Question 1

While reading a physician's progress notes, a student notes that an assigned patient is having hypoxia. What abnormal assessments would the student expect to find?&#10;A) abdominal pain, hyperthermia, dry skin&#10;B) diarrhea, flatulence, decreased skin turgor&#10;C) hypotension, reddened skin, edema&#10;D) dyspnea, tachycardia, cyanosis

Accepted Answer

Hypoxia refers to a decreased level of oxygen in the blood. The symptoms associated with hypoxia include dyspnea (difficulty breathing), tachycardia (fast heart rate), and cyanosis (bluish discoloration of the skin or mucous membranes). Therefore, option D is the correct choice. The other options do not describe symptoms associated with hypoxia.

Question 2

A nurse is percussing the thorax of a patient with chronic emphysema. What percussion sound would most likely be assessed?&#10;A) resonance&#10;B) hyperresonance&#10;C) flat&#10;D) tympany

Accepted Answer

Patients with chronic emphysema often have hyperinflated lungs, which can result in a hyperresonant percussion sound. Resonance is normal. Flat percussion sound can be heard in conditions like pleural effusion and atelectasis. Tympanic sound can be heard in conditions like pneumothorax.

Question 3

What is the action of codeine when used to treat a cough?&#10;A) antisuppressant&#10;B) suppressant&#10;C) antihistamine&#10;D) expectorant

Accepted Answer

Codeine is a cough suppressant, meaning it works to reduce coughing by suppressing the body's urge to cough. It does not act as an expectorant to help loosen or break up mucus in the lungs, nor does it have antihistamine properties to treat allergy-related coughs.

Question 4

A nurse is teaching a home care patient and his family about using prescribed oxygen. What is a critical factor that must be included in teaching?&#10;A) the importance of communicating with the patient&#10;B) the safety measures necessary to prevent a fire&#10;C) the cost and source of supply for the oxygen&#10;D) the need to provide good skin care

Accepted Answer

Safety measures necessary to prevent a fire are critical when teaching patients and their families about using prescribed oxygen. Oxygen is highly flammable and can ignite if an ignition source such as a lit cigarette or open flame is near the oxygen equipment. It is important to review safety precautions such as not smoking near the oxygen and keeping the equipment away from heat sources.

Question 5

What can a nurse ask a patient to do before suctioning to prevent hypoxemia?&#10;A) Sit in an upright position and cough.&#10;B) Breathe normally for at least 5 minutes.&#10;C) Lie flat in bed and practice relaxation.&#10;D) Take several deep breaths.

Accepted Answer

Taking several deep breaths before suctioning can help the patient to oxygenate the blood and prevent hypoxemia. Sitting in an upright position and coughing can help to clear secretions, but may not necessarily prevent hypoxemia. Breathing normally or lying flat in bed may not increase oxygenation adequately before suctioning.

Question 6

A patient has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy tube is removed for cleaning?&#10;A) obturator&#10;B) outer cannula&#10;C) inner cannula&#10;D) cuff

Accepted Answer

The inner cannula is the removable inner portion of the tracheostomy tube that sits within the outer cannula. It can be removed for cleaning to prevent blockages and maintain proper airflow. The obturator is used for insertion of the tube but is not removed for cleaning. The outer cannula and cuff stay in place and are not removed for cleaning unless there is a complication.

Question 7

What is the rationale for placing a writing board in the room of a patient who has had surgery to insert a tracheostomy tube?&#10;A) The patient is not able to speak.&#10;B) Verbal communication will be too tiring.&#10;C) It will occupy the patient's time.&#10;D) Voice rest will decrease pain levels.

Accepted Answer

Placing a writing board in the room allows the patient to communicate while they are unable to speak due to the presence of a tracheostomy tube.

Question 8

A student observes a nurse instilling a small amount of saline into a tracheostomy tube before suctioning. What should the student discuss with the nurse?&#10;A) a description of how the nurse is carrying out the skill&#10;B) saline is no longer recommended for routine suctioning&#10;C) nothing; the nurse has been doing this for years&#10;D) compliments for carrying out the procedure skillfully

Accepted Answer

The student should discuss with the nurse that saline is no longer recommended for routine suctioning. It can increase the risk of infection and can also cause damage to the respiratory tract. It is important for the nurse to be using evidence-based practice and following the latest recommendations for patient care.

Question 9

A home care nurse finds a patient lying on the floor. The patient is not breathing. Her response is based on the ABCs of basic life support. What does the B stand for in these initials?&#10;A) blood&#10;B) beware&#10;C) breathing&#10;D) be sure

Accepted Answer

The B in ABCs stands for breathing. In a situation where a patient is not breathing, the nurse should prioritize providing artificial ventilation to restore the patient's breathing.

Question 10

A nurse is caring for older adults in a nursing home. Which of the following age-related changes may affect the respiratory functioning of the patients living there? Select all that apply.&#10;A) increased elastic recoil of the lungs&#10;B) less fibrous tissue in alveoli&#10;C) increase in vital capacity and residual volume&#10;D) less air exchange, more secretions in lungs&#10;E) greater risk for aspiration due to slower gastric motility&#10;F) impaired mobility and inactivity, effects of medication

Accepted Answer

D) Age-related changes include decreased air exchange and increased secretions due to factors like reduced ciliary function. E) Older adults have a greater risk for aspiration partly because of slower gastric motility, which can affect respiratory function by increasing the risk of aspiration pneumonia. F) Impaired mobility, inactivity, and the effects of medication can lead to decreased lung expansion and increased risk of pneumonia, affecting respiratory function.

Question 11

Which of the following statements accurately describe a step for inserting an oropharyngeal airway? Select all that apply.&#10;A) Use an airway that is the correct size (size 90 mm is appropriate for the average adult).&#10;B) Airway should reach from opening of mouth to the back angle of the jaw.&#10;C) Position patient on his or her stomach with neck hyperextended (unless this is inappropriate).&#10;D) Open patient's mouth by using your thumb and index finger to gently pry teeth apart.&#10;E) Insert the airway with the curved tip pointing up toward the roof of the mouth.&#10;F) Rotate the airway 360 degrees as it passes the uvula.

Accepted Answer

The answer of Which of the following statements accurately describe...

Deck 29: Activity