Exam 3

Question 1

Eupena

Answer 1

Normal respirations, with equal rate and depth, 12-20 breaths/min

Question 2

Bradypnea

Answer 2

Slow respirations less than 10 breaths/min

Question 3

Tachypnea

Answer 3

Fast respirations, greater than 24 breaths/min

Question 4

Kussmaul respirations

Answer 4

Respirations that are regular but abnormally deep and increased in rate

Question 5

Cheyne stokes respirations

Answer 5

Gradual increase in depth of respirations, followed by gradual decrease and then a period of apnea

Question 6

Apnea

Answer 6

Absence of breathing

Question 7

Maceration

Answer 7

Moisture

Question 8

Medications

Answer 8

Affect the skin; side effects; itching, rashes

Question 9

Superficial

Answer 9

Epidermal ( ex shearing)

Question 10

Partial thickness

Answer 10

Through epidermis not dermis

Question 11

Granulated tissue

Answer 11

Is when it starting to heal

Question 12

Four phases of wound healing

Answer 12

Hemostasis , inflammation, proliferation and maturation

Question 13

A marathon runner arrives at the emergency department complaining of a headache, muscle cramps,
weakness, nausea, and confusion after a race. Which statement made by the client might explain these
symptoms?

A. I was really thirsty after the race. I drank several large bottles of water.”
B. I am diabetic and checked my blood sugar after the race. It was normal.”
C. I sweat quite a bit during the race, so I drank sports drinks when finished
D. I take steroids regularly and did not stop them for the race

Answer 13

I was really thirsty after the race, so I drank sports drinks when I finished

Question 14

Which of the following are common contions that contribute to a clients self care deficit, meaning they are unable to perform one or more ADLs such as bathing and toileting?SATA
-lack of knowledge
-medication side effects
-lack of motivation
-pain
-fatigue

Answer 14

All of the above

Question 15

During an assessment of a wound the nurse should recognize which of the following findings as a manifestation of a stage 4 pressure ulcer?
A. Exposes bone
B. Necrotic subcutaneous tissue
C. Partial-thickness skin loss
D. Blood filled blisters

Answer 15

Exposed bone

Question 16

While bathing a client, the nurse observes that they have dry skin. The best action by the nurse is to do which of the following?
A. Use an emollient (lotion)
B. Bathe the client more frequently
C. Discourage fluid intake
D. Massage the skin with water

Answer 16

Use an emollient (lotion)

Question 17

The nurse caring for a client who is 24 hours post op after a major abdominal surgery and observes internal visceral protruding through the inscision site. Which of the following actions should the nurse take first?
A. Immediately notify the surgeon
B. Have the client bent their knees and remain in bed
C. Cover the wound with a sterile saline dressing
D. Put an abdominal binder on the client

Answer 17

C. Cover the wound with a sterile saline dressing

Question 18

During an annual checkup, a client ask the nurse to explain the difference between chronic and acute wounds. Which of the following would best describe the primary difference between chronic and acute?
A. Chronic wounds are the result of pressure, but acute wounds result
B. Chronic wounds do not heal within an expected time frames

Question 19

After the nurse receives beside report, the nurse must prioritize which of the following assessment findings that warrants immediate intervention?
A. Edema
B. Pallor
C. Slough
D. Cyanosis

Answer 19

D. Cyanosis

Question 20

A client is admitted with a stage 4 pressure ulcer. When developing a plan of care, which of the following is the best planned outcome for this client?
A. Wound will improve prior to discharge as evidenced by a decrease in drainage
B. Client will maintain intact skin throughout hospitalization
C. Client will limit pressure to wound site throughout treatment course
D. Wound will close with no evidence of infection within 6 weeks

Answer 20

D. Wound will close with no evidence of infection with 6 weeks

Question 21

During the physical assessment of a client, the nurse notes a pressure ulcer on the coccyx. Which of the following scale does the nurse utilize for this assessment?
A. Braden Scale
B. Push Scale
C. Glasgow Scale
D. William Scale

Answer 21

B. PUSH Scale

Question 22

The nurse admits an older adult client to the long term care facility. When assessing for pressure injury risk, what should the nurse do after receiving a low risk on the Braden scale assessment?
A. Reassess by using the PUSH scale
B. Massage ares over the bony prominences
C. Apply transparent film dressing to buttocks
D. Conduct another assessment in 48 hrs

Answer 22

D. Conduct another assessment in 48 hrs

Question 23

A nurse identifies a pressure ulcer after a client had a long recovery following a surgical procedure. When completing an occurrence report about the pressure ulcer, the nurse should take which of the following actions
A. Document what the nurse believed was the cause of ulcer development.
B. Question the charge nurse about care deficits that might have contributed to the ulcer’s development
C. Include any relevant statements the client made about the ulcer
D. Document the clients medical record that she completed an incident report

Answer 23

C. Include any relevant statements the client made about the ulcer

Question 24

Ischemia

Answer 24

Lack of blood flow to a certain area

Question 25

Hematoma

Answer 25

Blood clotting in the tissue underneath the skin

Question 26

Granulation tissue

Answer 26

When the tissue starts forming together

Question 27

A 55 year old female with chronic obstructive pulmonary disorder (COPD) does not understand the need to stop smoking. Which of the following statements by the nurse best helps with understanding the need to stop smoking? A. Once you stop smoking, your body will begin to repair some of the damage to your lungs B. You should ask your primary care provide for a prescription for a nicotine patch to help you quit C. You should quit so your family does not get sick from exposure to second hand smoke D. You will need to use oxygen, but remember it is a fire hazard to smoke with oxygen in your home

Answer 27

A. Once you stop smoking, your body will begin to repair some of the damage to your lungs

Question 28

A nurse discusses the respiratory system with a client. The nurse explains to a client that which of the following factors influence normal lung volumes and capacities? SATA -gender -race -activity level -age -body size

Answer 28

-body size -age -gender -activity level

Question 29

A client has a nursing diagnosis of ineffective breathing pattern identified on the care plan. Which should the nurse expect when assessing this client? A. Respiratory rate of 8 breaths/min B.cold extremities C. Coughing D. Abnormal breath sounds

Answer 29

A. Respiratory rate of 8 breaths/min

Question 30

After the nurse receives bedside report, the nurse must prioritize which of the following assessment findings that warrants immediate intervention? A. Edema B. Pallor C. Slough D. Cyanosis

Answer 30

D. Cyanosis

Question 31

During a routine assessment, a client begins having dyspnea and shortness of breath (SOB). What is the first action take? A. Administer oxygen to the client through a nasal cannula B. Review and implement the primary care providers prescription for treatment C. Perform a quick physical assessment of breathing, circulation and oxygenation D. Gather a thorough medical history, including current symptoms, from the family

Answer 31

C. Perform a quick physical assessment of breathing, circulation and oxygenation

Question 32

While logrolling a client to perform a bed change, the client yells, “I am having trouble breathing!” Which of the following interventions should the nurse implement first? A. Notify the physician B. Raise the head of the bed C. Perform oral suction D. Prepare to administer oxygen

Answer 32

B. Raise the head of the bed

Question 33

The nurse is planning care for an older adult client with a nursing diagnosis of ineffective airway clearance. Which of the following is the nurse’s priority intervention? A. Position the client to optimize maximum ventilation B. Teaching cough and deep breathing excercise C. Encourage the use and incentive spirometer every hour D. Teach the importance of pneumonia immunization

Answer 33

A. Position the client to optimize maximum ventilation

Question 34

A nurse is documenting after performing tracheostomy suctioning on a client. Which of the following information provides the most reliable data about the effectiveness of airway suctioning? A. The amount, color, consistency and order secretions B. The number of suctioning passes required to clear secretions C. The clients tolerance for the procedure D. Breath sounds, vital signs and pulse oximetry before and after suctioning

Answer 34

D. Breath sounds, vital signs and pulse oximetry before and after suctioning

Question 35

When demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning which of the following actions should the nurse include in the teaching? A. Inhale rapidly through the nose B. Exhale slowly through the mouth C. Hold the breath for at least 10 secs D. Place the hands on the sides of the rib cage

Answer 35

B. Exhale slowly through the mouth

Question 36

The nurses assess a client diagnosed with pneumonia. Which of the following data findings indicate that the client is oxygenation adequately? -Euphrates rate of breathing -cyanosis of the lips -respiratory rate of 24 breaths/min -oxygenation saturation of 87% -clear lung sounds in all fields

Answer 36

- eupnea rate of breathing -clear lung sounds in all fields

Question 37

Chest physiotherapy (CTP) and postural drainage would be an appropriate intervention for which of the following conditions? A. Pneumonia B. Pulmonary embolus C. Sinusitis D. Hypertension

Answer 37

A. Pneumonia

Question 38

A nurse is caring for a client diagnosed with pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? A. Encourage the client to ambulate frequently B. Encourage the client to increase fluid intake C. Encourage coughing and deep breathing D. Encourage regular use of the incentive spirometer

Answer 38

B. Encourage the client to increase fluid intake

Question 39

After receiving report in the SBAR method on four clients, the nurse determines which of the following clients has the best lung function and lowest risk for acute lung complications

Question 40

A client has sustained a spinal cord injury and needs assistance with mobility while bathing. Which nursing diagnosis approximately addresses this problem? A. Feeding self-care deficit B. Bathing self-care deficit C. Dressing self-care deficit D. Activity intolerance

Answer 40

B. Bathing self-care deficit

Question 41

A client has an ischial wound that extends through the subcutaneous tissue. How should the wound care nurse document the depth of this wound? A. Partial thickness wound B. Penetration wound C. Superficial wound D. Full thickness wound

Answer 41

D. Full thickness wound

Question 42

A 66 year old male client with acute confusion becomes belligerent when the nurse attempts to give him a bath. How should the nurse proceed? A. Call for assistance to help the client into the bathtub B. Wait for the client to calm down , and then give him a partial bath C. Allow the client to go with out bathing for a day or two D. Ask another staff member to attempt the tub bath

Answer 42

A. Call for assistance to help the client into the bathtub

Question 43

A clinical instructor is explaining the lymphatic system to a group of clinical nursing student. Which of the following does the instructor correctly identify as the body’s first line of defense against bacteria? A. Intact skin B. White blood cells C. Lymph glands D. Inflammatory response

Answer 43

A. Intact skin

Question 44

A nurse is evaluating the client’s understanding of an open wound healing after surgery. Which of the following statements made by the client would best indicate the clients understands the most important aspect of healing ? A I will need to take antibiotic until my wound feel better B. Because my wound was left open it will likely become infected C. I will have more scar tissue formation than a closed wound after surgery would D. I should expect to remain hospitalized until the wound completely heals