Flashcards in Exam 5 (Ch 35 Test Questions) Deck (33):
1. The nurse is providing care to a pregnant woman in preterm labor. The patient is 32 weeks pregnant. Initially, the patient states, “I’ve gained 30 pounds. That should be enough for the baby. Everything will be OK if I deliver now.” After teaching the patient about fetal development, the nurse will know her teaching is effective if the patient makes which of the following statements?
1) “The baby’s lungs are well developed now, but he will be at increased risk for sudden infant death syndrome if I deliver early.”
2) “We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early.”
3) “If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening.”
4) “Thanks for reassuring me; I was pretty sure there isn’t much risk to the baby this far along in my pregnancy.”
2. The nurse is caring for a patient who is experiencing dyspnea. Which of the following positions would be most effective if incorporated into the patient’s care?
2) Head of bed elevated 80°
3) Head of bed elevated 30°
4) Lying on left side
3. While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal drainage system (CDU). Which action should the nurse take immediately?
1) Clamp the chest tube close to the insertion site.
2) Set up a new drainage system, and connect it to the chest tube
3) Have the patient take and hold a deep breath while the nurse reconnects the tube to the CDU.
4) Place the disconnected end nearest the patient into a bottle of sterile water.
4. The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which of the following responses indicates to the nurse that the medication is effective?
1) The amount of sputum the patient expectorates decreases with each dose administered.
2) Cough is completely suppressed, and she is able to sleep through the night.
3) Dry, unproductive cough is reduced, but her voluntary coughing is more productive.
4) Involuntary coughing produces large amounts of thick yellow sputum.
5. A patient diagnosed with hypertension is taking an angiotensin-converting enzyme (ACE) inhibitor. When planning care, which of the following outcomes would be appropriate for the patient?
1) BP will be lower than 135/85 on all occasions.
2) BP will be normal after 2 to 3 weeks on medication.
3) Patient will not experience dizziness on rising.
4) Urine output will increase to at least 50 ml/hr
6. The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure. The patient is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take?
1) Review and implement the primary care provider’s prescriptions for treatments.
2) Perform a quick physical examination of breathing, circulation, and oxygenation.
3) Gather a thorough medical history, including current symptoms, from the family.
4) Administer oxygen to the patient through a nasal cannula.
7. You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patient’s respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern?
1) Biot’s breathing
2) Kussmaul’s respirations
3) Sleep apnea
4) Cheyne-Stokes respirations
8. You are preparing the nursing care plan for a middle-aged patient admitted to the intensive care unit for an acute myocardial infarction (heart attack). His symptoms include tachycardia, palpitations, anxiety, jugular vein distention, and fatigue. Which of the following nursing diagnoses is most appropriate?
1) Decreased Cardiac Output
2) Impaired Tissue Perfusion
3) Impaired Cardiac Contractility
4) Impaired Activity Tolerance
9. You are to connect a patient to a cardiac monitor. Which of the following actions should you take to ensure an accurate electrocardiogram tracing?
1) Select electrode placement sites over bony prominences.
2) Apply the electrodes immediately after cleansing the skin, before the alcohol evaporates.
3) Before applying the electrodes, rub the placement sites with gauze until the skin reddens.
4) Ensure that the gel on the back of the electrodes is dry.
10. You are admitting a 54-year-old patient with chronic obstructive pulmonary disease (COPD). The physician prescribes O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient?
1) Nonrebreather mask
2) Nasal cannula
3) Partial rebreather mask
4) Venturi mask
11. Which of the following provide the most reliable data about the effectiveness of airway suctioning?
1) The amount, color, consistency and odor of secretions
2) The patient’s tolerance for the procedure
3) Breath sounds, vital signs, and pulse oximetry before and after suctioning
4) The number of suctioning passes required to clear secretions
12. What is the rationale for wrapping petroleum gauze around a chest tube insertion site?
1) Prevents air from leaking around the site
2) Prevents infection at the insertion site
3) Absorbs drainage from the insertion site
4) Protects the tube from becoming dislodged
13. You are caring for an adult patient with a tracheostomy who is on a mechanical ventilator. His pulse oximetry reading of 85%, heart rate is 113, and respiratory rate is 30. The patient is very restless. His respirations are labored, and you hear gurgling sounds. You auscultate crackles and rhonchi in both lungs. What is the most appropriate action to take?
1) Call the respiratory therapist to check the ventilator settings.
2) Provide endotracheal suctioning.
3) Provide tracheostomy care.
4) Notify the physician of signs of fluid overload.
14. Chest percussion and postural drainage would be an appropriate intervention for which of the following conditions?
1) Congestive heart failure
2) Pulmonary edema
4) Pulmonary embolus
15. For a patient with peripheral venous insufficiency, which of the following interventions would help to promote peripheral circulation?
1) Have the patient sit in a recliner, with legs lower than the heart.
2) Teach the patient to avoid sitting with the legs crossed.
3) Be sure intravenous medications are adequately diluted.
4) Regularly assess skin color and temperature of the legs.
16. Which of the following blood levels normally provides the primary stimulus for breathing?
4) Carbon dioxide
17. Chronic stress may lead directly to cardiovascular disease because of the repeated release of which of the following?
18. The nurse is teaching a pregnant woman about the increased oxygen demand that develops during pregnancy. The nurse knows the patient comprehends the teaching when she makes the following statement:
1) “I may need to drink more fluids in order to make more oxygen.”
2) “I may need to take an iron supplement so that I am not anemic.”
3) “I will need a multivitamin supplement for several months.”
4) “I will need to eat more fruits and vegetables.”
19. A 62-year-old man with emphysema says, “My doctor wants me to quit smoking. It’s too late now, though; I already have lung problems.” Which of the following would be the best response to his statement?
1) “You should quit so your family does not get sick from exposure to secondhand smoke.”
2) “You will need to use oxygen, but remember it is a fire hazard to smoke with oxygen in your home.”
3) “Once you stop smoking, your body will begin to repair some of the damage to your lungs.”
4) “You should ask your primary care provider for a prescription for a nicotine patch so that you can quit.”
20. The nurse administers intravenous morphine sulfate to a patient for pain control. She will need to monitor her patient for which of the following adverse effects?
1) Decreased heart rate
2) Muscle weakness
3) Decreased urine output
4) Respiratory depression
21. When using sterile technique to perform tracheostomy care of a new tracheostomy, which of the following is correct?
1) You will need a single pair of sterile gloves.
2) Place the patient in semi-Fowler’s position, if possible
3) Clean the stoma under the faceplate with hydrogen peroxide.
4) Cut a slit in sterile 4 x 4 gauze halfway through to make a dressing.
22. A patient has just had a chest tube inserted to dry-seal suction drainage. Which of the following is a correct nursing intervention for maintenance?
1) Keep the head of the bed flat for 6 hours.
2) Avoid using mouth rinses or mouthwashes.
3) Provide the patient with a paper and pencil or letter board.
4) Drain condensation into the humidifier when it collects in the tubing.
1. The nurse is counseling a 17-year-old girl on smoking cessation. The nurse should include which of the following helpful tips in her education? Choose all that apply.
1) “Keep healthy snacks or gum available to chew instead of smoking a cigarette.”
2) “Don’t tell your friends and family you are trying to quit, until you feel comfortable you’ll be successful.”
3) “Plan a time to quit when you will not have many other demands or stressors in your life.”
4) “Reward yourself with an activity you enjoy when you quit smoking.”
2. A patient has a history of COPD. His pulse oximetry reading is 97%. What other findings would indicate adequate tissue and organ oxygenation? Choose all that apply.
1) Normal urine output
2) Strong peripheral pulses
3) Clear breath sounds bilaterally
4) Normal muscle strength
3. The nurse is teaching a patient about her chest drainage system. Which of the following should the nurse include in the teaching? Choose all that apply.
1) Perform frequent coughing and deep-breathing exercises
2) Sit up in a chair but not walk while the drainage system is in place
3) Get out of bed on her own as much as possible
4) Immediately notify the nurse if she experiences increased shortness of breath
4. Nursing interventions to reduce the risk of thromboembolism include which of the following activities? Choose all that apply.
1) Keep the patient’s hips and knees flexed while the patient is in bed.
2) Apply compression devices (e.g., sequential compression devices).
3) Turn the patient frequently or encourage frequent position changes.
4) Promote adequate hydration by encouraging oral intake.
5. When providing safety education to the mother of a toddler, you would inform the mother that, based on the child’s developmental stage, he is at high risk for which of the following factors that influence oxygenation? Choose all that apply.
1) Frequent, serious respiratory infections
2) Airway obstruction from aspiration of small objects
3) Drowning in small amounts of water around the home
4) Development of asthma
6. Obesity is associated with higher risk for which of the following conditions that affect the pulmonary and cardiovascular systems? Choose all that apply.
1) Reduced alveolar-capillary gas exchange
2) Lower respiratory tract infections
3) Sleep apnea
7. Which of the following is/are accurate about nasotracheal suctioning? Choose all that apply.
1) Apply suction for no longer than 10 sec during a single pass.
2) Apply suction while inserting and removing the catheter.
3) Reapply oxygen between suctioning passes for ventilator patients.
4) Gently rotate the suction catheter as you remove it.
8. Which of the following medications would you expect to be included in the treatment of a patient with congestive heart failure? Choose all that apply.
2) Beta-adrenergic agents
9. Which of the following factors influence normal lung volumes and capacities? Choose all that apply.
3) Body size
4) Activity level
10. As the nurse caring for a patient who has suffered a myocardial infarction that has damaged the sinoatrial (SA) node, you should plan to monitor for which of the following potential complications? Choose all that apply.
1) Decreased heart rate
2) Increased heart rate
3) Decreased cardiac output
4) Decreased strength of ventricular contractions