Question 1

The patient's tuberculosis test appears red and flat after the injection 48 hours ago.Which is the appropriate action of the nurse?

Accepted Answer

A reddened flat area is not a positive reaction that does not need to be measured.A positive tuberculosis skin result is a palpable,elevated,hardened area around the injection site.

Question 2

Which patient would benefit from education about pursed-lip breathing?

Accepted Answer

A patient with emphysema would benefit from pursed-lip breathing as it facilitates exhalation of air from the lungs.Pursed-lip breathing is not recommended for patients with chest tubes.Patients with tracheostomy or respiratory muscle paralysis would not be able to do pursed-lip breathing.

Question 3

The nurse is caring for a patient who has pneumonia and chronic bronchitis.The patient is very congested,coughing up copious amounts of thick green sputum.Which breath sounds will the nurse expect to hear?

Accepted Answer

Coarse rhonchi are heard when thick sputum is heard in the airways.Fine crackles are heard when there is watery fluid in the airways.Diminished bases are heard when the patient is taking shallow breaths.Scattered wheezes are heard when there is narrowing of the airways such as from asthma.

Question 4

Which assessment findings indicate that the patient is at risk for developing ventricular fibrillation?

Accepted Answer

Hyperkalemia,coronary artery disease,and recent incidents of ventricular tachycardia are all risk factors for development of ventricular fibrillation.Impaired SA node conduction and vagal stimulation would lead to bradycardia rather than fibrillation.

Question 5

The nurse is caring for a patient a serum potassium level of 7.4 mEq/L.Which is the highest priority nursing diagnosis for this patient?

Accepted Answer

The patient's dangerously high potassium level causes risk of ventricular fibrillation.The highest priority nursing diagnosis for the patient is risk for decreased cardiac output related to altered heart rhythm.Nausea is not the highest priority diagnosis.Fluid volume excess is not expected with a potassium level of 7.4 mEq/L.There is no indication of the patient having an altered mental status.

Question 6

The nurse is caring for a dying patient in hospice.The patient's respirations are slow and uneven with deep breaths and long periods of apnea.Which term best describes this breathing pattern?

Accepted Answer

Cheyne-Stokes respirations have uneven with deep breaths and long periods of apnea.Kussmaul respirations are deep and rapid to blow off excess carbon dioxide with metabolic acidosis.Rhonchal bradypnea and Forrest-Shiley breaths are not accepted terms.

Question 7

Which is the priority action of the nurse for a patient with ventricular tachycardia?

Accepted Answer

The patient with ventricular tachycardia may or may not have a pulse.The most appropriate option is for the nurse to start chest compressions if there is no palpable pulse.Checking the patient's BP,drawing blood for laboratory testing,and assessing for digoxin toxicity are not priority interventions for a patient without a palpable pulse.

Question 8

Which patient would benefit from BiPAP therapy?

Accepted Answer

A patient with pulmonary edema would benefit from BiPAP therapy as it will assist with inspiration,prevent alveolar collapse during exhalation,and improve oxygenation.BiPAP is not appropriate for patients who are confused or unable to swallow.Patients under general anesthesia must be intubated in order to maintain the airway as well as ventilation.

Question 9

Which nursing diagnosis is appropriate for a patient using CPAP therapy to treat sleep apnea?

Accepted Answer

The patient's facial skin may become irritated from the tight-fitting CPAP mask.This is the highest priority diagnosis as it addresses a patient safety need.Risk for disuse syndrome is inappropriate for sleep apnea as the diagnosis relates to deterioration of a body part because of inactivity.Disturbed body image and readiness for enhanced sleep are lower priority nursing diagnoses for this patient.

Question 10

The nurse assists a patient who collapsed in cardiac arrest.Which is the first action of the nurse?

Accepted Answer

The first action of the nurse is to begin chest compressions.Determining the cardiac rhythm,ensuring a patent airway,and ventilating the patient are done after chest compressions are initiated.

Question 11

The nursing staff is caring for a patient who collapsed in cardiac arrest.When will breaths be delivered via the bag-valve mask device?

Accepted Answer

Two breaths are delivered via the bag-valve mask device after each set of 30 chest compressions.The mask device is not used after the patient is intubated.Frequency of breaths is not determined by the presence or absence of cyanosis or change of staff providing chest compressions.

Question 12

Which interventions are appropriate for the patient with the nursing diagnosis decreased cardiac output related to reduced stroke volume and contractility?

Accepted Answer

Lung sounds and pulse oximetry will monitor for impaired oxygenation and pulmonary edema.Strict intake and output will monitor for weight gain seen with congestive heart failure.Constipation should be avoided as straining at stool can lead to dysrhythmias.The patient's pulse oximetry should be kept at least 95% to promote oxygenation of tissues.Additional salt will increase cardiac workload and lead to worsening of heart failure.

Question 13

Which assessment findings indicate to the nurse that the patient is hypoxic?

Accepted Answer

Bradycardia,impaired mental status,and poor circulation all indicate that the patient is hypoxic.Soft abdomen with bowel sounds × 4 quadrants and urine output at least 30 mL/hour are normal findings.

Question 14

The nurse assesses distended neck veins in a patient sitting in a chair to eat.Which is the priority intervention of the nurse?

Accepted Answer

Distended neck veins indicate venous congestion in the systemic circulation and possibly right-sided heart failure.The nurse's priority action is to check the patient's pulse and blood pressure.Distended neck veins may be documented in the chart but that is not the priority action of the nurse.There is no need to check specific gravity or deep tendon reflexes.

Question 15

The nurse assesses a patient during suctioning.Which finding indicates that the procedure should be stopped immediately?

Accepted Answer

Decreased heart rate to 40 beats/minute indicates that the patient is not tolerating the suction procedure and it should be stopped immediately.Pulse of 92%,respiratory rate of 20,and BP 120/80 do not warrant immediately stopping suction.

Question 16

The nurse has orders to titrate the patient's oxygen to maintain a pulse oximetry level greater than 94%.The patient's pulse oximetry will not rise above 90% despite use of a nonrebreather mask.Which is the appropriate action of the nurse?

Accepted Answer

BiPAP is a form of noninvasive ventilation that is used to assist patients in respiratory failure without intubation.The nurse should respiratory therapy to consider BiPAP support for the patient because oxygen via nonrebreather mask is not sufficient to maintain oxygenation.Inserting an oral airway will cause the patient to gag.The nonrebreather mask covers the mouth and nose already.Venturi mask will deliver less oxygen than a nonrebreather mask.An oxygen nasal cannula should not be placed underneath the nonrebreather mask.

Question 17

Which type of sterile dressing will be applied to the chest wall after removal of the patient's chest tube?

Accepted Answer

An occlusive dressing must be applied to the chest tube site following removal to prevent entry of air into the chest cavity.Gauze impregnated with petroleum jelly is an example of an occlusive dressing.Dry gauze is not occlusive and will allow air into the chest cavity.Absorbent foam dressings are used to absorb large amounts of drainage from wounds and are not appropriate for chest tube sites.

Quiz 32: Oxygenation