
a. Diminished breath sounds
b. Wheezing during inhalation
c. Wheezing during exhalation
d. Wheezing throughout the lung fields
8)The nurse is performing CPR on a 7year old
child. The nurse delivers how many breaths per
minute the child?
a. 6
b. 8
c. 10
d. 20
9) A client in cardiogenic shock has a pulmonary
artery catheter (Swan-Ganz type) placed. The
nurse would interpret which of the following
cardiac output (CO)and pulmonary capillary
wedge pressure (PCWP) readings as indicating
that the client is most unstable?
a. CO 5l/min PCWP low
b. CO 2l/min PCWP low
c. CO 4l/min PCWP high
d. CO 3l/min PCWP high
10)A client is undergoing fluid replacement
after burned on 20% of her body 12 hr. ago. The
nursing assessment reveals a Blood pressure of
90/50mmHg, Pulse rate of 110b/t, and urine
output of 20ml/hr. The nurse reports the
findings to the physician and anticipates which
of the following prescriptions?
a. Transfusing One packed red blood cells
b. Administering a diuretic to increase the urine
output
c. Increasing the amount of IV Lactated Ringer’s
solution
d. Changing the IV lactated Ringer’s solution to
dextrose in water
11) A nurse is performing an assessment on a
client who was admitted to the hospital with a
diagnosis of carbon monoxide poisoning. Which
of the following assessments performed by the
nurse would primarily elicit data related to a
deterioration of the client’s condition?
a. Skin color
b. Apical rate
c. Respiratory rate
d. Level of consciousness
12)A nurse suspects that a pulmonary embolism
has developed in a postpartum client with
femoral thrombophlebitis. The immediate
nursing action would be to:
a. Monitor vital signs
b. Elevate the head of the bed 30 to 40degrees
c. Initiate an intravenous line if one is not
already in place
d. Administer oxygen by face mask as
prescribed at 8-10l/min
13)A nurse is planning care for a client with
intracranial pressure (ICP) monitoring. Which of
the following interventions would be
contraindicated in the plan of care?

a. Using strict aseptic technique when touching

the monitoring system

b. Assessing the insertion site for signs and

symptoms of infection

c. Leveling the transducer at the lowest point of

the ear

d. Checking all stopcocks and connections for

leaks

14) A client with a history of silicosis is admitted

to the hospital with respiratory distress and
impending respiratory failure. The nurse plans
to have which of the following items readily
available at the client’s bedside?

a. Chest tube drainage system

b. Intubation tray

c. Thoracentesis tray

d. Crash cart

15) A client in shock is receiving dopamine

hydrochloride by intravenous infusion. The
nurse should have which of the following
medications available for local injection if IV
infiltration and medication extravasation occur?

a. Vitamin K

b. Phentolamine

c. Atropine sulphate

d. Protamine sulphate