Upgrade to remove ads
419 - 41
Terms in this set (141)
Which underlying physiological process is occurring in a patient who has severe dehydration and reports restlessness, an inability to concentrate, dizziness, and difficulty breathing?
Reduced circulating blood volume
Which adventitious lung sounds would the nurse hear upon auscultation of a patient with severe left-sided heart failure?
Inspiratory crackles in the lung bases
Which condition causes hypoventilation in a patient who has a history of chronic obstructive pulmonary disease (COPD) and diabetes mellitus?
Overdose of oxygen therapy
Which action would the nurse include in the plan of care for a patient with atrial fibrillation? Select all that apply. One, some, or all responses may be correct.
Assess lung sounds.
Monitor heart rhythm
Which factor can affect the oxygen-carrying capacity of the blood? Select all that apply. One, some, or all responses may be correct.
To determine patient with anemia's oxygen status, the nurse would assess for which symptoms during the physical assessment?
Decreased activity tolerance and increased breathlessness
Even though the patient's color is ruddy from carbon monoxide (CO) poisoning, the nurse understands that the patient is at risk of decreased oxygen-carrying capacity of blood because of which effect of CO?
Forms a strong bond with hemoglobin, creating a functional anemia
When assessing a patient's respiratory status, which environmental factor would the nurse obtain?
Which physiological factor is directly responsible for a patient whose hemoglobin is low, is weak, and has pallor with a heart rate of 110 beats per minute and a respiratory rate of 30 breaths/min?
Decreased oxygen-carrying capacity
While assessing the patient with left-sided heart failure, which symptom would the nurse likely find? Select all that apply. One, some, or all responses may be correct.
Which reason would the nurse cite for increased risk of respiratory tract infections in infants?
Secondhand smoke exposure
Which physiological process occurs in anemia?
Decreased oxygenation of blood
A patient with a history of chronic obstructive pulmonary disease (COPD) is hospitalized with respiratory failure. Which laboratory value does the nurse assess to determine adequate oxygenation?
Arterial blood gases (ABGs)
Chronologically arrange the pathophysiologic events involved in the development of left-sided heart failure.
(1) decreased functioning of the left ventricle
(2) decreased amount of blood ejected from the left ventricle
(3) decreased cardiac output
(4) development of tissue hypoxia
(5) development of symptoms such as fatigue and breathlessness
The nurse is caring for a patient who presents with an oxygen saturation 85% on room air. Which assessment finding is most likely affecting this patient's oxygenation?
Heart rate 48 beats/min
Which condition is likely induced by salicylate poisoning?
A patient who is hospitalized reports shortness of breath and extreme anxiety. The nurse performs an assessment and notes that the patient is sitting in an upright position and has an oxygen saturation of 86%. Which delivery device does the nurse select to administer oxygen to the patient?
Which body structure is blue in central and peripheral cyanosis?
Which condition causes hypoxia because of decreased movements of the chest wall?
Which symptom consistent with hypoxia would the nurse find in a patient whose arterial oxygen (PaO2) is 50 mm Hg and arterial oxygen saturation (SpO2) is 76%? Select all that apply. One, some, or all responses may be correct.
Which principle would the nurse remember while providing care to a patient who sustained fractures of the C3, C4, and C5 vertebrae from an accident?
Phrenic nerve paralysis may be attributed to a fractured C5 vertebrae.
Which clinical manifestation occurs with right-sided heart failure? Select all that apply. One, some, or all responses may be correct
Distended neck veins
Which common symptom would the nurse find in a patient who experienced a myocardial infarction? Select all that apply. One, some, or all responses may be correct.
Crushing or squeezing chest pain
Pain not relieved by rest or nitroglycerine
Shortness of breath with chest pain
Which pulmonary manifestation would the nurse assess for in a patient with underlying left-sided heart failure? Select all that apply. One, some, or all responses may be correct.
Paroxysmal nocturnal dyspnea
Difficulty in breathing
Crackles in base of lungs on auscultation
Which assessment would the nurse perform before providing endotracheal tube care? Select all that apply. One, some, or all responses may be correct.
Color of secretions
Which statement is true regarding endotracheal and tracheal airways? Select all that apply. One, some, or all responses may be correct.
A specially trained clinician should insert the endotracheal tube.
Tracheostomy suctioning should be performed only when necessary.
The most common complication associated with a tracheostomy tube is partial or complete obstruction.
For which reason would the nurse leave space to snugly fit two fingers under the neck strap while placing the tracheostomy tube?
To prevent skin necrosis
Which purpose does noninvasive ventilation serve? Select all that apply. One, some, or all responses may be correct.
Improves alveolar ventilation
Maintains positive airway pressure
Which artificial airway is the simplest type?
Which statement about a simple face mask is true?
It is used while transporting the patient
The nurse manager is implementing a program to decrease the incidence of ventilator-associated pneumonia (VAP) by 25% on a nursing unit. Which action would be classified as beneficial to meeting this goal? Select all that apply. One, some, or all responses may be correct.
Perform sterile endotracheal suctioning.
Provide daily oral care with chlorhexidine.
Elevate the head of the bed greater than 30 degrees.
Which finding is the nurse least likely to observe in a client receiving invasive mechanical ventilation?
Which complication occurs in a patient with noninvasive ventilation? Select all that apply. One, some, or all responses may be correct.
Dry mucous membranes
The nurse is developing the plan of care for a patient with a well-established tracheostomy tube. Which action is safe to delegate to the assistive personnel (AP)?
Perform oral suctioning.
What is the disadvantage of using an oxygen-conserving cannula? Select all that apply. One, some, or all responses may be correct.
Cannula cannot be cleaned
More expensive than standard cannula
Which step in the nursing process is the nurse performing when suctioning the tracheostomy in a patient?
Which complication is associated with invasive mechanical ventilation? Select all that apply. One, some, or all responses may be correct.
Which information would the nurse provide to a patient's family who asks about the rationale for noninvasive ventilation (NIV) that has been prescribed for the patient? Select all that apply. One, some, or all responses may be correct.
It corrects atelectasis.
It improves oxygenation.
It promotes adequate sleep.
It decreases pulmonary edema.
Which condition is the consequence of using an artificial airway that is too large?
While performing endotracheal tube care, which action by the nurse reduces anxiety, encourages cooperation, and reduces risks associated with the treatment?
Explaining the importance of trying not to cough
Which complication is the most common in a patient with a tracheostomy?
Partial airway obstruction
Which nursing action is most appropriate to prevent biting while inserting an oropharyngeal airway into an unconscious patient?
Pushing the tongue into the oropharynx when placing an oropharyngeal airway
Which aspect of care for a patient with a tracheostomy can be safely delegated to assistive personnel? Select all that apply. One, some, or all responses may be correct.
Reporting a change in the color of the stoma
Reporting unexpected drainage from the tracheostomy tube
After endotracheal intubation, the patient coughs continuously. For which reason might this occur?
Tip of the tube is at the level of the carina
Which nursing skill is categorized in the planning phase while delivering care to a patient with an artificial airway?
Assisting the patient to attain a semi-Fowler's position
The nurse asks a patient to take six deep breaths over 30 seconds to provide preoxygenation before suctioning the tracheostomy tube. Which rationale explains this intervention?
Replenishes the oxygen lost in suctioning
Which initial dressing application is required for endotracheal tube care? Select all that apply. One, some, or all responses may be correct.
Tincture of benzoin and liquid adhesive
0.12% to 0.20% chlorhexidine mouthwash
Which nursing intervention maintains the patient's supply of oxygen?
Placing the tracheostomy tube over the outer cannula
Which nursing intervention prevents impaired oxygenation in a patient with a tracheostomy?
Maintaining patency of the airway
A nurse auscultates a patient's lung sounds before inserting an endotracheal tube to maintain the artificial airway. Which rationale explains this nursing intervention?
To provide a baseline measure of ventilation
Which nursing action would be beneficial to prevent skin necrosis in a patient who has undergone a tracheostomy?
Verifying the space of two snug finger widths under the neck strap
Which statement by the patient indicates the need for further teaching regarding diaphragmatic breathing?
"I should practice the exercise initially in the sitting position and then in the supine position."
Which assessment by the nurse is least likely to support the suspicion of an accumulation of secretions in a patient with an artificial airway?
Observing the condition of the surrounding tissues
Which nursing process involves clamping the chest tubes under specific circumstances as per the health care provider's prescription?
Which action would the nurse take for a patient 2 hours after surgery for insertion of a chest tube who has 100 mL of dark-red drainage in the chest tube?
Record the amount and continue to monitor drainage.
Which position is appropriate in a patient who has a chest tube drainage system to drain fluid from the chest?
Which statement about home oxygen storage systems indicates a need for correction?
Compressed gas cylinder systems are the choice for high-volume users.
Which statement made by the caregiver indicates successful teaching about safety measures for oxygen?
"I should check the oxygen level of portable tanks before transporting."
Which action by the nurse involves squeezing, twisting, and kneading the chest tube to create a burst of suction to move clots?
Which type of oxygen mask is contraindicated for patients who have carbon dioxide retention?
Simple face mask
While caring for a patient who has a chest tube, the nurse monitors the vital signs and pulse oximetry as prescribed by the health care provider. Which nursing skill does this demonstrate?
Which statement is true regarding oxygen concentrators?
They provide large sources of oxygen.
Why is clamping a chest tube contraindicated while ambulating a patient?
It causes tension pneumothorax.
or which reason would the water-seal chamber have continuous bubbling?
There is a leak between the patient and the chamber.
Arrange the steps in order for refilling an oxygen tank.
Checking for the amount of oxygen in the tank
Wiping both filling connectors with a clean, dry, lint-free cloth
Turing off the flow selector of the ambulatory unit
Attaching the ambulatory unit to the stationary reservoir
Opening the fill value on the ambulatory tank and applying firm pressure to the top of the stationary pressure
Connecting the oxygen-delivery device to the oxygen system
Performing hand hygiene
Which intervention is appropriate for a patient who has a tension pneumothorax? Select all that apply. One, some, or all responses may be correct.
Determining that the chest tube is not kinked
Preparing immediately for another chest tube insertion
Which feature is typical of a Venturi mask?
Provides a specific amount of oxygen with humidity added
While assessing a patient who has a chest tube, the nurse suspects tension pneumothorax. Which symptom supports the nurse's suspicion? Select all that apply. One, some, or all responses may be correct.
Stabbing chest pain
While caring for a patient with chest tubes, the nurse asks the patient to rate the level of comfort on a scale of 0 to 10. Which rationale best explains this? Select all that apply. One, some, or all responses may be correct.
To assess for atelectasis
To assess for pneumonia
When should the chest tube be clamped? Select all that apply. One, some, or all responses may be correct.
While assessing for an air leak
When replacing the chest drainage system
Why would the nurse request a humidification device while delivering oxygen to a patient in the home care setting?
Oxygen delivery greater than 4 L/min
While administering home oxygen, which nursing intervention is included under the planning phase of the nursing process?
Instructing the family to investigate municipal requirements for home medical equipment
The registered nurse asks the patient and family to state safety guidelines, emergency precautions, and an emergency plan for the patient who is using home oxygen equipment. Which rationale best explains this?
It helps determine the patient's knowledge of what to do if the power fails, there is a failure in equipment, or the patient's status worsens.
A patient who has atelectasis has a tracheostomy. While providing care, the nurse elevates the head of the patient's bed to 30 degrees and also changes the patient's body position frequently. Which statement is true regarding the rationale behind the nurse's actions?
To prevent pulmonary aspiration
The registered nurse instructs the assistive personnel (AP) to frequently reposition the elastic strap on the patient's oxygen mask. Which rationale best explains this?
To prevent skin breakdown
Which action would the nurse take to perform suctioning in a patient who has chronic obstructive pulmonary disorder (COPD) and is spontaneously breathing?
Administer oxygen at a rate of no more than 3 L/min.
Which assessment finding would alert the nurse to stop suctioning a patient?
Heart rate of 40 beats per minute
Which amount is the maximum time for the nurse to apply suction when performing endotracheal suctioning of a patient?
Which nursing intervention, if performed before suctioning, minimizes hypoxemia after suctioning?
Hyperoxygenating the patient before suctioning
While performing tracheal suctioning, which nursing action is appropriate in removing secretions adhered to the sides of the endotracheal (ET) tube?
Rotating the catheter
Which nursing action is appropriate during suctioning?
Applying clean gloves to both hands for oropharyngeal suctioning
The nurse identifies that which event indicates the need to perform oropharyngeal suctioning?
The patient is able to cough effectively but is unable to clear secretions by expectorating
How far would the nurse insert a nasopharyngeal suction catheter into a young child?
4 to 7.5 cm (1.5 to 3 inches)
Which nursing action is likely responsible for the patient's blood pressure being low and finding that the patient has hypoxemia and arrhythmias?
Performing too-frequent suctioning
Which risk is associated with suctioning when performed in an appropriate time interval on a patient who has a head injury?
Increased intracranial pressure
Which information does the nurse document after performing endotracheal suctioning for a patient with cystic fibrosis? Select all that apply. One, some, or all responses may be correct.
Color of secretions
Amount of secretions
Respiratory assessments before and after suctioning
Consistency of secretions
Pulse oximetry values
Which action would the nurse take when performing tracheal suctioning in a patient who has a history of respiratory distress?
Maintain the suction pressure between 80 and 120 mm Hg while withdrawing the catheter.
While performing oropharyngeal suctioning, which intervention performed by the nurse helps move secretions from the lower to the upper airway and then into the mouth?
Encouraging the patient to cough
Which type of suctioning can the nurse delegate to assistive personnel (AP)?
Which purpose does asking the patient to say "ahh" while performing suctioning accomplish?
Assists in opening the glottis
Which statement by the new nurse indicates the charge nurse needs to intervene?
"I will apply negative pressure while inserting the catheter."
Which type(s) of suctioning would the nurse use for a patient who is unable to manage secretions by coughing?
Orotracheal and nasotracheal
Which situation would cause the nurse to ask the patient to say "ahh" while guiding the suction catheter?
Difficulty in passing the suction catheter in the first attempt
Which rationale explains assisting the patient in taking deep breaths with an oxygen delivery device before nasopharyngeal suctioning?
To minimize hypoxemia after suctioning
Which action would the nurse take if having difficulty passing the catheter while suctioning a patient because of incomplete opening of the glottis?
Advise the patient to cough.
Which situation leads to tracheal mucosa trauma from artificial airway suctioning?
Providing deep tracheal suctioning
The nurse is preparing to perform endotracheal suctioning for a patient after a craniotomy. Which action would the nurse perform before inserting the catheter?
Administers 100% oxygen through tracheostomy collar
Which statement by the nurse indicates a correct understanding of suctioning safety guidelines?
"The mouth is suctioned with a separate oral suction device when there is an abundance of oral secretions."
Which action would the nurse take when the patient gags and becomes nauseated upon inserting the suction catheter into the trachea?
Gently remove the catheter and wait until the patient breathes normally.
Which condition may be observed in a patient who receives frequent suctioning?
Which parameter would the nurse assess to determine frequency of suctioning? Select all that apply. One, some, or all responses may be correct.
Gurgling breath sounds
Rhonchi breath sounds
The nurse is caring for a patient experiencing an exacerbation of asthma. Which intervention does the nurse perform to immediately improve oxygenation? Select all that apply. One, some, or all responses may be correct.
Identify asthma triggers.
Provide supplemental oxygen.
Which topic discussed by the nurse with the patient is about orthopnea?
Feeling of comfort when sleeping in a reclining chair
Which intervention is a simple and cost-effective method for reducing pulmonary secretions stasis and reduced chest wall expansion in a patient who has decreased mobility?
Frequent change of position
Which immediate action would the nurse take for a patient with chronic obstructive pulmonary disorder (COPD) who is receiving oxygen therapy using a simple face mask whose blood analysis reveals abnormally high levels of carbon dioxide?
Remove the mask and use a nasal cannula as an oxygen supply.
Remove the mask and use a nasal cannula as an oxygen supply.
Which instruction would the nurse include in a teaching session about lifestyle practices to promote heart health? Select all that apply. One, some, or all responses may be correct.
Eat foods rich in fiber.
Participate in aerobic exercises.
Exercise for at least 150 minutes a week.
Which goal is the primary motive for why a nurse would perform pulse oximetry on a patient who is cyanotic?
To assess the oxygenation level
Which information is true regarding chest percussion?
Involves rhythmically clapping on the chest wall
Which abnormality is caused by chronic hypoxemia?
Which action would the nurse take first for the patient with chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min and becomes short of breath while in the supine position during a bath?
Assist the patient to a semi-Fowler's position.
Which assessment finding would indicate the patient needs airway suctioning?
Decreased independent ability to cough
Which condition would a patient with a respiratory rate of 25 breaths/min have?
Which intervention would the nurse perform for a patient with a nursing diagnosis of impaired airway clearance? Select all that apply. One, some, or all responses may be correct.
Perform chest physiotherapy.
Provide supplemental oxygen.
Which diagnostic test prescribed by the health care provider is less reliable when used on a patient with human immunodeficiency virus (HIV)?
Tuberculosis skin testing (TST)
Which intervention will relieve dryness of the mucous membranes for a patient having a chronic dry cough in the mornings, with occasional production of thick, yellow-green sputum in small quantities?
Offering plenty of oral fluids
Which nursing diagnosis presents with a cough producing thick, yellow-green sputum, which is aggravated when lying down flat, along with dry mucous membranes and crackles in the lower lobes bilaterally?
Impaired airway clearance
Which diagnostic test is used in the daily measurement for early detection of asthma exacerbations?
Peak expiratory flow rate
Which condition causes the patient to have cyanotic conjunctivae?
Which statement is true about the various patterns of respiration? Select all that apply. One, some, or all responses may be correct.
Apnea is the absence of respirations for 15 seconds or longer.
Kussmaul respiration is the increase in rate and depth of breathing.
Cheyne-Stokes breathing is a period of apnea following a period of deep breathing and then shallow breathing.
Which intervention would the nurse include in a teaching session to patients about preventing airborne allergen respiratory problems?
Discourage the patients from playing with pets.
Which guideline would the nurse follow when administering chest physiotherapy?
Patients on long-term steroids should not undergo chest physiotherapy.
Which oxygen-delivery system would the nurse select to administer oxygen at 4 L/min to a patient needing a low-flow delivery device?
Which diagnostic study would the nurse anticipate for a patient who has chest pain from cardiac problems? Select all that apply. One, some, or all responses may be correct.
Serum cardiac enzymes
Which instruction given by the nurse is appropriate for a patient who has intermittent episodes of cough accompanied with thick, yellow sputum and crackles in the lungs? Select all that apply. One, some, or all responses may be correct.
"Drink plenty of water."
"Walk around as much as you can."
"Perform deep-breathing exercises once every 2 hours."
Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient?
Which nursing intervention may be beneficial for a patient who has thick pulmonary secretions? Select all that apply. One, some, or all responses may be correct.
Encouraging fluid intake
Teaching cascade coughing
Which instruction would the nurse include when teaching a patient about the procedure for diaphragmatic breathing? Select all that apply. One, some, or all responses may be correct.
"Inhale slowly to make the abdomen push out."
"Start practicing the technique in a supine position initially."
"Place one hand on the breastbone and the other hand on the abdomen."
Which condition causes central cyanosis on the patient's tongue, soft palate, and conjunctiva?
During an assessment, which finding indicates the presence of a pneumothorax?
Pleuritic pain that worsens on inspiration
Which goal would be the primary motive behind administering continuous positive airway pressure (CPAP) to a patient with a diagnosis of sleep apnea?
To prevent airway collapse
Which information about breathing patterns is true? Select all that apply. One, some, or all responses may be correct.
Bradypnea is less than 12 breaths per minute.
Tachypnea is greater than 20 breaths per minute.
Apnea is the absence of respirations for a period of time.
Which statement by the nurse indicates a correct understanding about the assessment of a patient who has decreased tissue oxygenation? Select all that apply. One, some, or all responses may be correct.
"I should ask the patient about any history of cardiovascular problems."
"I should obtain pulse oximetry readings to obtain the patient's oxygenation level."
"I should perform capnography to obtain instant information about the patient's ventilation status."
Which action would the nurse take for a patient who has a chest tube to drain a pneumothorax? Select all that apply. One, some, or all responses may be correct.
Keep the drainage below the chest level of the patient.
Fill the water-seal chamber to the mark given by the manufacturer and observe it.
If the tube disconnects, crimp tubing with a gloved hand.
Which response would the nurse make to a patient with chronic obstructive pulmonary disease (COPD) who is trying to do diaphragmatic breathing exercises for the first time in a sitting position?
"You have to practice these exercises first in the supine position and then in the sitting position."
Which clinical manifestation would the nurse likely observe in a patient diagnosed with a pneumothorax? Select all that apply. One, some, or all responses may be correct.
Sharp pain in the chest
Which statement made by the new nurse about suctioning a patient with an endotracheal tube indicates the charge nurse needs to intervene?
"I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."
Which terminology would the nurse chart to document the patient saying, "It's hard for me to breathe, and I feel short-winded all the time?"
Which age-related change in the older adult may result in decreased tissue oxygenation caused by impaired chest expansion? Select all that apply. One, some, or all responses may be correct.
Ossification of costal cartilage
Decreased intervertebral space
Diminished respiratory muscle strength
Which assessment finding would the nurse observe in a patient with a pneumothorax after a blunt injury to the chest? Select all that apply. One, some, or all responses may be correct.
Sharp pain in the chest
Difficulty in breathing
Pain that increases on inspiration
In which position would the nurse place the patient to drain the apical segments of the lungs?
Sitting on side of bed
YOU MIGHT ALSO LIKE...
TAN FINAL-TEST II
Vital Sign Questions: Chapter 17
OTHER SETS BY THIS CREATOR
Hondros RN BIO254 Final
Hondros Nur 212 Exam 2
NUR 212 finals
Chapter 15: Cancer: Prevention and Detection
OTHER QUIZLET SETS
7. COMMON STOCK
Speak - 3rd Marking Period
Music Appreciation Final Review
Anatomy ch 10