Respiratory🫁
The nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns the nurse immediately?
a. Fine bibasilar crackles
b. Respiratory rate of 8 breaths/min
c. Patient sitting up and leaning over the nightstand
d. A large barrel chest
b. Respiratory rate of 8 breaths/min
The nurse is preparing to implement teaching about a heart-healthy diet and activity levels for a patient who has had a myocardial infarction and the patient’s spouse. The patient says, “I don’t see why I need any teaching. I don’t think I need to change anything right now.” Which response is most appropriate?
a. “Do you think your family may want you to make some lifestyle changes?”
b. “Can you tell me why you don’t feel that you need to make any changes?”
c. “You are still in the stage of denial, but you will want this information later on.”
d. “Even though you don’t want to change, it’s important that you have this teaching.”
b. “Can you tell me why you don’t feel that you need to make any changes?”
The nurse is assessing a patient with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse’s best action?
a. Perform a complete neurologic assessment.
b. Assess the cranial nerve functions.
c. Contact the rapid response team.
d. Reassess the patient in 30 minutes.
c. Contact the rapid response team.
Which laboratory results would the nurse check to determine if there are untoward effects associated with vomiting, nasogastric suction, or lavage?
a. White blood cell (WBC) counts
b. Hematocrit and hemoglobin
c. Serum electrolytes
d. Blood urea nitrogen (BUN) and serum creatinine
c. Serum electrolytes
A patient has urolithiasis and is passing the stones into the lower urinary tract. What is the priority nursing concern for the patient at this time?
a. Pain
b. Infection
c. Injury
d. Anxiety
a. Pain
The nurse is the team leader RN working with a student nurse. The student nurse is teaching a patient how to use a metered-dose inhaler (MDI) without a spacer. Put in the correct order the steps that the student nurse should teach the patient.
1. Remove the inhaler cap and shake the inhaler.
2. Open your mouth and place the mouthpiece 1 to 2 inches (2.5 to 5.0 cm) away.
3. Breathe out completely.
4. Hold your breath for at least 10 seconds.
5. Press down firmly on the canister and breathe deeply through your mouth.
6. Wait at least 1 minute between puffs.
Correct Order: 1, 3, 2, 5, 4, 6
The clinic nurse is evaluating a patient who had coronary artery stenting through the right femoral artery a week previously and is taking metoprolol, clopidogrel, and aspirin. Which information reported by the patient is most important to report to the health care provider?
a. Patient is experiencing shortness of breath and fatigue.
b. Bruising is present at the right groin.
c. Home blood pressure today was 104/52 mm Hg.
d. Home radial pulse rate has been 55 to 60 beats/min.
a. Patient is experiencing shortness of breath and fatigue.
A nursing student is teaching a patient and family about epilepsy before the patient’s discharge. For which statement should the nurse intervene?
a. “You should avoid consumption of all forms of alcohol.”
b. “Wear your medical alert bracelet at all times.”
c. “Protect your loved one’s airway during a seizure.”
d. “It’s OK to take over-the-counter medications.
d. “It’s OK to take over-the-counter medications.
The nurse is planning a treatment and prevention program for chronic bowel incontinence for an older patient. Which intervention should the nurse try first?
a. Administer a glycerin suppository 15 minutes before evacuation time.
b. Insert a rectal tube at specified intervals each day.
c. Assist the patient to the commode or toilet 30 minutes after meals.
d. Use incontinence briefs or adult-sized diapers.
c. Assist the patient to the commode or toilet 30 minutes after meals.
The nurse is creating a care plan for older adult patients with incontinence. For which patient will a bladder-training program be an appropriate intervention?
a. Patient with functional incontinence caused by mental status changes
b. Patient with stress incontinence due to weakened bladder neck support
c. Patient with urge incontinence and abnormal detrusor muscle contractions
d. Patient with transient incontinence related to loss of cognitive function
c. Patient with urge incontinence and abnormal detrusor muscle contractions
The nurse is caring for a patient after thoracentesis. Which actions can be delegated by the nurse to the assistive personnel (AP)? Select all that apply.
a. Assess puncture site and dressing for leakage.
b. Check vital signs every 15 minutes for 1 hr.
c. Auscultate for absent or reduced lung sounds.
d. Remind the patient to take deep breaths.
e. Take the specimens to the laboratory.
f. Teach the patient the symptoms of pneumothorax.
b. Check vital signs every 15 minutes for 1 hr.
d. Remind the patient to take deep breaths.
e. Take the specimens to the laboratory.
The emergency department nurse is caring for a patient who was just admitted with left anterior chest pain, suggesting possible acute myocardial infarction (MI). Which action will the nurse take first?
a. Insert an IV catheter.
b. Auscultate heart sounds.
c. Administer sublingual nitroglycerin.
d. Draw blood for troponin I measurement.
c. Administer sublingual nitroglycerin.
The nurse is providing care for a patient with an acute hemorrhagic stroke. The patient’s spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse’s best response?
a. “Your wife was not admitted within the time frame that alteplase is usually given.”
b. “This drug is used primarily for patients who experience an acute heart attack.”
c. “Alteplase dissolves clots and may cause more bleeding into your wife’s brain.”
d. “Your wife just had gallbladder surgery 6 months ago, so we can’t use alteplase.”
c. “Alteplase dissolves clots and may cause more bleeding into your wife’s brain.”
After a nasogastric tube is inserted, which assessment finding is cause for greatest concern?
a. The patient reports that the tube is irritating their nose and their throat feels sore.
b. Gastric contents have a coffee-ground appearance.
c. The patient demonstrates coughing and cannot speak clearly.
d. Gastric fluid is bright red and has small clots.
c. The patient demonstrates coughing and cannot speak clearly.
The nurse is caring for a patient at risk for kidney disease for whom a urinalysis has been ordered. What time would the nurse instruct the assistive personnel is best to collect this sample?
a. With first morning void
b. Before any meal
c. At bedtime
d. Immediately
a. With first morning void
When a patient with tuberculosis (TB) is being prepared for discharge, which statement by the patient indicates a need for further teaching?
a. “Everyone in my family needs to go and see the doctor for TB testing.”
b. “I will continue to take my isoniazid until I am feeling completely well.”
c. “I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag.”
d. “I will change my diet to include more foods rich in iron, protein, and vitamin C.”
b. “I will continue to take my isoniazid until I am feeling completely well.”
The nurse in the cardiovascular clinic receives telephone calls from four patients. Which patient should be scheduled to be seen most urgently?
a. Patient with peripheral arterial disease who complains of leg cramps when walking
b. Patient with atrial fibrillation who reports episodes of lightheadedness and syncope
c. Patient with a new permanent pacemaker who has severe itchiness at the wound site
d. Patient with angina who took nitroglycerin twice in the last week while exercising
b. Patient with atrial fibrillation who reports episodes of lightheadedness and syncope
All of the following nursing care activities are included in the care plan for a 78-year-old man with Parkinson disease who has been referred to the home health agency. Which activities will the nurse delegate to the assistive personnel (AP)? Select all that apply.
a. Checking for orthostatic changes in pulse and blood pressure
b. Assessing for improvement in tremor after levodopa is given
c. Reminding the patient to allow adequate time for meals
d. Monitoring for signs of toxic reactions to anti-Parkinson medications
e. Assisting the patient with prescribed strengthening exercises
f. Adapting the patient’s preferred activities to his level of function
a. Checking for orthostatic changes in pulse and blood pressure
c. Reminding the patient to allow adequate time for meals
e. Assisting the patient with prescribed strengthening exercises
The nurse would be most concerned about a prescription for a total parenteral nutrition (TPN) fat emulsion for a patient with which condition?
a. Gastrointestinal (GI) obstruction
b. Severe anorexia nervosa
c. Chronic diarrhea and vomiting
d. Fractured femur
d. Fractured femur
The nurse is caring for a patient with risk for incomplete bladder emptying. Which noninvasive finding best supports this problem?
a. Patient is able to void additional 100 mL after nurse massages over the bladder.
b. Patient voids additional 350 mL with insertion of an intermittent catheter.
c. Patient has postvoid residual of 275 mL documented by bedside bladder scanner.
d. Patient has constant dribbling between voidings.
c. Patient has postvoid residual of 275 mL documented by bedside bladder scanner.
The nurse is acting as a preceptor for a newly graduated RN during the second week of orientation. The nurse would assign and supervise the new RN to provide nursing care for which patients? Select all that apply.
a. A 38 yr-old patient with moderate persistent asthma awaiting discharge.
b. A 63 yr-old patient with a tracheostomy needed tracheostomy care every shift.
c. A 56 yr-old patient with lung cancer who has just undergone left lower lobectomy.
d. A 49 yr-old patient just admitted with a new diagnosis of esophageal cancer.
e. A 76 yr-old patient newly diagnosed with type 2 DM.
f. A 69 yr-old patient with emphysema to be discharged tomorrow.
a. A 38 yr-old patient with moderate persistent asthma awaiting discharge.
b. A 63 yr-old patient with a tracheostomy needed tracheostomy care every shift.
f. A 69 yr-old patient with emphysema to be discharged tomorrow.
The nurse is caring for a patient who has heart failure and a new prescription for sacubitril–valsartan. Which patient information is most important to discuss with the health care provider before administration of the medication?
a. The patient’s oxygen saturation is 92%.
b. The patient receives lisinopril 10 mg/day.
c. The patient’s blood pressure is 150/90 mm Hg.
d. The patient’s potassium is 3.3 mEq/L (3.3 mmol/L).
b. The patient receives lisinopril 10 mg/day.
A patient with a spinal cord injury reports a sudden severe throbbing headache that started a short time ago. Assessment of the patient reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should the nurse take first?
a. Administer the ordered acetaminophen.
b. Check the indwelling catheter tubing for kinks or obstruction.
c. Adjust the temperature in the patient’s room.
d. Notify the health care provider (HCP) about the change in status.
b. Check the indwelling catheter tubing for kinks or obstruction.
The nurse is caring for an obese postoperative patient who underwent surgery for bowel resection. As the patient is moving in bed, he comments, “Something popped open.” Upon examination, the nurse notes wound evisceration. Place the steps in order for handling this complication.
1. Cover the intestine with sterile moistened gauze.
2. Stay calm and stay with the patient.
3. Check the vital signs, especially blood pressure and pulse.
4. Ask assistive personnel (AP) to get sterile supplies.
5. Put the patient into semi-Fowler position with knees slightly flexed.
6. Prepare the patient for surgery as ordered.
7. Ask charge nurse to call the surgeon.
Correct Order: 2, 5, 3, 7, 4, 1, 6
The RN is teaching a patient how to perform intermittent self-catheterization for a long-term problem with incomplete bladder emptying. Which are the most important points for teaching this technique? Select all that apply.
a. Always use sterile techniques.
b. Proper hand washing and cleaning of the catheter reduce the risk for infection.
c. A small lumen and good lubrication of the catheter prevent urethral trauma.
d. A regular schedule for bladder emptying prevents distention and mucosal trauma.
e. The social work department can help you with the purchase of sterile supplies.
f. If you are uncomfortable with this procedure, a home health nurse can do it.
b. Proper hand washing and cleaning of the catheter reduce the risk for infection.
c. A small lumen and good lubrication of the catheter prevent urethral trauma.
d. A regular schedule for bladder emptying prevents distention and mucosal trauma.