NUR 2571 EXAM 1 PROFESSIONAL NURSING II PN2 EXAM 1

NUR 2571 EXAM 1 PROFESSIONAL NURSING II / PN2 EXAM 1

LATEST ACTUAL EXAM 10 0 QUESTIONS AND CORRECT

DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY

GRADED A+

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?

• Measure and compare cuff pressures.

ANS: B

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention?

• Client has reduced breath sounds. Nurse calls physician immediately.

ANS: C

A nurse assesses a clients respiratory status. Which information is of highest priority for the nurse to obtain?

• Occupation and hobbies

ANS: D

A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first?

• Cardiac rate and rhythm

ANS: A

A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next?

• Assess clients rate, rhythm, and depth of respiration.

A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?

• Absent breath sounds

ANS: B

A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first?

• Apply oxygen by mask or nasal cannula.

A nurse is caring for a client who is scheduled to undergo a thoracentesis.Which intervention should the nurse complete prior to the procedure?

• Validate that informed consent has been given by the client.

ANS: D

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?

• The trachea is deviated toward the opposite side of the neck.

ANS: D

A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?

• Ensure an x-ray is completed to confirm placement.

ANS: B

A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients teaching?

• Avoid carrying your grandchild with the arm that has the central catheter.

ANS: A

A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?

• Report of headache and stif f neck

ANS: B

A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?

• Upper extremity swelling is noted.

ANS: D

A nurse teaches a client who is prescribed a central vascular access device.Which statement should the nurse include in this clients teaching?

• Ask all providers to vigorously clean the connections prior to accessing the device.

ANS: C

A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?

• Place warm compresses on the site.

ANS: B

A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of heparin. The pharmacy supplies a multi-dose vial of heparin with a concentration of 100 units/mL. Which of the syringes shown below should the nurse use to draw up and administer the heparin?

ANS: D (10-mL syringe picture)

A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which complications should the nurse assess? (Select all that apply.)

• Phlebitis
• Thrombophlebitis

ANS: A, C

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first?

• Contact the provider and prepare for intubation.

ANS: A

A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?

• Stop the infusion of intravenous fluids.

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.)

• Stridor
• Ecchymosis behind the ear

ANS: A, D