NSG 100 Exam 2: Safety, Functional Ability, Gas Exchange Flashcards
1
Q
What is the most significant modifiable risk factor for the development of impaired gas exchange?
a. Age
b. Tobacco use
c. Drug overdose
d. Prolonged immobility
A
b. Tobacco use
2
Q
How does a nurse support a culture of safety? (Select ALL that apply)
a. Completing an incident report for a near miss
b. Identifying the person responsible for an incident
c. Communicating product concerns to an immediate supervisor
d. Participating in safety and health training
A
a. Completing an incident report for a near miss
c. Communicating product concerns to an immediate supervisor
d. Participating in safety and health training
3
Q
A sentinel event refers to which situation?
a. An event that could have harmed a patient, but serious harm didn’t occur because of chance
b. An event that harms a patient as a result of underlying disease or condition
c. An event that harms a patient by omission or commission, not an underlying disease or condition
d. An event that signals the need for immediate investigation and response
A
d. An event that signals the need for immediate investigation and response
A sentinel event is an unexpected occurrence involving death or serious physical injury.
4
Q
The nurse is caring for a patient experiencing an allergic reaction to a bee sting with an order for diphenhydramine (Benadryl). The only medication in the patient’s medication bin is labeled BenaZEPRIL. The nurse contacts the pharmacy for the correct medication to avoid what type of error?
a. Communication
b. Diagnostic
c. Preventive
d. Treatment
A
d. Treatment
Treatment error occurs in the performance of an operation or procedure.
Communication error results from the failure to communicate.
Diagnostic error results from a delay in diagnosis.
Preventive error occurs due to inadequate monitoring.
5
Q
Which concepts should a nurse recognize have the strongest link to safety? (Select all that apply.)
Select all that apply.
a. Regulation
b. Teamwork
c. Communication
d. Cognition
e. Quality
A
a. Regulation
b. Teamwork
c. Communication
e. Quality
6
Q
The nurse is providing discharge instructions on ways to prevent falls at home. Which of the following guidelines are helpful in preventing falls? (Select all that apply.)
a. Always wear socks when walking to protect your feet when ambulating.
b. Remove rugs that can slip; use rubber mats instead.
c. Use your walker or cane even if only moving short distances.
d. Use lightweight, easily moveable chairs to assist with mobility.
e. Put frequently used items in easy-to-reach places.
f. Use handrails when available.
A
b. Remove rugs that can slip; use rubber mats instead.
c. Use your walker or cane even if only moving short distances.
e. Put frequently used items in easy-to-reach places.
f. Use handrails when available.
7
Q
A nurse administers an incorrect medication to a patient. In reviewing this medication error, the nurse finds out that incorrect medication was placed in the Pyxis system. What type of error has the nurse committed?
a. Latent error
b. Blunt end
c. Did not follow nursing process
d. Latent error resulting in active error
A
d. Latent error resulting in active error
Latent error aka blunt end vs Active error aka sharp end.
8
Q
Prior to drug administration the nurse reviews the seven rights, which include right patient, right medication, right time, right
dose, right education, right documentation, and what other right?
a. Room
b. Route
c. Physician
d. Manufacturer
A
b. Route
9
Q
Which nursing action indicates that a nurse is more likely to incur a medication error during medication administration?
a. Checks the original medication order on the patient’s chart
b. Asks the patient to state his/her name and date of birth
c. Does not scan the barcode of the patient prior to administering the medication
d. Does not provide the patient with a glass of water
A
c. Does not scan the barcode of the patient prior to administering the medication
10
Q
To promote safety, the nurse manager sensitive to point of care (sharp end) and systems level (blunt end) exemplars works
closely with staff to address which point of care exemplar?
a. Care coordination
b. Documentation
c. Electronic records
d. Fall prevention
A
d. Fall Prevention
11
Q
Aspects of safety culture that contribute to a culture of safety in a healthcare organization include which component?
a. Communication
b. Fear of punishment
c. Malpractice implications
d. Team nursing
A
a. Communication
12
Q
A staff nurse reports a medication error due to failure to administer a medication at the scheduled time. What is the charge
nurse’s best response?
a. “We’ll conduct a root cause analysis.”
b. “That means you’ll have to do continuing education.”
c. “Why did you let that happen?”
d. “You’ll need to tell the patient and family.”
A
a. “We’ll conduct a root cause analysis.”
13
Q
- To promote a culture of safety, the nurse manager preparing the staff schedule considers the anticipated census in planning the number and experience of staff on any given shift. Which is the human factor primarily addressed with this consideration?
a. Available supplies
b. Interdisciplinary communication
c. Interruptions in work
d. Workload fluctuations
A
d. Workload fluctuations
14
Q
Quality and Safety Education for Nurses (QSEN) includes 3 elements:
A
Attitude, Knowledge, and Skill
15
Q
The nurse knows changes in which body system affect overall mobility increasing the propensity of falling?
a. Neurologic
b. Hepatic
c. Cardiopulmonary
d. Musculoskeletal
A
d. Musculoskeletal
Impaired mobility through range of motion.
16
Q
The nurse is visiting a patient with cardiac disease who has been experiencing increased episodes of shortness of breath when
exercise is attempted. The nurse is concerned that the patient’s decrease in activity may lead to which outcome?
a. Orthostatic hypotension
b. Increase risk of heart disease
c. Loss of short-term memory
d. Worsening shortness of breath
A
a. Orthostatic hypotension
Orthostatic hypotension: drop in BP with position changes
17
Q
The nurse recognizes conversations about safe sexual practices, including the consequences of unprotected sex such as pregnancy and sexually transmitted infections, are important to begin in what patient population?
a. Adults
b. School-aged children
c. Adolescents
d. Older adults
A
c. Adolescents
18
Q
The nurse manager is developing a training guide and identifies which organization that is the best for resources to help develop
guidelines to prevent exposure to hazardous situations and decrease the risk of injury in the workplace?
a. OSHA (Occupational Safety and Health Administration)
b. CDC (Centers for Disease Control and Prevention)
c. QSEN (Quality and Safety Education for Nurses)
d. NIOSH (National Institute for Occupational Safety and Health)
A
a. OSHA (Occupational Safety and Health Administration)
19
Q
The nurse recognizes that a patient is using a portable generator in the house as a power source. What source of poisoning does the
nurse appropriately identify?
a. Lead
b. Carbon monoxide
c. Antifreeze
d. Pesticide
A
b. Carbon monoxide
20
Q
The nurse is educating the patient about the proper disposal of medications in the home. Which statement by the patient indicates a
good understanding of the information?
a. “Remove the label from the bottle and throw in the trash.”
b. “Flush the medication down the disposal.”
c. “Mix the medications with kitty litter, place the mixture in a jar, and put the jar in the trash.”
d. “Dissolve the medication in water and pour down the drain.”
A
c. “Mix the medications with kitty litter, place the mixture in a jar, and put the jar in the trash.”
21
Q
The nurse knows that which patient has a teaching need based on statements by the patient’s parents?
a. “My 6-month-old daughter only sleeps with me when she’s ill.”
b. “I do not put pillows in the bed with my 3-month-old son.”
c. “I do not feed popcorn to my 2-year-old.”
d. “I have discussed the risks of the ‘choking game’ with my 16-year-old.”
A
a. “My 6-month-old daughter only sleeps with me when she’s ill.”
Small children should never sleep with parents due to risk of suffocation.
22
Q
The nurse is teaching a student nurse about restraint use in patients. Which statement by the student nurse indicates a learning need
regarding restraints?
a. “Having all four side rails up on the bed is considered a restraint.”
b. “The use of restraints has been shown to decrease fall-related injuries.”
c. “Death has been associated with the use of restraints.”
d. “Medications administered to control behavior are considered a chemical
restraint.”
A
b. “The use of restraints has been shown to decrease fall-related injuries.”
23
Q
The nurse displays an understanding of high-risk populations for MRSA when identifying which group as the lowest risk?
a. Prison inmates
b. College dorm residents
c. Team athletes
d. Food service workers
A
d. Food service workers
24
Q
The nurse knows that which assessment tool is not used to assess fall risk?
a. Glasgow Falls Scale
b. Johns Hopkins Hospital Fall Assessment Tool
c. Morse Fall Scale
d. Hendrich II Fall Risk Model
A
a. Glasgow Falls Scale
Glasgow is a coma scale used to measure level of consciousness.
25
The patient has a nursing diagnosis of Risk for Falls. The nurse identifies which goal to be most important?
a. Patient will ambulate twice a day.
b. Patient will have no symptoms of infection.
c. Patient will perform activities of daily living.
d. Patient will have no injuries during hospital stay.
d. Patient will have no injuries during hospital stay.
26
Which collaborative team member would be most effective in assisting the nurse to identify medication alternatives that are less
likely to cause drowsiness and dizziness to reduce the risk of falls in the elderly patient?
a. Nursing case manager
b. Charge nurse
c. Physical therapist
d. Pharmacist
d. Pharmacist
27
The nurse is concerned about helping the patient find resources to obtain assistive equipment to be used in the home. Which team member should the nurse contact first?
a. Occupational therapist
b. Physical therapist
c. Health care provider
d. Social worker
d. Social worker
28
Which statement by the patient indicates to the nurse a teaching need regarding safety in the home?
a. “I will put a night light in every room.”
b. “I will not use an extension cord to plug in multiple items.”
c. “I will wash my throw rugs in the bathroom regularly.”
d. “I will keep all cleaning supplies out of reach of children.”
c. “I will wash my throw rugs in the bathroom regularly.”
Throw rugs present fall or trip hazard.
29
The ER nurse is triaging a patient with suspected poisoning. Who should the nurse anticipate contacting first?
a. Family services
b. Radiology
c. Poison Control Center
d. Respiratory
c. Poison Control Center
30
The staff nurse knows that many health care facilities use the fire emergency response defined by which acronym?
a. RACE
b. PASS
c. PACE
d. QSEN
a. RACE
Rescue, Alarm, Contain, and Extinguish
31
The nurse is ambulating a patient back from the bathroom when the patient begins to have a seizure. Which action should the nurse
do first?
a. Lower the patient to the floor if standing.
b. Move sharp or hard objects away from the patient.
c. Turn the patient’s head to the side to prevent aspiration.
d. Attempt to place a tongue blade to prevent choking.
a. Lower the patient to the floor if standing.
During a seizure, a patient should be protected from injury by first lowering the patient to the ground if standing.
32
The nurse is caring for a confused, combative patient. Which action would be considered last by the nurse to control the behavior of the client?
a. Orient the patient frequently.
b. Apply restraints.
c. Move the patient to a room close to the nurse’s station.
d. Encourage the family to spend time with the patient.
b. Apply restraints.
33
The nurse knows which method to be an appropriate way to tie restraints?
a. Knot tied to the bed frame
b. Quick-release knot tied to the side rail
c. Bow tied to the bed rail
d. Quick-release ties attached to the bed frame
d. Quick-release ties attached to the bed frame
34
Which statement by the nurse correctly identifies the UAP role in patient restraint use?
a. “The UAP can perform initial assessment.”
b. “The UAP can apply a restraint.”
c. “The UAP can assist with applying and monitoring of a physical restraint.”
d. “The UAP can contact the health care provider and request an order for
restraints.”
c. “The UAP can assist with applying and monitoring of a physical restraint.”
35
The nurse is explaining the National Patient Safety Goals (NPSG) to the student nurse. Which answers indicate that the student has
a good understanding of these goals? (Select all that apply.)
a. The NPSG’s focus on treating chronic infections quickly
b. The NPGS’s focus on improving staff communication
c. The NPGS’s focus on using medications safely
d. The NPGS’s focus on identifying patients correctly
b. The NPGS’s focus on improving staff communication
c. The NPGS’s focus on using medications safely
d. The NPGS’s focus on identifying patients correctly
36
The nurse is providing education to a cardiac patient who has multiple life stressors that are impacting the patient’s health. Which
statements by the patient indicate a good understanding of actions that can be taken to reduce stressors? (Select all that apply.)
a. “I should change my job.”
b. “I should plan some downtime.”
c. “I should meet with a financial counselor.”
d. “I should talk with my family about my situation.”
e. “I should make my family go to counseling with me.”
b. “I should plan some downtime.”
c. “I should meet with a financial counselor.”
d. “I should talk with my family about my situation.”
37
The nurse is providing education to a community group on environmental safety. Which safety measures are effective in improving their environmental safety? (Select all that apply.)
a. Use of night-lights throughout the home
b. Illumination of stairwells and pathways
c. Installation of motion-activated lighting on the exterior of the home
d. Application of wax to all floors to increase shine
e. Staying indoors when air pollution is high
a. Use of night-lights throughout the home
b. Illumination of stairwells and pathways
c. Installation of motion-activated lighting on the exterior of the home
e. Staying indoors when air pollution is high
38
The nurse makes a medication error. Which action will the nurse take first?
a. Prepare an incident report.
b. Explain to the patient that a medication error has occurred.
c. Assess the patient for any adverse reactions.
d. Document the medication given, the response, and corrective actions taken.
c. Assess the patient for any adverse reactions.
39
The nurse is assessing a patient’s functional ability. Which patient best demonstrates the definition of functional ability?
a. Considers self as a healthy individual; uses a cane for stability
b. College-educated; travels frequently; can balance a checkbook
c. Works out daily, reads well, cooks, and cleans house on the weekends
d. Healthy individual, volunteers at church, works part-time, takes care of family and
house
d. Healthy individual, volunteers at church, works part-time, takes care of family and
house
Functional ability refers to the individual’s ability to perform the normal daily activities required to meet basic needs; fulfill usual
roles in the family, workplace, and community; and maintain health and well-being.
40
The nurse is assessing a patient’s functional performance. What assessment parameters will be most important in this assessment?
a. Continence assessment, gait assessment, feeding assessment, dressing assessment,
transfer assessment
b. Height, weight, body mass index (BMI), vital signs assessment
c. Sleep assessment, energy assessment, memory assessment, concentration
assessment
d. Health and well-being, amount of community volunteer time, working outside the
home, and ability to care for family and house
a. Continence assessment, gait assessment, feeding assessment, dressing assessment,
transfer assessment
41
The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patient’s functional ability. What questions would be the most appropriate?
a. “Are you able to shop for yourself?”
b. “Do you use a cane, walker, or wheelchair to ambulate?”
c. “Do you know what today’s date is?”
d. “Were you sad or depressed more than once in the last 3 days?”
b. “Do you use a cane, walker, or wheelchair to ambulate?”
This statement will assist the nurse in determining the patient’s ability to perform
self-care activities.
42
The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney Model of Nursing for a patient who is
currently unconscious. Which interventions would be most critical to developing a plan of care for this patient?
a. Eating and drinking, personal cleansing and dressing, working and playing
b. Toileting, transferring, dressing, and bathing activities
c. Sleeping, expressing sexuality, socializing with peers
d. Maintaining a safe environment, breathing, maintaining temperature
d. Maintaining a safe environment, breathing, maintaining temperature
43
The home care nurse is trying to determine the necessary services for a 65-year-old patient who was admitted to the home care
service after left knee replacement. Which tool is the best for the nurse to utilize?
a. Minimum Data Set (MDS)
b. Functional Status Scale (FSS)
c. 24-Hour Functional Ability Questionnaire (24hFAQ)
d. The Edmonton Functional Assessment Tool
c. 24-Hour Functional Ability Questionnaire (24hFAQ)
44
The nurse is assessing a patient’s functional abilities and asks the patient, “How would you rate your ability to prepare a balanced
meal?” “How would you rate your ability to balance a checkbook?” “How would you rate your ability to keep track of your
appointments?” Which tool would be indicated for the best results of this patient’s perception of their abilities?
a. Functional Activities Questionnaire (FAQ)™
b. Mini Mental Status Exam (MMSE)
c. 24hFAQ
d. Performance-based functional measurement
a. Functional Activities Questionnaire (FAQ)™
45
A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is assessing the patient’s risk for falls so that falls prevention can be implemented if necessary. Select all the risk factors that apply from this patient's history and physical.
(Select all that apply.)
a. Being a woman
b. Taking more than six medications
c. Having hypertension
d. Having cataracts
e. Muscle strength 3/5 bilaterally
f. Incontinence
b. Taking more than six medications
d. Having cataracts
e. Muscle strength 3/5 bilaterally
f. Incontinence
46
The family of a patient who was in a motor vehicle accident tells the nurse “I’m just not the person I was before the crash.” The
nurse recognizes this is likely because of the injury to what area of brain?
a. Parietal lobes
b. Frontal lobes
c. Occipital lobes
d. Temporal lobes
b. Frontal lobes
The frontal lobes of the cerebrum are the areas of the brain responsible for voluntary motor function, concentration, communication, decision-making, and personality.
47
The nurse is educating the family of a patient in the intensive care unit about the patient’s cognitive status, including the current
problem of delirium. Which statement by the family indicates a need for further education?
a. “The delirium can be caused by sensory overload.”
b. “The delirium is reversible.”
c. “The delirium is a mood disorder.”
d. “The delirium is a state of confusion.”
c. “The delirium is a mood disorder.”
48
The nurse is caring for a patient with depression. Which statement by the patient indicates a need for further education?
a. “Depression can be caused by chemical changes in the brain.”
b. “Depression is always treated with medication.”
c. “Depression is a mood disorder.”
d. “Depression can have a rapid onset.”
b. “Depression is always treated with medication.”
49
The nurse is caring for a patient who is complaining of tingling in the hands and fingers. The nurse knows this is a sign of what
electrolyte imbalance?
a. Hyponatremia
b. Hypernatremia
c. Hypocalcemia
d. Hypercalcemia
c. Hypocalcemia
50
The nurse is providing discharge instructions to an older adult who is being discharged with orthostatic hypotension. Which response by the patient indicates a need for further education?
a. “I should take my blood pressure once a day at home.”
b. “I should get up quickly to avoid my blood pressure dropping.”
c. “I should drink plenty of water during the day.”
d. “I should get up slowly and carefully.”
b. “I should get up quickly to avoid my blood pressure dropping.”
51
The nurse is assessing the patient’s ability to hear and knows which is the correct procedure for doing this.
a. The nurse whispers to the patient while standing on each side of the patient.
b. The nurse speaks in a normal voice while standing on each side of the patient.
c. The nurse speaks in a normal voice while standing directly in front of the patient.
d. The nurse speaks in a normal voice while standing slightly behind the patient.
d. The nurse speaks in a normal voice while standing slightly behind the patient.
52
The nurse notices her 50-year-old patient is holding the lunch menu at arm’s length while trying to read the choices. The nurse
knows this is an indication of which condition?
a. Retinopathy
b. Presbyopia
c. Cataracts
d. Macular degeneration
b. Presbyopia
53
The nurse is providing discharge education to the patient with diabetes regarding foot care. Which statement by the patient
indicates a need for further education?
a. “I can go barefoot outside only in the summer.”
b. “I should wear good fitting shoes.”
c. “I cannot soak my feet in a hot tub.”
d. “I can use lotion on my feet.”
a. “I can go barefoot outside only in the summer.”
54
The nurse identifies which goal to be most appropriate for the Nursing diagnosis of acute confusion?
a. The patient will use the call light before getting out of bed within 48 hours.
b. The patient will use a calendar to remember the date within 48 hours.
c. The patient will respond appropriately to questions about place within 48 hours.
d. The patient will remain within the unit while in long-term care.
c. The patient will respond appropriately to questions about place within 48 hours.
55
The nurse recognizes which goal to be appropriate for the patient with a Nursing diagnosis of social isolation?
a. The patient will participate in cognitive exercises.
b. The patient will interact with other residents during activities.
c. The patient will communicate basic needs through use of photos.
d. The patient will remain within the unit while in long-term care.
b. The patient will interact with other residents during activities.
56
The nurse is educating the family to care for a patient at home with cognitive alterations. Which statement by the family indicates a
need for further education?
a. “I should keep the home free of scissors.”
b. “I should minimize the number of visitors.”
c. “I should use push-button door locks.”
d. “24-hour supervision may become necessary.”
c. “I should use push-button door locks.”
57
The nurse is delegating care to an unlicensed assistive personnel (UAP) to a patient who has sensory overload. Which statement by
the UAP indicates a need for further orientation?
a. “I should keep the noise levels low.”
b. “I should schedule all the care together.”
c. “I should keep the room well lit.”
d. “I should allow the family to visit.”
c. “I should keep the room well lit.”
58
The nurse is providing discharge instructions to a patient with visual alterations. Which statement by the patient indicates a need
for further education?
a. “I should make sure the passageways are wide.”
b. “I should remove all the throw rugs.”
c. “I should keep the lights dim.”
d. “I can use a cane to feel for objects in front of me.”
c. “I should keep the lights dim.”
59
The nurse is completing an assessment of an older adult and notices some cognitive impairment not normally associated with aging.
Which of these alterations would prompt further follow-up? (Select all that apply.)
a. The patient does not remember where her son lives.
b. The patient is unable to balance her checkbook.
c. The patient got lost in a city she never traveled to before.
d. The patient often has difficulty remembering words.
e. The patient got lost going to her usual grocery store.
a. The patient does not remember where her son lives.
b. The patient is unable to balance her checkbook.
d. The patient often has difficulty remembering words.
e. The patient got lost going to her usual grocery store.
60
The nurse is providing education to the family of a patient being discharged with dementia. Which statement by the family
indicates an appropriate level of understanding of dementia? (Select all that apply.)
a. “The condition is permanent and has an acute onset.”
b. “Alzheimer is the most common type of dementia.”
c. “The condition worsens over time.”
d. “I should observe for wandering behavior.”
e. “Agitation can be worse in the evening.”
b. “Alzheimer is the most common type of dementia.”
c. “The condition worsens over time.”
d. “I should observe for wandering behavior.”
e. “Agitation can be worse in the evening.”
61
The nurse is caring for a patient who suffered a stroke on the right side of the brain. The nurse is careful to implement what safety
measures? (Select all that apply.)
a. Puts a picture board in the room to communicate with the patient.
b. Places the call light on the patient’s left side.
c. Leaves a light on in the bathroom at night for good visibility.
d. Places the call light on the patient’s right side.
e. Makes sure there are no trip hazards in the patient’s room.
c. Leaves a light on in the bathroom at night for good visibility.
d. Places the call light on the patient’s right side.
e. Makes sure there are no trip hazards in the patient’s room.
62
The nurse is performing a health history to determine the patient’s cognitive status. Which questions will be best suited to elicit the information needed? (Select all that apply.)
a. “Are you able to drive to the store or do errands?”
b. “Do you have any pain?”
c. “Is your vision blurry?”
d. “Are you able to smell different foods?”
e. “Have you noticed any difficulty adding up numbers?”
a. “Are you able to drive to the store or do errands?”
e. “Have you noticed any difficulty adding up numbers?”
63
The nurse is performing a health history to determine the patient’s sensory status. Which questions will be best suited to elicit the
information needed? (Select all that apply.)
a. “Do you ever lose your balance?”
b. “Do you wear glasses?”
c. “Do you like to read the newspaper?”
d. “Can you feel the difference between hot and cold water?”
e. “Do you wear a hearing aid?"
a. “Do you ever lose your balance?”
b. “Do you wear glasses?”
d. “Can you feel the difference between hot and cold water?”
e. “Do you wear a hearing aid?"
64
The nurse is caring for a diabetic patient who has had a long history of poor glucose control. For what complications is the patient
at risk? (Select all that apply.)
a. Sudden loss of consciousness
b. Diabetic retinopathy
c. Stroke
d. Peripheral neuropathy
e. Memory loss
b. Diabetic retinopathy
c. Stroke
d. Peripheral neuropathy
e. Memory loss
65
The nurse is caring for a patient who is hospitalized with cognitive impairment and recognizes which interventions will assist the
patient in orientation? (Select all that apply.)
a. Keep a photo of the family in the room.
b. Use a clock on the wall.
c. Make sure the room is kept bright and well lit.
d. Avoid moving the patient from room to room.
e. Have each nurse introduce himself or herself to the patient
a. Keep a photo of the family in the room.
b. Use a clock on the wall.
d. Avoid moving the patient from room to room.
e. Have each nurse introduce himself or herself to the patient
66
The nurse is caring for a patient with expressive aphasia. Which interventions will assist the nurse in communicating with the
patient? (Select all that apply.)
a. Use simple phrases.
b. Speak loudly.
c. Use yes/no questions.
d. Use a picture board.
e. Be patient and unrushed.
c. Use yes/no questions.
d. Use a picture board.
e. Be patient and unrushed.
67
The nurse is preparing discharge instructions for a patient who has tactile alterations in his legs. Which instructions would be
included? (Select all that apply.)
a. Verify bath water temperature is approximately 39.5 °C.
b. Do not use hot or cold therapy on any extremity.
c. Use sturdy shoes when walking outside or on hard surfaces.
d. Report any changes in skin color on your legs to your health care provider.
e. Set your water heater so that scalding is not possible.
c. Use sturdy shoes when walking outside or on hard surfaces.
d. Report any changes in skin color on your legs to your health care provider.
e. Set your water heater so that scalding is not possible.
68
The nurse is preparing discharge instructions for a patient who has equilibrium alterations. Which instructions will the nurse
include? (Select all that apply.)
a. Use grab bars in the tub and/or shower at home.
b. Keep rooms well-lit and focus ahead when walking.
c. Change positions quickly to avoid dizziness.
d. Use a cane or walker for stability.
e. Ride in the back seat of the car and look ahead.
a. Use grab bars in the tub and/or shower at home.
b. Keep rooms well-lit and focus ahead when walking.
d. Use a cane or walker for stability.
69
The nurse would identify which patient condition as a problem of impaired gas exchange secondary to a perfusion problem?
a. Peripheral arterial disease of the lower extremities
b. Chronic obstructive pulmonary disease (COPD)
c. Chronic asthma
d. Severe anemia secondary to chemotherapy
a. Peripheral arterial disease of the lower extremities
70
The nurse is assessing a patient’s differential white blood cell count. What implications would this test have on evaluating the
adequacy of a patient’s gas exchange?
a. An elevation of the total white cell count indicates generalized inflammation.
b. Eosinophil count will assist to identify the presence of a respiratory infection.
c. White cell count will differentiate types of respiratory bacteria.
d. Level of neutrophils provides guidelines to monitor a chronic infection.
a. An elevation of the total white cell count indicates generalized inflammation.
71
The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis?
a. Chronic lung disease with increased carbon dioxide retention
b. Acute anxiety, hyperventilation, and decreased carbon dioxide retention
c. Decreased cardiac output with increased serum lactic acid production
d. Gastric drainage with increased removal of gastric acid
a. Chronic lung disease with increased carbon dioxide retention
72
A 3-month-old infant is at increased risk for developing anemia. The nurse would identify which principle contributing to this risk?
a. The infant is becoming more active.
b. There is an increase in intake of breast milk or formula.
c. The infant is unable to maintain an adequate iron intake.
d. A depletion of fetal hemoglobin occurs.
d. A depletion of fetal hemoglobin occurs.
73
Which clinical management prevention concept would the nurse identify as representative of secondary prevention?
a. Decreasing venous stasis and risk for pulmonary emboli
b. Implementation of strict hand washing routines
c. Maintaining current vaccination schedules
d. Prevention of pneumonia in patients with chronic lung disease
d. Prevention of pneumonia in patients with chronic lung disease
74
The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.)
a. Neurologic system
b. Endocrine system
c. Pulmonary system
d. Immune system
e. Cardiovascular system
f. Hepatic system
a. Neurologic system
c. Pulmonary system
e. Cardiovascular system
75
The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good
ventilation? (Select all that apply.)
a. Respiratory rate is 24 breaths/min.
b. Oxygen saturation level is 98%.
c. The right side of the thorax expands slightly more than the left.
d. Trachea is just to the left of the sternal notch.
e. Nail beds are pink with good capillary refill.
f. There is presence of quiet, effortless breath sounds at lung base bilaterally.
b. Oxygen saturation level is 98%.
e. Nail beds are pink with good capillary refill.
f. There is presence of quiet, effortless breath sounds at lung base bilaterally.
76
The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which oxygen delivery device will the nurse
use for this patient?
a. Non-rebreather mask
b. Bag-valve-mask unit
c. Continuous positive airway pressure (CPAP)
d. High-flow nasal cannula
b. Bag-valve-mask unit
77
The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient is breathing spontaneously but is minimally responsive and having difficulty maintaining a patent airway. Which intervention is the most appropriate for the patient to improve oxygenation?
a. Insert an oral airway.
b. Lower the head of the bed.
c. Turn the patient’s head to the side.
d. Monitor the patient’s pulse oximetry.
a. Insert an oral airway.
78
The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient’s pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of the nurse?
a. Administer the ordered intravenous diuretic.
b. Prepare for insertion of a chest tube.
c. Suction secretions from the patient’s respiratory tract.
d. Have the patient use the ordered incentive spirometer.
a. Administer the ordered intravenous diuretic.
79
The nurse is caring for a patient who has been intubated with an oral endotracheal tube for several weeks. The physicians predict
that the patient will need to remain on a ventilator for at least several more weeks before he will be able to maintain his airway and breathe on his own. What procedure does the nurse anticipate will be planned for the patient to facilitate recovery?
a. Placement of a tracheostomy tube
b. Diagnostic thoracentesis
c. Pulmonary angiogram
d. Lung transplantation surgery
a. Placement of a tracheostomy tube
80
The nurse is caring for a patient with a chest tube who was transported to radiology for testing. When the patient returns to the
nursing unit, the transporter shows the nurse the patient’s chest tube collection device, which was badly damaged after being caught
in the elevator door. What is the priority action of the nurse?
a. Clamp the chest tube until the collection device is replaced.
b. Cover the insertion site with a new occlusive dressing.
c. Ensure that there is gentle bubbling in the water seal chamber.
d. Check the patient’s lung sounds and pulse oximetry.
a. Clamp the chest tube until the collection device is replaced.
81
The nurse is caring for a patient who is hospitalized for pneumonia. Which Nursing diagnosis has the highest priority?
a. Activity intolerance r/t generalized weakness and hypoxemia
b. Impaired nutritional intake r/t poor appetite and increased metabolic needs
c. Impaired airway clearance r/t thick secretions in trachea and bronchi
d. Lack of knowledge r/t use of nebulizer and inhaled bronchodilators
c. Impaired airway clearance r/t thick secretions in trachea and bronchi
82
The nurse is caring for a patient who developed a pulmonary embolism after surgery. Which goal statement is the highest priority for the nurse to include in the patient’s care plan for the diagnosis impaired gas exchange r/t impaired pulmonary blood flow from embolus?
a. The patient will maintain pulse oximetry values of at least 95% on room air.
b. The patient will verbalize understanding of ordered anticoagulants.
c. The patient will report chest pain of no greater than 3 on a 1 to 10 scale.
d. The patient will ambulate 50 feet in hallway without shortness of breath.
a. The patient will maintain pulse oximetry values of at least 95% on room air.
83
The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented. What is the priority
action of the nurse?
a. Obtain an arterial blood gas to check for carbon dioxide retention.
b. Increase the patient’s oxygen until the pulse oximetry is greater than 98%.
c. Lower the head of the patient’s bed and insert a nasal airway.
d. Administer a mild sedative and reorient the patient as needed.
a. Obtain an arterial blood gas to check for carbon dioxide retention.
84
The nurse is caring for a patient who has been prescribed warfarin (Coumadin) therapy after being diagnosed with atrial fibrillation.
The patient asks the nurse what could happen if the prescription doesn’t get filled. What is the nurse’s best response?
a. “You could have a stroke.”
b. “Your kidneys could fail.”
c. “You could develop heart failure.”
d. “You could go into respiratory failure.”
a. “You could have a stroke.”
85
The preceptor is working with a new nurse to provide care for a patient with a chest tub to relieve a pneumothorax. Which action
by the new nurse indicates need for additional teaching about chest tube care?
a. The suction is discontinued when the patient is ambulated to the bathroom.
b. The collection device is emptied at the end of the shift and output recorded in the
chart.
c. The patient’s bed is placed in the semi-Fowler’s position to facilitate lung
reexpansion.
d. The patient is encouraged to use his incentive spirometer at least 10 times every
hour.
b. The collection device is emptied at the end of the shift and output recorded in the
chart.
86
The nurse is caring for a postoperative patient who has just been diagnosed with a deep vein thrombosis (DVT) in the right leg.
Which focused assessment question has the highest priority for this patient?
a. “Do you have a headache or any dizziness?”
b. “Do you have any chest pain or shortness of breath?”
c. “When did you first notice the swelling and redness in your leg?”
d. “Do you have any cramping or muscle spasms in your leg?
b. “Do you have any chest pain or shortness of breath?”
87
The nurse identifies which patient who would benefit from postural drainage?
a. A patient with a heart murmur and jugular venous distention
b. A patient with asthma and audible wheezing
c. A patient with right-sided heart failure and pitting edema
d. A patient with chronic bronchitis and congested cough
d. A patient with chronic bronchitis and congested cough
88
The nurse is caring for a patient who has presented to the ER with chest pain. Which diagnostic test will best indicate if there is
significant blockage of important blood vessels that provide oxygen to the heart muscle?
a. Cardiac catheterization
b. Chest x-ray
c. Echocardiogram
d. Electrocardiogram
a. Cardiac catheterization
89
The nurse hears a loud murmur when listening to the patient’s heart. Which diagnostic test will best display the condition of the
valves and structures within the patient’s heart that could be causing the murmur?
a. Chest x-ray
b. Cardiac catheterization
c. Echocardiogram
d. Electrocardiogram
c. Echocardiogram
90
The nurse is caring for a patient who will be returning to the nursing unit following a cardiac catheterization via the right femoral
artery. Which assessment is the highest priority for the nurse to perform when the patient arrives on the unit?
a. Checking the patient’s right pedal pulse and warmth of the right leg
b. Checking pulse oximetry and listening to the patient’s lung sounds
c. Checking bilateral radial pulses to check for a pulse deficit
d. Estimating the patient’s jugular venous pressure
a. Checking the patient’s right pedal pulse and warmth of the right leg
91
The home care nurse is caring for a patient who has severe COPD and home oxygen therapy. The patent tells the nurse that she
feels much better after increasing the oxygen flowmeter from 2 L to 5 L/min. The patient’s pulse oximetry is 98%. What is the
priority action of the nurse?
a. Reduce the oxygen flow rate until the patient’s pulse oximetry value is more than
90%.
b. Inform the patient’s physician and obtain an order for oxygen at 5 L/min.
c. Document the intervention and findings in the patient’s medical record.
d. Listen to the patient’s lung fields and reinforce pursed-lip breathing techniques
a. Reduce the oxygen flow rate until the patient’s pulse oximetry value is more than 90%.
92
The nurse is caring for a patient with advanced COPD who reports feeling short of breath. The nurse notes that the patient’s lung
sounds are diminished bilaterally and the patient’s pulse oximetry is 91% on 2 L/min oxygen via nasal cannula. What actions will
the nurse take to make the patient more comfortable? (Select all that apply.)
a. Increase the patient’s oxygen to 4 L/min via nasal cannula.
b. Suction the patient’s airway using sterile technique.
c. Maintain eye contact and provide calm reassurance.
d. Turn the patient onto the side for postural drainage.
e. Administer the ordered nebulized bronchodilator.
f. Elevate the head of the patient’s bed to fully upright.
c. Maintain eye contact and provide calm reassurance.
e. Administer the ordered nebulized bronchodilator.
f. Elevate the head of the patient’s bed to fully upright.
93
The nurse is performing a respiratory assessment on a patient. Which assessment findings indicate to the nurse that the patient has a history of long-standing chronic respiratory disease? (Select all that apply.)
a. All the patient’s fingernails are noticeably clubbed.
b. The patient needs to sleep on at least four to five pillows at night.
c. The patient’s chest has equal antero-posterior and transverse diameters.
d. The patient’s lower legs have large areas of brownish spotted discoloration.
e. The patient reports puffiness of both feet when standing for long periods.
f. The patient’s forced vital capacity test result is 3.8 L of air
a. All the patient’s fingernails are noticeably clubbed.
b. The patient needs to sleep on at least four to five pillows at night.
c. The patient’s chest has equal antero-posterior and transverse diameters.
94
The nurse notes the following findings when assessing a patient with COPD. Which require prompt nursing intervention? (Select
all that apply.)
a. The patient is unable to speak without gasping.
b. The patient’s fingernails are noticeably clubbed.
c. The patient’s sputum has turned from yellow to greenish-brown.
d. The patient has stridor with wheezes heard in all lung fields.
e. The patient’s forced vital capacity has increased from 2.8 to 3.4 L.
f. The patient has become confused and mildly disoriented.
a. The patient is unable to speak without gasping.
c. The patient’s sputum has turned from yellow to greenish-brown.
d. The patient has stridor with wheezes heard in all lung fields.
f. The patient has become confused and mildly disoriented.
95
The nurse is working with a nursing assistant to care for a patient with a new tracheostomy. Which tasks may the nurse delegate to
the assistant? (Select all that apply.)
a. Obtaining masks, gloves, and suction supplies from the utility room
b. Helping to reassure the patient before, during, and after suctioning
c. Changing the Velcro or twill ties used to secure the tracheostomy
d. Transporting sputum specimens to the lab for culture and sensitivity testing
e. Assessing need for suctioning of the oropharynx or tracheostomy
f. Teaching the patient how to remove and clean the inner cannula
a. Obtaining masks, gloves, and suction supplies from the utility room
b. Helping to reassure the patient before, during, and after suctioning
d. Transporting sputum specimens to the lab for culture and sensitivity testing
