ALL t6 questions t6 including 1 case study

Question 1

1. For which of the following health problems is a patient who has a 40-year history of smoking at risk?
2. Alcoholism and hypertension
3. Obesity and diabetes
4. Stress-related illnesses
5. Cardiopulmonary disease and lung cancer

Answer 1

4. Cardiopulmonary disease and lung cancer

Question 2

2. A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation as a result of the anemia?
3. Increased breathlessness but increased activity tolerance
4. Decreased breathlessness and decreased activity tolerance
5. Increased activity tolerance and decreased breathlessness
6. Decreased activity tolerance and increased breathlessness

Answer 2

4. Decreased activity tolerance and increased breathlessness

Question 3

3. A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient’s color is ruddy and not cyanotic, the nurse understands the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following:
4. Stimulates hyperventilation, causing respiratory alkalosis
5. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs
6. Stimulates hypoventilation, causing respiratory acidosis
7. Causes alveoli to overinflate, leading to atelectasis

Answer 3

2. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs

Question 4

4. An 86-year-old woman is admitted to the unit with chills and a fever of 104° F. What physiological process explains why she is at risk for dyspnea?
5. Fever increases metabolic demands, requiring increased oxygen need.
6. Blood glucose stores are depleted and the cells do not have energy to use oxygen.
7. Carbon dioxide production increases due to hyperventilation.
8. Carbon dioxide production decreases due to hypoventilation.

Answer 4

1. Fever increases metabolic demands, requiring increased oxygen need.

Question 5

5. A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation?
6. Sonorous wheezes in the left lower lung
7. Rhonchi mid sternum
8. Crackles only in apex of lungs
9. Inspiratory crackles in lung bases

Answer 5

4. Inspiratory crackles in lung bases

Question 6

4. Inspiratory crackles in lung bases

Answer 6

2. Frequent change of position

Question 7

7. A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning?
8. Coughing up sputum occasionally
9. Coughing up thin, watery sputum after nebulization
10. Decreased ability to clear airway through coughing
11. Lung sounds clear only after coughing

Answer 7

3. Decreased ability to clear airway through coughing

Question 8

8. A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply.)
9. Sharp pleuritic pain that worsens on inspiration
10. Crackles over lung bases of affected lung
11. Tracheal deviation toward the affected lung
12. Worsening dyspnea
13. Absent lung sounds to auscultation on affected side

Answer 8

1. Sharp pleuritic pain that worsens on inspiration
2. Worsening dyspnea
3. Absent lung sounds to auscultation on affected side

Question 9

9. A patient has been newly diagnosed with chronic lung disease. In discussing the lung disease with the nurse, which of the patient’s statements would indicate a need for further education?
10. “I’ll make sure that I rest between activities so I don’t get so short of breath.”
11. “I’ll practice the pursed-lip breathing technique to improve my exercise tolerance.”
12. “If I have trouble breathing at night, I’ll use two or three pillows to prop up.”
13. “If I get short of breath, I’ll turn up my oxygen level to 6 L/min.”

Answer 9

4. “If I get short of breath, I’ll turn up my oxygen level to 6 L/min.”

Question 10

10. The nurse assesses a new patient and finds the patient short of breath with a respiratory rate of 32 and lying supine in bed. What is the priority nursing action?
11. Raise the head of the bed to 45 degrees or higher.
12. Get the oxygen saturation with a pulse oximeter.
13. Take the blood pressure and respiratory rate.
14. Notify the health care provider of the shortness of breath.

Answer 10

1. Raise the head of the bed to 45 degrees or higher.

Question 11

11. The nurse is caring for a patient who exhibits labored breathing, is using accessory muscles, and is coughing up pink frothy sputum. The patient has diminished breath sounds in bilateral lung bases. What are the priority nursing assessments for the nurse to perform prior to notifying the patient’s health care provider? (Select all that apply.)
12. SpO2 levels
13. Amount, color, and consistency of sputum production
14. Fluid status
15. Change in respiratory rate and pattern
16. Pain in lower leg

Answer 11

1. SpO2 levels
2. Amount, color, and consistency of sputum production
3. Change in respiratory rate and pattern

Question 12

12. Place the following in correct sequence for suctioning a patient. 4, 6, 1, 3, 2, 5, 8, 7;
13. Open kit and basin
14. Apply gloves
15. Lubricate catheter
16. Verify functioning of suction device and pressure
17. Connect suction tubing to suction catheter
18. Increase supplemental oxygen
19. Reapply oxygen
20. Suction airway

Answer 12

4, 6, 1, 3, 2, 5, 8, 7;

Question 13

13. Which of the following skills can the nurse delegate to nursing assistive personnel (NAP)? (Select all that apply.)
14. Nasotracheal suctioning
15. Oropharyngeal suctioning of a stable patient
16. Suctioning a new artificial airway
17. Permanent tracheostomy tube suctioning
18. Care of an endotracheal tube

Answer 13

2. Oropharyngeal suctioning of a stable patient

4. Permanent tracheostomy tube suctioning

Question 14

14. 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?
15. Record the amount and continue to monitor drainage.
16. Notify the physician.
17. Strip the chest tube starting at the chest.
18. Increase the suction by 10 mm Hg.

Answer 14

1. Record the amount and continue to monitor drainage.

Question 15

15. The nurse is reviewing the results of the patient’s diagnostic testing. Of the following results, the finding that falls within expected or normal limits is:
16. Palpable, elevated hardened area around a tuberculosis skin testing site
17. Sputum for culture and sensitivity identifies mycobacterium tuberculosis
18. Presence of acid-fast bacilli in sputum
19. Arterial oxygen tension (PaO2) of 95 mm Hg

Answer 15

4. Arterial oxygen tension (PaO2) of 95 mm Hg

Question 16

Review Questions
Are You Ready to Test Your Nursing Knowledge?
1. A patient has been on contact isolation for 4 days because of a hospital-acquired infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? (Select all that apply.)
1. Teaching how activities such as reading and using crossword puzzles provide stimulation
2. Moving him to a room away from the nurse’s station
3. Turning on the lights and opening the room blinds
4. Sitting down, speaking, touching, and listening to his feelings and perceptions
5. Providing auditory stimulation for the patient by keeping the television on continuously

Answer 16

1. Teaching how activities such as reading and using crossword puzzles provide stimulation
2. Turning on the lights and opening the room blinds
3. Sitting down, speaking, touching, and listening to his feelings and perceptions

Question 17

2. The home care nurse is instructing a nursing assistant about interventions to facilitate location of items for patients with vision impairment. Which are effective strategies for enhancing a patient’s impaired vision? (Select all that apply.)
3. Use of fluorescent lighting
4. Use of warm, incandescent lighting
5. Use of yellow or amber lenses to decrease glare
6. Use of adjustable blinds, sheer curtains, or draperies
7. Indirect lighting to reduce glare

Answer 17

2. Use of warm, incandescent lighting

3. Use of yellow or amber lenses to decrease glare

Question 18

3. An elderly patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitates communication with her?
4. Talk to the patient at a distance so he or she may read your lips.
5. Keep your arms at your side; speak directly into the patient’s left ear.
6. Face the patient when speaking; demonstrate ideas you wish to convey.
7. Position the patient so the light is on his or her face when speaking.

Answer 18

3. Face the patient when speaking; demonstrate ideas you wish to convey.

Question 19

4. The nurse is caring for a patient with glaucoma. When developing a discharge plan, which priority intervention enables the patient to function safely with existing deficits and continue a normal lifestyle?
5. Encourage the patient to rearrange her home furnishings regularly to keep active.
6. Suggest to the patient that he or she consider either moving to a smaller home or long-term care facility.
7. Say nothing because it is most appropriate that the patient identify personal interventions to compensate for a sensory
   alteration.
8. Work closely with the patient and family to identify in-home modifications to create a comfortable and accessible environment.

Answer 19

4. Work closely with the patient and family to identify in-home modifications to create a comfortable and accessible environment.

Question 20

5. A patient is returning to an assisted-living apartment following a diagnosis of declining, progressive visual loss. Although she is familiar with her apartment and residence, she reports feeling a little uncertain about walking alone. There is one step into her apartment. Her children are scheduling themselves to be available to their mom for the next 2 weeks. Which of the following approaches will you teach the children to assist ambulation? (Select all that apply.)
6. Walk one-half step behind and slightly to her side.
7. Have her grasp your arm just above the elbow and walk at a comfortable pace.
8. Stand next to your mom at the top and bottom of stairs.
9. Stand one step ahead of mom at the top of the stairs.
10. Place yourself alongside your mom and hold onto her waist.

Answer 20

2. Have her grasp your arm just above the elbow and walk at a comfortable pace.

Question 21

6. A new nurse is going to help a patient walk down the corridor and sit in a chair. The patient has an eye patch over the left eye and poor vision in the right eye. What is the correct order of steps to help the patient safely walk down the hall and sit in the chair? . 3, 4, 2, 1, 5
7. Tell patient when you are approaching the chair.
8. Walk at a relaxed pace.
9. Guide patient’s hand to nurse’s arm, resting just above the elbow.
10. Position yourself one-half step in front of patient.
11. Position patient’s hand on back of chair.

Answer 21

1. Tell patient when you are approaching the chair.
2. Walk at a relaxed pace.
3. Guide patient’s hand to nurse’s arm, resting just above the elbow.
4. Position yourself one-half step in front of patient.
5. Position patient’s hand on back of chair.

Question 22

7. Because hearing impairment is one of the most common disabilities among children, a health promotion intervention is to teach parents and children to:
8. Avoid activities in which there may be crowds.
9. Delay childhood immunizations until hearing can be verified.
10. Take precautions when involved in activities associated with high-intensity noises.
11. Prophylactically administer antibiotics to reduce the incidence of infections.

Answer 22

3. Take precautions when involved in activities associated with high-intensity noises.

Question 23

8. A nurse is conducting discharge teaching for a patient with diminished tactile sensation. Which of the following statements made by the patient indicates that additional teaching is needed?
9. “I am at risk for injury from temperature extremes.”
10. “I may be able to dress more easily with zippers or pull over sweaters.”
11. “A home care nurse may help me figure out how to be more independent.”
12. “I have right-sided partial paralysis and reduced sensation; so I should dress the left side of my body first.”

Answer 23

4. “I have right-sided partial paralysis and reduced sensation; so I should dress the left side of my body first.”

Question 24

9. Which of the following is the best nursing intervention when communicating with a patient who has expressive aphasia?
10. Ask open-ended questions
11. Speak to the patient as if he or she is a child
12. Use a dry-erase board or paper and pen for writing messages
13. Avoid the use of gestures and other nonverbal forms of communication

Answer 24

3. Use a dry-erase board or paper and pen for writing messages

Question 25

10. A patient with progressive vision impairments had to surrender his driver’s license 6 months ago. He comes to the medical clinic for a routine checkup. He is accompanied by his son. His wife died 2 years ago, and he admits to feeling lonely much of the time. Which of the following interventions reduce loneliness? (Select all that apply.)

Answer 25

1. Sharing information about senior transportation services
2. Providing information about local social groups in the patient’s neighborhood
3. Recommending that the patient consider making living arrangements that will put him closer to family or friends

Question 26

11. A nurse is performing an assessment on a patient admitted to the unit following treatment in the emergency department for severe bilateral eye trauma. During patient admission the nurse’s priority interventions include which of the following? (Select all that apply.)

Answer 26

3. Placing necessary objects such as the call light and water in front of the patient to prevent falls caused by reaching
4. Orienting the patient to the environment to reduce anxiety an prevent further injury to the eye
5. Placing signage on the patient’s room door and over the bed to alert health care providers about patient’s visual status

Question 27

12. Which patient is most likely to experience sensory overload?

Answer 27

1. A patient in the intensive care unit whose pain is not well controlled

Question 28

13. An older adult is admitted from a skilled nursing home to a medical unit with pneumonia. A review of the medical record reveals that he had a stroke affecting the right hemisphere of the brain6 months ago and was placed in the skilled nursing home because he was unable to care for himself. Which of these assessment findings does the nurse expect to find? (Select all that apply.)

Answer 28

2. Inattention and neglect, especially to the left side

4. Visual spatial alterations such as loss of half of a visual field

Question 29

14. A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, “I think my hearing aid is broken. I can’t hear anything.” Which of the following teaching strategies does the nurse implement? (Select all that apply.)

Answer 29

1. Demonstrate hearing aid battery replacement.
2. Review method to check volume on hearing aid.
3. Discuss the importance of having wax buildup in the ear canal removed.

Question 30

15. Identify the measures to ensure safety for a patient who has no sensation on one side of the body.

Answer 30

(see evolve)

Question 31

Chapter 36: Antihistamines, Decongestants, Antitussives, and
Expectorants
MULTIPLE CHOICE
1. When giving dextromethorphan, the nurse understands that this drug suppresses the cough reflex by which mechanism of action?

Answer 31

c. Having direct action on the cough center

Question 32

2. During a routine checkup, a patient states that she is unable to take the prescribed antihistamine because of one of its most common adverse effects. The nurse suspects that which adverse effect has been bothering this patient?

Answer 32

c. Drowsiness

Question 33

3. A gardener needs a decongestant because of seasonal allergy problems and asks the nurse whether he should take an oral form or a nasal spray. Which of these is a benefit of orally administered decongestants?

Answer 33

c. Lack of rebound congestion

Question 34

4. A patient is taking guaifenesin (Humibid) as part of treatment for a sinus infection. Which instruction will the nurse include during patient teaching?

Answer 34

a. Force fluids to help loosen and liquefy secretions.

Question 35

5. The nurse will instruct patients about a possible systemic effect that may occur if excessive amounts of topically applied adrenergic nasal decongestants are used. Which systemic effect may occur?

Answer 35

d. Palpitations

Question 36

6. A patient with a tracheostomy has difficulty removing excessive, thick mucus from the respiratory tract. The nurse expects that which drug will be ordered to aid in the removal of mucus?

Answer 36

a. Guaifenesin (Humibid)

Question 37

7. A patient has been advised to add a nasal spray (an adrenergic decongestant) to treat a cold. The nurse will include which instruction?

Answer 37

b. 􀂳Limi􀁗 􀁘􀁖e of 􀁗hi􀁖 􀁖pra􀁜 􀁗o 3 􀁗o 5 da􀁜􀁖.􀂴

Question 38

8. A patient asks the nurse about the uses of echinacea. Which use will the nurse include in the response?

Answer 38

b. Boosting the immune system

Question 39

MULTIPLE RESPONSE
1. When teaching a patient who will be receiving antihistamines, the nurse will include which instructions? (Select all that apply.)

Answer 39

c. 􀂳Take 􀁗he medica􀁗ion 􀁚i􀁗h food 􀁗o minimi􀁝e ga􀁖􀁗roin􀁗e􀁖􀁗inal di􀁖􀁗re􀁖􀁖.􀂴
d. 􀂳Drink e􀁛􀁗ra fl􀁘id􀁖 if po􀁖􀁖ible.􀂴
f. 􀂳A􀁙oid ac􀁗i􀁙i􀁗ie􀁖 􀁗ha􀁗 req􀁘ire aler􀁗ne􀁖􀁖 􀁘n􀁗il 􀁜o􀁘 kno􀁚 ho􀁚 ad􀁙er􀁖e effec􀁗􀁖 are

Question 40

2. A patient tells the nurse that she wants to start taking the herbal product goldenseal to improve her health. The nurse will assess for which potential cautions or contraindications to goldenseal?(Select all that apply.)

Answer 40

a. Taking a proton-pump inhibitor
d. Hypertension
f. Pregnancy

Question 41

1. A child will be receiving diphenhydramine (Benadryl), 5 mg/kg/day, in divided doses, every 6hours. The child weighs 80 pounds. Identify how many milligrams of medication will the child receive with each dose. (record answer using one decimal place) _______

Answer 41

.

Question 42

2. A patient will be receiving diphenhydramine (Benadryl) via a PEG tube, 25 mg, every 8 hours for an allergic rash. The medication is available as a 12.5 mg/5 mL syrup. Identify how many milliliters will the nurse administer with each dose. _______

Answer 42

.

Question 43

Chapter 37: Respiratory Drugs
MULTIPLE CHOICE
1. A patient is taking intravenous aminophylline for a severe exacerbation of chronic obstructive pulmonary disease. The nurse will assess for which therapeutic response?

Answer 43

d. Increased ease of breathing

Question 44

2. A patient is taking a xanthine derivative as part of treatment for chronic obstructive pulmonary disease. The nurse will monitor for which adverse effects associated with the use of xanthine derivatives?2. A patient is taking a xanthine derivative as part of treatment for chronic obstructive pulmonary disease. The nurse will monitor for which adverse effects associated with the use of xanthine derivatives?

Answer 44

b. Palpitations

Question 45

3. A patient is in an urgent care center with an acute asthma attack. The nurse expects that which medication will be used for initial treatment?

Answer 45

b. A short-acting beta2 agonist such as albuterol (Proventil)

Question 46

4. The pre􀁖criber ha􀁖 changed 􀁗he pa􀁗ien􀁗􀂶􀁖 medica􀁗ion regimen 􀁗o incl􀁘de 􀁗he le􀁘ko􀁗riene recep􀁗or antagonist (LTRA) montelukast (Singulair) to treat asthma. The nurse will emphasize which point about this medication?

Answer 46

…

Question 47

5. After receiving a nebulizer treatment with a beta agonist, the patient complains of feeling slightly nervous and wonders if her a􀁖􀁗hma i􀁖 ge􀁗􀁗ing 􀁚or􀁖e. Wha􀁗 i􀁖 􀁗he n􀁘r􀁖e􀂶􀁖 be􀁖􀁗 re􀁖pon􀁖e?

Answer 47

a. 􀂳Thi􀁖 i􀁖 an e􀁛pec􀁗ed ad􀁙er􀁖e effec􀁗. Le􀁗 me 􀁗ake 􀁜o􀁘r p􀁘l􀁖e.􀂴

Question 48

6. A patient has prescriptions for two inhalers. One inhaler is a bronchodilator, and the other is a corticosteroid. Which instruction regarding these inhalers will the nurse give to the patient?

Answer 48

b. 􀂳Take 􀁗he bronchodila􀁗or inhaler fir􀁖􀁗.􀂴

Question 49

7. When educating a patient recently placed on inhaled corticosteroids, the nurse will discuss which potential adverse effects?

Answer 49

d. Oral candidiasis and dry mouth

Question 50

8. The nurse is monitoring drug levels for a patient who is receiving theophylline. The most recent theophylline level was 22 mcg/mL, and the nurse evaluates this level to be:

Answer 50

c. above the therapeutic level.

Question 51

9. When e􀁙al􀁘a􀁗ing a pa􀁗ien􀁗􀂶􀁖 􀁘􀁖e of a me􀁗ered-dose inhaler (MDI), the nurse notes that the patient is unable to coordinate the activation of the inhaler with her breathing. What intervention is most appropriate at this time?

Answer 51

c. Obtain an order for a spacer device.

Question 52

10. The nurse is providing instructions about the Advair inhaler (fluticasone propionate and salmeterol). Which statement about this inhaler is accurate?

Answer 52

d. It is used for the prevention of bronchospasms.

Question 53

MULTIPLE RESPONSE
1. The nurse is reviewing medications for the treatment of asthma. Which drugs are used for acute asthma attacks? (Select all that apply.)

Answer 53

b. Albuterol (Proventil) nebulizer solution

c. Epinephrine

Question 54

2. The nurse is providing instructions to a patient who has a new prescription for a corticosteroid metered-dose inhaler. Which statement by the patient indicates that further instruction is needed?(Select all that apply.)

Answer 54

b. 􀂳I 􀁚ill gargle af􀁗er 􀁘􀁖ing 􀁗he inhaler and 􀁗hen 􀁖􀁚allo􀁚.􀂴

d. 􀂳I 􀁚ill 􀁘􀁖e 􀁗hi􀁖 inhaler for a􀁖􀁗hma a􀁗􀁗ack􀁖.􀂴

Question 55

1. A patient has a metered-do􀁖e inhaler 􀁗ha􀁗 con􀁗ain􀁖 200 ac􀁗􀁘a􀁗ion􀁖 (􀂵p􀁘ff􀁖􀂶), and i􀁗 doe􀁖 no􀁗 ha􀁙e a
   dose counter. He is to take two puffs two times a day. If he does not take any extra doses, identify how many days will this inhaler last at the prescribed dose. _______

Answer 55

50 days

Question 56

2. A patient will be receiving oral theophylline (Theo-Dur), 600 mg/day, in three divided doses.
   Identify how many milligrams will the patient receive per dose. _______

Answer 56

.

Question 57

132. A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, “No speak English, need interpreter.”Which is the best action for the nurse to take?

Answer 57

3. Page an interpreter from the hospital’s interpreter services.

Question 58

4. Obtain a Spanish-English dictionary and attempt to triage the client. The nurse is performing a neurological assessment
   on a client and elicits a positive Romberg’s sign.The nurse makes this determination based on which observation?

Answer 58

3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

Question 59

134. The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment
     of the client, the nurse should expect to note which finding?
     v

Answer 59

1. Rhythmic respirations with periods of apnea

Question 60

135. A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?

Answer 60

3. A physical obstruction to the transmission of sound waves

Question 61

136. While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates
     a murmur. The nurse documents the finding and describes the sound as which?

Answer 61

3. A blowing or swooshing noise

Question 62

137. The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

Answer 62

2. Test the 6 cardinal positions of gaze.

Question 63

138. The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam?

Answer 63

1. After a shower or bath

Question 64

139. The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski’s sign. Which finding did the nurse observe?

Answer 64

3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

Question 65

140. A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

Answer 65

3. Wheezes

Question 66

141. The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply.

Answer 66

1. Auscultating lung sounds
2. Obtaining the client’s temperature
3. Obtaining information about the client’s respirations

Question 67

Chapter 41: Oxygenation
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. A nurse is teaching staff about the conduction of the heart. In which order will the nurse present
the conduction cycle, starting with the first structure?
1. Bundle of His
2. Purkinje network
3. Intraatrial pathways
4. Sinoatrial (SA) node
5. Atrioventricular (AV) node

Answer 67

b. 4, 3, 5, 1, 2

Question 68

3. A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli’s function will the nurse share with the patient?

Answer 68

a. Carries out gas exchange

Question 69

4. A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing
   close?

Answer 69

c. Aortic and pulmonic

Question 70

5. The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process?

Answer 70

d. Diffusion

Question 71

6. A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority?

Answer 71

b. Respirations

Question 72

7. The patient is breathing normally. Which process does the nurse consider is working properly
   when the patient inspires?

Answer 72

a. Stimulation of chemical receptors in the aorta

Question 73

8. The home health nurse recommends that a patient with respiratory problems install a carbon
   monoxide detector in the home. What is the rationale for the nurse’s action?

Answer 73

b. Carbon monoxide tightly binds to hemoglobin, causing hypoxia.

Question 74

9. While performing an assessment, the nurse hears crackles in the patient’s lung fields. The nurse
   also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the
   night. Which condition will the nurse most likely observe written in the patient’s medical record?

Answer 74

c. Left-sided heart failure

Question 75

10. A patient has a myocardial infarction. On which primary blood vessel will the nurse focus care to
    reduce ischemia?

Answer 75

c. Coronary artery

Question 76

11. A nurse is teaching a health class about the heart. Which information from the class members
    indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the
    right atrium?

Answer 76

c. Right ventricle, left atrium, left ventricle

Question 77

12. The nurse suspects the patient has increased afterload. Which piece of equipment should the
    nurse obtain to determine the presence of this condition?

Answer 77

c. Blood pressure cuff

Question 78

13. A patient has heart failure and cardiac output is decreased. Which formula can the nurse use to
    calculate cardiac output?

Answer 78

c. Stroke volume × Heart rate

Question 79

14. A patient’s heart rate increased from 94 to 164 beats/min. What will the nurse expect?

Answer 79

c. Decrease in cardiac output

Question 80

15. The nurse is careful to monitor a patient’s cardiac output. Which goal is the nurse trying to
    achieve?

Answer 80

a. To determine peripheral extremity circulation

Question 81

16. A nurse is caring for a group of patients. Which patient should the nurse see first?

Answer 81

a. A patient with hypercapnia wearing an oxygen mask

Question 82

17. A patient has inadequate stroke volume related to decreased preload. Which treatment does the
    nurse prepare to administer?

Answer 82

d. Intravenous (IV) fluids

Question 83

18. A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which
    finding will cause the nurse to stop suctioning?

Answer 83

d. Oxygen saturation 88%

Question 84

19. The patient has right-sided heart failure. Which finding will the nurse expect when performing an
    assessment?

Answer 84

a. Peripheral edema

Question 85

20. A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction
    system does the nurse consider when evaluating the P wave?

Answer 85

a. SA node

Question 86

21. A nurse teaches a patient about atelectasis. Which statement by the patient indicates an
    understanding of atelectasis?

Answer 86

b. “It is important to do breathing exercises every hour to prevent atelectasis.”

Question 87

22. The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a
    late sign of hypoxia?
    v

Answer 87

d. Cyanosis

Question 88

23. A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this
    patient to hyperventilate. Which factor does the nurse remember when planning care for this type of
    hyperventilation?

Answer 88

c. Increased metabolic demands

Question 89

24. A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform
the steps, beginning with the first step?
1. Insert catheter.
2. Apply suction and remove.
3. Have patient deep breathe.
4. Encourage patient to cough.
5. Attach catheter to suction system.
6. Rinse catheter and connecting tubing.

Answer 89

c. 5, 3, 1, 2, 4, 6

Question 90

25. A patient has carbon dioxide retention from lung problems. Which type of diet will the
    nurse most likely suggest for this patient?

Answer 90

a. Low-carbohydrate

Question 91

26. A nurse is caring for a patient who is taking warfarin (Coumadin) and discovers that the patient is
    taking garlic to help with hypertension. Which condition will the nurse assess for in this patient?

Answer 91

c. Bleeding

Question 92

27. A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When
    the patient asks what to eat for breakfast, which meal should the nurse suggest?

Answer 92

a. A cup of nonfat yogurt with granola and a handful of dried apricots

Question 93

28. Upon auscultation of the patient’s chest, the nurse hears a whooshing sound at the fifth
    intercostal space. What does this finding indicate to the nurse?

Answer 93

b. Regurgitation of the mitral valve

Question 94

29. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is
    receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to
    administer the oxygen?

Answer 94

a. Nasal cannula

Question 95

30. The nurse needs to closely monitor the oxygen status of an older-adult patient undergoing
    anesthesia because of which age-related change?

Answer 95

b. Diminished respiratory muscle strength may cause poor chest expansion.

Question 96

31. The nurse determines that an older-adult patient is at risk for infection due to decreased
    immunity. Which plan of care best addresses the prevention of infection for the patient?

Answer 96

b. Encourage the patient to stay up-to-date on all vaccinations.

Question 97

32. The nurse is caring for a patient with fluid volume overload. Which physiological effect does the
    nurse most likely expect?

Answer 97

a. Increased preload

Question 98

33. A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which
    rhythm will cause the nurse to intervene immediately?

Answer 98

a. Ventricular tachycardia

Question 99

34. The patient is experiencing angina pectoris. Which assessment finding does the nurse expect
    when conducting a history and physical examination?

Answer 99

a. Experiences chest pain after eating a heavy meal

Question 100

35. A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the
    nurse describe as modifiable?

Answer 100

stress

Question 101

36. The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to
    ineffective breathing. Which intervention best addresses a short-term goal the patient could
    achieve?

Answer 101

a. Sleeping on two to three pillows at night

Question 102

37. A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has
    a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30

Answer 102

b. Impaired gas exchange

Question 103

38. Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an
    older-adult patient?

Answer 103

c. Assist the patient to cough, turn, and deep breathe every 2 hours.

Question 104

39. The nurse is assessing a patient with emphysema. Which assessment finding requires further
    follow-up with the health care provider?

Answer 104

d. Hemoptysis

Question 105

40. A patient with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing
    occurs. Which response by the nurse is most therapeutic?

Answer 105

a. “Your disease doesn’t send enough oxygen to your fingers.”

Question 106

41. A patient with a pneumothorax has a chest tube inserted and is placed on low constant suction.
    Which finding requires immediate action by the nurse?

Answer 106

c. No bubbling is present in the suction control chamber of the drainage device.

Question 107

42. The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention
    is most effective in promoting effective airway clearance?

Answer 107

b. Administering humidified oxygen through a tracheostomy collar

Question 108

43. The nurse is educating a student nurse on caring for a patient with a chest tube. Which
    statement from the student nurse indicates successful learning?

Answer 108

b. “I should report if I see continuous bubbling in the water-seal chamber.”

Question 109

44. Which coughing technique will the nurse use to help a patient clear central airways?

Answer 109

a. Huff

Question 110

45. The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take?

Answer 110

b. Limit the length of suctioning to 10 seconds.

Question 111

46. The nurse is caring for a patient who needs oxygen via a nasal cannula. Which task can the
    nurse delegate to the nursing assistive personnel?

Answer 111

a. Applying the nasal cannula

Question 112

47. The nurse is using a closed suction device. Which patient will be most appropriate for this
    suctioning method?

Answer 112

d. A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation

Question 113

48. While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the
    tracheostomy tube. Which action will the nurse take first?

Answer 113

b. Insert a spare tracheostomy with the obturator.

Question 114

MULTIPLE RESPONSE
1. A nurse is following the Ventilator Bundle standards to prevent ventilator-associated pneumonia.
Which strategies is the nurse using? (Select all that apply.)

Answer 114

b. Daily oral care with chlorhexidine
c. Cuff monitoring for adequate seal
e. Daily “sedation vacations”

Question 115

2. A nurse is teaching a community health promotion class and discusses the flu vaccine. Which information will the nurse include in the teaching session? (Select all that apply.)

Answer 115

a. It is given yearly.

f. The inactivated flu vaccine is given to people over 50.

Question 116

3. A nurse is caring for a patient with sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.)

Answer 116

c. Bilevel positive airway pressure (BiPAP)

d. Continuous positive airway pressure (CPAP)

Question 117

Chapter 49: Sensory Alterations
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. A nurse is administering a vaccine to a child who is visually impaired. After the needle enters the
arm, the child says, “Ow, that was sharp!” How will the nurse interpret the finding when the child said
that it was sharp?

Answer 117

c. The child’s perception is intact.

Question 118

2. A nurse is describing the transmission of sound to a patient. In which order will the nurse list the
   pathway of sound, beginning with the first structure?
3. Eardrum
4. Perilymph
5. Oval window
6. Bony ossicles
7. Eighth cranial nerve

Answer 118

d. 1, 4, 3, 2, 5

Question 119

3. A nurse is caring for a patient with presbycusis. Which assessment finding indicates an adaptation
   to the sensory deficit?

Answer 119

c. The patient turns one ear toward the nurse during conversation.

Question 120

4. The nurse will be most concerned about the risk of malnutrition for a patient with which sensory
   deficit?

Answer 120

a. Xerostomia

Question 121

5. A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during
   the assessment?

Answer 121

a. Impaired night vision

Question 122

6. A nurse is caring for an older-adult patient who was in a motor vehicle accident because the
   patient thought the stoplight was green. The patient asks the nurse “Should Istop driving?” Which
   response by the nurse is most therapeutic?

Answer 122

c.
“No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is lit up, it
means stop, and if the bottom is lit up, it means go.”

Question 123

7. A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end
   of the week. The nurse notices that the patient is having difficulty with communication and becomes
   tearful at times. Which intervention will the nurse include in the patient’s plan of care?

Answer 123

a. Teach the patient about special assistive devices.

Question 124

8. A patient has both hearing and visual sensory impairments. Which psychological nursing
   diagnosis will the nurse add to the care plan?

Answer 124

c. Social isolation

Question 125

9. During an assessment of a patient, the nurse finds the patient experiences vertigo. Which sensory
   deficit will the nurse assess further?

Answer 125

d. Balance deficit

Question 126

10. A home health nurse is assembling a puzzle with an older-adult patient and notices that the
    patient is having difficulty connecting two puzzle pieces. Which aspect of sensory deprivation will the
    nurse document as being most affected?

Answer 126

a. Perceptual

Question 127

11. Which assessment question should the nurse ask to best understand how visual alterations are
    affecting the patient’s self-care ability?

Answer 127

c. “Are you able to prepare a meal or write a check?”

Question 128

12. A nurse is assessing cognitive functioning of a patient. Which action will the nurse take?

Answer 128

a. Administer a Mini-Mental State Examination (MMSE).

Question 129

13. The nurse is using the Snellen chart. Which patient is the nurse assessing?

Answer 129

a. A patient who frequently reports the incorrect time from the clock across the room.

Question 130

14. A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is
    becoming malnourished because nothing tastes good. Which recommendation by the nurse will
    be most appropriate for this patient?

Answer 130

a. “Rinse your mouth several times a day to hydrate your taste buds.”

Question 131

15. The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis will the
    nurse include in the care plan to address a safety complication of the sensory deficit?

Answer 131

c. Risk for falls

Question 132

16. The nurse is caring for a patient who is having difficulty understanding the written and spoken
    word. Which type of aphasia will the nurse report to the oncoming shift?

Answer 132

b. Receptive

Question 133

17. The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen
    impaction. Which intervention by the nurse is most important in establishing effective
    communication with the patient?

Answer 133

a. Speaking with hands, face, and expressions

Question 134

18. The home health nurse is caring for a patient with tactile and visual deficits. The nurse is
    concerned about injury related to inability to feel harmful stimuli and teaches the patient safety
    strategies to maintain independence. Which action by the patient indicates successful learning?

Answer 134

b. Places colored stickers on faucet handles to indicate temperature.

Question 135

19. A nurse is working to prevent blindness. Which preventive action is a priority?

Answer 135

b. Include rubella and syphilis screening in the preconception care plan.

Question 136

20. The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring
    systems on that constantly beep and make noise. The patient is becoming agitated and frustrated
    over the inability to sleep. Which action by the nurse is most appropriate for this patient?
21. The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring
    systems on that constantly beep and make noise. The patient is becoming agitated and frustrated
    over the inability to sleep. Which action by the nurse is most appropriate for this patient?

Answer 136

d. Provide the patient with earplugs.

Question 137

21. The nurse is caring for a patient with expressive aphasia from a traumatic brain injury. Which
    goal will the nurse include in the plan of care?
    v

Answer 137

d. Patient will communicate nonverbally.

Question 138

22. The nurse is caring for a group of patients and is monitoring for sensory deprivation. Which
    patient will the nurse monitor most closely?

Answer 138

b. A patient on the unit with tuberculosis on airborne precautions

Question 139

23. A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which
    action will the nurse take?

Answer 139

a. Offer the patient a back rub.

Question 140

24. The nurse is caring for a patient who is a well-known surgeon at the hospital. The nurse notices
    the patient becoming more agitated and withdrawn with each group of surgeon visitors. The nurse
    and patient agree to place a “Do not disturb” sign on the door. A few hours later, the nurse notices a
    surgeon who is not involved in the patient’s care attempting to enter the room. Which response by
    the nurse is most appropriate?

Answer 140

c. Firmly explain that the patient does not wish to have visitors at this time.

Question 141

25. The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently
    becomes disoriented to everything except location. Which nursing intervention will the nurse add to
    the care plan to reduce confusion?

Answer 141

a. Keep a day-by-day calendar at the patient’s bedside.

Question 142

26. A nurse is establishing a relationship with the patient who is severely visually impaired and is
    teaching the patient how to contact the nurse for assistance. Which action will the nurse take?

Answer 142

a. Place a raised Braille sticker on the call button.

Question 143

27. The nurse is caring for a patient who is taking gentamicin for an infection. Which assessment is
    a priority?

Answer 143

Hearing

Question 144

28. A nurse is teaching a patient about vision. In which order will the nurse describe the pathway for
    vision, beginning with the first structure?
29. Lens
30. Pupil
31. Retina
32. Cornea
33. Optic nerve

Answer 144

c. 4, 2, 1, 3, 5

Question 145

29. A nurse is caring for a patient with a right hemisphere stroke and partial paralysis. Which action
    by the nursing assistive personnel (NAP) will cause the nurse to praise the NAP?

Answer 145

a. Dressing the left side first

Question 146

MULTIPLE RESPONSE
1. A home care nurse is inspecting a patient’s house for safety issues. Which findings will cause the
nurse to address the safety problems? (Select all that apply.)

Answer 146

a. Stairway faintly lit
c. Scatter rugs in the kitchen
d. Absence of smoke alarms