med surg cards

8/10/2019 Med Surg Cards

1/54

Cards

Front Back

1. The nurse assesses a patient with shortness of breath for

evidence of long-standing hypoxemia by inspecting: A. Chest

excursion B. Spinal curvatures C. The respiratory pattern D.

The fingernail and its base

D. The fingernail and its base Clubbing, a sign of long-

standing hypoxemia, is evidenced by an increase in the

angle between the base of the nail and the fingernail to 180

degrees or more, usually accompanied by an increase in

the depth, bulk, and sponginess of the end of the finger.

2. The nurse is caring for a patient with COPD and

pneumonia who has an order for arterial blood gases to be

drawn. Which of the following is the minimum length of timethe nurse should plan to hold pressure on the puncture site?

A. 2 minutes B. 5 minutes C. 10 minutes D. 15 minutes

B. 5 minutes Following obtaining an arterial blood gas, the

nurse should hold pressure on the puncture site for 5

minutes by the clock to be sure that bleeding has stopped.An artery is an elastic vessel under higher pressure than

veins, and significant blood loss or hematoma formation

could occur if the time is insufficient.

3. The nurse notices clear nasal drainage in a patient newly

admitted with facial trauma, including a nasal fracture. The

nurse should: A. test the drainage for the presence of

glucose. B. suction the nose to maintain airway clearance. C.

document the findings and continue monitoring. D. apply a

drip pad and reassure the patient this is normal.

A. test the drainage for the presence of glucose. Clear

nasal drainage suggests leakage of cerebrospinal fluid

(CSF). The drainage should be tested for the presence of

glucose, which would indicate the presence of CSF.

4. When caring for a patient who is 3 hours postoperative

laryngectomy, the nurse's highest priority assessment would

be: A. Airway patency B. Patient comfort C. Incisional

drainage D. Blood pressure and heart rate

A. Airway patency Remember ABCs with prioritization.

Airway patency is always the highest priority and is

essential for a patient undergoing surgery surrounding the

upper respiratory system.


2/54

Front Back

5. When initially teaching a patient the supraglottic swallow

following a radical neck dissection, with which of the followingfoods should the nurse begin? A. Cola B. Applesauce C.

French fries D. White grape juice

A. ColaWhen learning the supraglottic swallow, it may be

helpful to start with carbonated beverages because theeffervescence provides clues about the liquid's position.

Thin, watery fluids should be avoided because they are

difficult to swallow and increase the risk of aspiration.

Nonpourable pureed foods, such as applesauce, would

decrease the risk of aspiration, but carbonated beverages

are the better choice to start with.

6. The nurse is caring for a patient admitted to the hospital

with pneumonia. Upon assessment, the nurse notes atemperature of 101.4F, a productive cough with yellow

sputum and a respiratory rate of 20. Which of the following

nursing diagnosis is most appropriate based upon this

assessment? A. Hyperthermia related to infectious illness B.

Ineffective thermoregulation related to chilling C. Ineffective

breathing pattern related to pneumonia D. Ineffective airway

clearance related to thick secretions

A. Hyperthermia related to infectious illness Because the

patient has spiked a temperature and has a diagnosis ofpneumonia, the logical nursing diagnosis is hyperthermia

related to infectious illness. There is no evidence of a chill,

and her breathing pattern is within normal limits at 20

breaths per minute. There is no evidence of ineffective

airway clearance from the information given because the

patient is expectorating sputum.

7. Which of the following physical assessment findings in a

patient with pneumonia best supports the nursing diagnosis

of ineffective airway clearance? A. Oxygen saturation of 85%

B. Respiratory rate of 28 C. Presence of greenish sputum D.

Basilar crackles

D. Basilar crackles The presence of adventitious breath

sounds indicates that there is accumulation of secretions in

the lower airways. This would be consistent with a nursing

diagnosis of ineffective airway clearance because the

patient is retaining secretions.

8. Which of the following clinical manifestations would the

nurse expect to find during assessment of a patient admitted

with pneumococcal pneumonia? A. Hyperresonance on

C. Increased vocal fremitus on palpation. A typical physical

examination finding for a patient with pneumonia is

increased vocal fremitus on palpation. Other signs of


3/54

Front Back

percussion B. Fine crackles in all lobes on auscultation C.

Increased vocal fremitus on palpation D. Vesicular breathsounds in all lobes

pulmonary consolidation include dullness to percussion,

bronchial breath sounds, and crackles in the affected area.

9. Which of the following nursing interventions is of the

highest priority in helping a patient expectorate thick

secretions related to pneumonia? A. Humidify the oxygen as

able B. Increase fluid intake to 3L/day if tolerated. C.

Administer cough suppressant q4hr. D. Teach patient to

splint the affected area.

B. Increase fluid intake to 3L/day if tolerated. Although

several interventions may help the patient expectorate

mucus, the highest priority should be on increasing fluid

intake, which will liquefy the secretions so that the patient

can expectorate them more easily. Humidifying the oxygen

is also helpful, but is not the primary intervention. Teaching

the patient to splint the affected area may also be helpful,but does not liquefy the secretions so that they can be

removed.

10. During discharge teaching for a 65-year-old patient with

emphysema and pneumonia, which of the following vaccines

should the nurse recommend the patient receive? A. S.

aureus B. H. influenzae C. Pneumococcal D. Bacille

Calmette-Gurin (BCG)

C. Pneumococcal The pneumococcal vaccine is important

for patients with a history of heart or lung disease,

recovering from a severe illness, age 65 or over, or living in

a long-term care facility.

11. The nurse evaluates that discharge teaching for a patient

hospitalized with pneumonia has been most effective when

the patient states which of the following measures to prevent

a relapse? A. "I will increase my food intake to 2400 calories

a day to keep my immune system well." B. "I must use home

oxygen therapy for 3 months and then will have a chest x -ray

to reevaluate." C. "I will seek immediate medical treatment

for any upper respiratory infections." D. "I should continue to

D. "I should continue to do deep-breathing and coughing

exercises for at least 6 weeks." It is important for the patient

to continue with coughing and deep breathing exercises for

6 to 8 weeks until all of the infection has cleared from the

lungs. A patient should seek medical treatment for upper

respiratory infections that persist for more than 7 days.

Increased fluid intake, not caloric intake, is required to

liquefy secretions. Home O2 is not a requirement unless


4/54

Front Back

do deep-breathing and coughing exercises for at least 6

weeks."

the patient's oxygenation saturation is below normal.

12. After admitting a patient to the medical unit with a

diagnosis of pneumonia, the nurse will verify that which of the

following physician orders have been completed before

administering a dose of cefotetan (Cefotan) to the patient? A.

Serum laboratory studies ordered for AM B. Pulmonary

function evaluation C. Orthostatic blood pressures D. Sputum

culture and sensitivity

D. Sputum culture and sensitivityThe nurse should ensure

that the sputum for culture and sensitivity was sent to the

laboratory before administering the cefotetan. It is important

that the organisms are correctly identified (by the culture)

before their numbers are affected by the antibiotic; the test

will also determine whether the proper antibiotic has been

ordered (sensitivity testing). Although antibiotic

administration should not be unduly delayed while waitingfor the patient to expectorate sputum, all of the other

options will not be affected by the administration of

antibiotics.

22. The nurse is assigned to care for a patient who has

anxiety and an exacerbation of asthma. Which of the

following is the primary reason for the nurse to carefully

inspect the chest wall of this patient? A. Observe for signs of

diaphoresis B. Allow time to calm the patient C. Monitor the

patient for bilateral chest expansion D. Evaluate the use of

intercostal muscles

D. Evaluate the use of intercostal muscles The nurse

physically inspects the chest wall to evaluate the use of

intercostal (accessory) muscles, which gives an indication

of the degree of respiratory distress experienced by the

patient.

13. Which of the following nursing interventions is most

appropriate to enhance oxygenation in a patient with

unilateral malignant lung disease? A. Positioning patient on

right side. B. Maintaining adequate fluid intake C. Performing

postural drainage every 4 hours D. Positioning patient with

D. Positioning patient with good lung down Therapeutic

positioning identifies the best position for the patient

assuring stable oxygenation status. Research indicates that

positioning the patient with the unaffected lung (good lung)

dependent best promotes oxygenation in patients with


5/54

Front Back

good lung down unilateral lung disease. For bilateral lung disease, the right

lung down has best ventilation and perfusion. Increasingfluid intake and performing postural drainage will facilitate

airway clearance, but positioning is most appropriate to

enhance oxygenation.

14. A 71-year-old patient is admitted with acute respiratory

distress related to cor pulmonale. Which of the following

nursing interventions is most appropriate during admission of

this patient? A. Delay any physical assessment of the patient

and review with the family the patients history of respiratoryproblems. B. Perform a comprehensive health history with

the patient to review prior respiratory problems. C. Perform a

physical assessment of the respiratory system and ask

specific questions related to this episode of respiratory

distress. D. Complete a full physical examination to

determine the effect of the respiratory distress on other body

functions.

C. Perform a physical assessment of the respiratory system

and ask specific questions related to this episode of

respiratory distress.Because the patient is having

respiratory difficulty, the nurse should ask specific

questions about this episode and perform a physicalassessment of this system. Further history taking and

physical examination of other body systems can proceed

once the patient's acute respiratory distress is being

managed.

15. When planning appropriate nursing interventions for a

patient with metastatic lung cancer and a 60-pack-year

history of cigarette smoking, the nurse recognizes that the

smoking has most likely decreased the patient's underlying

respiratory defenses because of impairment of which of the

following? A. Reflex bronchoconstriction B. Ability to filter

particles from the air C. Cough reflex D. Mucociliary

clearance

D. Mucociliary clearance Smoking decreases the ciliary

action in the tracheobronchial tree, resulting in impaired

clearance of respiratory secretions, chronic cough, and

frequent respiratory infections.


6/54

Front Back

16. While ambulating a patient with metastatic lung cancer,

the nurse observes a drop in oxygen saturation from 93% to86%. Which of the following nursing interventions is most

appropriate based upon these findings? A. Continue with

ambulation as this is a normal response to activity. B. Move

the oximetry probe from the finger to the earlobe for more

accurate monitoring during activity. C. Obtain a physicians

order for supplemental oxygen to be used during ambulation

and other activity. D. Obtain a physicians order for arterial

blood gas determinations to verify the oxygen saturation.

C. Obtain a physicians order for supplemental oxygen to

be used during ambulation and other activity. An oxygensaturation level that drops below 90% with activity indicates

that the patient is not tolerating the exercise and needs to

have supplemental oxygen applied.

17. The nurse is caring for a 73-year-old patient who

underwent a left total knee arthroplasty. On the third

postoperative day, the patient complains of shortness of

breath, slight chest pain, and that "something is wrong."

Temperature is 98.4o F, blood pressure 130/88, respirations

36, and oxygen saturation 91% on room air. Which of the

following should the nurse first suspect as the etiology of this

episode? A. Septic embolus from the knee joint B. Pulmonary

embolus from deep vein thrombosis C. New onset of angina

pectoris D. Pleural effusion related to positioning in the

operating room

B. Pulmonary embolus from deep vein thrombosis The

patient presents the classic symptoms of pulmonary

embolus: acute onset of symptoms, tachypnea, shortness

of breath, and chest pain.

18. In the case of pulmonary embolus from deep vein

thrombosis, which of the following actions should the nurse

take first? A. Notify the physician. B. Administer a

nitroglycerin tablet sublingually. C. Conduct a thorough

assessment of the chest pain. D. Sit the patient up in bed as

D. Sit the patient up in bed as tolerated and apply

oxygen.The patient's clinical picture is consistent with

pulmonary embolus, and the first action the nurse takes

should be to assist the patient. For this reason, the nurse

should sit the patient up as tolerated and apply oxygen


7/54

Front Back

tolerated and apply oxygen. before notifying the physician.

19. The nurse is caring for a postoperative patient with

sudden onset of respiratory distress. The physician orders a

STAT ventilation-perfusion scan. Which of the following

explanations should the nurse provide to the patient about

the procedure? A. This test involves injection of a

radioisotope to outline the blood vessels in the lungs,

followed by inhalation of a radioisotope gas. B. This test will

use special technology to examine cross sections of the

chest with use of a contrast dye. C. This test will usemagnetic fields to produce images of the lungs and chest. D.

This test involves injecting contrast dye into a blood vessel to

outline the blood vessels of the lungs.

A. This test involves injection of a radioisotope to outline

the blood vessels in the lungs, followed by inhalation of a

radioisotope gas.A ventilation-perfusion scan has two parts.

In the perfusion portion, a radioisotope is injected into the

blood and the pulmonary vasculature is outlined. In the

ventilation part, the patient inhales a radioactive gas that

outlines the alveoli.

20. During assessment of a 45-year-old patient with asthma,

the nurse notes wheezing and dyspnea. The nurse interprets

that these symptoms are related to which of the following

pathophysiologic changes? A. Laryngospasm B.

Overdistention of the alveoli C. Narrowing of the airway D.

Pulmonary edema

C. Narrowing of the airwayNarrowing of the airway leads to

reduced airflow, making it difficult for the patient to breathe

and producing the characteristic wheezing.

21. A 45-year-old man with asthma is brought to the

emergency department by automobile. He is short of breath

and appears frightened. During the initial nursing

assessment, which of the following clinical manifestations

might be present as an early symptom during an

exacerbation of asthma? A. Anxiety B. Cyanosis C.

A. Anxiety An early symptom during an asthma attack is

anxiety because he is acutely aware of the inability to get

sufficient air to breathe. He will be hypoxic early on with

decreased PaCO2 and increased pH as he is

hyperventilating.


8/54

Front Back

Hypercapnia D. Bradycardia

23. Which of the following positions is most appropriate for

the nurse to place a patient experiencing an asthma

exacerbation? A. Supine B. Lithotomy C. High-Fowlers D.

Reverse Trendelenburg

C. High-FowlersThepatient experiencing an asthma attack

should be placed in high-Fowler's position to allow for

optimal chest expansion and enlist the aid of gravity during

inspiration.

24. The nurse is caring for a patient with an acute

exacerbation of asthma. Following initial treatment, which of

the following findings indicates to the nurse that the patient's

respiratory status is improving? A. Wheezing becomes louder

B. Vesicular breath sounds decrease C. Aerosol

bronchodilators stimulate coughing D. The cough remains

nonproductive

A. Wheezing becomes louder The primary problem during

an exacerbation of asthma is narrowing of the airway and

subsequent diminished air exchange. As the airways begin

to dilate, wheezing gets louder because of better air

exchange.

25. The nurse identifies the nursing diagnosis of activity

intolerance for a patient with asthma. The nurse assesses for

which of the following etiologic factor for this nursing

diagnosis in patients with asthma? A. Anxiety and

restlessness B. Effects of medications C. Fear of suffocationD. Work of breathing

D. Work of breathingWhen the patient does not have

sufficient gas exchange to engage in activity, the etiologic

factor is often the work of breathing. When patients with

asthma do not have effective respirations, they use all

available energy to breathe and have little left over forpurposeful activity.

26. The nurse is assigned to care for a patient in the

emergency department admitted with an exacerbation of

asthma. The patient has received a -adrenergic

bronchodilator and supplemental oxygen. If the patient's

condition does not improve, the nurse should anticipate

B. Systemic corticosteroids Systemic corticosteroids speed

the resolution of asthma exacerbations and are indicated if

the initial response to the -adrenergic bronchodilator is

insufficient.


9/54

Front Back

which of the following is likely to be the next step in

treatment? A. Pulmonary function testing B. Systemiccorticosteroids C. Biofeedback therapy D. Intravenous fluids

27. A patient with acute exacerbation of COPD needs to

receive precise amounts of oxygen. Which of the following

types of equipment should the nurse prepare to use? A.

Venturi mask B. Partial non-rebreather mask C. Oxygen tent

D. Nasal cannula

A. Venturi mask The Venturi mask delivers precise

concentrations of oxygen and should be selected whenever

this is a priority concern. The other methods are less

precise in terms of amount of oxygen delivered.

28. While teaching a patient with asthma about the

appropriate use of a peak flow meter, the nurse instructs the

patient to do which of the following? A. Use the flow meter

each morning after taking medications to evaluate their

effectiveness. B. Empty the lungs and then inhale quickly

through the mouthpiece to measure how fast air can be

inhaled. C. Keep a record of the peak f low meter numbers if

symptoms of asthma are getting worse. D. Increase the

doses of the long-term control medication if the peak flow

numbers decrease.

C. Keep a record of the peak flow meter numbers if

symptoms of asthma are getting worse. It is important to

keep track of peak flow readings daily and when the

patient's symptoms are getting worse. The patient should

have specific directions as to when to call the physician

based on personal peak flow numbers. Peak flow is

measured by exhaling into the meters and should be

assessed before and after medications to evaluate their

effectiveness.

56. When admitting a 45-year-old female with a diagnosis of

pulmonary embolism, the nurse will assess the patient for

which of the following risk factors? (Select all that apply.) A.

Obesity B. Pneumonia C. Hypertension D. Cigarette smoking

A,C,D Research has demonstrated an increased risk of

pulmonary embolism in women associated with obesity,

heavy cigarette smoking, and hypertension. Other risk

factors include immobilization, surgery within the last 3

months, stroke, history of DVT, and malignancy.


10/54

Front Back

29. The physician has prescribed salmeterol (Serevent) for a

patient with asthma. In reviewing the use of dry powderinhalers (DPIs) with the patient, the nurse should provide

which of the following instructions? A. Close lips tightly

around the mouthpiece and breathe in deeply and quickly.

B. To administer a DPI, you must use a spacer that holds

the medicine so that you can inhale it. C. Hold the inhaler

several inches in front of your mouth and breathe in slowly,

holding the medicine as long as possible. D. You will know

you have correctly used the DPI when you taste or sense the

medicine going into your lungs.

A. Close lips tightly around the mouthpiece and breathe in

deeply and quickly. Dry powder inhalers do not requirespacer devices. The patient should be instructed to breathe

in deeply and quickly to ensure medicine moves down

deeply into lungs. The patient may not taste or sense the

medicine going into the lungs.

30. The nurse determines that a patient is experiencing

common adverse effects from the inhaled corticosteroid

beclomethasone (Beclovent) after noting which of the

following? A. Adrenocortical dysfunction and hyperglycemia

B. Elevation of blood glucose and calcium levels C.

Oropharyngeal candidiasis and hoarseness D. Hypertension

and pulmonary edema

C. Oropharyngeal candidiasis and hoarseness

Oropharyngeal candidiasis and hoarseness are common

adverse effects from the use of inhaled corticosteroids

because the medication can lead to overgrowth of

organisms and local irritation if the patient does not rinse

the mouth following each dose.

31. The nurse determines that the patient understood

medication instructions about the use of a spacer device

when taking inhaled medications after hearing the patient

state which of the following as the primary benefit? A. Now I

will not need to breathe in as deeply when taking the inhaler

medications. B. This device will make it so much easier and

faster to take my inhaled medications. C. I will pay less for

medication because it will last longer. D. More of the

D. More of the medication will get down into my lungs to

help my breathing. A spacer assists more medication to

reach the lungs, with less being deposited in the mouth and

the back of the throat.


11/54

Front Back

medication will get down into my lungs to help my breathing.

32. Which of the following test results identify that a patient

with an asthma attack is responding to treatment? A. A

decreased exhaled nitric oxide B. An increase in CO2 levels

C. A decrease in white blood cell count D. An increase in

serum bicarbonate levels

A. A decreased exhaled nitric oxide. Nitric oxide levels are

increased in the breath of people with asthma. A decrease

in the exhaled nitric oxide concentration suggests that the

treatment may be decreasing the lung inflammation

associated with asthma.

33. The nurse determines that the patient is not experiencing

adverse effects of albuterol (Proventil) after noting which of

the following patient vital signs? A. Oxygen saturation 96% B.

Respiratory rate of 18 C. Temperature of 98.4F D. Pulse

rate of 76

D. Pulse rate of 76 Albuterol is a 2-agonist that can

sometimes cause adverse cardiovascular effects. These

would include tachycardia and angina. A pulse rate of 76

indicates that the patient did not experience tachycardia as

an adverse effect.

34. The patient has an order for each of the following

inhalers. Which of the following should the nurse offer to the

patient at the onset of an asthma attack? A. Albuterol

(Proventil) B. Beclomethasone (Beclovent) C. Ipratropium

bromide (Atrovent) D. Salmeterol (Serevent)

A. Albuterol (Proventil) Albuterol is a short-acting

bronchodilator that should initially be given when the patient

experiences an asthma attack.

35. The nurse who has administered a first dose of oral

prednisone (Deltasone) to the patient with asthma writes on

the care plan to begin monitoring which of the following

patient parameters? A. Intake and output B. Bowel sounds C.

Apical pulse D. Deep tendon reflexes

A. Intake and output Corticosteroids such as prednisone

can lead to fluid retention. For this reason, it is important to

monitor the patient's intake and output.


12/54

Front Back

36. The nurse is assisting a patient to learn self-

administration of beclomethasone two puffs inhalation q6hr.The nurse explains that the best way to prevent oral infection

while taking this medication is to do which of the following as

part of the self-administration techniques? A. Chew a hard

candy before the first puff of medication. B. Ask for a breath

mint following the second puff of medication. C. Rinse the

mouth with water before each puff of medication. D. Rinse

the mouth with water following the second puff of medication.

D. Rinse the mouth with water following the second puff of

medication. The patient should rinse the mouth with waterfollowing the second puff of medication to reduce the risk of

fungal overgrowth and oral infection.

37. The nurse is scheduled to give a dose of salmeterol by

metered dose inhaler (MDI). The nurse would administer the

right drug by selecting the inhaler with which of the following

trade names? A. Vanceril B. Serevent C. AeroBid D. Atrovent

B. Serevent The trade or brand name for salmeterol, an

adrenergic bronchodilator, is Serevent.

38. The nurse is evaluating whether a patient understands

how to safely determine whether a metered dose inhaler is

empty. The nurse interprets that the patient understands this

important information to prevent medication underdosing

when the patient describes which method to check the

inhaler? A. Place it in water to see if it floats. B. Shake thecanister while holding it next to the ear. C. Check the

indicator line on the side of the canister. D. Keep track of the

number of inhalations used.

D. Keep track of the number of inhalations used. It is no

longer appropriate to see if a canister floats in water or not

as research has demonstrated this is not accurate. The

best method to determine when to replace an inhaler is by

knowing the maximum puffs available per MDI and then

replacing when those inhalations have been used.

39. The nurse is scheduled to give a dose of ipratropium

bromide by metered dose inhaler. The nurse would

administer the right drug by selecting the inhaler with which

D. Atrovent The trade or brand name for ipratropium

bromide, an anticholinergic medication, is Atrovent.


13/54

Front Back

of the following trade names? A. Vanceril B. Pulmicort C.

AeroBid D. Atrovent

40. The patient has an order for albuterol 5 mg via nebulizer.

Available is a solution containing 2 mg/ml. How many

milliliters should the nurse use to prepare the patient's dose?

A. 0.2 B. 2.5 C. 3.75 D. 5.0

B. 2.5

41. When planning patient teaching about emphysema, the

nurse understands that the symptoms of emphysema are

caused by which of the following? A. Hypertrophy and

hyperplasia of goblet cells in the bronchi B. Collapse and

hypoventilation of the terminal respiratory unit C. An

overproduction of the antiprotease alpha1-antitrypsin D.

Hyperinflation of alveoli and destruction of alveolar walls

D. Hyperinflation of alveoli and destruction of alveolar walls

In emphysema, there are structural changes that include

hyperinflation of alveoli, destruction of alveolar walls,

destruction of alveolar capillary walls, narrowing of small

airways, and loss of lung elasticity.

42. The patient has an order for albuterol 5 mg via nebulizer.

Available is a solution containing 1 mg/ml. How many

milliliters should the nurse use to prepare the patient's dose?

A. 0.2 B. 2.5 C. 3.75 D. 5.0

D. 5.0

43. The nurse evaluates that nursing interventions to

promote airway clearance in a patient admitted with COPD

are successful based on which of the following findings? A.

Absence of dyspnea B. Improved mental status C. Effective

and productive coughing D. PaO2 within normal range for the

C. Effective and productive coughing The issue of the

question is airway clearance, which is most directly

evaluated as successful if the patient can engage in

effective and productive coughing.


14/54

Front Back

patient

44. When caring for a patient with COPD, the nurse identifies

a nursing diagnosis of imbalanced nutrition less than body

requirements after noting a weight loss of 30 lb. Which of the

following would be an appropriate intervention to add to the

plan of care for this patient? A. Teach the patient to use

frozen meals at home that can be microwaved. B. Provide a

high-calorie, high-carbohydrate, nonirritating, frequent

feeding diet. C. Order fruits and fruit juices to be offered

between meals. D. Order a high-calorie, high-protein diet with

six small meals a day.

D. Order a high-calorie, high-protein diet with six small

meals a day.Because the patient with COPD needs to use

greater energy to breathe, there is often decreased oral

intake because of dyspnea. A full stomach also impairs the

ability of the diaphragm to descend during inspiration,

interfering with the work of breathing. Finally, the

metabolism of a high carbohydrate diet yields large

amounts of CO2, which may lead to acidosis in patients

with pulmonary disease. For these reasons, the patient with

emphysema should take in a high-calorie, high-protein diet,

eating six small meals per day.

45. The nurse reviews pursed lip breathing with a patient

newly diagnosed with emphysema. The nurse reinforces that

this technique will assist respiration by which of the following

mechanisms? A. Preventing bronchial collapse and air

trapping in the lungs during exhalation B. Increasing the

respiratory rate and giving the patient control of respiratory

patterns C. Loosening secretions so that they may becoughed up more easily D. Promoting maximal inhalation for

better oxygenation of the lungs

A. Preventing bronchial collapse and air trapping in the

lungs during exhalation The focus of pursed lip breathing is

to slow down the exhalation phase of respiration, which

decreases bronchial collapse and subsequent air trapping

in the lungs during exhalation.

46. Nursing assessment findings of jugular vein distention

and pedal edema would be indicative of which of the

following complications of emphysema? A. Acute respiratory

failure B. Pulmonary edema caused by left-sided heart failure

C. Fluid volume excess secondary to cor pulmonale Cor

pulmonale is a right-sided heart failure caused by

resistance to right ventricular outflow due to lung disease.

With failure of the right ventricle, the blood emptying into


15/54

Front Back

C. Fluid volume excess secondary to cor pulmonale D.

Secondary respiratory infection

the right atrium and ventricle would be slowed, leading to

jugular venous distention and pedal edema.

47. A patient has been receiving oxygen per nasal cannula

while hospitalized for COPD. The patient asks the nurse

whether oxygen use will be needed at home. Which of the

following would be the most appropriate response by the

nurse? A. Long-term home oxygen therapy should be used

to prevent respiratory failure. B. Oxygen will be needed

when your oxygen saturation drops to 88% and you have

symptoms of hypoxia. C. Long-term home oxygen therapy

should be used to prevent heart problems related to

emphysema. D. Oxygen will not be needed until or unless

you are in the terminal stages of this disease.

B. Oxygen will be needed when your oxygen saturation

drops to 88% and you have symptoms of hypoxia.Long-

term oxygen therapy in the home should be considered

when the oxygen saturation is 88% or less and the patient

has signs of tissue hypoxia, such as cor pulmonale,

erythrocytosis, or impaired mental status.

48. Before discharge, the nurse discusses activity levels with

a 61-year-old patient with COPD and pneumonia. Which of

the following exercise goals is most appropriate once the

patient is fully recovered from this episode of illness? A.

Slightly increase activity over the current level. B. Walk for 20

minutes a day, keeping the pulse rate less than 130 beatsper minute. C. Limit exercise to activities of daily living to

conserve energy. D. Swim for 10 min/day, gradually

increasing to 30 min/day.

B. Walk for 20 minutes a day, keeping the pulse rate less

than 130 beats per minute. The patient will benefit from

mild aerobic exercise that does not stress the

cardiorespiratory system. The patient should be

encouraged to walk for 20 min/day, keeping the pulse rate

less than 75% to 80% of maximum heart rate (220 minuspatient's age).

49. The nurse evaluates that a patient is experiencing the

expected beneficial effects of ipratropium (Atrovent) after

noting which of the following assessment findings? A.

A. Increased peak flow readings. Ipratropium is a

bronchodilator that should lead to increased PEFRs.


16/54

Front Back

Increased peak flow readings B. Increased level of

consciousness C. Decreased sputum production D.Increased respiratory rate

50. The nurse is teaching a patient how to self-administer

ipratropium (Atrovent) via a metered dose inhaler. Which of

the following instructions given by the nurse is most

appropriate to help the patient learn proper inhalation

technique? A. Avoid shaking the inhaler before use. B.

Breathe out slowly before positioning the inhaler. C. After

taking a puff, hold the breath for 30 seconds before

exhaling. D. Using a spacer should be avoided for this type

of medication.

B. Breathe out slowly before positioning the inhaler. It is

important to breathe out slowly before positioning the

inhaler. This allows the patient to take a deeper breath

while inhaling the medication thus enhancing the

effectiveness of the dose.

51. Which of the following statements made by a patient with

COPD indicates a need for further education regarding the

use of an ipratropium inhaler? A. I should rinse my mouth

following the two puffs to get rid of the bad taste. B. I should

wait at least 1 to 2 minutes between each puff of the inhaler.

C. If my breathing gets worse, I should keep taking extra

puffs of the inhaler until I can breathe more easily. D.Because this medication is not fast-acting, I cannot use it in

an emergency if my breathing gets worse.

C. If my breathing gets worse, I should keep taking extra

puffs of the inhaler until I can breathe more easily. The

patient should not take extra puffs of the inhaler at will to

make breathing easier. Excessive treatment could trigger

paradoxical bronchospasm, which would worsen the

patient's respiratory status.

52. When assessing a patient's sleep-rest pattern related to

respiratory health, the nurse would ask if the patient: (Select

all that apply.) A. Has trouble falling asleep B. Awakens

abruptly during the night C. Sleeps more than 8 hours per

A,B,D The patient with sleep apnea may have insomnia

and/or abrupt awakenings. Patients with cardiovascular

disease (e.g., heart failure that may affect respiratory

health) may need to sleep with the head elevated on


17/54

Front Back

night D. Has to sleep with the head elevated several pillows (orthopnea). Sleeping more than 8 hours

per night is not indicative of impaired respiratory health.

53. A patient is being discharged from the emergency

department after being treated for epistaxis. In teaching the

family first aid measures in the event the epistaxis would

recur, which of the following measures would the nurse

suggest? (Select all that apply.) A. Tilt patients head

backwards B. Apply ice compresses to the nose C. Pinch the

entire soft lower portion of the nose D. Partially insert a small

gauze pad into the bleeding nostril

B,C,D First aid measures to control epistaxis includes

placing the patient in a sitting position, leaning forward.

Tilting the head back does not stop the bleeding, but rather

allows the blood to enter the nasopharynx, which could

result in aspiration or nausea/vomiting from swallowing

blood. All of the other options are appropriate first aid

treatment of epistaxis.

54. To promote airway clearance in a patient with

pneumonia, the nurse instructs the patient to do which of the

following? (Select all that apply.) A. Splint the chest when

coughing B. Maintain a semi-Fowler's position C. Maintain

adequate fluid intake D. Instruct patient to cough at end of

exhalation

A,C,D The nurse should instruct the patient to splint the

chest while coughing. This will reduce discomfort and allow

for a more effective cough. Maintaining adequate fluid

intake liquefies secretions, allowing easier expectoration.

Coughing at the end of exhalation promotes a more

effective cough. The patient should be positioned in an

upright sitting position (high-Fowler's) with head slightly

flexed.

55. During admission of a patient diagnosed with nonsmall

cell carcinoma of the lung, the nurse questions the patient

related to a history of which of the following risk factors for

this type of cancer? (Select all that apply.) A. Asbestos

exposure B. Cigarette smoking C. Exposure to uranium D.

Chronic interstitial fibrosis

A,B,C Non-small carcinoma is associated with cigarette

smoking and exposure to environmental carcinogens,

including asbestos and uranium. Chronic interstitial fibrosis

is associated with the development of adenocarcinoma of

the lung.


18/54

Front Back

57. When admitting a patient with the diagnosis of asthma

exacerbation, the nurse will assess for which of the followingpotential triggers? (Select all that apply.) A. Exercise B.

Allergies C. Emotional stress D. Decreased humidity

A,B,C Although the exact mechanism of asthma is

unknown, there are several triggers that may precipitate anattack. These include allergens, exercise, air pollutants,

respiratory infections, drug and food additives, psychologic

factors, and GERD.

1. The arterial blood gas (ABG) readings that indicate

compensated respiratory acidosis are a PaCO2 of A. 30 mm

Hg and bicarbonate level of 24 mEq/L. B. 30 mm Hg and

bicarbonate level of 30 mEq/L. C. 50 mm Hg and bicarbonate

level of 20 mEq/L. D. 50 mm Hg and bicarbonate level of 30

mEq/L.

D. 50 mm Hg and bicarbonate level of 30 mEq/L. If

compensation is present, carbon dioxide and bicarbonate

are abnormal (or nearly so) in opposite directions (e.g., one

is acidotic and the other alkalotic).

2. A patient admitted to the emergency department with

tension pneumothorax and mediastinal shift following an

automobile crash is most likely to exhibit A. bradycardia. B.

severe hypotension. C. mediastinal flutter. D. a sucking chest

wound.

B. severe hypotension. Mediastinal shift may cause

compression of the lung in the direction of the shift and

compression, traction, torsion, or kinking of the great

vessels. Blood return to the heart is dangerously impaired

and causes a subsequent decrease in cardiac output and

blood pressure. Tachycardia is a clinical manifestation of

tension pneumothorax. An uncovered opened

pneumothorax is associated with a sucking chest woundand mediastinal flutter.

3. In preparing the preoperative teaching plan for a patient

who is to undergo a total laryngectomy, a nurse should give

highest priority to the A. tracheostomy being in place for 2 to

3 days. B. patient's not being able to speak normally again.

C. insertion of a gastrostomy feeding tube during surgery. D.

B. patient's not being able to speak normally again. Patients

who have a total laryngectomy have a permanent

tracheostomy and will need to learn how to speak using

alternative methods, such as an artificial larynx. The

tracheostomy will be permanent to allow normal breathing


19/54

Front Back

patient's not being able to perform deep-breathing exercises. patterns and air exchange. After surgery, the patient's

nutrition is supplemented with enteral feedings, and whenthe patient can swallow secretions, oral feedings can begin.

Deep-breathing exercises should be performed with the

patient at least every 2 hours to prevent further pulmonary

complications.

4. After a posterior nasal pack is inserted by a physician, the

patient is very anxious and states, "I don't feel like I'm

breathing right." The immediate intervention the nurse should

initiate is to A. monitor ABGs. B. reassure the patient that this

is normal discomfort. C. cut the pack strings and pull the

packing out with a hemostat. D. direct a flashlight into the

patient's mouth and inspect the oral cavity.

D. direct a flashlight into the patient's mouth and inspect the

oral cavity. The nurse should inspect the oral cavity for the

presence of blood, soft palate necrosis, and proper

placement of the posterior plug. If the posterior plug is

visible, the physician should be notified for readjustment of

the packing. Reassurance, cutting the strings, and ABGs

are not top priority interventions. The nurse needs further

data before intervening.

5. A nurse is performing assessment for a patient diagnosed

with chronic obstructive pulmonary disease (COPD). Which

of the following findings should the nurse expect to observe?

A. Nonproductive cough B. Prolonged inspiration C.

Vesicular breath sounds D. Increased anterior-posteriorchest diameter

D. Increased anterior-posterior chest diameter An

increased anterior-posterior diameter is a compensatory

mechanism experienced by patients with COPD and is

caused by air-trapping. Patients with COPD have a

productive cough, often expectorating copious amounts ofsputum. Because of air-trapping, patients with COPD

experience a prolonged expiration because the rate of gas

on exhalation takes longer to escape. Chest auscultation

for patients with COPD often reveals wheezing, crackles,

and other adventitious breath sounds.

6. A nurse is working on a respiratory care unit where many A. Wearing perfume to work People with asthma should


20/54

Front Back

of the patients are affected by asthma. Which of the following

actions by the nurse would most likely increase respiratorydifficulty for the patients? A. Wearing perfume to work B.

Encouraging patients to ambulate daily C. Allowing the

patients to eat green leafy vegetables D. Withholding

antibiotic therapy until cultures are obtained

avoid extrinsic allergens and irritants (e.g., dust, pollen,

smoke, certain foods, colognes and perfumes, certain typesof medications) because their airways become inflamed,

producing shortness of breath, chest tightness, and

wheezing. Many green leafy vegetables are rich in vitamins,

minerals, and proteins, which incorporate healthy lifestyle

patterns into the patients' daily living routines. Routine

exercise is a part of a prudent lifestyle, and for patients with

asthma the physical and psychosocial effects of ambulation

can incorporate feelings of well-being, strength, and

enhancement of physical endurance. Antibiotic therapy is

always initiated after cultures are obtained so that the

sensitivity to the organism can be readily identified.

7. The most appropriate position to assist a patient with

chronic obstructive pulmonary disease (COPD) who is having

difficulty breathing would be a A. high Fowler's position

without a pillow behind the head. B. semi-Fowler's position

with a single pillow behind the head. C. right side-lying

position with the head of the bed at 45 degrees' elevation. D.

sitting upright and forward position with arms supported on

an over-the-bed table.

D. sitting upright and forward position with arms supported

on an over-the-bed table.Sitting upright and leaning forward

with arms supported on an over-the-bed table would be of

most help to this patient, because it allows for expansion of

the thoracic cage in all four directions (front, back, and two

sides).

8. A person complains of fatigue and malaise and has a

slight temperature elevation for 2 days before symptoms of

influenza (fever, chest congestion, and productive cough)

become noticeable. During the time immediately before the

illness is diagnosed, the patient A. could avoid contracting

C. is in the prodromal stage and is highly contagious and

able to spread the disease. The prodromal stage is a short

period of time (hours to several days) immediately

preceding the onset of an illness during which the patient is

very contagious. Antibiotics are not effective against viral


21/54

Front Back

the disease if treatment is begun with antibiotics. B. is unable

to spread the disease because it is still in the incubationperiod. C. is in the prodromal stage and is highly contagious

and able to spread the disease. D. has a nosocomial

infection, which affects approximately two million individuals

a year.

illnesses. The incubation period is the time from entry of the

organism to the onset of symptoms and, in some viralillnesses, may be contagious. Nosocomial infections are

those acquired in a hospital, and this scenario does not

suggest the source of the infection.

9. In older adults, infection after exposure to respiratory

illness is most likely to A. result in similar rates of infection as

in the younger adult. B. be easily prevented with the use of

antibiotics after being exposed. C. result in serious lower

respiratory infection related to weakened respiratory muscles

and fewer cilia. D. be less serious because the older adult

has less contact with younger children who are most likely to

carry serious infections.

C. result in serious lower respiratory infection related to

weakened respiratory muscles and fewer cilia. Changes in

the older adult respiratory system make older adults more

susceptible to infections that can be very serious and life

threatening. Use of antibiotics to "prevent" lung infections is

not recommended and is ineffective for viral infections.

10. If a nurse is caring for an 80-year-old patient with a

temperature of 100.4F, crackles at the right lung base, pain

with deep inspiration, and dyspnea, which of the following

orders is the nurse's priority? A. Sputum specimen for culture

and sensitivity B. Codeine 15 mg orally every 6 hours asneeded C. Incentive spirometer every 2 hours while awake

D. Amoxicillin (Amoxil) 500 mg orally 4 times a day

A. Sputum specimen for culture and sensitivity The patient

presents with signs of a respiratory infection. To initiate the

most effective therapy, the health care prescriber must

know the pathogen causing the infection. Therefore, the

sputum specimen is the nurse's priority. If the antibiotic isadministered before the specimen is obtained, the results of

the culture might not be as accurate and could impair the

effectiveness of therapy. After the specimen is obtained,

the nurse can administer codeine for coughing and begin

the incentive spirometry to mobilize secretions and improve

the patient's ability to expectorate the secretions.


22/54

Front Back

27. A patient with COPD is receiving oxygen at 2 L/min.

While in the supine position for a bath, the patient complainsof shortness of breath. What is the most appropriate first

nursing action? A. Increase the flow of oxygen. B. Perform

tracheal suctioning. C. Report this to the physician. D. Assist

the patient to Fowler's position.

D. Assist the patient to Fowler's position. Breathing is

easier in Fowler's position because it permits greaterexpansion of the chest cavity. If repositioning does not

improve the situation, then oxygenation and physician

reporting might be appropriate. The patient would not

benefit from tracheal suctioning.

11. When assessing a patient's respiratory status, which of

the following nonrespiratory data are most important for the

nurse to obtain? A. Height and weight B. Neck circumference

C. Occupation and hobbies D. Usual daily fluid intake

C. Occupation and hobbiesMany respiratory problems

occur as a result of chronic exposure to inhalation irritants.

Common occupational sources of inhalation irritants include

mines, granaries, farms, lawn care companies, paint,

plastics and rubber manufacture, and building remodeling.

Hobbies associated with inhalation irritants include

woodworking, metal finishing, furniture refinishing, painting,

and ceramics. Daily fluids, height, and weight are more

related to respiratory problems secondary to cardiac issues.

12. If a nurse is assessing a patient whose recent blood gas

determination indicated a pH of 7.32 and respirations are

measured at 32 breaths/min, which of the following is the

most appropriate nursing assessment? A. The rapidbreathing is causing the low pH. B. The nurse should sedate

the patient to slow down respirations. C. The rapid breathing

is an attempt to compensate for the low pH. D. The nurse

should give the patient a paper bag to breathe into to correct

the low pH.

C. The rapid breathing is an attempt to compensate for the

low pH. The respiratory system influences pH (acidity)

through control of carbon dioxide exhalation. Thus, rapid

breathing increases the pH. Breathing into a paper bag aidsa patient who is hyperventilating; in respiratory alkalosis, it

aids in lowering the pH. The use of sedation can cause

respiratory depression and hypoventilation, resulting in an

even lower pH.

13. If a patient with an uncuffed tracheostomy tube coughs B. attempt to reinsert the tracheostomy tube.Retention


23/54

Front Back

violently during suctioning and dislodges the tracheostomy

tube, a nurse should first A. call the physician. B. attempt toreinsert the tracheostomy tube. C. position the patient in a

lateral position with the neck extended. D. cover the stoma

with a sterile dressing and ventilate the patient with a manual

bag-mask until the physician arrives.

sutures may be grasped (if present) and the tracheostomy

opening spread, or a hemostat may be used to spread theopening. The obturator is inserted into the replacement

tube (one size smaller than the original tube), lubricated

with saline solution, and inserted into the stoma at a 45-

degree angle to the neck. If the attempt is successful, the

obturator tube should immediately be removed.

14. Upon entering the room of a patient who has just

returned from surgery for total laryngectomy and radical neck

dissection, a nurse should recognize a need for intervention

when finding A. a gastrostomy tube that is clamped. B. the

patient coughing blood-tinged secretions from the

tracheostomy. C. the patient positioned in a lateral position

with the head of the bed flat. D. 200 ml of serosanguineous

drainage in the patient's portable drainage device.

C. the patient positioned in a lateral position with the head

of the bed flat. After total laryngectomy and radical neck

dissection, a patient should be placed in a semi-Fowler's

position to decrease edema and limit tension on the suture

line.

15. When administering oxygen to a patient with COPD with

the potential for carbon dioxide narcosis, the nurse should A.

never administer oxygen at a rate of more than 2 L/min. B.

monitor the patients use of oxygen to detect oxygendependency. C. monitor the patient for symptoms of oxygen

toxicity, such as paresthesias. D. use ABGs as a guide to

determine what FIO2 level meets the patients needs.

D. use ABGs as a guide to determine what FIO2 level

meets the patients needs. It is critical to start oxygen at low

flow rates and then use ABGs as a guide to determine what

FIO2 level is sufficient and can be tolerated.

16. To ensure the correct amount of oxygen delivery for a

patient receiving 35% oxygen via a Venturi mask, it is most

important that the nurse A. keep the air-entrainment ports

A. keep the air-entrainment ports clean and unobstructed.

Oxygen is delivered to a small jet in the center of a wide-

based cone. Air is entrained (pulled through) openings in


24/54

Front Back

clean and unobstructed. B. apply an adaptor to increase

humidification of the oxygen. C. drain moisture condensationfrom the oxygen tubing every hour. D. keep the flow rate high

enough to keep the bag from collapsing during inspiration.

the cone as oxygen flows through the small jet. The degree

of restriction or narrowness of the jet determines theamount of entrainment and the dilution of pure oxygen with

room air and thus the concentration of oxygen. Although

applying an adaptor can increase the humidification with

the Venturi mask, it is not the best answer, because an

open port is essential to proper functioning. Draining

moisture condensation from the oxygen tubing is performed

as often as needed, not on an hourly schedule. A plastic

face mask with a reservoir bag needs to have sufficient flow

rate to keep the bag inflated.

17. While caring for a patient with respiratory disease, a

nurse observes that the oxygen saturation drops from 94% to

85% when the patient ambulates. The nurse should

determine that A. supplemental oxygen should be used when

the patient exercises. B. ABG determinations should be done

to verify the oxygen saturation reading. C. this finding is a

normal response to activity and that the patient should

continue to be monitored. D. the oximetry probe should be

moved from the finger to the earlobe for an accurate oxygen

saturation measurement during activity.

A. supplemental oxygen should be used when the patient

exercises.An oxygen saturation lower than 90% indicates

inadequate oxygenation. If the drop is related to activity of

some type, supplemental oxygen is indicated.

18. A nurse establishes the presence of a tension

pneumothorax when assessment findings reveal a(n) A.

absence of lung sounds on the affected side. B. inability to

auscultate tracheal breath sounds. C. deviation of the

trachea toward the side opposite the pneumothorax. D. shift

C. deviation of the trachea toward the side opposite the

pneumothorax. Tension pneumothorax is caused by rapid

accumulation of air in the pleural space, causing severely

high intrapleural pressure. This results in collapse of the

lung, and the mediastinum shifts toward the unaffected


25/54

Front Back

of the point of maximal impulse (PMI) to the left, with

bounding pulses.

side, which is subsequently compressed.

28. To find the infection site associated with acute

lymphangitis, the nurse should look _____ to the

inflammation. A. distal B. anterior C. proximal D. contralateral

A. distal The nurse should assess distal to swelling to

locate the initial site of infection. Examining proximal,

contralateral, or anterior to the inflammation does not

describe swelling associated with infection.

19. Which of the following statements made by a nurse would

indicate proper teaching principles regarding feeding and

tracheostomies? A. Follow each spoon of food consumed

with a drink of fluid. B. Thin your foods to a liquid

consistency whenever possible. C. Tilt your chin forward

toward the chest when swallowing your food. D. Make sure

your cuff is overinflated before eating if you have swallowing

problems.

C. Tilt your chin forward toward the chest when swallowing

your food. A nurse should instruct a patient to tilt the chin

toward the chest, which will close the glottis and allow food

to enter the normal passageway. Ideally, foods should be of

a thick consistency to enable effective swallowing and

reduce the risk of aspiration. Overinflation of the cuff

causes swallowing difficulties. Fluids should be consumed

in small amounts after swallowing to prevent the risk of

aspiration.

20. If a patient states, "It's hard for me to breathe and I feel

short-winded all the time," what is the most appropriateterminology to be applied in documenting this assessment by

a nurse? A. Apnea B. Dyspnea C. Tachypnea D. Respiratory

fatigue

B. Dyspnea Dyspnea is a subjective description reflective of

the patient's statement indicating difficulty in breathing.Apnea refers to absence of breath or breathing. Tachypnea

refers to an increased rate of breathing, usually greater

than 20 breaths per minute. Respiratory fatigue is

subjective and usually refers to the patient exhibiting signs

and symptoms associated with a comprehensive

respiratory assessment including laborious breathing, use

of accessory muscles, and slowing of respirations.


26/54

Front Back

21. To prevent atelectasis in an 82-year-old patient with a hip

fracture, a nurse should A. supply oxygen. B. suction theupper airway. C. ambulate the patient frequently. D. assist

the patient with aggressive coughing and deep breathing.

D. assist the patient with aggressive coughing and deep

breathing. Decreased mobility after surgery in older adultscreates the possibility of fluid buildup and retention in lung

tissue. One of the primary goals of nursing intervention is to

prevent atelectasis in a high-risk patient. Aggressive

coughing and deep breathing can prevent atelectasis in the

postoperative patient.

22. Respiratory acidosis is at highest risk in a patient with A.

hypokalemia. B. pulmonary fibrosis. C. salicylate overdose.

D. COPD.

D. COPD. Chronic respiratory acidosis is most commonly

caused by COPD. Pulmonary fibrosis, hypokalemia, and

salicylate overdose do not predispose a patient to

respiratory acidosis. Hypokalemia can lead to cardiac

dysrhythmias. Salicylate overdose results in central

nervous system changes, and pulmonary fibrosis can result

in respiratory arrest.

40. Select all that apply. Atelectasis can be caused by A.

long-term smoking. B. inadequate surfactant. C. localized

airway obstruction. D. an increase in lung expansion. E. an

increase in elastic recoil.

BCE The collapse of lung tissue has several causes,

including reduced lung expansion, localized airway

obstruction, inadequate surfactant, and an increase in

elastic recoil. Smoking, although harmful, does not in itself

cause atelectasis.

23. A patient is having inspiratory stridor (crowing respiration)

and the nurse suspects he is experiencing a laryngospasm.

Which of the following would be most appropriate to

implement for a patient experiencing a laryngospasm? A.

Administer 100% oxygen. B. Position the patient in high

Fowler's position. C. Insert a 16-gauge (large-bore) IV

A. Administer 100% oxygen.A nurse should immediately

administer 100% oxygen to the patient until the airway is

fully reestablished, the larynx relaxes, and the spasms stop.

Activating the emergency response team is not an

immediate nursing action at this time because the nurse

can administer the oxygen without the assistance of others.


27/54

Front Back

needle. D. Activate the emergency response team (code blue

team) to the patient's room.

Positioning the patient in high Fowler's will not address the

patient's need for immediate reoxygenation because of thepatient's compromised respiratory state. Insertion of an IV

device is not the first priority response but should be

implemented after the nurse has assessed that the airway

is stable.

24. A nurse is preparing to establish oxygen therapy for a

patient with COPD, and the physician's prescription reads

"oxygen per nasal cannula at 5 L per minute." Which of the

following actions should the nurse take? A. Administer the

oxygen as prescribed. B. Call the physician and question the

correct flow rate of the oxygen. C. Establish the oxygen as

prescribed and obtain an ABG. D. Change the delivery

device from a nasal cannula to a simple oxygen mask.

B. Call the physician and question the correct flow rate of

the oxygen. The nurse should call the physician

immediately and question the flow rate for delivery of the

oxygen before implementation. Oxygen is used cautiously

in patients with COPD because of longstanding hypoxemia

serving as the respiratory drive mechanism. If high levels of

oxygen are administered, the respiratory drive can be

obliterated. Changing the device to a simple oxygen mask

may alter the oxygen concentration being delivered to the

patient and will further enhance the obliteration of the

patient's respiratory drive. Obtaining an ABG sample is not

a priority at this time, and the action does not address the

validity of the prescribed oxygen dosing for the patient.

25. A 75-year-old obese patient who is snoring loudly and

having periods of apnea several times each night is most

likely experiencing A. narcolepsy. B. sleep apnea. C. sleep

deprivation. D. paroxysmal nocturnal dyspnea.

B. sleep apnea. Sleep apnea is most common in obese

patients. Typical symptoms include snoring and periods of

apnea. Narcolepsy is when a patient falls asleep

unexpectedly. Sleep deprivation could result from sleep

apnea. Paroxysmal nocturnal dyspnea occurs when a

patient has shortness of breath during the night.


28/54

Front Back

26. Which of the following conditions is manifested by

unexplained shortness of breath and a high mortality rate? A.Bleeding ulcer B. Transient ischemia C. Pulmonary embolism

D. MI

C. Pulmonary embolism A high mortality rate is associated

with a pulmonary embolism. A pulmonary embolism is anobstruction of the pulmonary artery caused by an embolus.

It presents with hypoxia, anxiety, restlessness, and

shortness of breath. Bleeding ulcers, MI, and transient

ischemia are not associated with such a high mortality rate.

10. Anticoagulant therapy is used in the treatment of

thromboembolic disease because anticoagulants can A.

dissolve the thrombi. B. decrease blood viscosity. C. prevent

absorption of vitamin K. D. inhibit the synthesis of clotting

factors.

D. inhibit the synthesis of clotting factors. Anticoagulant

therapy is based on the premise that the initiation or

extension of thrombi can be prevented by inhibiting the

synthesis of clotting factors or by accelerating their

inactivation. The anticoagulants heparin and warfarin do not

induce thrombolysis but effectively prevent clot extension.

29. Which of the following instructions are most appropriate

in the home management of a patient who has undergone

surgery for oral cancer? A. You should drink plenty of fluids

and eat foods you enjoy. B. It is normal to have some

leakage of saliva from the suture line. C. Lying in a prone

position helps decrease swelling at the suture line. D. You

should avoid foods high in protein while your suture line ishealing.

A. You should drink plenty of fluids and eat foods you

enjoy. For patients who have undergone treatment for

head and neck cancers, maintaining adequate nutrition is a

challenge. The nurse encourages the patient to increase

fluids to prevent dehydration and liquefy secretions. These

patients are more likely to eat foods that they enjoy and can

tolerate.

30. Which of the following conditions or factors in a 64-year-

old patient diagnosed with head and neck cancer most likely

contributed to this health problem? A. Patient's hobby is oil

painting. B. Patient's father also had head and neck cancer.

C. Patient uses chewing tobacco and drinks beer daily. D.

C. Patient uses chewing tobacco and drinks beer daily.

Many environmental risk factors contribute to the

development of head and neck cancer, although the actual

cause is unknown. There does not appear to be a genetic

predisposition to this type of cancer. The two most


29/54

Front Back

Patient quit school at age 16 and has worked in a butcher

shop for more than 40 years.

important risk factors are tobacco and alcohol use,

especially in combination. Other risk factors includechewing tobacco, pipe smoking, marijuana use, voice

abuse, chronic laryngitis, exposure to industrial chemicals

or hardwood dust, and poor oral hygiene.

31. A patient's ABGs include a PaO2 of 88 mm Hg and a

PaCO2 of 38 mm Hg and mixed venous blood gases include

a PvO2 of 40 mm Hg and PvCO2 of 46 mm Hg. These

findings indicate that the patient has A. impaired cardiac

output. B. unstable hemodynamics. C. inadequate delivery of

oxygen to the tissues. D. normal capillary oxygencarbon

dioxide exchange.

D. normal capillary oxygencarbon dioxide exchange.

Normal venous blood gas values reflect the normal uptake

of oxygen from arterial blood and the release of carbon

dioxide from cells into the blood, resulting in a much lower

PaO2 and an increased PaCO2. The pH is also decreased

in mixed venous blood gases because of the higher

PvCO2. Normal mixed venous blood gases also have much

lower PvO2 and SvO2 than arterial blood bases. Mixed

venous blood gases are used when patients are

hemodynamically unstable to evaluate the amount of

oxygen delivered to the tissue and the amount of oxygen

consumed by the tissues.

32. An excess of carbon dioxide in the blood causes an

increased respiratory rate and volume because CO2 A.displaces oxygen on hemoglobin, leading to a decreased

PaO2. B. causes an increase in the amount of hydrogen ions

available in the body. C. combines with water to form

carbonic acid, lowering the pH of cerebrospinal fluid. D.

directly stimulates chemoreceptors in the medulla to increase

respiratory rate and volume.

C. combines with water to form carbonic acid, lowering the

pH of cerebrospinal fluid. A combination of excess CO2 andH2O results in carbonic acid, which lowers the pH of the

cerebrospinal fluid and stimulates an increase in the

respiratory rate. Peripheral chemoreceptors in the carotid

and aortic bodies also respond to increases in PaCO2 to

stimulate the respiratory center. Excess CO2 does not

increase the amount of hydrogen ions available in the body

but does combine with the hydrogen of water to form an


30/54

Front Back

acid.

33. A patient with an acute pharyngitis is seen at the clinic

with fever and severe throat pain that affects swallowing. On

inspection the throat is reddened and edematous with patchy

yellow exudates. The nurse anticipates that collaborative

management will include A. treatment with antibiotics. B.

treatment with antifungal agents. C. a throat culture or rapid

strep antigen test. D. treatment with medication only if the

pharyngitis does not resolve in 3 to 4 days.

C. a throat culture or rapid strep antigen test. Although

inadequately treated -hemolytic streptococcal infections

may lead to rheumatic heart disease or glomerulonephritis,

antibiotic treatment is not recommended until strep

infections are definitely diagnosed with culture or antigen

tests. The manifestations of viral and bacterial infections

are similar, and appearance is not diagnostic except when

candidiasis is present.

34. Following a supraglottic laryngectomy, the patient is

taught how to use the supraglottic swallow to minimize the

risk of aspiration. In teaching the patient about this technique,

the nurse instructs the patient to A. perform Valsalva

maneuver immediately after swallowing. B. breathe between

each Valsalva maneuver and cough sequence. C. cough

after swallowing to remove food from the top of the vocal

cords. D. practice swallowing thin, watery fluids before

attempting to swallow solid foods.

C. cough after swallowing to remove food from the top of

the vocal cords. A supraglottic laryngectomy involves

removal of the epiglottis and false vocal cords, and the

removal of the epiglottis allows food to enter the trachea.

Supraglottic swallowing requires performance of the

Valsalva maneuver before placing food in the mouth and

swallowing. The patient then coughs to remove food from

the top of the vocal cords, swallows again, and then

breathes after the food has been removed from the vocal

cords.

35. A patient is admitted to the hospital with fever, chills, a

productive cough with rusty sputum, and pleuritic chest pain.

Pneumococcal pneumonia is suspected. An appropriate

nursing diagnosis for the patient based on the patient's

manifestations is A. hyperthermia related to acute infectious

process. B. chronic pain related to ineffective pain

A. hyperthermia related to acute infectious process. The

patient with pneumococcal pneumonia is acutely ill with

fever and the systemic manifestations of fever, such as

chills, thirst, headache, and malaise. Interventions that

monitor temperature and aid in lowering body temperature

are appropriate. Ineffective airway clearance would be


31/54

Front Back

management. C. risk for injury related to disorientation and

confusion. D. ineffective airway clearance related to retainedsecretions.

manifested by adventitious breath sounds and difficulty

producing secretions. Disorientation and confusion are notnoted in this patient and are not typical unless the patient is

very hypoxemic. Pleuritic pain is an acute pain that is due

to inflammation of the pleura.

11. If a patient has pernicious anemia, the nurse should

provide information regarding A. frequent bouts of dyspnea.

B. risks relative to dehydration. C. deficiency of intrinsic

factor. D. lack of any effective treatment for this condition.

C. deficiency of intrinsic factor. Pernicious anemia is a type

of anemia caused by failure of absorption of vitamin B12

(cobalamin). The most common cause is lack of intrinsic

factor, a glucoprotein produced by the parietal cells of the

gastric lining.

36. The resurgence in TB resulting from the emergence of

multidrug-resistant strains of Mycobacterium tuberculosis is

primarily the result of A. a lack of effective means to

diagnose TB. B. poor compliance with drug therapy in

patients with TB. C. the increased population of

immunosuppressed individuals with AIDS. D. indiscriminate

use of antitubercular drugs in treatment of other infections.

B. poor compliance with drug therapy in patients with TB.

Drug-resistant strains of TB have developed because TB

patients' compliance to drug therapy has been poor and

there has been general decreased vigilance in monitoring

and follow-up of TB treatment. Antitubercular drugs are

almost exclusively used for TB infections. TB can be

effectively diagnosed with sputum cultures. The incidence

of TB is at epidemic proportions in patients with HIV, but

this does not account for drug-resistant strains of TB.

37. The chronic inflammation of the bronchi characteristic of

chronic obstructive pulmonary disease (COPD) results in A.

collapse of small bronchioles on expiration. B. permanent,

abnormal dilation of the bronchi. C. hyperplasia of mucus-

secreting cells and bronchial edema. D. destruction of the

C. hyperplasia of mucus-secreting cells and bronchial

edema. Chronic bronchitis is characterized by chronic

inflammation of the bronchial lining, with edema and

increased mucus production. Collapse of small bronchioles

on expiration is common in emphysema, and abnormal

dilation of the bronchi because of destruction of the elastic


32/54

Front Back

elastic and muscular structures of the bronchial wall. and muscular structures is characteristic of bronchiectasis.

38. In teaching the patient with COPD about the need for

physical exercise, the nurse informs the patient that A. all

patients with COPD should be able to increase walking

gradually up to 20 min/day. B. a bronchodilator inhaler should

be used to relieve exercise-induced dyspnea immediately

after exercise. C. shortness of breath is expected during

exercise but should return to baseline within 5 minutes after

the exercise. D. monitoring the heart rate before and after

exercise is the best way to determine how much exercise can

be tolerated.

C. shortness of breath is expected during exercise but

should return to baseline within 5 minutes after the

exercise.Shortness of breath usually increases during

exercise, but the activity is not being overdone if breathing

returns to baseline within 5 minutes after stopping.

Bronchodilators can be administered 10 minutes before

exercise but should not be administered for at least 5

minutes after activity to allow recovery. Patients are

encouraged to walk 15 to 20 minutes a day with gradual

increases, but actual patterns will depend on patient

tolerance. Dyspnea most frequently limits exercise and is a

better indication of exercise tolerance than is heart rate in

the patient with COPD.

39. Select all that apply. Which of the following are clinical

manifestations of tension pneumothorax? A. Midline trachea

B. Severe hypertension C. Progressive cyanosis D. A loud

bruit on affected side E. Asymmetrical chest wall movement

F. Subcutaneous emphysema in the neck

C,E, F The indicators of tension pneumothorax are

asymmetrical chest wall movement, severe hypotension,

subcutaneous emphysema in the neck and upper chest,

and progressive cyanosis.

41. Select all that apply. During initial assessment, a nurse

should record which of the following manifestations of

respiratory distress? A. Tachypnea B. Nasal flaring C.

Thready pulse D. Panting or grunting E. Use of intercostal

muscles F. An inspiratory-to-expiratory ratio of 1:2

AD Manifestations of respiratory distress include

tachypnea, grunting and panting on respiration, central

cyanosis, use of accessory muscles, and flaring nares.


33/54

Front Back

42. Select all that apply. Which of the following nursing

actions can help clear tracheobronchial secretions in apatient with cystic fibrosis? A. Postural drainage B.

Suppressing the cough C. Ensuring adequate hydration D.

Administering mucolytic aerosols E. Encouraging the patient

to lie flat F. Administering water-soluble vitamins

ACD Postural drainage, adequate hydration, and

administration of mucolytic aerosols all encourage coughingand the clearing of secretions. A patient with cystic fibrosis

will be more comfortable sitting upright.

43. Select all that apply. Which of the following is included in

a comprehensive respiratory assessment? A. Pulse oximetry

B. Chest auscultation C. Apical radial pulse D. Nail-bed

assessment E. Evaluation of respiratory effort F. Rate and

character of respirations

ABDEF The total assessment of the respiratory system

includes pulse oximetry; auscultation; skin and nail-bed

assessment for the detection of cyanosis; and rate,

character, and degree of effort of respirations. The apical

radial pulse is a cardiac assessment.

1. When assessing a patient's nutritional-metabolic pattern

related to hematologic health, the nurse would: A. Inspect the

skin for petechiae. B. Ask the patient about joint pain. C.

Assess for vitamin C deficiency. D. Determine if the patient

can perform ADLs.

A. Inspect the skin for petechiae. Any changes in the skin's

texture or color should be explored when assessing the

patient's nutritional-metabolic pattern related to hematologic

health. The presences of petechiae or ecchymotic areas

could be indicative of hematologic deficiencies related to

poor nutritional intake or related causes.

20. Using light pressure with the index and middle fingers,

the nurse cannot palpate any of the patient's superficial

lymph nodes. The nurse A. records this finding as normal. B.

should reassess the lymph nodes using deeper pressure. C.

asks the patient about any history of any radiation therapy. D.

notifies the health care provider that x-rays of the nodes will

be necessary.

A. records this finding as normal. Superficial lymph nodes

are evaluated by light palpation, but they are not normally

palpable. It may be normal to find small (


34/54

Front Back

2. When assessing lab values on a patient admitted with

septicemia, the nurse would expect to find: A. Increasedplatelets B. Decreased red blood cells C. Decreased

erythrocyte sedimentation rate (ESR) D. Increased bands in

the WBC differential (shift to the left)

D. Increased bands in the WBC differential (shift to the left)

When infections are severe, such as in septicemia, moregranulocytes are released from the bone marrow as a

compensatory mechanism. To meet the increased demand,

many young, immature polymorphonuclear neutrophils

(bands) are released into circulation. WBCs are usually

reported in order of maturity, with the less mature forms on

the left side of a written report. Hence, the term "shift to the

left" is used to denote an increase in the number of bands.

3. When caring for a patient with metastatic cancer, the nurse

notes a hemoglobin level of 8.7 g/dl and hematocrit of 26%.

The nurse would place highest priority on initiating

interventions that will reduce which of the following? A.

Fatigue B. Thirst C. Headache D. Abdominal pain

A. Fatigue The patient with a low hemoglobin and

hematocrit (normal values approximately 13.5% to 17% and

40% to 54%, respectively) is anemic and would be most

likely to experience fatigue. This symptom develops

because of the lowered oxygen-carrying capacity that leads

to reduced tissue oxygenation to carry out cellular

functions.

4. The nurse is caring for a patient who is to receive a

transfusion of two units of packed red blood cells. After

obtaining the first unit from the blood bank, the nurse wouldask which of the following health team members in the

nurses' station to assist in checking the unit before

administration? A. Unit secretary B. Another registered nurse

C. A physicians assistant D. A phlebotomist

B. Another registered nurseBefore hanging a transfusion,

the registered nurse must check the unit with another RN or

with a licensed practical (vocational) nurse, depending onagency policy.

5. Before starting a transfusion of packed red blood cells for

an anemic patient, the nurse would arrange for a peer to

D. 15 As part of standard procedure, the nurse remains

with the patient for the first 15 minutes after hanging a


35/54

Front Back

monitor his or her other assigned patients for how many

minutes when the nurse begins the transfusion? A. 60 B. 5 C.

30 D. 15

blood transfusion. Patients who are likely to have a

transfusion reaction will more often exhibit signs within the

first 15 minutes that the blood is infusing.

6. When preparing to administer an ordered blood

transfusion, the nurse selects which of the following

intravenous solutions to use when priming the blood tubing?

A. 5% dextrose in water B. Lactated Ringers C. 0.9% sodium

chloride D. 0.45% sodium chloride

C. 0.9% sodium chloride The blood set should be primed

before the transfusion with 0.9% sodium chloride, also

known as normal saline. It is also used to flush the blood

tubing after the infusion is complete to ensure the patient

receives blood that is left in the tubing when the bag is

empty.

7. The nurse notes a physician's order written at 10:00 AM

for 2 units of packed red blood cells to be administered to a

patient who is anemic secondary to chronic blood loss. If the

transfusion is picked up at 11:30, the nurse should plan to

hang the unit no later than which of the following times? A.

11:45 AM B. 12:00 noon C. 12:30 PM D. 3:30 PM

B. 12:00 noon The nurse must hang the unit of packed red

blood cells within 30 minutes of signing them out from the

blood bank

8. The nurse receives a physician's order to transfuse fresh

frozen plasma to a patient suffering from an acute blood loss.Which of the following procedures is most appropriate for

infusing this blood product? A. Hand the fresh frozen plasma

as a piggyback to a new bag of primary IV solution without

KCl. B. Infuse the fresh frozen plasma as rapidly as the

patient will tolerate. C. Hang the fresh frozen plasma as a

piggyback to the primary IV solution. D. Infuse the fresh

frozen plasma as a piggyback to a primary solution of normal

B. Infuse the fresh frozen plasma as rapidly as the patient

will tolerate. The fresh frozen plasma should beadministered as rapidly as possible and should be used

within 2 hours of thawing. Fresh frozen plasma is infused

using any straight-line infusion set. Any existing IV should

be interrupted while the fresh frozen plasma is infused,

unless a second IV line has been started for the

transfusion.


36/54

Front Back

saline.

9. Before beginning a transfusion of RBCs, which of the

following actions by the nurse would be of highest priority to

avoid an error during this procedure? A. Check the identifying

information on the unit of blood against the patients ID

bracelet. B. Select new primary IV tubing primed with

lactated Ringers solution to use for the transfusion. C. Add

the blood transfusion as a secondary line to the existing IV

and used the IV controller to maintain correct flow. D.

Remain with the patient for 60 minutes after beginning the

transfusion to watch for signs of a transfusion reaction. The

patient's identifying information (name, date of birth, medical

record number) on the identification bracelet should exactly

match the information on the blood bank tag that has been

placed on the unit of blood. If any information does not

match, the transfusions should

med surg cards

Documents