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NURS110 > ALL t6 questions t6 including 1 case study > Flashcards

ALL t6 questions t6 including 1 case study Flashcards

1
Q
  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
A
  1. Cardiopulmonary disease and lung cancer
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2
Q
  1. 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?
  2. Increased breathlessness but increased activity tolerance
  3. Decreased breathlessness and decreased activity tolerance
  4. Increased activity tolerance and decreased breathlessness
  5. Decreased activity tolerance and increased breathlessness
A
  1. Decreased activity tolerance and increased breathlessness
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3
Q
  1. 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:
  2. Stimulates hyperventilation, causing respiratory alkalosis
  3. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs
  4. Stimulates hypoventilation, causing respiratory acidosis
  5. Causes alveoli to overinflate, leading to atelectasis
A
  1. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs
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4
Q
  1. 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?
  2. Fever increases metabolic demands, requiring increased oxygen need.
  3. Blood glucose stores are depleted and the cells do not have energy to use oxygen.
  4. Carbon dioxide production increases due to hyperventilation.
  5. Carbon dioxide production decreases due to hypoventilation.
A
  1. Fever increases metabolic demands, requiring increased oxygen need.
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5
Q
  1. A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation?
  2. Sonorous wheezes in the left lower lung
  3. Rhonchi mid sternum
  4. Crackles only in apex of lungs
  5. Inspiratory crackles in lung bases
A
  1. Inspiratory crackles in lung bases
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6
Q
  1. Inspiratory crackles in lung bases
A
  1. Frequent change of position
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7
Q
  1. A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning?
  2. Coughing up sputum occasionally
  3. Coughing up thin, watery sputum after nebulization
  4. Decreased ability to clear airway through coughing
  5. Lung sounds clear only after coughing
A
  1. Decreased ability to clear airway through coughing
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8
Q
  1. 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.)
  2. Sharp pleuritic pain that worsens on inspiration
  3. Crackles over lung bases of affected lung
  4. Tracheal deviation toward the affected lung
  5. Worsening dyspnea
  6. Absent lung sounds to auscultation on affected side
A
  1. Sharp pleuritic pain that worsens on inspiration
  2. Worsening dyspnea
  3. Absent lung sounds to auscultation on affected side
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9
Q
  1. 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?
  2. “I’ll make sure that I rest between activities so I don’t get so short of breath.”
  3. “I’ll practice the pursed-lip breathing technique to improve my exercise tolerance.”
  4. “If I have trouble breathing at night, I’ll use two or three pillows to prop up.”
  5. “If I get short of breath, I’ll turn up my oxygen level to 6 L/min.”
A
  1. “If I get short of breath, I’ll turn up my oxygen level to 6 L/min.”
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10
Q
  1. 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?
  2. Raise the head of the bed to 45 degrees or higher.
  3. Get the oxygen saturation with a pulse oximeter.
  4. Take the blood pressure and respiratory rate.
  5. Notify the health care provider of the shortness of breath.
A
  1. Raise the head of the bed to 45 degrees or higher.
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11
Q
  1. 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.)
  2. SpO2 levels
  3. Amount, color, and consistency of sputum production
  4. Fluid status
  5. Change in respiratory rate and pattern
  6. Pain in lower leg
A
  1. SpO2 levels
  2. Amount, color, and consistency of sputum production
  3. Change in respiratory rate and pattern
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12
Q
  1. Place the following in correct sequence for suctioning a patient. 4, 6, 1, 3, 2, 5, 8, 7;
  2. Open kit and basin
  3. Apply gloves
  4. Lubricate catheter
  5. Verify functioning of suction device and pressure
  6. Connect suction tubing to suction catheter
  7. Increase supplemental oxygen
  8. Reapply oxygen
  9. Suction airway
A

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

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13
Q
  1. Which of the following skills can the nurse delegate to nursing assistive personnel (NAP)? (Select all that apply.)
  2. Nasotracheal suctioning
  3. Oropharyngeal suctioning of a stable patient
  4. Suctioning a new artificial airway
  5. Permanent tracheostomy tube suctioning
  6. Care of an endotracheal tube
A
  1. Oropharyngeal suctioning of a stable patient

4. Permanent tracheostomy tube suctioning

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14
Q
  1. 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?
  2. Record the amount and continue to monitor drainage.
  3. Notify the physician.
  4. Strip the chest tube starting at the chest.
  5. Increase the suction by 10 mm Hg.
A
  1. Record the amount and continue to monitor drainage.
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15
Q
  1. 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:
  2. Palpable, elevated hardened area around a tuberculosis skin testing site
  3. Sputum for culture and sensitivity identifies mycobacterium tuberculosis
  4. Presence of acid-fast bacilli in sputum
  5. Arterial oxygen tension (PaO2) of 95 mm Hg
A
  1. Arterial oxygen tension (PaO2) of 95 mm Hg
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16
Q

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

A
  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
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17
Q
  1. 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.)
  2. Use of fluorescent lighting
  3. Use of warm, incandescent lighting
  4. Use of yellow or amber lenses to decrease glare
  5. Use of adjustable blinds, sheer curtains, or draperies
  6. Indirect lighting to reduce glare
A
  1. Use of warm, incandescent lighting

3. Use of yellow or amber lenses to decrease glare

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18
Q
  1. 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?
  2. Talk to the patient at a distance so he or she may read your lips.
  3. Keep your arms at your side; speak directly into the patient’s left ear.
  4. Face the patient when speaking; demonstrate ideas you wish to convey.
  5. Position the patient so the light is on his or her face when speaking.
A
  1. Face the patient when speaking; demonstrate ideas you wish to convey.
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19
Q
  1. 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?
  2. Encourage the patient to rearrange her home furnishings regularly to keep active.
  3. Suggest to the patient that he or she consider either moving to a smaller home or long-term care facility.
  4. Say nothing because it is most appropriate that the patient identify personal interventions to compensate for a sensory
    alteration.
  5. Work closely with the patient and family to identify in-home modifications to create a comfortable and accessible environment.
A
  1. Work closely with the patient and family to identify in-home modifications to create a comfortable and accessible environment.
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20
Q
  1. 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.)
  2. Walk one-half step behind and slightly to her side.
  3. Have her grasp your arm just above the elbow and walk at a comfortable pace.
  4. Stand next to your mom at the top and bottom of stairs.
  5. Stand one step ahead of mom at the top of the stairs.
  6. Place yourself alongside your mom and hold onto her waist.
A
  1. Have her grasp your arm just above the elbow and walk at a comfortable pace.
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21
Q
  1. 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
  2. Tell patient when you are approaching the chair.
  3. Walk at a relaxed pace.
  4. Guide patient’s hand to nurse’s arm, resting just above the elbow.
  5. Position yourself one-half step in front of patient.
  6. Position patient’s hand on back of chair.
A
  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.
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22
Q
  1. Because hearing impairment is one of the most common disabilities among children, a health promotion intervention is to teach parents and children to:
  2. Avoid activities in which there may be crowds.
  3. Delay childhood immunizations until hearing can be verified.
  4. Take precautions when involved in activities associated with high-intensity noises.
  5. Prophylactically administer antibiotics to reduce the incidence of infections.
A
  1. Take precautions when involved in activities associated with high-intensity noises.
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23
Q
  1. 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?
  2. “I am at risk for injury from temperature extremes.”
  3. “I may be able to dress more easily with zippers or pull over sweaters.”
  4. “A home care nurse may help me figure out how to be more independent.”
  5. “I have right-sided partial paralysis and reduced sensation; so I should dress the left side of my body first.”
A
  1. “I have right-sided partial paralysis and reduced sensation; so I should dress the left side of my body first.”
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24
Q
  1. Which of the following is the best nursing intervention when communicating with a patient who has expressive aphasia?
  2. Ask open-ended questions
  3. Speak to the patient as if he or she is a child
  4. Use a dry-erase board or paper and pen for writing messages
  5. Avoid the use of gestures and other nonverbal forms of communication
A
  1. Use a dry-erase board or paper and pen for writing messages
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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.)
1. Sharing information about senior transportation services 4. Providing information about local social groups in the patient's neighborhood 5. Recommending that the patient consider making living arrangements that will put him closer to family or friends
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.)
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
27
12. Which patient is most likely to experience sensory overload?
1. A patient in the intensive care unit whose pain is not well controlled
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.)
2. Inattention and neglect, especially to the left side | 4. Visual spatial alterations such as loss of half of a visual field
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.)
1. Demonstrate hearing aid battery replacement. 2. Review method to check volume on hearing aid. 4. Discuss the importance of having wax buildup in the ear canal removed.
30
15. Identify the measures to ensure safety for a patient who has no sensation on one side of the body.
(see evolve)
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?
c. Having direct action on the cough center
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?
c. Drowsiness
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?
c. Lack of rebound congestion
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?
a. Force fluids to help loosen and liquefy secretions.
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?
d. Palpitations
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?
a. Guaifenesin (Humibid)
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?
b. 􀂳Limi􀁗 􀁘􀁖e of 􀁗hi􀁖 􀁖pra􀁜 􀁗o 3 􀁗o 5 da􀁜􀁖.􀂴
38
8. A patient asks the nurse about the uses of echinacea. Which use will the nurse include in the response?
b. Boosting the immune system
39
MULTIPLE RESPONSE 1. When teaching a patient who will be receiving antihistamines, the nurse will include which instructions? (Select all that apply.)
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
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.)
a. Taking a proton-pump inhibitor d. Hypertension f. Pregnancy
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) _______
.
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. _______
.
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?
d. Increased ease of breathing
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?
b. Palpitations
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?
b. A short-acting beta2 agonist such as albuterol (Proventil)
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?
...
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?
a. 􀂳Thi􀁖 i􀁖 an e􀁛pec􀁗ed ad􀁙er􀁖e effec􀁗. Le􀁗 me 􀁗ake 􀁜o􀁘r p􀁘l􀁖e.􀂴
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?
b. 􀂳Take 􀁗he bronchodila􀁗or inhaler fir􀁖􀁗.􀂴
49
7. When educating a patient recently placed on inhaled corticosteroids, the nurse will discuss which potential adverse effects?
d. Oral candidiasis and dry mouth
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:
c. above the therapeutic level.
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?
c. Obtain an order for a spacer device.
52
10. The nurse is providing instructions about the Advair inhaler (fluticasone propionate and salmeterol). Which statement about this inhaler is accurate?
d. It is used for the prevention of bronchospasms.
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.)
b. Albuterol (Proventil) nebulizer solution | c. Epinephrine
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.)
b. 􀂳I 􀁚ill gargle af􀁗er 􀁘􀁖ing 􀁗he inhaler and 􀁗hen 􀁖􀁚allo􀁚.􀂴 | d. 􀂳I 􀁚ill 􀁘􀁖e 􀁗hi􀁖 inhaler for a􀁖􀁗hma a􀁗􀁗ack􀁖.􀂴
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. _______
50 days
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. _______
.
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?
3. Page an interpreter from the hospital’s interpreter services.
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?
3. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed
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
1. Rhythmic respirations with periods of apnea
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?
3. A physical obstruction to the transmission of sound waves
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?
3. A blowing or swooshing noise
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?
2. Test the 6 cardinal positions of gaze.
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?
1. After a shower or bath
64
139. The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski’s sign. Which finding did the nurse observe?
3. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.
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?
3. Wheezes
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.
1. Auscultating lung sounds 2. Obtaining the client’s temperature 4. Obtaining information about the client’s respirations
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
b. 4, 3, 5, 1, 2
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?
a. Carries out gas exchange
69
4. A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?
c. Aortic and pulmonic
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?
d. Diffusion
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?
b. Respirations
72
7. The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires?
a. Stimulation of chemical receptors in the aorta
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?
b. Carbon monoxide tightly binds to hemoglobin, causing hypoxia.
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?
c. Left-sided heart failure
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10. A patient has a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia?
c. Coronary artery
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?
c. Right ventricle, left atrium, left ventricle
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12. The nurse suspects the patient has increased afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition?
c. Blood pressure cuff
78
13. A patient has heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output?
c. Stroke volume × Heart rate
79
14. A patient’s heart rate increased from 94 to 164 beats/min. What will the nurse expect?
c. Decrease in cardiac output
80
15. The nurse is careful to monitor a patient’s cardiac output. Which goal is the nurse trying to achieve?
a. To determine peripheral extremity circulation
81
16. A nurse is caring for a group of patients. Which patient should the nurse see first?
a. A patient with hypercapnia wearing an oxygen mask
82
17. A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer?
d. Intravenous (IV) fluids
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?
d. Oxygen saturation 88%
84
19. The patient has right-sided heart failure. Which finding will the nurse expect when performing an assessment?
a. Peripheral edema
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?
a. SA node
86
21. A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis?
b. “It is important to do breathing exercises every hour to prevent atelectasis.”
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22. The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia? v
d. Cyanosis
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?
c. Increased metabolic demands
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``` 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. ```
c. 5, 3, 1, 2, 4, 6
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25. A patient has carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient?
a. Low-carbohydrate
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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?
c. Bleeding
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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?
a. A cup of nonfat yogurt with granola and a handful of dried apricots
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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?
b. Regurgitation of the mitral valve
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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?
a. Nasal cannula
95
30. The nurse needs to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change?
b. Diminished respiratory muscle strength may cause poor chest expansion.
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?
b. Encourage the patient to stay up-to-date on all vaccinations.
97
32. The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most likely expect?
a. Increased preload
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?
a. Ventricular tachycardia
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34. The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination?
a. Experiences chest pain after eating a heavy meal
100
35. A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the nurse describe as modifiable?
stress
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?
a. Sleeping on two to three pillows at night
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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
b. Impaired gas exchange
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38. Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient?
c. Assist the patient to cough, turn, and deep breathe every 2 hours.
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39. The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider?
d. Hemoptysis
105
40. A patient with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic?
a. “Your disease doesn’t send enough oxygen to your fingers.”
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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?
c. No bubbling is present in the suction control chamber of the drainage device.
107
42. The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance?
b. Administering humidified oxygen through a tracheostomy collar
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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?
b. “I should report if I see continuous bubbling in the water-seal chamber.”
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44. Which coughing technique will the nurse use to help a patient clear central airways?
a. Huff
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45. The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take?
b. Limit the length of suctioning to 10 seconds.
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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?
a. Applying the nasal cannula
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47. The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method?
d. A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation
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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?
b. Insert a spare tracheostomy with the obturator.
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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.)
b. Daily oral care with chlorhexidine c. Cuff monitoring for adequate seal e. Daily “sedation vacations”
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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.)
a. It is given yearly. | f. The inactivated flu vaccine is given to people over 50.
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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.)
c. Bilevel positive airway pressure (BiPAP) | d. Continuous positive airway pressure (CPAP)
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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?
c. The child’s perception is intact.
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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? 1. Eardrum 2. Perilymph 3. Oval window 4. Bony ossicles 5. Eighth cranial nerve
d. 1, 4, 3, 2, 5
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3. A nurse is caring for a patient with presbycusis. Which assessment finding indicates an adaptation to the sensory deficit?
c. The patient turns one ear toward the nurse during conversation.
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4. The nurse will be most concerned about the risk of malnutrition for a patient with which sensory deficit?
a. Xerostomia
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5. A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment?
a. Impaired night vision
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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?
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.”
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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?
a. Teach the patient about special assistive devices.
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8. A patient has both hearing and visual sensory impairments. Which psychological nursing diagnosis will the nurse add to the care plan?
c. Social isolation
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9. During an assessment of a patient, the nurse finds the patient experiences vertigo. Which sensory deficit will the nurse assess further?
d. Balance deficit
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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?
a. Perceptual
127
11. Which assessment question should the nurse ask to best understand how visual alterations are affecting the patient’s self-care ability?
c. “Are you able to prepare a meal or write a check?”
128
12. A nurse is assessing cognitive functioning of a patient. Which action will the nurse take?
a. Administer a Mini-Mental State Examination (MMSE).
129
13. The nurse is using the Snellen chart. Which patient is the nurse assessing?
a. A patient who frequently reports the incorrect time from the clock across the room.
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?
a. “Rinse your mouth several times a day to hydrate your taste buds.”
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?
c. Risk for falls
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?
b. Receptive
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?
a. Speaking with hands, face, and expressions
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?
b. Places colored stickers on faucet handles to indicate temperature.
135
19. A nurse is working to prevent blindness. Which preventive action is a priority?
b. Include rubella and syphilis screening in the preconception care plan.
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? 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?
d. Provide the patient with earplugs.
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
d. Patient will communicate nonverbally.
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?
b. A patient on the unit with tuberculosis on airborne precautions
139
23. A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which action will the nurse take?
a. Offer the patient a back rub.
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?
c. Firmly explain that the patient does not wish to have visitors at this time.
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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?
a. Keep a day-by-day calendar at the patient’s bedside.
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?
a. Place a raised Braille sticker on the call button.
143
27. The nurse is caring for a patient who is taking gentamicin for an infection. Which assessment is a priority?
Hearing
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? 1. Lens 2. Pupil 3. Retina 4. Cornea 5. Optic nerve
c. 4, 2, 1, 3, 5
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?
a. Dressing the left side first
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.)
a. Stairway faintly lit c. Scatter rugs in the kitchen d. Absence of smoke alarms

NURS110 (2 decks)

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