Fund questions

Question 1

A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder:

A) Alcoholism and hypertension
B) Obesity and diabetes
C) Stress-related illnesses    D)  Cardiopulmonary disease and lung cancer

Answer 1

D
Effects of nicotine on blood vessels and lung tissue have been proven to increase pathological changes, leading to heart disease and lung cancer.

Cpt40

Question 2

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient’s oxygen status?

A) Increased breathlessness but increased activity tolerance
B) Decreased breathlessness and decreased activity tolerance    C)  Increased activity tolerance and decreased breathlessness    D)  Decreased activity tolerance and increased breathlessness

Answer 2

D
Hypoxia occurs because of decreased circulating blood volume, which leads to decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a feeling of shortness of breath.

Cpt40

Question 3

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient’s color is ruddy, not cyanotic, the nurse understands that the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following:

A) Stimulates hyperventilation, causing respiratory alkalosis
B) Forms a strong bond with hemoglobin, creating a functional anemia.    C)  Stimulates hypoventilation, causing respiratory acidosis
D) Causes alveoli to overinflate, leading to atelectasis

Answer 3

B

Carbon monoxide strongly binds to hemoglobin, making it unavailable for oxygen binding and transport.

Cpt 40

Question 4

A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104°F (40°C). What physiological process explains why the child is at risk for developing dyspnea?

A) Fever increases metabolic demands, requiring increased oxygen need.
B) Blood glucose stores are depleted, and the cells do not have energy to use oxygen.    C)  Carbon dioxide production increases as result of hyperventilation.
D) Carbon dioxide production decreases as a result of hypoventilation.

Answer 4

A

When the body cannot meet the increased oxygenation need, the increased metabolic rate causes breakdown of protein and wasting of respiratory muscles, increasing the work of breathing.

Cpt 40

Question 5

A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds?

A) Sonorous wheezes in the left lower lung
B) Rhonchi midsternum
C) Crackles only in apex of lungs
D) Inspiratory crackles in lung bases

Answer 5

D

Decreased effective contraction of left side of heart leads to back up of fluid in the lungs, increasing hydrostatic pressure and causing pulmonary edema, resulting in crackles in lung base

Cpt 40

Question 6

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?

A) Antibiotics
B) Frequent change of position
C) Oxygen humidification
D) Chest physiotherapy

Answer 6

B

Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting the effectiveness of gas exchange processes.

Cpt 40

Question 7

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning?

A) Coughing up thick sputum only occasionally
B) Coughing up thin, watery sputum easily after nebulization
C) Decreased independent ability to cough
D) Lung sounds clear only after coughing

Answer 7

C

Impaired ability to cough up mucus caused by weakness or very thick secretions indicates a need for suctioning when you know the patient has pneumonia.

Cpt 40

Question 8

A patient was admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax, which includes which of the following?

A) Sharp pleuritic pain that worsens on inspiration
B) Crackles over lung bases of affected lung
C) Tracheal deviation toward the affected lung
D) ncreased diaphragmatic excursion on side of rib fractures

Answer 8

A

When the lung collapses, the thoracic space fills with air on each inspiration, and the atmospheric air irritates the parietal pleura, causing pain.

Cpt 40

Question 9

A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education?

A) “I’ll make sure that I rest between activities so I don’t get so short of breath.”
B) “I’ll rest for 30 minutes before I eat my meal.”
C) “If I have trouble breathing at night, I’ll use two to three pillows to prop up.”    D)  “If I get short of breath, I’ll turn up my oxygen level to 6 L/min.”

Answer 9

D

Hypoxia is the drive to breathe in a patient with chronic obstructive pulmonary disease who has become used to acidic pH and elevated CO2 levels. Turning up to 6 L/min increases the oxygen level, which turns off the drive to breathe.

Cpt 40

Question 10

The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first?

A) Raise the head of the bed to 45 degrees.
B) Take his oxygen saturation with a pulse oximeter.    C) Take his blood pressure and respiratory rate.    D)  Notify the health care provider of his shortness of breath.

Answer 10

A

Raising the head of the bed brings the diaphragm down and allows for better chest expansion, thus improving ventilation.

Cpt 40

Question 11

The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? (Select all that apply.)

A) SpO2 levels
B) Amount of sputum production
C) Change in respiratory rate and pattern
D) Pain in lower calf area

Answer 11

A,B,C,D

Pain in the lower calf area indicates vascular, not respiratory, status.

Cpt 40

Question 12

Which of the following statements made by a student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube?

A)“Suctioning the patient requires sterile technique.”
B)“I’ll apply suction while rotating and withdrawing the suction catheter.”
C)“I’ll suction the mouth after I suction the endotracheal tube.”
D)“I’ll instill 5 mL of normal saline into the tube before hyperoxygenating the patient.”

Answer 12

D

Saline has been found to cause more side effects when suctioning and does not increase the amount of secretions removed.

Cpt 40

Question 13

Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform?

A)Record the amount and continue to monitor drainage
B)Notify the health care provider
C)Strip the chest tube starting at the chest    D) Increase the suction by 10 mm Hg

Answer 13

A

Dark-red drainage after surgery (50 to 200 mL per hour in first 3 hours) is expected, but be aware of sudden increases greater than 100 mL per hour after the first 3 hours, especially if it becomes bright red in color.

Cpt 40

Question 14

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient?

A) Postural drainage
B) Chest percussion
C) Incentive spirometer
D) Suctioning

Answer 14

C

An incentive spirometer is used to encourage deep breathing to inflate alveoli and open pores of Kohn. The rest are used to treat atelectasis and increased mucus production.

Cpt 40

Question 15

The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient?

A) Nasal cannula
B) Venturi mask
C) Simple face mask without inflated reservoir bag
D) Plastic face mask with inflated reservoir bag

Answer 15

A

A nasal cannula delivers precise, high-flow rates of oxygen.

Cpt 40

Question 16

The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initiates the nurse-patient relationship?

A) Appearance and behavior
B) Measurement of vital signs
C) Observing specific body systems
D) Conducting a detailed health history

Answer 16

A

The nurse inspects appearance and behavior first as part of the nursing assessment. As the patient enters the room, the nurse can observe his or her appearance and behavior, noting any unusual choice of clothing or hygiene or any signs of confusion, anxiety, or happiness.

Chpt 30

Question 17

The nurse is teaching a young mother to palpate her 8-year-old child to quickly evaluate if the child has a fever. Which information is important for the nurse to include?

A) Place the palm of the hand on the child’s back.
B) Lightly touch the child’s forehead with the fingertips.
C) Place the back of your hand against the child’s forehead and then on the back of the neck.
D) Use the pads of your fingers and press against the child’s neck and over the thorax.

Answer 17

C

Temperature is best evaluated by palpating the skin with the dorsum or back of the hand. It is best to select two areas to compare to allow you to detect a change in body surface temperature.

cpt 30

Question 18

While assessing the adult patient’s lungs, the nurse identifies the following assessment findings. Which finding should be reported to the health care provider?

A) Respiratory rate: 14
B) Pain reported when palpating posterior lower thorax
C) Thorax rising and falling symmetrically for right and left lungs
D) Vesicular breath sounds heard with auscultation of peripheral lung fields

Answer 18

B

Any areas of tenderness or pain over the posterior thorax could indicate injury such as a broken rib or disturbance of the integumentary system. Further palpation should be avoided until more assessment data are collected, either through further health history or diagnostic testing. All other findings are normal.

chpt30

Question 19

The nurse is teaching a young female patient to practice good skin health. Which information is important for the nurse to include?

A) Avoid sunbathing between 3 PM and 7 PM.
B) Oral contraceptives and antiinflammatories make the skin more sensitive to the sun.
C) Call the health care provider for the presence of a mole on an arm or leg that appears uniformly brown.
D) Wear sunscreen with an SPF of 30 or greater if using a sunlamp or tanning parlor.

Answer 19

B

Some medications such as oral contraceptives or antiinflammatory medications may increase the skin’s sensitivity to ultraviolet (UV) rays. Skin self-care and self-evaluation practices include avoiding the sun when UV rays are strongest (10 AM to 4 PM). In addition, good skin practices indicate that skin protection should be used when using a tanning bed or sunlamp. Moles that are uniformly brown are not a cause of concern.

cpt30

Question 20

As a nurse prepares to provide morning care and treatments, it is important to question a patient about a latex allergy before which intervention? (Select all that apply.)

A) Applying adhesive tape to anchor a nasogastric tube
B) Inserting a rubber Foley catheter into the patient’s bladder
C) Providing oral hygiene using a standard toothbrush and toothpaste
D) Giving an injection using plastic syringes with rubbercoated plungers
E) Applying a transparent wound dressing

Answer 20

A,B,D

Cpt 30

Question 21

The nurse is assessing a patient who returned 3 hours ago from a cardiac catheterization, during which the large catheter was inserted into the patient’s femoral artery in the right groin. Which assessment finding would require immediate follow-up?

A) Palpation of a femoral pulse with a heart rate of 76    B)  Auscultation of a heart murmur over the left thorax
C) Identification of mild bruising at the catheter insertion site
D) Palpation of a right dorsalis pedis pulse with strength of +1

Answer 21

D

A weak pulse may indicate disruption of arterial flow and should be reported immediately. Mild bruising is normal, but if it increases in size, the femoral artery may be leaking, requiring further follow-up with the health care provider. Other findings are within normal limits and do not require notification.

Chpt30

Question 22

The patient reports having a sore throat, coughing, and sneezing. While performing a focused assessment, which finding supports the patient’s reported symptoms related to upper respiratory infection?

A) Buccal mucosa is moist and dark pink.
B) Respiratory rate is 18, rhythm is even.
C) Retropharyngeal lymph nodes are enlarged and firm.
D) Inspection with a tongue depressor on the posterior tongue causes gagging.

Answer 22

C

The retropharyngeal nodes are located posteriorly to the throat and are enlarged when an infection is located in the throat or pharynx.

Cpt 30

Question 23

The nurse is teaching a patient with poor arterial circulation about checking blood flow in the legs. Which information should the nurse include? (Select all that apply.)

A) A normal pulse on the top of the foot indicates adequate blood flow to the foot.
B) To locate the dorsalis pedis pulse, take the fingers and palpate behind the knee
C) When there is poor arterial blood flow, the leg is generally warm to the touch.
D) Loss of hair on the lower leg indicates a long-term problem with arterial blood flow.

Answer 23

A,D

Cpt 30

Question 24

How should the patient be positioned to best palpate for lumps or tumors during an examination of the right breast?

A)Supine with both arms overhead with palms upward
B) Sitting with hands clasped just above the umbilicus
C) Supine with the right arm abducted and hand under the head and neck
D) Lying on the right side, adducting the right arm on the side of the body

Answer 24

C

Lying on the back allows breast tissue to relax; raising the arm over the patient’s head causes the breast tissue to flatten, and palpation can more accurately locate any nodules or tumors, especially cancerous tumors that are fixed against the chest wall.

Cpt 30

Question 25

The nurse is planning a staff education conference about abdominal assessment. Which point is important for the nurse to include?

A) The aorta can be felt using deep palpation in the upper abdomen near the midline.
B) The patient should be sitting to best determine the contour and shape of the abdomen.
C) Always wear gloves when palpating the skin on the patient’s abdomen.
D) Avoid palpating the abdomen if the patient reports any discomfort or feelings of fullness.

Answer 25

A

Complete abdominal assessment includes inspection, followed by auscultation, palpation, and percussion (if warranted). Anatomically the aorta is located in the upper abdomen and can be palpated on an average-sized patient. The assessment should be performed when the patient is supine so all assessment techniques can be included. Unless there is an open wound or other abdominal drainage, the aorta should be palpated without gloves to be able to assess skin texture, temperature, and any unusual pulsations. Palpation should be performed routinely, but leave areas of discomfort or pain until last.

Cpt 30

Question 26

The nurse is teaching a patient how to perform a testicular self-examination. Which statement by the nurse is correct?

A) “The testes are normally round and feel smooth and rubbery.”
B) “The best time to do a testicular self-examination is before your bath or shower.”
C) “Perform a testicular self-examination weekly to detect signs of testicular cancer.”
D) “Since you are over 40 years old, you are in the highest risk group for testicular cancer.”

Answer 26

A

Men ages 18 to 24 are in the group at most risk for testicular cancer. Teaching should include normal anatomy. A testicular examination should be planned monthly during a shower since the soap and water ease movement of the fingertips over the skin.

Cpt 30

Question 27

The patient is assessed for range of joint movement. He or she is unable to move the right arm above the shoulder. How should the nurse document this finding?

A) Patient was not able to flex arm at shoulder.
B) Extension of right arm is limited.
C) Patient’s abduction of right arm was limited to 100 degrees.
D) Internal rotation of right arm is limited to less than 90 degrees.

Answer 27

C

Abduction of the arm includes raising the arm away from the side and above the shoulder.

Cpt 30

Question 28

The nurse plans to assess the patient’s abstract reasoning. Which task should the nurse ask the patient to perform?

A) “Tell me where you are.”
B) “What can you tell me about your illness?”
C) “Repeat these numbers back to me: 7…5…8.”
D) “What does this mean: ‘A stitch in time saves nine? ’ ”

Answer 28

D

Abstract reasoning requires cognitive functioning and the ability to identify relationships between concepts.

Cpt 30

Question 29

The nurse teaches a patient about cranial nerves to help explain why the patient’s right side of the mouth droops instead of moving up into a smile. What nerve does the nurse explain to the patient?

A) VII — Facial
B) V — Trigeminal
C) XII — Hypoglossal
D) XI— Spinal accessory

Answer 29

A

The facial nerve innervates the sensory and motor functions of the face above the brow, the cheeks, and the chin and controls face symmetry and smile.

Cpt 30

Question 30

The nurse is planning to teach the student nurse how to assess the hydration status of an older adult. Which techniques are appropriate for this situation? (Select all that apply.)

A) Inspect the lips and mucous membranes to determine if they are moist.
B) Pinch the skin on the back of the hand to see if the skin tents.
C) Check the patient’s pulse and blood pressure.
D) Weigh the patient daily.

Answer 30

A,C,D

Cpt 30