Online Practice Test 50

Your Results for: "NCLEX® Review"

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 50 > NCLEX® Review Date/Time Submitted: August 2, 2012 at 2:19 AM (UTC/GMT)

Summary of Results 50% Correct of 10 Scored items: 5 Correct:  50% 5 Incorrect:  50% More information about scoring

1.		The nurse is to teach a client with Chronic Obstructed Pulmonary Disease safety precautions for using oxygen at home. The nurse knows that the client understands the safety principles discussed when he says the following: Your Answer: "Avoid materials that generate static electricity."
		Objective: Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. Rationale: Oxygen is a highly combustible substance. When near a client using oxygen, smoke only outside or in a room provided for smoking, away from the client. Inappropriate substances for use are noted in answer 3. Fire extinguishers should be readily available, and there should be an individual/family member with knowledge of its use. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		The nursing intervention that is appropriate for use with clients having an endotracheal tube is:  Your Answer: Frequently assessing nasal and oral mucosa for redness and irritation Correct Answer: Providing room air
		Objective: Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. Rationale: Humidified air or oxygen should be given, because the endotracheal tube bypasses the upper airways, which normally moistens air. Notepads and picture boards help to give the client some control in communication with others. Frequent assessments of nasal and oral mucosa monitor for skin breakdown and infection. Placing the client in a side-lying position prevents aspiration of fluids, which can lead to infection. Nursing Process: Planning and Implementation Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Decide what is the best action for client and situation.
3.		Which is the appropriate method to use when a client is suffering respiratory difficulty and in need of suctioning? Your Answer: Portable or wall suction machine with tubing and collection receptacle
		Objective: Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. Rationale: A dextrose-and-water solution is not used here. Controversy exists with using normal saline to assist in loosening secretions. The nasal cannula is not used in this technique. Goggles are worn for protection from any secretions splashed during the suctioning process. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Physiologic needs come first then safety. Psychosocial needs are addressed after physiologic and safety.
4.		Appropriate follow-up evaluation of a client after suctioning does not include which of the following assessments?  Your Answer: Only document findings abnormal in the client record; the doctor will see the results when rounds on the client are done.
		Objective: Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. Rationale: All findings after suctioning clients are documented in the record. Abnormal findings are not only documented, but called to the physician's attention as well. All other actions are appropriate. Nursing Process: Assessment Client Need: Physiological Integrity Nursing Process: Analysis Strategy: Physiologic needs come first then safety. Psychosocial needs are addressed after physiologic and safety.
5.		While suctioning a client in ICU, the nurse notices that the activity brings about deep breathing and coughing maneuvers by the client. This is considered a good action because:  Your Answer: Deep breathing oxygenates the lungs, and coughing loosens and moves secretions in the lungs.
		Objective: Explain the use of therapeutic measures such as medications, inhalation therapy, oxygen therapy, artificial airways, airway suctioning, and chest tubes to promote respiratory function. Rationale: The movement allows for expansion of the lungs, and the force and pressures exerted in coughing loosen the secretions. The other statements are not accurate. Nursing Process: Assessment Client Need: Physiological Integrity Nursing Process: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
6.		An appropriate nursing responsibility in caring for clients with chest drainage systems would be: Your Answer: Monitoring the patency and integrity of the drainage system
		Objective: State outcome criteria for evaluating client responses to measures that promote adequate oxygenation. Rationale: Actions taken directly from the text in book. No tube can drain effectively if it is clogged or damaged in any manner. The water seal level is marked for most effective level of use. Overfilling it adds no additional effectiveness. Clamps are readily available at the bedside for emergency purposes, such as dislodgement of the tube. Monitoring of client status after tube insertion includes all vital signs, and is set according to client need and hospital guidelines. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
7.		Which client is most at risk for developing an upper respiratory infection? Your Answer: A 13-year-old with a broken leg Correct Answer: A 3-year-old in preschool
		Objective: Identify factors influencing respiratory function. Rationale: During infancy and childhood, upper respiratory infections are common due to changes in developing respiratory systems. Adolescents and young- and middle-adult individuals would suffer this problem only if their immune systems were compromised in any manner, or if they suffered from chronic illness. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		The nurse is providing wellness teaching to a group of seniors in the community. Which action is not appropriate to follow in promoting healthy breathing? Your Answer: (blank)
9.		Which clinical signs are indicative of hypoxia? (Select all that apply.) Your Answer: Flaring of nostrils Mouth breathing Cyanosis  Rapid pulse Substernal or intercostals retractions Correct Answers: Flaring of nostrils Cyanosis  Rapid pulse Substernal or intercostals retractions
		Objective: Describe nursing measures to promote respiratory function and oxygenation. Rationale: Signs of hypoxia include: rapid pulse, rapid, shallow respirations and dyspnea, increased restlessness and lightheadedness, flaring of the nares, substernal or intercostals retractions and cynaosis. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection. Objective: Describe nursing measures to promote respiratory function and oxygenation. Rationale: Signs of hypoxia include: rapid pulse, rapid, shallow respirations and dyspnea, increased restlessness and lightheadedness, flaring of the nares, substernal or intercostals retractions and cynaosis. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
10.		_____________ or clapping is forceful striking of the skin with cupped hands to dislodge tenacious secretions.  Your Answer: Lifestyle Correct Answer: Time of day
		Objective: Identify and describe nursing measures to promote respiratory function and oxygenation. Rationale: Percussion is forceful striking with cupped hands and used to dislodge tenacious secretions. The nurse should cover the area with a towel or blanket, ask the client to breathe slowly, alternately flex and extend the wrists rapidly to slap the chest for 1 to 2 minutes. Nursing Process: Implementing Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge of pulmonary care.