1ST MAJOR EXAM CA 103

UNIVERSITY OF MINDANAO

SITUATION: Psychological distress directly influences body functioning. Therefore, it is important to

identify any anxiety the patient is experiencing prior to a surgical operation.
1. A patient who is being admitted to the surgical unit for a hysterectomy paces the floor, repeatedly saying, “I
just want this over.” What should the nurse do to promote a positive surgical outcome for the patient?
a. Ask the patient what her specific concerns are about the surgery.
b. Reassure the patient that the surgery will be over soon and she will be fine.
c. Redirect the patient’s attention to the necessary preoperative preparations.
d. Tell the patient she should not be so anxious because she is having a common, safe surgery.
2. The morning before a scheduled hysterectomy related to uterine cancer, the client informs the nurse that she
does not want to go through with the procedure. Which of the following steps should the nurse take next?
a. Inform the client that the surgery is necessary and that there is nothing to worry about.
b. Notify the surgeon that the client is refusing surgery and needs to be sedated.
c. Inform the surgeon of the client’s statement so that the surgeon can talk with the client.
d. Note the client’s statement on the chart and reassess the client.
3. Choose the appropriate response to the statement of the patient, “I’m so nervous about my surgery.”
a. “Relax. Your recovery period will be shorter if you’re less nervous.”
b. “Stop worrying. It only makes you more nervous.”
c. “You needn’t worry. Your doctor has done this surgery many times before.”
d. “You seem nervous about your surgery.”
4. The nurse's preoperative psychological assessment of the patient can be essential in helping to:
a. determine the coping mechanisms the patient has for his or her feelings of anxiety
b. categorise subjective data reported by the patient in the health history
c. provide a psychological baseline for the patient throughout the perioperative period
d. support the results of laboratory and diagnostic studies done on the patient
5. Expected patient outcomes for relief of anxiety related to a surgical procedure include all of the following
except:
a. understands the nature of the surgery and voluntarily signs an informed consent.
b. verbalizes an understanding of the preanesthetic medication.
c. requests a visit with a member of the clergy.
d. questions the anesthesiologist about anesthesia-related concerns.
SITUATION Collaboration of the surgical team using evidence-based practice tailored to the specific
case results in optimum patient care and improved outcomes.
6. Preoperatively, an anesthesiologist is responsible for:
1. assessing pulmonary status.
2. inquiring about preexisting pulmonary infections.
3. knowing the patient’s history of smoking.
4. securing the informed consent for the surgery

a. 1 only b. 1 & 2 c. 1, 2, & 3 d. 1, 2, 3 & 4

7. What is the primary goal of the circulating nurse during preparation of the operating room, transferring and
positioning the patient, and assisting the anesthesia team?
a. Avoiding any type of injury to the patient
b. Maintaining a clean environment for the patient
c. Providing for patient comfort and sense of well-being
d. Preventing breaks in aseptic technique by the sterile members of the team
8. During surgery, who is most responsible for monitoring for possible breaks in sterile technique?
a. Circulating nurse c. Anesthesiologist
b. Holding nurse d. Surgeon
9. The circulating nurse’s responsibilities, in contrast to the scrub nurse’s responsibilities, include:
a. assisting the surgeon.
b. coordinating the surgical team.
c. setting up the sterile tables.
d. passing instruments.
SITUATION: Surgery may be performed for various reasons and this is the reason why it is imperative
for nurses to know important aspects of surgical techniques.
10. Which of the following is not essential to a valid definition of perioperative nursing?
a. Continuity of care throughout the perioperative period
b. Commitment to one plan that applies throughout the three phases of surgical intervention
c. Use of scientific and behavioural practices to meet patient needs
d. Respect for the individuality of the patient's needs
11. An example of a surgical procedure classified as urgent is:
a. an appendectomy.
b. an exploratory laparotomy.
 c. a repair of multiple stab wounds.
d. a face-lift.
12. A mammoplasty would be classified as surgery that is:
a. urgent. c. required
b. optional. d. reconstructive.
13. The nurse is educating a preoperative client about colostomy surgery. The colostomy surgery is categorized as
what type of surgery?
a. Cosmetic c. Diagnostic
b. Curative d. Palliative
SITUATION 5 - Voluntary and written informed consent from the patient is necessary before
nonemergent surgery can be performed in order to protect the patient from unsanctioned surgery and
protect the surgeon from claims of an unauthorized operation.
14. The unidentified client from the emergency department requires immediate surgery, but he is not conscious
and no one is with him. What must the nurse who is verifying the informed consent do?
a. Ensure written consultation of two noninvolved physicians.
b. Read the surgeon's consult to determine whether the client's condition is life threatening.
c. Sign the operative permit.
d. Withhold surgery until the next of kin is notified.
15. The surgical client has signed do-not-resuscitate (DNR) orders before going to the operating room (OR). A
complication requiring resuscitation happens during surgery. What is the nurse's proper action?
a. Call the legal department.
b. Call the client's medical physician.
c. Honor the DNR order.
d. Resuscitate per OR procedure.
16. The nurse asks a preoperative patient to sign a surgical consent form as specified by the surgeon and then
signs the form after the patient does so. By this action, what is the nurse doing?
a. Witnessing the patient’s signature
b. Obtaining informed consent from the patient for the surgery
c. Verifying that the consent for surgery is truly voluntary and informed
d. Ensuring that the patient is mentally competent
17. Valid surgical consent for treatment can only be given by a person who:
a. freely and voluntarily consents and is competent and is guided by a doctor
b. is appropriately informed and is competent and freely and voluntarily consents
c. is competent and freely and voluntarily consents and has an advanced care directive
d. is appropriately informed and freely and voluntarily consents and has appointed somebody with an
enduring power of attorney
18. An informed consent is required for:
a. closed reduction of a fracture.
b. insertion of an intravenous catheter.
c. irrigation of the external ear canal.
d. urethral catheterization.
SITUATION: The goal in the preoperative period is for the patient to be as healthy as possible. Every
attempt is made by the nurse to address risk factors that otherwise lead to postoperative
complications.

19. It is recommended that those who smoke cigarettes should stop smoking how long before surgery?
a. 2 months c. 2 weeks
b. 3 months d. 3 weeks
20. Surgery would be contraindicated for a renal patient with:
a. a blood urea nitrogen level of 42 mg/dL.
b. a creatine kinase level of 120 U/L.
c. a serum creatinine level of 0.9 mg/dL.
d. a urine creatinine level of 1.2 mg/dL.
21. The chief life-threatening hazard for surgical patients with uncontrolled diabetes is:
a. dehydration. c. hypoglycemia.
b. hypertension. d. glucosuria.
22. Assessment of a gerontologic patient reveals bilateral dimmed vision. This information alerts the nurse to plan
for:
a. a safe environment.
b. restrictions of the patient’s unassisted mobility activities.
c. probable cataract extractions.
d. referral to an ophthalmologist
23. During a preoperative physical examination, the nurse is alerted to the possibility of compromised respiratory
function during or after surgery in a patient with which problem?
a. Obesity c. Enlarged liver
b. Dehydration d. Decreased peripheral pulses
SITUATION 7 - Before any surgical treatment is initiated, a health history is obtained, a physical
examination is performed during which vital signs are noted, and a database is established for future
comparisons. During the physical examination, many factors that have the potential to affect the
patient undergoing surgery are considered.

24. When the nurse asks a preoperative patient about allergies, the patient reports a history of seasonal
environmental allergies and allergies to a variety of fruits. What should the nurse do next?
a. Note this information in the patient’s record as hay fever and food allergies.
b. Place an allergy alert wristband that identifies the specific allergies on the patient.
c. Ask the patient to describe the nature and severity of any allergic responses experienced from these
agents.
d. Notify the anesthesia care provider (ACP) because the patient may have an increased risk for allergies to
anesthetics.
25. The nurse is reviewing the laboratory results for a preoperative patient. Which test result should be brought to
the attention of the surgeon immediately?
a. Serum K+ of 3.8 mEq/L
b. Hemoglobin of 15 g/dL
c. Blood glucose of 100 mg/dL
d. White blood cell (WBC) count of 18,500/μL
26. During a preoperative assessment, which statement by the client requires further investigation by the nurse to
assess risk?
a. "I am taking vitamins."
b. "I drink a glass of wine a night."
c. "I had a heart attack 4 months ago."
d. "I don't like latex balloons."
27. The nurse completes the preoperative checklist on the client scheduled for general surgery. Which factor
contributes the greatest risk for the planned procedure?
a. Age of 59 years
b. General anesthesia complications experienced by the client's brother
c. Diet-controlled diabetes mellitus
d. Ten pounds over the client's ideal body weight
28. A nurse records a client’s vital signs before transferring him to the preanesthesia unit for an exploratory
laparotomy. The client’s temperature is 39° C (102.2° F) orally. Which of the following should the nurse do
next?
a. Contact and inform the surgeon regarding the temperature.
b. Transfer the client to the preanesthesia unit and notify the accepting nurse about the temperature.
c. Administer 650 mg acetaminophen and recheck the temperature in 1 hr.
d. Apply a cooling blanket and recheck the client’s temperature in 30 min.
SITUATION 9 - Nurses have long recognized the value of preoperative instruction. Each patient is
taught as an individual, with consideration for any unique concerns or learning needs.

29. When preparing to conduct a preoperative teaching program, the perioperative nurse should first:
a. ask the patient what he or she knows about the planned surgical event
b. determine the patient's knowledge of his or her current health status
c. determine the patient's readiness to learn
d. describe the physical environment
30. In teaching about pain management, a nurse-educator should discuss:
a. the need to use pain medication only when absolutely necessary.
b. that pain medication will be ordered and given according to the patient’s needs.
c. how the method of pain medication administration can’t be altered after surgery.
d. the need to limit narcotics to avoid addiction.
31. The nurse reviews with the client a routine discharge teaching plan concerning postoperative care. Which
statement by the client indicates that teaching was effective?
a. "I may need to restrict my activities for several months."
b. "The dressing should stay in place unless it gets wet."
c. "The incision needs to be cleaned every 4 hours with hydrogen peroxide."
d. "The wound will completely heal in about 2 months."
32. The preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best
physical outcomes?
a. Instructs the client to quit smoking
b. Teaches about the dangers of tobacco
c. Teaches the importance of incentive spirometry
d. Tells the client where the smoking lounge is
33. The best time to perform preoperative teaching is:
a. Upon admission c. Days prior to discharge
b. On the day of surgery d. After the operation
SITUATION: The patient’s natural skin flora or a previously existing infection may cause postoperative
wound infection. Rigorous adherence to the principles of surgical asepsis by OR personnel is basic to
preventing surgical site infections.

34. Perioperative nurses contribute to infection control practices by:

a. limiting contact with patients
b. using Standard Precautions
a. immunization
b. isolating patients
35. Double gloving is recommended to:
a. improve dexterity when handling instruments
b. protect against sharps injury
c. reduce the length of the surgical scrub
d. increase protection against electric shocks
36. When opening a wrapped sterile item, The OR nurse should:
a. first check the external sterility indicator
b. open the wrapper closest to you first
c. remove all adhesive tapes first
d. always wear gloves when opening wrapped items
37. A break in sterile technique occurs during surgery when the scrub nurse touches
a. the mask with sterile gloved hands.
b. sterile gloved hands to the gown at chest level.
c. the drape at the incision site with sterile gloved hands.
d. the lower arm to the instruments on the instrument tray.
38. A nurse has just finished scrubbing, gowning and gloving in preparation for a transurethral prostatectomy.
Following principles of sterile technique, which of the following hand positions of a scrub nurse is a clear
violation?
a. Hands are kept away from the face.
b. Hands are folded under the arms.
c. Hands are resting on top of the sterile table.
d. Hands are holding autoclaved instruments.
39. Place the examples of drugs in the order of usage according to the World
Health Organization (WHO) analgesic ladder. a. Morphine, hydromorphone,
acetaminophen and lorazepam b. NSAIDs and corticosteroids c. Codeine,
oxycodone and diphenhydramine
a. B, A, C
b. C, A, B
c. B, C, A
d. A, B, C
40. Which client is at greater risk for respiratory depression while receiving
opioids for analgesia?
a. An elderly chronic pain client with a hip fracture
b. A client with a heroin addiction and back pain
c. A young female client with advanced multiple myeloma
d. A child with an arm fracture and cystic fibrosis
41. A client appears upset and tearful, but denies pain and refuses pain
medication, because “my sibling is a drug addict and has ruined out lives.”
What is the priority intervention for this client?
a. Encourage expression of fears on past experiences
b. Provide accurate information about use of pain medication
c. Explain that addiction is unlikely among acute care clients
d. Seek family assistance in resolving this problem
42. A client is being tapered off opioids and the nurse is watchful for signs of
withdrawal. What is one of the first signs of withdrawal?
a. Fever
 b. Nausea
c. Diaphoresis
d. Abdominal cramps
43. In caring for clients with pain and discomfort, which task is most
appropriate to delegate to the nursing assistant?
a. Assist the client with preparation of a sitz bath.
b. Monitor the client for signs of discomfort while ambulating
c. Coach the client to deep breathe during painful procedures
d. Evaluate relief after applying a cold application.
44. The physician has ordered a placebo for a chronic pain client. You are
newly hired nurse and you feel very uncomfortable administering the
medication. What is the first action that you should take?
a. Prepare the medication and hand it to the physician
b. Check the hospital policy regarding use of the placebo.
c. Follow a personal code of ethics and refuse to give it.
d. Contact the charge nurse for advice.
45. For a cognitively impaired client who cannot accurately report pain, what
is the first action that you should take?
a. Closely assess for nonverbal signs such as grimacing or rocking.
b. Obtain baseline behavioral indicators from family members.
c. Look at the MAR and chart, to note the time of the last dose and response.
d. Give the maximum PRS dose within the minimum time frame for relief.
46. Which route of administration is preferable for administration of daily
analgesics (if all body systems are functional)?
a. IV
b. IM or subcutaneous
c. Oral
d. Transdermal
e. PCA
47. A first day postoperative client on a PCA pump reports that the pain
control is inadequate. What is the first action you should take?
a. Deliver the bolus dose per standing order.
b. Contact the physician to increase the dose.
c. Try non-pharmacological comfort measures.
d. Assess the pain for location, quality, and intensity.
48. Which non-pharmacological measure is particularly useful for a client with
acute pancreatitis
a. Diversional therapy, such as playing cards or board games
b. Massage of back and neck with warmed lotion
c. Side-lying position with knees to chest and pillow against abdomen
d. Transcutaneous electrical nerve stimulation (TENS)
49. What is the best way to schedule medication for a client with constant
pain?
a. PRN at the client’s request
b. Prior to painful procedures
c. IV bolus after pain assessment
 d. Around-the-clock
50. Which client(s) are appropriate to assign to the LPN/LVN, who will
function under the supervision of the RN or team leader? (Choose all that
apply.)
1. A client who needs pre-op teaching for use of a PCA pump
2. A client with a leg cast who needs neurologic checks and PRN hydrocodone
3. A client post-op toe amputation with diabetic neuropathic pain
4. A client with terminal cancer and severe pain who is refusing medication
a. 1 & 2 c. 1&3 c. 2 &3 d. 2 & 4

OXYGENATION – RESPIRATORY DISORDERS

51. A male client who takes theophylline for chronic obstructive pulmonary disease is seen in the urgent
care center for respiratory distress. Once the client is stabilized, the nurse begins discharge teaching.
The nurse would be especially vigilant to include information about complying with medication
therapy if the client’s baseline theophylline level was:
A. 10 mcg/Ml b. 12 mcg/mL c. 15 mcg/mL d. 18mcg/mL
52. Nurse Kim is caring for a client with a pneumothorax and who has had a chest tube inserted notes
continuous gentle bubbling in the suction control chamber. What action is appropriate?
A. Do nothing, because this is an expected finding.
B. Immediately clamp the chest tube and notify the physician.
C. Check for an air leak because the bubbling should be intermittent.
D. Increase the suction pressure so that bubbling becomes vigorous.
53. A nurse has assisted a physician with the insertion of a chest tube. The nurse monitors the adult
client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted.
Based on this assessment, which action would be appropriate?
A. Inform the physician.
B. Continue to monitor the client.
C. Reinforce the occlusive dressing.
D. Encourage the client to deep-breathe.
54. The nurse caring for a male client with a chest tube turns the client to the side, and the chest tube
accidentally disconnects. The initial nursing action is to:
A. Call the physician.
B. Place the tube in a bottle of sterile water.
C. Immediately replace the chest tube system.
D. Place the sterile dressing over the disconnection site.
55. Nurse Paul is assisting a physician with the removal of a chest tube. The nurse should instruct the
client to:
A. Exhale slowly c. Inhale and exhale quickly.
B. Stay very still d. Perform the Valsalva maneuver.
56. While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged.
The initial nursing action is to:
A. Call the physician to reinsert the tube.
B. Grasp the retention sutures to spread the opening.
C. Call the respiratory therapy department to reinsert the tracheotomy.
D. Cover the tracheostomy site with a sterile dressing to prevent infection.
57. A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse
reports which of the following signs immediately if experienced by the client?
A. Stridor
B. Occasional pink-tinged sputum
 C. A few basilar lung crackles on the right
D. Respiratory rate of 24 breaths/min
58. 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?
A. A low respiratory
B. Diminished breathe sounds
C. The presence of a barrel chest
D. A sucking sound at the site of injury
59. A nurse is caring for a male client hospitalized with acute exacerbation of chronic obstructive
pulmonary disease. Which of the following would the nurse expect to note on assessment of this
client?
A. Hypocapnia
B. A hyperinflated chest noted on the chest x-ray
C. Increase oxygen saturation with exercise
D. A widened diaphragm noted on the chest x-ray
60. A community health nurse is conducting an educational session with community members regarding
tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is:
A. Dyspnea
B. Chest pain
C. A bloody, productive cough
D. A cough with the expectoration of mucoid sputum
61. A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The
nurse reviews the results of which diagnostic test that will confirm this diagnosis?
A. Bronchoscopy c. Chest x-ray
B. Sputum culture d. Tuberculin skin test
62. The nursing instructor asks a nursing student to describe the route of transmission of tuberculosis.
The instructor concludes that the student understands this information if the student states that the
tuberculosis is transmitted by:
A. Hand and mouth c. The fecal-oral route
B. The airborne route d. Blood and body fluids
63. 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:
A. 1 L/min b. 2 L/min c. 6 L/min d. 10 L/min
64. A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the
nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary
purpose of pursed-lip breathing is to:
A. Promote oxygen intake.
B. Strengthen the diaphragm.
C. Strengthen the intercostal muscles.
D. Promote carbon dioxide elimination.
65. Nurse Hannah is preparing to obtain a sputum specimen from a client. Which of the following
nursing actions will facilitate obtaining the specimen?
A. Limiting fluids
B. Having the clients take three deep breaths
C. Asking the client to split into the collection container
D. Asking the client to obtain the specimen after eating
66. A nurse is caring for a female client after a bronchoscope and biopsy. Which of the following signs, if
noted in the client, should be reported immediately to the physicians?
A. Dry cough c. Bronchospasm
B. Hematuria d. Blood-streaked sputum
67. A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse
must limit the suctioning time to a maximum of:
A. 1 minute b. 5 seconds c. 10 seconds d. 30 seconds
68. A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning
procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following
is the appropriate nursing intervention?
A. Continue to suction.
B. Notify the physician immediately.
C. Stop the procedure and reoxygenate the client.
D. Ensure that the suction is limited to 15 seconds.
69. An unconscious male client is admitted to an emergency room. Arterial blood gas measurements
reveal a pH of 7.30, a low bicarbonate level, a normal carbon dioxide level, a normal oxygen level,
and an elevated potassium level. These results indicate the presence of:
A. Metabolic acidosis
B. Respiratory acidosis
C. Overcompensated respiratory acidosis
D. Combined respiratory and metabolic acidosis
70. A female client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing
that which of the following is a common clinical manifestation of pulmonary embolism?
A. Dyspnea c. Bradycardia
B. Bradypnea d. Decreased respiratory
71. A nurse teaches a male client about the use of a respiratory inhaler. Which action by the client
indicates a need for further teaching?
A. Inhales the mist and quickly exhales
B. Removes the cap and shakes the inhaler well before use
C. Presses the canister down with the finger as he breathes in
D. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed
72. A female client has just returned to a nursing unit following bronchoscopy. A nurse would implement
which of the following nursing interventions for this client?
A. Administering atropine intravenously
B. Administering small doses of midazolam (Versed)
C. Encouraging additional fluids for the next 24 hours
D. Ensuring the return of the gag reflex before offering food or fluids
73. A nurse is assessing the respiratory status of a male client who has suffered a fractured rib. The
nurse would expect to note which of the following?
A. Slow deep respirations
B. Rapid deep respirations
C. Paradoxical respirations
D. Pain, especially with inspiration
74. A female client with chest injury has suffered flail chest. A nurse assesses the client for which most
distinctive sign of flail chest?
A. Cyanosis c. Paradoxical chest movement
B. Hypotension d. Dyspnea, especially on exhalation
75. A male client has been admitted with chest trauma after a motor vehicle accident and has
undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the
ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the
lung. The nurse immediately assesses for other signs of:
A. Right pneumothorax
B. Pulmonary embolism
C. Displaced endotracheal tube
 D. Acute respiratory distress syndrome
76. A nurse is teaching a male client with chronic respiratory failure how to use a metered-dose inhaler
correctly. The nurse instructs the client to:
A. Inhale quickly
B. Inhale through the nose
C. Hold the breath after inhalation
D. Take two inhalations during one breath
77. A nurse is assessing a female client with multiple trauma who is at risk for developing acute
respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress
syndrome?
A. Bilateral wheezing c. Intercostal retractions
B. Inspiratory crackles d. Increased respiratory rate
78. A nurse is taking pulmonary artery catheter measurements of a male client with acute respiratory
distress syndrome. The pulmonary capillary wedge pressure reading is 12mm Hg. The nurse
interprets that this readings is:
A. High and expected c. Normal and expected
B. Low and unexpected d. Uncertain and unexpected
79. A nurse is assessing a male client with chronic airflow limitations and notes that the client has a
“barrel chest.” The nurse interprets that this client has which of the following forms of chronic
airflow limitations?
A. Emphysema c. Chronic obstructive bronchitis
B. Bronchial asthma d. Bronchial asthma and bronchitis
80. A nurse is caring for a female client diagnosed with tuberculosis. Which assessment, if made by the
nurse, is inconsistent with the usual clinical presentation of tuberculosis and may indicate the
development of a concurrent problem?
A. Cough c. Chills and night sweats
B. High-grade fever d. Anorexia and weight loss
81. When assessing the client with COPD, which health promotion information would be most important
for the nurse to obtain?
A. Number of years the client has smoked.
B. Risk factors for complications.
C. Ability to administer inhaled medication.
D. Possibility for lifestyle changes.
82. The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention
should the nurse implement first?
A. Assist the client into a sitting position at 90 degrees.
B. Give oxygen at six (6) LPM via nasal cannula.
C. Monitor vital signs with the client sitting upright.
D. Notify the health-care provider about the client’s status.
83. When assessing the client with the diagnosis of COPD, which data would require the nurse to take
immediate action?
A. Large amounts of thick white sputum.
B. Oxygen flow meter set on eight (8) liters.
C. Use of accessory muscles during inspiration.
D. Presence of a barrel chest and dyspnea.
84. While the nurse is caring for the client diagnosed with COPD, which outcome would require a
revision in the plan of care?
A. The client has no signs of respiratory distress.
B. The client shows an improved respiratory pattern.
C. The client demonstrates intolerance to activity.
 D. The client participates in establishing goals.
85. Which nursing diagnoses would be appropriate for the nurse to include in the plan of care for the
client diagnosed with COPD? Select all that apply.
1. Impaired gas exchange.
2. Inability to tolerate temperature extremes.
3. Activity intolerance.
4. Inability to cope with changes in roles.
5. Alteration in nutrition.
A. 1,2,4 b. 2,3,4,5 c. 1,2,4,5 d. 1,2,3,4,5
86. Which outcome would be appropriate for the client problem “ineffective gas exchange” for the client
recently diagnosed with COPD?
A. The client demonstrates the correct way to purse-lip breathe.
B. The client lists three (3) signs/symptoms to report to the HCP.
C. The client will drink at least 2500 mL of water daily.
D. The client will be able to ambulate 100 feet with dyspnea.
87. The primary nurse observes the unlicensed nursing assistant removing the nasal cannula from the
client diagnosed with COPD while ambulating the client to the bathroom. Which action should the
primary nurse take?
A. Praise the NA because this prevents the client from tripping on the oxygen tubing.
B. Place the oxygen back on the client while sitting in the bathroom and say nothing.
C. Explain to the NA in front of the client that the oxygen must be left in place at all times.
D. Discuss the NA’s action with the charge nurse so that appropriate action can be taken.
88. When assessing the client recently diagnosed with COPD, which sign and symptom should the nurse
expect?
A. Clubbing of the client’s fingers.
B. Infrequent respiratory infections.
C. Chronic sputum production.
D. Nonproductive hacking cough.
89. What statement made by the client would indicate that the nurse’s discharge teaching was effective
for the client diagnosed with COPD?
A. “I need to get an influenza vaccine each year, even when there is a shortage.”
B. “I need to get a vaccine for pneumonia each year with my flu shot.”
C. “If I reduce my cigarette smoking to six (6) a day, I won’t have difficulty breathing.”
D. “I need to restrict my drinking liquids to keep from having so much phlegm.”
90. The nurse is completing the admission assessment on a 13-year-old client diagnosed with asthma.
Which signs and symptoms would the nurse expect to find?
A. Fever and crepitus. c. Dyspnea and wheezing.
B. Rales and hives. d.Normal chest shape and eupnea.
91. The nurse is planning the care of a client diagnosed with asthma and has written a problem of
“anxiety.” Which nursing intervention should be implemented?
A. Stay with the client.
B. Notify the health-care provider.
C. Administer an anxiolytic medication.
D. Encourage the client to drink fluids.
92. The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should
the nurse implement first?
A. Assist the client into a sitting position at 90 degrees.
B. Give oxygen at six (6) LPM via nasal cannula.
C. Monitor vital signs with the client sitting upright.
D. Notify the health-care provider about the client’s status.
93. When assessing the client with the diagnosis of COPD, which data would require the nurse to take
immediate action?
A. Large amounts of thick white sputum.
B. Oxygen flow meter set on eight (8) liters.
C. Use of accessory muscles during inspiration.
D. Presence of a barrel chest and dyspnea.
94. While the nurse is caring for the client diagnosed with COPD, which outcome would require a revision in
the plan of care?
A. The client has no signs of respiratory distress.
B. The client shows an improved respiratory pattern.
C. The client demonstrates intolerance to activity.
D. The client participates in establishing goals.
95. The nurse is caring for the client diagnosed with end-stage COPD. Which data would warrant immediate
intervention by the nurse?
A. The client’s pulse oximeter reading is 92%.
B. The client’s arterial blood gas level is 74.
C. The client has SOB when walking to the bathroom.
D. The client’s sputum is rusty colored.
96. What statement made by the client diagnosed with chronic bronchitis indicates to the nurse that more
teaching is needed?
A. “I should contact my health-care provider if my sputum changes color or amount.”
B. “I will take my bronchodilator regularly to prevent having bronchospasms.”
C. “This metered dose inhaler gives a precise amount of medication with each dose.”
D. “I need to return to the HCP to have my blood drawn with my annual physical.”
97. Which nursing diagnoses would be appropriate for the nurse to include in the plan of care for the client
diagnosed with COPD? Select all that apply.
6. Impaired gas exchange.
7. Inability to tolerate temperature extremes.
8. Activity intolerance.
9. Inability to cope with changes in roles.
10. Alteration in nutrition.
a. 1,2,3,4
b. 1,3,4,5
c. 1,2,3
d. all of the above
98. Which outcome would be appropriate for the client problem “ineffective gas exchange” for the client
recently diagnosed with COPD?
A. The client demonstrates the correct way to purse-lip breathe.
B. The client lists three (3) signs/symptoms to report to the HCP.
C. The client will drink at least 2500 mL of water daily.
D. The client will be able to ambulate 100 feet with dyspnea.
99. The primary nurse observes the unlicensed nursing assistant removing the nasal cannula from the client
diagnosed with COPD while ambulating the client to the bathroom. Which action should the primary
nurse take?
A. Praise the NA because this prevents the client from tripping on the oxygen tubing.
B. Place the oxygen back on the client while sitting in the bathroom and say nothing.
C. Explain to the NA in front of the client that the oxygen must be left in place at all times.
D. Discuss the NA’s action with the charge nurse so that appropriate action can be taken.
100. When assessing the client recently diagnosed with COPD, which sign and symptom should the nurse
expect?
A. Clubbing of the client’s fingers.
B. Infrequent respiratory infections.
C. Chronic sputum production.
D. Nonproductive hacking cough.