Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
MS Exam 1
| Question | Answer |
|---|---|
| 27 After a patient has undergone a rhinoplasty, which nursing intervention will be included in the plan of care? | Instruct the patient to keep the head elevated for 48 hours to minimize swelling and pain. |
| 27 When teaching the patient with allergic rhinitis about management of the condition, the nurse explains that | identification and avoidance of environmental triggers are the best way to avoid symptoms. |
| 27 After discussing management of upper respiratory infections (URI) with a patient who has acute viral rhinitis, the nurse determines that additional teaching is needed when the patient says | “I can use my nasal decongestant spray until the congestion is all gone.” |
| 27 An RN is observing a nursing student who is suctioning a hospitalized patient with a tracheostomy in place. Which action by the student requires the RN to intervene? | The student puts on clean gloves and uses a sterile catheter to suction. |
| 27 When the nurse is deflating the cuff of a tracheostomy tube to evaluate the patient’s ability to swallow, it is important to | suction the patient’s mouth and trachea before deflation of the cuff. |
| 27 The nurse is caring for a spontaneously breathing patient who has a tracheostomy. To determine that the patient can protect the airway when eating without having the tracheostomy cuff inflated, the nurse will deflate the cuff and | have the patient drink a small amount of grape juice and observe for coughing. |
| 27 A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action will be included in the plan of care? | Assess the ability to swallow before using the fenestrated tube. |
| 27 When inflating the cuff on a tracheostomy tube to the appropriate level, the best action by the nurse will be to | use a manometer to ensure cuff pressure is at an appropriate level. |
| 27 A patient with laryngeal cancer has received teaching about radiation therapy. Which statement by the patient indicates that the teaching has been effective? | “I will need to buy a water bottle to carry with me.” |
| The nurse is obtaining a health history from a 67-year-old patient with a 40 pack-year smoking history, complaints of hoarseness and tightness in the throat, and difficulty swallowing. Which question is most important for the nurse to ask? | “How much alcohol do you drink in an average week?” |
| 27 A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, “How will I talk after the surgery?” The best response by the n27 A patient who had a total laryngectomy has a nursing diagnosis of hopele | “You will have a permanent opening into your neck, and you will need to have rehabilitation for some type of voice restoration.” |
| 27 A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse is the best indicator that the problem identified in nursing diagnosis is resolving? | The patient asks how to clean the tracheostomy stoma and tube. |
| 27 After completing discharge instructions for a patient with a total laryngectomy, the nurse determines that additional instruction is needed when the patient says, | “I must keep the stoma covered with a loose sterile dressing at all times.” |
| 27 Which action should the nurse take first when a patient develops a nosebleed? | Pinch the lower portion of the nose for 10 minutes. |
| 27 When the nurse is caring for a patient who has had a total laryngectomy and radical neck dissection during the first 24 hours after surgery, what is the priority nursing action? | Assess breath sounds. |
| 27 A patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first? | Insert the obturator and attempt to reinsert the tracheostomy tube. |
| 27 Which of these patients in the respiratory disease clinic should the nurse assess first? | A 23-year-old, complaining of a sore throat, who has a “hot potato” voice |
| 27 The nurse obtains the following assessment data in a 76-year-old patient who has influenza. Which information will be most important to communicate to the health care provider? | Diffuse crackles in the lungs |
| 27 Which of these nursing actions can the RN working in a long-term care facility delegate to an experienced LPN/LVN who is caring for a patient with a permanent tracheostomy? | Suctioning the tracheostomy when needed |
| The nurse is caring for a hospitalized 82-year-old patient who has nasal packing in place to treat a nosebleed. Which of the following assessment findings will require the most immediate action by the nurse? | The oxygen saturation is 89%. |
| 27 The teaching plan for a patient with acute sinusitis will need to include which of the following interventions (select all that apply)? | hot shower will increase sinus drainage and decrease pain,(OTC) antihistamines can be used to relieve congestion and inflammation, Saline nasal spray can madehome and used to wash out secretions, more comfortable you keep your head in an upright position. |
| 27 The nurse is reviewing the charts for five patients who are scheduled for their yearly physical examinations in October. Which of the following patients will require the inactivated influenza vaccination (select all that apply)? | A 36-year-old female patient who is pregnant, A 30-year-old patient who takes corticosteroids for rheumatoid arthritis |
| 27 The nurse enters the room of a patient who has just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems?____________________ | The patient is in a side-lying position with the head of the bed flat, The patient is coughing blood-tinged secretions from the tracheostomy, The Hemovac in the neck incision contains 200 mL of bloody drainage,(NG) tube disconnected suction clamped off |
| 28 Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? | The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern. |
| 28 During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find | increased tactile fremitus. |
| 28 A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse use to promote airway clearance? | Assist the patient to splint the chest when coughing. |
| 27 Which statement by a patient who has been hospitalized for pneumonia indicates a good understanding of the discharge instructions given by the nurse? | “I will continue to do the deep breathing and coughing exercises at home.” |
| 28 Which nursing action will be most effective in preventing aspiration pneumonia in patients who are at risk? | Place patients with altered consciousness in side-lying positions. |
| 28 After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective? | The patient’s white blood cell (WBC) count is 9000/µl. |
| 28 The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action will the nurse take? | Obtain consecutive sputum specimens from the patient for 3 days. |
| 27 Which information about a patient who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions? | Three sputum smears for acid-fast bacilli are negative. |
| 28 The nurse recognizes that the goals of teaching regarding the transmission of pulmonary tuberculosis (TB) have been met when the patient with TB | covers the mouth and nose when coughing. |
| 28 Which information will the nurse include in the patient teaching plan for a patient who is receiving rifampin (Rifadin) for treatment of tuberculosis? | “Your urine, sweat, and tears will be orange colored.” |
| 28 When teaching the patient who is receiving standard multidrug therapy for tuberculosis (TB) about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops | yellow-tinged skin. |
| 28 An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? | Arranging for a daily noontime meal at a community center and giving the medication then |
| 28 After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? | Ask the patient whether medications have been taken as directed. |
| 28 A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the | use and side effects of isoniazid (INH). |
| 28 When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member | puts on a surgical face mask before visiting the patient. |
| 28 Which action by the occupational health nurse at a manufacturing plant where there is potential exposure to inhaled dust will be most helpful in reducing incidence of lung disease? | Require the use of protective equipment. |
| 28 When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most important for the nurse to include information about | options for smoking cessation |
| 28 A lobectomy is scheduled for a patient with stage I non–small cell lung cancer. The patient tells the nurse, “I would rather have radiation than surgery.” Which response by the nurse is most appropriate? | “Tell me what you know about the various treatments available.” |
| 28 An hour after a thoracotomy, a patient complains of incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. best for the nurse to take next? | Administer the prescribed PRN morphine. |
| 28 A patient with newly diagnosed lung cancer tells the nurse, “I think I am going to die pretty soon.” Which response by the nurse is best? | “Can you tell me what it is that makes you think you will die so soon?” |
| 28 The health care provider inserts a chest tube in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about | 400 mL of blood in the collection chamber. |
| 28 A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about | paradoxic chest movement. |
| 28 When assessing a 24-year-old patient who has just arrived after an automobile accident, the emergency department nurse notes that the breath sounds are absent on the right side. The nurse will anticipate the need for | insertion of a chest tube with a chest drainage system. |
| 28 A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to | take no further action with the collection device |
| 28 When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes | frequent use of an incentive spirometer. |
| 28 To determine the effectiveness of prescribed therapies for a patient with cor pulmonale and right-sided heart failure, which assessment will the nurse make? | Peripheral edema |
| 28 A patient with primary pulmonary hypertension (PPH) is receiving nifedipine (Procardia). The nurse will evaluate that the treatment is effective if | the patient reports decreased exertional dyspnea. |
| 28 A patient with a pleural effusion is scheduled for a thoracentesis. Before the procedure, the nurse will plan to | position the patient sitting upright on the edge of the bed and leaning forward |
| 28 After discharge teaching has been completed for a patient who has had a lung transplant, the nurse will evaluate that the teaching has been effective if the patient states | “I will call the health care provider right away if I develop a fever.” |
| 28 Which of these orders will the nurse act on first for a patient who has just been admitted with probable bacterial pneumonia and sepsis? | Obtain blood cultures from two sites |
| 28 Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider? | Oxygen saturation is 89% |
| 28 A patient who has just been admitted with pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which of these prescribed medications should the nurse give first? | azithromycin (Zithromax) |
| 28 Which information obtained by the nurse about a patient who has been diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease is most important to communicate to the health care provider? | The patient is being treated with antiretrovirals for HIV infection. |
| 28 A patient with pneumonia has a fever of 101.2° F (38.5° C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is | impaired gas exchange related to respiratory congestion |
| 28 The nurse observes nursing assistive personnel (NAP) doing all the following activities when caring for a patient with right lower lobe pneumonia. The nurse will need to intervene when NAP | lower the head of the patient’s bed to 10 degrees |
| 28 A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP reading of 100/60, and respirations of 42. The nurse’s first action should be to | elevate the head of the bed to 45 to 60 degrees |
| 28 After the nurse has received change-of-shift report about the following four patients, which patient should be assessed first? | A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath |
| 28 The nurse is performing tuberculosis (TB) screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask? | “Have you received the bacille Calmette-Guérin (BCG) vaccine for TB?” |
| 28 A patient is admitted to the emergency department with an open stab wound to the right chest. What is the first action that the nurse should take? | Tape a nonporous dressing on three sides over the chest wound. |
| 28 The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? | Medicate the patient with the prescribed morphine. |
| 28 The nurse is caring for a patient with primary pulmonary hypertension who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action? | The patient’s central intravenous line is disconnected. |
| 28 A patient who was admitted the previous day with pneumonia complains of a sharp pain “whenever I take a deep breath.” Which action will the nurse take next? | Listen to the patient’s lungs |
| 28 The nurse notes new onset confusion in an 89-year-old patient in a long-term care facility. The patient is normally alert and oriented. In which order should the nurse take the following actions? | Obtain the oxygen saturation, Check the patient’s pulse rate, Notify the health care provider, Document the change in status |
| 29 A patient with chronic bronchitis who has a new prescription for Advair Diskus (combined fluticasone and salmeterol) asks the nurse the purpose of using two drugs. The nurse explains that | one drug decreases inflammation, and the other is a bronchodilator. |
| 29 The nurse has completed patient teaching about the administration of salmeterol (Serevent) using a metered-dose inhaler (MDI). Which action by the patient indicates good understanding of the teaching? | The patient attaches a spacer before using the MDI. |
| 29 When preparing a patient with possible asthma for pulmonary function testing, the nurse will teach the patient to | withhold bronchodilators for 6 to 12 hours before the examination. |
| 29 Which information will the nurse include when teaching the patient with asthma about the prescribed medications? | Tremors are an expected side effect of rapidly acting bronchodilators |
| 29 When the nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack, which finding is the best indicator that the therapy has been effective? | Oxygen saturation is >90%. |
| 29 A patient seen in the asthma clinic has recorded daily peak flows that are 85% of the baseline. Which action will the nurse plan to take? | Instruct the patient to continue to use current medications |
| 29 Which action by a patient who has asthma indicates a good understanding of the nurse’s teaching about peak flow meter use? | The patient uses the albuterol (Proventil) metered-dose inhaler (MDI) for peak flows in the yellow zone. |
| 29 A 32-year-old patient who denies any history of smoking is seen in the clinic with a new diagnosis of emphysema. The nurse will anticipate teaching the patient about | α1-antitrypsin testing |
| 29 Which information about a newly admitted patient with chronic obstructive pulmonary disease (COPD) indicates that the nurse should consult with the health care provider before administering the prescribed theophylline? | The patient takes cimetidine (Tagamet) 150 mg daily |
| 29 A patient with chronic bronchitis has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most appropriate to include in the plan of care? | Teach the patient how to effectively use pursed lip breathing. |
| 29 A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. An appropriate intervention for this problem is to | offer high calorie snacks between meals and at bedtime |
| 29 When the nurse is interviewing a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD), which information will help most in confirming a diagnosis of chronic bronchitis? | The patient complains about a productive cough every winter for 3 months |
| 29 After the nurse has finished teaching a patient about pursed lip breathing, which patient action indicates that more teaching is needed? | The patient puffs up the cheeks while exhaling |
| 29 Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment? | Pulse oximetry reading of 91% |
| 29 To evaluate the effectiveness of therapy for a patient with cor pulmonale, the nurse will monitor the patient for | jugular vein distention |
| 29 When a hospitalized patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen, the best action by the nurse is to | maintain the pulse oximetry level at 90% or greater |
| Which information will the nurse include in teaching a patient with chronic obstructive pulmonary disease (COPD) who has a new prescription for home oxygen therapy? | Oxygen use can improve the patient’s prognosis and quality of life. |
| 29 A patient is receiving 35% oxygen via a Venturi mask. To ensure the correct amount of oxygen delivery, it is most important that the nurse | keep the air entrainment ports clean and unobstructed. |
| 29 Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. The nurse will plan to | carry out the procedure 3 hours after the patient eats |
| 29 When developing a teaching plan to help increase activity tolerance at home for a 70-year-old with severe chronic obstructive pulmonary disease (COPD), the nurse should teach the patient that an appropriate exercise goal is to | walk for a total of 20 minutes daily |
| 29 A patient with severe chronic obstructive pulmonary disease (COPD) tells the nurse, “I wish I were dead! I cannot do anything for myself anymore.” Based on this information, which nursing diagnosis is most appropriate? | Chronic low self-esteem related to increased physical dependence |
| 29 A patient with chronic obstructive pulmonary disease (COPD) is admitted to the hospital. How can the nurse best position the patient to improve gas exchange? | Sitting up at the bedside in a chair and leaning slightly forward |
| 29 Which diagnostic test will the nurse plan to discuss with a 54-year-old patient with progressively increasing dyspnea who is being evaluated for a possible diagnosis of chronic obstructive pulmonary disease (COPD)? | Pulmonary function testing |
| 29 Which action will be included in the plan of care for a 23-year-old with cystic fibrosis (CF) who is admitted to the hospital with increased dyspnea? | Perform chest physiotherapy every 4 hours |
| 29 A patient who is hospitalized with cystic fibrosis (CF) coughs up large quantities of thick green mucus. The nurse will plan to teach the patient about | aerosolized tobramycin (TOBI) |
| 29 A 20-year-old patient with cystic fibrosis (CF) tells the nurse that she is considering having a child. Which initial response by the nurse is best? | “Do you need any information to help you with the decision?” |
| 29 A patient with chronic obstructive pulmonary disease (COPD) has rhonchi throughout the lung fields and a chronic, nonproductive cough. Which nursing action will be most effective? | Educate the patient to use the Flutter airway clearance device |
| 29 After the nurse has completed diet teaching for a patient with chronic obstructive pulmonary disease (COPD) who has a body mass index (BMI) of 20, which patient statement indicates that the teaching has been effective? | “I will have ice cream as a snack every day.” |
| 29 When teaching the patient with chronic obstructive pulmonary disease (COPD) about exercise, which information should the nurse include? | “Use the bronchodilator before you start to exercise.” |
| 29 Which information given by an asthmatic patient while the nurse is doing the admission assessment is most indicative of a need for a change in therapy? | The patient’s only medications are albuterol (Proventil) and salmeterol (Serevent) |
| 29 When the nurse takes an admission history for a patient with possible asthma who has new-onset wheezing and shortness of breath, which information may indicate a need for a change in therapy? | The patient takes propranolol (Inderal) for hypertension |
| 29 Which topic will the nurse include in medication teaching for a patient with newly-diagnosed persistent asthma? | Self-administration of inhaled corticosteroids |
| 29 A patient with cystic fibrosis (CF) has blood glucose levels that are consistently 200 to 250 mg/dL. Which nursing action will the nurse plan to implement? | Educate the patient about administration of insulin |
| 29 When caring for a patient with a history of asthma, which assessment finding should the nurse communicate immediately to the health care provider? | Use of accessory muscles in breathing |
| 29 Which action should the nurse anticipate taking first when a patient who is experiencing an asthma attack develops bradycardia and a decrease in wheezing? | Assist with endotracheal intubation |
| 29 A patient who is experiencing an acute asthma attack is admitted to the emergency department. The nurse’s first action should be to | listen to the patient’s breath sounds |
| 29 Which finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider? | Flushing and dizziness |
| 29 The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse? | 20-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg |
| 29 Which of these nursing actions included in the care plan for a patient with chronic obstructive pulmonary disease (COPD) should the nurse delegate to experienced nursing assistive personnel (NAP)? | Obtain oxygen saturation using pulse oximetry |
| 29 A patient with asthma who has a baseline peak flow reading of 600 mL calls the nurse, stating that the current peak flow is 420 mL. Which action should the nurse take first? | Instruct the patient to use the prescribed albuterol (Proventil) |
| 29 The following medications are prescribed by the health care provider for a patient having an acute asthma attack. Which one will the nurse administer first? | albuterol (Ventolin) 2.5 mg per nebulizer |
| 29 The nurse has received a change-of-shift report about the following patients with chronic obstructive pulmonary disease (COPD). Which patient should the nurse assess first? | A patient with a respiratory rate of 38 |
| 68 To evaluate the effectiveness of prescribed therapies for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse? | Arterial blood gas (ABG) analysis |
| 68 While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient’s oxygen saturation (SpO2) from 94% to 88%. The nurse will | increase the oxygen flow rate |
| A patient with respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. The nurse will anticipate assisting with | endotracheal intubation and positive pressure ventilation |
| 68 The pulse oximetry for a patient with right lower lobe pneumonia indicates an oxygen saturation of 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is best for the nurse to take? | Assist the patient with staged coughing |
| 68 When the nurse is caring for an obese patient with left lower lobe pneumonia, gas exchange will be best when the patient is positioned | on the right side |
| 68 When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? | The patient is somnolent |
| 68 A patient with acute respiratory distress syndrome (ARDS) and acute renal failure has the following medications prescribed. Which medication should the nurse discuss with the health care provider before administration? | gentamicin (Garamycin) 60 mg IV |
| 68 A patient develops increasing dyspnea and hypoxemia 2 days after having cardiac surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure | nserting a pulmonary artery catheter |
| 68 Which assessment finding by the nurse when caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates that the PEEP may need to be decreased? | The patient has subcutaneous emphysema |
| 68 Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct? | “PEEP prevents the lung air sacs from collapsing during exhalation.” |
| 68 When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? | The patient’s PaO2 is 90 mm Hg, and the SaO2 is 92%. |
| 68 The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? | Obtain oxygen saturation using pulse oximetry |
| 68 To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation? | Elevate head of bed to 30 to 45 degrees |
| 68 A patient has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action will be best for the nurse to include in the plan of care? | Offer the patient fluids at frequent intervals |
| 68 A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a pneumothorax. Which action will the nurse anticipate taking? | Lower the positive end-expiratory pressure (PEEP) |
| 68 A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea. Which assessment finding by the nurse is most important to report to the health care provider? | The patient’s respiratory rate has decreased from 30 to 10 breaths/min |
| 68 When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first? | Assess oxygenation using pulse oximetry |
| 68 The nurse is caring for a 22-year-old patient who came to the emergency department with acute respiratory distress. Which information about the patient requires the most rapid action by the nurse? | The patient’s PaO2 is 45 mm Hg |
| 9 Which information will the nurse plan to include when teaching a patient with narcolepsy about management of the disorder? | Driving an automobile may be possible with appropriate treatment of narcolepsy. |
| 9 The nurse takes the health history for four patients in the clinic. Which information regarding the patients’ sleep is most important to communicate to the health care provider? | A 41-year-old with a body mass index (BMI) of 42 kg/m2 says that the spouse complains about the patient’s snoring. |
| 9 A patient with sleep apnea who received a new prescription for a continuous positive airway pressure (CPAP) device a week ago returns to the clinic and says that severe daytime fatigue is still a problem. Which action should the nurse take first? | Ask the patient whether the CPAP is being used every night |
| 26 A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? | Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress. |
| When preparing the patient with a right-sided pleural effusion for a thoracentesis, how will the nurse position the patient? | Sitting upright with the arms supported on an over bed table |
| 26 A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis, the nurse would expect the patient to have | Kussmaul respirations |
| 26 On auscultation of a patient’s lungs, the nurse hears short, high-pitched sounds during exhalation in the lower 1/3 of both lungs. The nurse records this finding as | expiratory wheezes in both lungs. |
| 26 The nurse palpates the posterior chest while the patient says “99” and notes that no vibration is felt. How should this be charted? | Absent tactile fremitus |
| 26 A patient with a chronic cough has a bronchoscopy. Which action will be included in the nursing care plan after the procedure? | Keep the patient NPO until the gag reflex returns |
| 26 When auscultating a patient’s chest while the patient takes a deep breath, the nurse hears loud, high-pitched, “blowing” sounds at both lung bases. The nurse will document these as | abnormal sounds |
| 26 While caring for a patient with respiratory disease, the nurse observes that the patient’s SpO2 drops from 92% to 88% while the patient is ambulating in the hallway. Which action should the nurse take next? | Administer the PRN supplemental O2 |
| 26 Which action will the nurse plan to take for a patient who is scheduled for pulmonary function testing (PFT)? | Teach deep inhalation and forceful exhalation. |
| 26 The nurse is observing a student who is listening to a patient’s lungs. Which action by the student indicates a need to review respiratory assessment skills? | The student places the stethoscope over the scapulae and then auscultates |
| 26 A patient with chronic hypoxemia (SaO2 levels of 89% to 90%) caused by chronic obstructive pulmonary disease (COPD) has been hospitalized with increasing shortness of breath. In planning for discharge, | Arrange for the patient’s spouse to be present during the teaching. |
| 26 A patient is admitted to the emergency department complaining of sudden onset shortness of breath and is diagnosed with a possible pulmonary embolus. To confirm the diagnosis, the nurse will anticipate preparing the patient for a | spiral computed tomography (CT) scan |
| The nurse is admitting a patient who has a diagnosis of an acute asthma attack. Which information obtained by the nurse indicates that the patient may need teaching regarding medication use? | The patient has been using the albuterol (Proventil) inhaler more frequently over the last 4 days |
| 26 A patient with acute dyspnea is scheduled for a spiral computed tomography (CT) scan. Which information obtained by the nurse is most important to communicate to the health care provider before the CT? | The patient is allergic to shellfish |
| 26 When the nurse is analyzing the results of a patient’s arterial blood gases (ABGs), which finding indicates the need for most immediate action? | The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg. |
| 26 When assessing the respiratory system of a 78-year-old patient, which finding indicates that the nurse should take immediate action? | Crackles are heard from the lung bases to the midline. |
| 26 A hypothermic patient is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 96%. Which action should the nurse take next? | Place the patient on high-flow oxygen |
| After the nurse has received change-of-shift report, which of these patients should be assessed first? | A patient with possible lung cancer who has just returned after bronchoscopy |
| 26 The nurse has just received arterial blood gas (ABG) results on four patients. Which result is most important to report rapidly to the health care provider? | pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96% |
| 26 The nurse obtains this information when assessing a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important to report to the health care provider? | Respirations are 36 breaths/minute |
| 26 When performing an assessment of the patient’s respiratory system, the nurse uses the following illustrated technique to evaluate | chest expansion |
| 26 Which nursing actions will be included when sending a patient for computed tomography (CT) of the chest with contrast (select all that apply)? | Question the patient about allergies to iodine, Review the recent blood urea nitrogen (BUN) and creatinine levels |
| pH | 7.35-7.45 |
| PCO2 | 35-45 mmHg |
| HCO3 | 22-26 mEq/L |
| PO2 | 80-100mmHg |
| V/Q influenced by | partial pressure of O2 and CO2 |
| pH <7.35 | acidosis: increased hydrogen concentration in blood |
| pH>7.45 | alkalosis: decreased ion concentration in blood |
| PCO2 <35 | alkalosis |
| PCO2>45 | acidosis |
Created by:
mdoss81