Week 12 Sherpath Flashcards
Which findings would prompt the nurse to perform a focused cardiopulmonary assessment?
Select all that apply.
Medical history of a cardiovascular problem
Medical history of a respiratory problem
Signs and symptoms of decreased oxygenation
Signs and symptoms of activity intolerance
Signs and symptoms of increased peripheral perfusion
Medical history of a cardiovascular problem
Medical history of a respiratory problem
Signs and symptoms of decreased oxygenation
Signs and symptoms of activity intolerance
Which questions would the nurse include during the patient interview of a focused respiratory health assessment?
Select all that apply.
Have you ever smoked?
Have you had recent weight gain?
Do you use oxygen at home?
Do you have difficulty clearing secretions?
Do you have a cough? For how long?
Have you ever smoked?
Do you use oxygen at home?
Do you have difficulty clearing secretions?
Do you have a cough? For how long?
Which peripheral vascular assessment would the nurse perform when admitting a patient with impaired cardiac function?
Auscultating breath sounds
Auscultating an apical pulse
Inspecting skin color in the extremities
Measuring the chest for expansion
Inspecting skin color in the extremities
Which set of values would the nurse review to determine whether heart muscle injury has occurred?
Complete blood count (CBC) with differential
Lipid panel
Basic metabolic panel
Cardiac enzymes
Cardiac enzymes
Which information would the nurse expect to obtain from a chest x-ray prescribed for a patient with a cough and shortness of breath?
Select all that apply.
Hypoxia from diminished lung function
Areas of increased lung tissue density
Impaired electrical activity in the heart
Size of the heart
Atherosclerosis in heart blood vessels
Areas of increased lung tissue density
Size of the heart
Which health problem risk would be evaluated by obtaining a lipid panel?
Cardiac injury
Atherosclerosis
Fluid around heart
Blood electrolyte imbalances
Atherosclerosis
Match the pulmonary function test (PFT) with the measured element.
Air volume expelled with lungs maximally inflated
Air volume expelled in 1 second from start of FVC
Air volume left in lungs after forced expiration
Air volume left in lungs after normal expiration
Maximal flow rate in the middle of FVC maneuver
Answer choices
Functional residual capacity (FRC)
Residual volume (RV)
Forced vital capacity (FVC)
Forced expiratory flow (FEF)
Forced expiratory volume in 1 second (FEV1)
Air volume expelled with lungs maximally inflated
Forced vital capacity (FVC)
Air volume expelled in 1 second from start of FVC
Forced expiratory volume in 1 second (FEV1)
Air volume left in lungs after forced expiration
Residual volume (RV)
Air volume left in lungs after normal expiration
Functional residual capacity (FRC)
Maximal flow rate in the middle of FVC maneuver
Forced expiratory flow (FEF)
Which cues would the nurse expect to find in a patient with an inability to effectively pump blood to the tissues?
Select all that apply.
Dyspnea with exertion
Fatigue
Lower extremity edema
Crushing chest pain
Nausea and vomiting
Dyspnea with exertion
Fatigue
Lower extremity edema
Which condition would the nurse suspect in a postsurgical patient who is experiencing dyspnea with decreased breath sounds?
Chronic obstructive pulmonary disease (COPD)
Asthma
Atelectasis
Heart failure
Atelectasis
Which cues would the nurse expect in a patient with hypoxic myocardial tissue?
Select all that apply.
Fever
Dyspnea
Vomiting
Chest pain
Diaphoresis
Dyspnea
Vomiting
Chest pain
Diaphoresis
Which data would be obtained by the nurse preparing to perform a cough assessment on a patient with a respiratory disorder?
Sputum characteristics
Pulse oximetry
Capillary refill
Respiratory rate
Sputum characteristics
Which questions would the nurse include during the patient interview of a focused cardiovascular health assessment?
Select all that apply.
Are you having chest pain?
Have you had recent weight gain?
What type of work do you do?
How many pillows do you sleep with?
Do you ever experience dizziness?
Are you having chest pain?
Have you had recent weight gain?
How many pillows do you sleep with?
Do you ever experience dizziness?
Which questions would the nurse include as part of a focused respiratory health assessment?
Have you ever been exposed to hazardous materials at work?
Have you had recent weight gain?
Have you ever lost consciousness?
Do you take medications to prevent blood clots?
Have you ever been exposed to hazardous materials at work?
Which information would the nurse be aware of when using cardiac enzyme measurements for assessment of myocardial infarction?
Select all that apply.
They are released when death of cardiac cells occurs.
Elevated serum levels suggest cardiac damage.
There are “good” and “bad” types of cardiac enzymes.
Alterations in enzyme types may indicate infection.
Abnormally low levels are seen with decreased oxygenation.
They are released when death of cardiac cells occurs.
Elevated serum levels suggest cardiac damage.
The complete blood count results for a patient with chronic obstructive pulmonary disease (COPD) show an elevated red blood cell count. Which clinical manifestation would the nurse associate with this finding?
Hyperlipidemia
Hypoxia
Infection
Hemodilution
Hypoxia
When assessing a patient with low hemoglobin, the nurse looks for symptoms of fluid retention, understanding that the patient may have which condition?
Hemodilution
Hypoxia
Infection
Hyperlipidemia
Hemodilution
Which rationale explains why a patient with a recent myocardial infarction would have a basic metabolic panel drawn to monitor serum electrolytes?
Elevated levels increase the risk for atherosclerosis.
Abnormal levels can cause cardiac arrhythmias.
Reduced levels can result in decreased oxygen levels.
Normal levels suggest healing of muscle tissue.
Abnormal levels can cause cardiac arrhythmias.
Which assessment techniques would the nurse include when performing a physical assessment on a patient with an oxygenation problem?
Select all that apply.
Inspection
Palpation
Auscultation
Reflexes
Vital signs
Inspection
Palpation
Auscultation
Vital signs
Which major subjective symptom is associated with both chronic obstructive pulmonary disease (COPD) and pneumonia?
Dyspnea
Elevated arterial carbon dioxide level
Irregular heart rhythm
Chest pain
Dyspnea
Which objective data would the nurse focus on obtaining in a patient with signs of cardiac muscle hypoxia?
Select all that apply.
Chest pain
Dyspnea
Abnormal cardiac enzymes levels
Irregular heartbeat
Decreased breath sounds
Abnormal cardiac enzymes levels
Irregular heartbeat
Which postoperative complication can be prevented by regularly performing deep-breathing exercises?
Thrombus formation
Bronchospasm
Alveolar enlargement
Atelectasis
Atelectasis
Which delivery system would the nurse use when the health care provider prescribes a common low-flow system to deliver continuous oxygen at 2 L/min for a patient with pneumonia?
Nonrebreather mask
Bilevel positive airway pressure (BiPAP)
Nasal cannula
Ambu bag
Nasal cannula
Which alterations of oxygenation and perfusion may require supplemental oxygen therapy?
Select all that apply.
Increased respiratory rate
Decreased heart rate
Low oxygen saturation
Cyanosis
Elevated hemoglobin
Increased respiratory rate
Low oxygen saturation
Cyanosis
Match the type of oxygen mask to its description.
No reservoir bag; 1 L/min O2 ⇧ = ~5% O2 concentration ⇧
Reservoir bag present; room air is inspired with O2 delivered
Reservoir bag present; one-way valve prevents entry of exhaled air
No reservoir bag; ensures accuracy of O2 concentration; uses adaptors/dials
Answer choices
Nonrebreather mask
Simple face mask
Partial rebreather mask
Venturi mask
No reservoir bag; 1 L/min O2 ⇧ = ~5% O2 concentration ⇧
Simple face mask
Reservoir bag present; room air is inspired with O2 delivered
Partial rebreather mask
Reservoir bag present; one-way valve prevents entry of exhaled air
Nonrebreather mask
No reservoir bag; ensures accuracy of O2 concentration; uses adaptors/dials
Venturi mask
Which device would the nurse apply to a patient who has arrived unconscious and in respiratory arrest (is not breathing)?
Venturi mask
Ambu bag
Nasal cannula
Continuous positive airway pressure (CPAP) device
Ambu bag
Match the artificial airway tube with the correct situation.
Inserted in the patient’s nose to facilitate ease of suctioning
Inserted in mouth; maintains airway and breathing without ventilatory help
Inserted through the mouth for positive pressure mechanical ventilation
Inserted through trachea; provides ventilation when upper airway obstructed
Answer choices
Tracheostomy tube
Endotracheal tube
Oropharyngeal tube
Nasopharyngeal tube
Inserted in the patient’s nose to facilitate ease of suctioning
Nasopharyngeal tube
Inserted in mouth; maintains airway and breathing without ventilatory help
Oropharyngeal tube
Inserted through the mouth for positive pressure mechanical ventilation
Endotracheal tube
Inserted through trachea; provides ventilation when upper airway obstructed
Tracheostomy tube
Which guidelines would the nurse recall when inserting a nasopharyngeal tube?
Select all that apply.
The airway is inserted into the mouth over the tongue.
The length is measured from the tragus to the nostril plus 1 inch.
The airway is removed and changed at least every 24 hours.
Gentle to moderate force is applied when resistance is encountered.
The airway is lubricated before attempting insertion and inserted gently.
The length is measured from the tragus to the nostril plus 1 inch.
The airway is removed and changed at least every 24 hours.
The airway is lubricated before attempting insertion and inserted gently.
Which situations would indicate a need for the nurse to consider insertion of a pharyngeal airway?
Select all that apply.
Decreased level of consciousness
Inability to breathe effectively
Frequent suctioning needs
Loss of muscle tone
Requires mechanical ventilation
Decreased level of consciousness
Frequent suctioning needs
Loss of muscle tone
Which type of tube would a patient receiving general anesthesia require to maintain oxygenation?
Nasopharyngeal
Tracheostomy
Oropharyngeal
Endotracheal
Endotracheal
For which purpose would a chest tube be inserted in a patient injured in a car crash?
Provides oxygenation when respirations are impaired
Allows for removal of excessive airway secretions
Drains blood and fluid to promote full lung expansion
Keeps the airway open when there is airway damage
Drains blood and fluid to promote full lung expansion
Match the type of chest physiotherapy to its description.
Therapeutic positioning that facilitates gravity drainage from the lungs
Combines controlled coughing with deep breathing to maintain lung expansion
Helps a patient reach a set inhalation volume
Answer choices
Coughing/deep breathing
Postural drainage
Incentive spirometry
Therapeutic positioning that facilitates gravity drainage from the lungs
Postural drainage
Combines controlled coughing with deep breathing to maintain lung expansion
Coughing/deep breathing
Helps a patient reach a set inhalation volume
Incentive spirometry
Match the type of chest physiotherapy to its description.
Therapeutic positioning that facilitates gravity drainage from the lungs
Combines controlled coughing with deep breathing to maintain lung expansion
Helps a patient reach a set inhalation volume
Answer choices
Coughing/deep breathing
Postural drainage
Incentive spirometry
Therapeutic positioning that facilitates gravity drainage from the lungs
Postural drainage
Combines controlled coughing with deep breathing to maintain lung expansion
Coughing/deep breathing
Helps a patient reach a set inhalation volume
Incentive spirometry
Which actions are the nurse’s responsibilities during a chest tube insertion procedure?
Select all that apply.
Explaining the procedure to the patient
Positioning the patient
Ensuring that the drainage system is working properly
Administering a prescribed bronchodilator
Initiating oxygen therapy immediately before tube insertion
Positioning the patient
Ensuring that the drainage system is working properly
Match the pulmonary drug classification with the key principle of use.
Increase the diameter of the bronchi
Improve airway clearance
Decrease inflammation
Decrease the thickness of secretions
Answer choices
Corticosteroids
Anticholinergics
Mucolytics
Inhaled bronchodilators
Increase the diameter of the bronchi
Inhaled bronchodilators
Improve airway clearance
Anticholinergics
Decrease inflammation
Corticosteroids
Decrease the thickness of secretions
Mucolytics
Which finding indicates that the prescribed inhaled bronchodilator administered to a patient with chronic obstructive pulmonary disease (COPD) has been effective?
Decreased secretions
Decreased wheezing
Increased heart rate
Decreased body temperature
Decreased wheezing
Which action describes the primary rationale for administering a corticosteroid (methylprednisolone) to a patient with a pulmonary disease?
Treats the underlying infection
Decreases inflammation
Increases the diameter of the bronchi
Decreases the thickness of airway secretions
Decreases inflammation
Which patient changes would the nurse expect when medications used to treat pulmonary disease are effective?
Select all that apply.
Decreased symptoms
Fewer exacerbations
Increased exercise tolerance
Improved overall health status
Reduced laboratory testing requirement
Decreased symptoms
Fewer exacerbations
Increased exercise tolerance
Improved overall health status
Match the drug classification with the key assessment associated with evaluation of treatment.
Blood pressure.
Daily weights, intake and output
Heart rate and rhythm
Bleeding
Answer choices
Antiarrhythmics
Diuretics
Anticoagulants
Antihypertensives
Blood pressure.
Antihypertensives
Daily weights, intake and output
Diuretics
Heart rate and rhythm
Antiarrhythmics
Bleeding
Anticoagulants
Which cautions would the nurse include when discussing home oxygen therapy with a patient who has chronic obstructive pulmonary disease (COPD)?
Select all that apply.
High oxygen levels can be toxic.
Use oxygen therapy only as absolutely needed.
Limit oxygen concentration to low-flow.
Do not smoke while using oxygen.
Avoid humidified oxygen.
High oxygen levels can be toxic.
Limit oxygen concentration to low-flow.
Do not smoke while using oxygen.
Which potential outcomes for a patient with chronic obstructive pulmonary disease (COPD) are associated with daily extended supplemental oxygen therapy?
Select all that apply.
Increased level of daily function
Slowed progression of the disease
Improved mental status
Increased activity tolerance
Decreased inflammation of the alveoli
Increased level of daily function
Improved mental status
Increased activity tolerance
Which course of action would the nurse initiate on discovering a recently discharged patient refuses to use a CPAP machine because of claustrophobia?
Teaching deep breathing exercises
Seeking readmission to the hospital for oxygen therapy
Suggesting counseling to overcome the unreasonable fear
Requesting a prescription for a high-flow nasal cannula
Requesting a prescription for a high-flow nasal cannula
Which emergency preparedness equipment would the nurse need to confirm is available in the room of a patient with a tracheostomy tube?
Select all that apply.
Obturator
Inner cannula
Bag-valve-mask (BVM) device
Blood pressure equipment
Tracheostomy care kit
Obturator
Inner cannula
Bag-valve-mask (BVM) device
Tracheostomy care kit
Which explanation would the nurse give when preparing a patient for placement of an oropharyngeal tube?
“There will be a small incision made to help you breathe”
“This will help facilitate clearing secretions from your mouth and throat.”
“This will remain in place only as long as you are under general anesthesia.”
“Your nares will be lubricated to ease insertion.”
“This will help facilitate clearing secretions from your mouth and throat.”
Which alteration resulting from improper tube placement and found by palpating the skin around the stoma site during tracheostomy care would prompt the nurse to call the primary health care provider?
Excessive secretions
Reddened incision
Respiratory infection
Subcutaneous emphysema
Subcutaneous emphysema
Which information would the nurse give to a postsurgical patient who states that performing incentive spirometry is uncomfortable and wants to know why it is necessary?
It facilitates gravity drainage of secretions.
It prevents atelectasis.
It removes mucus from the respiratory tract.
It drains fluid from the pleural space.
It prevents atelectasis.
Which type of chest physiotherapy involves percussion?
Aerobic exercise
Postural drainage
Incentive spirometry
Coughing/deep breathing
Postural drainage
The nurse would instruct a patient to hold each breath for
____ seconds when explaining coughing/deep breathing chest physiotherapy? Record your answer as two whole numbers separated by a hyphen.
Use numbers only.
3-5
Which route would the nurse use when administering medication to a patient with non–life-threatening lower airway inflammation?
Subcutaneous
Nasal
Intravenous
Inhalation
Inhalation
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) and administers a bronchodilator. Which primary action would the nurse conclude is relieving the wheezing?
Decreases inflammation
Increases the diameter of the bronchi
Decreases the thickness of secretions
Protects against disease
Increases the diameter of the bronchi
Which medications would the nurse expect to be added to the patient’s drug regimen when a patient with infectious bronchitis (inflammation of the bronchi) is admitted to the hospital?
Select all that apply.
Corticosteroids
Antibiotics
Vaccines
Anticholinergics
Mucolytics
Corticosteroids
Antibiotics
Anticholinergics
Which explanation would the nurse give to a patient experiencing an abnormally rapid heartbeat who asks about the purpose of an antiarrhythmic medication?
It promotes increased urine flow.
Low doses prevent blood clot formation.
It is needed to reduce high blood pressure.
It suppresses abnormal rhythms of the heart.
It suppresses abnormal rhythms of the heart.
Which interventions would the nurse implement when providing care for a patient prescribed a diuretic?
Select all that apply.
Applying antiembolic stockings
Monitoring daily weight
Monitoring intake and output
Elevating the head of the bed to the semi-Fowler position
Monitoring for bleeding tendencies
Monitoring daily weight
Monitoring intake and output
Which benefit is important for the nurse to include when educating a patient about antihypertensive medications?
Control an irregular heart rate
Reduce the risk for stroke
Reduce the risk for blood clots
Control swelling of the feet
Reduce the risk for stroke
Which medications would the nurse expect to be on the medication administration record for a patient with chronic cardiovascular disease?
Select all that apply.
Diuretics
Anticoagulants
Antiarrhythmics
Calcium channel blockers
Bronchodilators
Diuretics
Anticoagulants
Antiarrhythmics
Calcium channel blockers
Which discharge instruction would be included during patient education of a patient prescribed anticoagulant therapy?
Expect bleeding and bruising while taking the medication.
Limit intake of green, leafy vegetables.
Monitor blood pressure daily.
Take daily weights at the same time every day.
Limit intake of green, leafy vegetables.
Which patient health history finding would alert the nurse to the possibility of a fluid volume imbalance?
Weight loss of 5 kg over the past month
Weight gain of 2 kg since yesterday morning
Loss of appetite for the past few weeks
Occasional headaches
Weight gain of 2 kg since yesterday morning
Which laboratory results would a nurse expect when caring for a patient with vomiting and diarrhea who has developed rapid onset isotonic fluid volume deficit (FVD)?
Select all that apply.
Elevated red blood cell (RBC) levels
Increased blood urea nitrogen (BUN) and creatinine levels
Low serum osmolality
Decreased urine specific gravity
Decreased urine osmolality
Elevated red blood cell (RBC) levels
Increased blood urea nitrogen (BUN) and creatinine levels
Which datum would support the presence of fluid volume excess (FVE) in a patient with associated risk factors?
Weak, thready pulse
Weight loss of 1 kg since yesterday
Poor skin turgor
Crackles auscultated in lung bases
Crackles auscultated in lung bases
Match each laboratory test with the information it provides.
Indicator of overall renal function
Helps determine hydration status, useful in managing fluid requirements
Measure of the oxygen-carrying capacity of the blood
Measure of the concentration of solutes in the urine
Answer choices
Serum osmolality
Red blood cell (RBC), hemoglobin, hematocrit
Urine osmolality
Blood urea nitrogen, creatinine
Indicator of overall renal function
Blood urea nitrogen, creatinine
Helps determine hydration status, useful in managing fluid requirements
Serum osmolality
Measure of the oxygen-carrying capacity of the blood
Red blood cell (RBC), hemoglobin, hematocrit
Measure of the concentration of solutes in the urine
Urine osmolality
Which level on the dehydration scale would a nurse use to describe a patient with a weight loss of 8% of total body weight secondary to vomiting and diarrhea?
Mild dehydration
Moderate dehydration
Severe dehydration
Life-threatening dehydration
Severe dehydration
Which patients would a nurse conclude are experiencing fluid volume deficit (FVD)?
Select all that apply.
An 86-year-old woman with a fever who has dry mucous membranes and decreased urination
A 50-year-old man with mild hypertension and flat neck veins while seated who has lost 8% total body weight over a year’s time
An infant with diarrhea who has increased respiratory rate, tachycardia, and sunken fontanel
A 75-year-old woman with orthostatic hypotension and tachycardia after an increase in her blood pressure medication dosage
A 40-year-old woman with bleeding who has a weak, thready pulse and decreased skin turgor
An 86-year-old woman with a fever who has dry mucous membranes and decreased urination
An infant with diarrhea who has increased respiratory rate, tachycardia, and sunken fontanel
A 40-year-old woman with bleeding who has a weak, thready pulse and decreased skin turgor
Which sign or symptom in a patient with fluid volume deficit would be a result of decreased interstitial fluid?
Decreased skin turgor
Weak, thready pulse
Lightheadedness
Sunken fontanel in an infant
Decreased skin turgor
Which manifestation, specifically caused by an increase in interstitial fluids, would a nurse expect when caring for a patient who has developed fluid volume excess (FVE)?
Confusion
Dependent edema
Bounding peripheral pulses
Jugular vein distension
Dependent edema
Which degree of fluid volume excess (FVE) would a nurse document for an adult patient with a 5% weight gain over the last 24 hours because of fluid retention?
Mild FVE
Moderate FVE
Irreversible FVE
Severe FVE
Moderate FVE
Which laboratory results would a nurse expect in a patient who has developed a hypertonic fluid volume deficit?
Select all that apply.
Decreased urine specific gravity
Decreased hematocrit levels
Increased blood urea nitrogen (BUN) and creatinine levels
Low red blood cell (RBC) count
Elevated serum osmolality
Increased blood urea nitrogen (BUN) and creatinine levels
Elevated serum osmolality
Which questions would be appropriate for the nurse to ask to obtain fluid balance information?
Select all that apply.
“What types of fiber-containing food do you eat during a typical day?”
“Have you lost or gained weight recently?”
“Do you have a history of renal disease or diabetes mellitus?”
“Have you noticed swelling of your hands and feet?”
“Do you have any food allergies?”
“Have you lost or gained weight recently?”
“Do you have a history of renal disease or diabetes mellitus?”
“Have you noticed swelling of your hands and feet?”
Which patient assessments would suggest a significant fluid volume deficit (FVD) in an acutely ill patient brought into the urgent treatment center?
Select all that apply.
Hypertension
Elevated serum blood urea nitrogen (BUN) and creatinine -levels
Rapid, weak, thready pulse
Weight loss of 0.5 kg over the past 2 days
Dry, cracked lips and furrows on the tongue
Elevated serum blood urea nitrogen (BUN) and creatinine -levels
Rapid, weak, thready pulse
Dry, cracked lips and furrows on the tongue
Which amount of fluid would the nurse calculate has been lost by a patient with a fluid volume deficit reporting a 10 kg loss of total body weight in the last 48 hours as a result of vomiting and diarrhea?
1 liter of fluid
5 liters of fluid
10 liters of fluid
15 liters of fluid
10 liters of fluid
Which specific clinical findings would be expected by a nurse caring for an adult patient with isotonic fluid volume deficit (FVD)?
Select all that apply.
Hypotension
Flat neck veins when supine
Confusion
Low urine output
Slow, thready pulse
Hypotension
Flat neck veins when supine
Low urine output
Which rationale would explain the neurologic signs and symptoms caused by hypertonic fluid volume deficit?
Decreased serum osmolality causes water to shift out of brain cells by osmosis.
Decreased intracellular osmolality causes water to shift into the brain cells by osmosis.
Increased intracellular osmolality causes sodium to shift into the brain cells by osmosis.
Increased serum osmolality causes water to shift out of brain cells by osmosis.
Increased serum osmolality causes water to shift out of brain cells by osmosis.
