Question 1
Situation: Ben has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Jenny’s care plan is to loosen and remove secretions in the airway.
Jenny listens to Ben’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Jenny does percussion would be:
A. Client lying on his back and then flat on his abdomen on Trendelenburg position
B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomen
C. Client lying flat on his back and the flat on his abdomen
D. Client lying on his right the left side on Trendelenburg position
Situation: Ben has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Jenny’s care plan is to loosen and remove secretions in the airway.
Jenny listens to Ben’s bilateral sounds and finds that congestion is in the upper lobes of the lungs. The appropriate position to drain the anterior and posterior apical segments of the lungs when Jenny does percussion would be:
A. Client lying on his back and then flat on his abdomen on Trendelenburg position
B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomen
C. Client lying flat on his back and the flat on his abdomen
D. Client lying on his right the left side on Trendelenburg position
Answer
B. Client seated upright in bed or on a chair then leaning forward in sitting position then flat on his back and on his abdomen
Question 2
Situation: Ben has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Jenny’s care plan is to loosen and remove secretions in the airway.
When documenting outcome of Ben’s treatment, Jenny should include the following on her recording except:
A. Color, amount, and consistency of sputum
B. Character of breath sounds and respiratory rate before and after the procedure
C. Amount of fluid intake of client before and after the procedure
D. Significant changes in vital signs
Situation: Ben has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Jenny’s care plan is to loosen and remove secretions in the airway.
When documenting outcome of Ben’s treatment, Jenny should include the following on her recording except:
A. Color, amount, and consistency of sputum
B. Character of breath sounds and respiratory rate before and after the procedure
C. Amount of fluid intake of client before and after the procedure
D. Significant changes in vital signs
Answer
C. Amount of fluid intake of client before and after the procedure
Question 3
Situation: Ben has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Jenny’s care plan is to loosen and remove secretions in the airway.
When assessing Ben for chest percussion or chest vibration, and postural drainage, Jenny would focus on the following except:
A. Amount of food and fluid taken during the last meal before treatment
B. Respiratory rate, breath sounds, and location of congestion
C. Teaching the client’s relatives to perform the procedure
D. Doctor’s order regarding position restrictions and client’s tolerance for lying flat
Situation: Ben has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Jenny’s care plan is to loosen and remove secretions in the airway.
When assessing Ben for chest percussion or chest vibration, and postural drainage, Jenny would focus on the following except:
A. Amount of food and fluid taken during the last meal before treatment
B. Respiratory rate, breath sounds, and location of congestion
C. Teaching the client’s relatives to perform the procedure
D. Doctor’s order regarding position restrictions and client’s tolerance for lying flat
Answer
C. Teaching the client’s relatives to perform the procedure
Question 4
Situation: Ben has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Jenny’s care plan is to loosen and remove secretions in the airway.
Jenny prepares Ben for postural drainage and percussion. Which of the following is a special consideration when doing the procedure?
A. Respiratory rate of 16 to 20 per minute
B. Client able to tolerate sitting and lying position
C. Client has no signs of infection
D. Time of last food and fluid intake of the client
Situation: Ben has a nursing diagnosis of ineffective airway clearance related to excessive secretions and is at risk for infection because of retained secretions. Part of Nurse Jenny’s care plan is to loosen and remove secretions in the airway.
Jenny prepares Ben for postural drainage and percussion. Which of the following is a special consideration when doing the procedure?
A. Respiratory rate of 16 to 20 per minute
B. Client able to tolerate sitting and lying position
C. Client has no signs of infection
D. Time of last food and fluid intake of the client
Answer
D. Time of last food and fluid intake of the client
Question 5
The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:
A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretions loose on the exhalation cycle
C. In both percussion and vibration, the hands are on top of each other and hand action is in tune with client’s breath rhythm
D. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation of air
The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:
A. Percussion uses only one hand while vibration uses both hands
B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretions loose on the exhalation cycle
C. In both percussion and vibration, the hands are on top of each other and hand action is in tune with client’s breath rhythm
D. Percussion slaps the chest to loosen secretions while vibration shakes the secretions along with the inhalation of air
Answer
B. Percussion delivers cushioned blows to the chest with cupped palms while vibration gently shakes secretions loose on the exhalation cycle
Question 6
Situation: Mrs. Silva, 50 years old, asks about possible problems regarding her elimination now that she is in the menopausal stage.
Instruction on health promotion regarding urinary elimination is important. Which would you include?
A. Hold urine as long as she can before emptying her bladder to strengthen her sphincter muscles
B. If burning sensation is experienced while voiding, drink pineapple juice
C. After urination, wipe from anal area towards the pubis
D. Tell client to empty the bladder eat each voiding
Situation: Mrs. Silva, 50 years old, asks about possible problems regarding her elimination now that she is in the menopausal stage.
Instruction on health promotion regarding urinary elimination is important. Which would you include?
A. Hold urine as long as she can before emptying her bladder to strengthen her sphincter muscles
B. If burning sensation is experienced while voiding, drink pineapple juice
C. After urination, wipe from anal area towards the pubis
D. Tell client to empty the bladder eat each voiding
Answer
D. Tell client to empty the bladder eat each voiding
Question 7
Mrs. Silva talks about her fear of being incontinent due to a prior experience of dribbling urine when laughing or sneezing, and when she has a full bladder. Your most appropriate action would be to:
A. Tell client to drink less fluid to avoid incontinence
B. Instruct client to start wearing thin adult diapers
C. Ask the client to bring an extra underwear “just in case”
D. Teach client pelvic exercises to strengthen perineal muscles
Mrs. Silva talks about her fear of being incontinent due to a prior experience of dribbling urine when laughing or sneezing, and when she has a full bladder. Your most appropriate action would be to:
A. Tell client to drink less fluid to avoid incontinence
B. Instruct client to start wearing thin adult diapers
C. Ask the client to bring an extra underwear “just in case”
D. Teach client pelvic exercises to strengthen perineal muscles
Answer
D. Teach client pelvic exercises to strengthen perineal muscles
Question 8
Mrs. Silva asked for instructions for skin care for her mother who has urinary incontinence and is almost always in bed. Your instruction would focus on prevention of skin irritation and breakdown by:
A. Using thick diapers to absorb urine well
B. Drying the skin with baby powder to prevent or mask the smell of ammonia
C. Thorough washing, rinsing, and drying of skin area that gets her wet with urine
D. Making sure that the linen are smooth and dry at all times
Mrs. Silva asked for instructions for skin care for her mother who has urinary incontinence and is almost always in bed. Your instruction would focus on prevention of skin irritation and breakdown by:
A. Using thick diapers to absorb urine well
B. Drying the skin with baby powder to prevent or mask the smell of ammonia
C. Thorough washing, rinsing, and drying of skin area that gets her wet with urine
D. Making sure that the linen are smooth and dry at all times
Answer
C. Thorough washing, rinsing, and drying of skin area that gets her wet with urine
Question 9
Which of the following is the priority nursing action when a urinary catheter has been inserted in a female client with no urine return?
A. Insert the catheter another four inches
B. Secure the catheter tubing to the inside of the thigh
C. Encourage the client to increase fluid intake
D. Leave the catheter in the vagina and insert another catheter
Which of the following is the priority nursing action when a urinary catheter has been inserted in a female client with no urine return?
A. Insert the catheter another four inches
B. Secure the catheter tubing to the inside of the thigh
C. Encourage the client to increase fluid intake
D. Leave the catheter in the vagina and insert another catheter
Answer
D. Leave the catheter in the vagina and insert another catheter
Question 10
Which of the following is the most appropriate nursing action when the nurse has inserted a urinary catheter in a male client but there is no return of urine?
A. Advance the catheter further
B. Remove catheter
C. Tape the catheter in place and encourage fluids
D. Report signs of urinary infection
Which of the following is the most appropriate nursing action when the nurse has inserted a urinary catheter in a male client but there is no return of urine?
A. Advance the catheter further
B. Remove catheter
C. Tape the catheter in place and encourage fluids
D. Report signs of urinary infection
Answer
A. Advance the catheter further
