1. A perioperative nurse is caring for a postoperative patient. The patient has a
shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse
should address the patients increased risk for what complication?
A) Acute respiratory distress syndrome (ARDS)
B) Atelectasis
C) Aspiration
D) Pulmonary embolism
Rationale:
A shallow, monotonous respiratory pattern coupled with immobility places the
patient at an increased risk of developing atelectasis. These specific factors are
less likely to result in pulmonary embolism or aspiration. ARDS involves an
exaggerated inflammatory response and does not normally result from factors
such as immobility and shallow breathing.
2. A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical
complication. The nurses assessment reveals that the patient has an increased work of
breathing due to copious tracheobronchial secretions. What should the nurse
encourage the patient to do?
A) Increase oral fluids unless contraindicated.
B) Call the nurse for oral suctioning, as needed.
C) Lie in a low Fowler's or supine position.
D) Increase activity.
Rationale:
Adequate hydration thins and loosens pulmonary secretions. Oral suctioning is
not sufficiently deep to remove tracheobronchial secretions. The patient
should have the head of the bed raised, and rest should be promoted to avoid
exacerbation of symptoms.
3. The public health nurse is administering Mantoux tests to children who are being
registered for kindergarten in the community. How should the nurse administer this
test?
A) Administer intradermal injections into the children's inner forearms.
B) Administer intramuscular injections into each child's vastus lateralis.
C) Administer a subcutaneous injection into each child s umbilical area.
D) Administer a subcutaneous injection at a 45-degree angle into each child's deltoid.
Rationale:
The purified protein derivative (PPD) is always injected into the intradermal
layer of the inner aspect of the forearm. The subcutaneous and intramuscular
routes are not utilized.
4. The nurse is caring for a patient who has been in a motor vehicle accident and the
care team suspects that the patient has developed pleurisy. Which of the nurses
assessment findings would best corroborate this diagnosis?
A) The patient is experiencing painless hemoptysis.
B) The patients arterial blood gases (ABGs) are normal, but he demonstrates
increased work of breathing.
C) The patients oxygen saturation level is below 88%, but he denies shortness of
breath.
D) The patients pain intensifies when he coughs or takes a deep breath.
Rationale:
,The key characteristic of pleuritic pain is its relationship to respiratory
movement. Taking a deep breath, coughing, or sneezing worsens the pain. The
patients ABGs would most likely be abnormal and shortness of breath would be
expected
5. The nurse caring for a patient recently diagnosed with lung disease encourages the
patient not to smoke. What is the primary rationale behind this nursing action?
A) Smoking decreases the amount of mucus production.
B) Smoke particles compete for binding sites on hemoglobin.
C) Smoking causes atrophy of the alveoli.
D) Smoking damages the ciliary cleansing mechanism.
Rationale:
In addition to irritating the mucous cells of the bronchi and inhibiting the
function of alveolar macrophage (scavenger) cells, smoking damages the ciliary
cleansing mechanism of the respiratory tract. Smoking also increases the amount
of mucus production and distends the alveoli in the lungs. It reduces the
oxygen-carrying capacity of hemoglobin, but not by directly competing for
binding sites.
6. A patient has been brought to the ED by the paramedics. The patient is suspected
of having ARDS. What intervention should the nurse first anticipate?
A) Preparing to assist with intubating the patient
B) Setting up oxygen at 5 L/minute by nasal cannula
C) Performing deep suctioning
D) Setting up a nebulizer to administer corticosteroids
Rationale:
A patient who has ARDS usually requires intubation and mechanical ventilation.
Oxygen by nasal cannula would likely be insufficient. Deep suctioning and
nebulizers may be indicated, but the priority is to secure the airway.
7. The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis
of lung cancer. While assisting with a subclavian vein central line insertion, the nurse
notes the clients oxygen saturation rapidly dropping. The patient complains of
shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has
developed. Further assessment findings supporting the presence of a
pneumothorax include what?
A) Diminished or absent breath sounds on the affected side
B) Paradoxical chest wall movement with respirations
C) Sudden loss of consciousness
D) Muffled heart sounds
Rationale:
In the case of a simple pneumothorax, auscultating the breath sounds will reveal
absent or diminished breath sounds on the affected side. Paradoxical chest wall
movements occur in flail chest conditions. Sudden loss of consciousness does not
typically occur. Muffled or distant heart sounds occur in pericardial tamponade.
8. The nurse is providing discharge teaching for a patient who developed a
pulmonary embolism after total knee surgery. The patient has been converted from
heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse
teach the client?
, A) Coumadin will continue to break up the clot over a period of weeks
B) Coumadin must be taken concurrent with ASA to achieve anticoagulation.
C) Anticoagulant therapy usually lasts between 3 and 6 months.
D) He should take a vitamin supplement containing vitamin K
Rationale:
Anticoagulant therapy prevents further clot formation, but cannot be used to
dissolve a clot. The therapy continues for approximately 3 to 6 months and is not
combined with ASA. Vitamin K reverses the effect of anticoagulant therapy and
normally should not be taken.
9. A new employee asks the occupational health nurse about measures to prevent
inhalation exposure of the substances. Which statement by the nurse will decrease the
patients exposure risk to toxic substances?
A) Position a fan blowing on the toxic substances to prevent the substance from
becoming stagnant in the air.
B) Wear protective attire and devices when working with a toxic substance.
C) Make sure that you keep your immunizations up to date to prevent respiratory
diseases resulting from toxins.
D) Always wear a disposable paper face mask when you are working with inhalable
toxins.
Rationale:
When working with toxic substances, the employee must wear or use protective
devices such as face masks, hoods, or industrial respirators. Immunizations do
not confer protection from toxins and a paper mask is normally insufficient
protection. Never position a fan directly blowing on the toxic substance as it will
disperse the fumes throughout the area.
10. An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed
with a small flail chest injury. Which intervention should the nurse include in the
patients plan of care?
A) Suction the patients airway secretions.
B) Immobilize the ribs with an abdominal binder.
C) Prepare the patient for surgery.
D) Immediately sedate and intubate the patient.
Rationale:
As with rib fracture, treatment of flail chest is usually supportive. Management
includes clearing secretions from the lungs, and controlling pain. If only a small
segment of the chest is involved, it is important to clear the airway through
positioning, coughing, deep breathing, and suctioning. Intubation
is required for severe flail chest injuries, and surgery is required only in rare
circumstances to stabilize the flail segment.
11. The nurse is caring for a patient who is receiving oxygen therapy for pneumonia.
How should the nurse best assess whether the patient is hypoxemic?
A) Assess the patients level of consciousness (LOC).
B) Assess the patients extremities for signs of cyanosis.
C) Assess the patients oxygen saturation level.
D) Review the patients hemoglobin, hematocrit, and red blood cell levels.
Rationale:
shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse
should address the patients increased risk for what complication?
A) Acute respiratory distress syndrome (ARDS)
B) Atelectasis
C) Aspiration
D) Pulmonary embolism
Rationale:
A shallow, monotonous respiratory pattern coupled with immobility places the
patient at an increased risk of developing atelectasis. These specific factors are
less likely to result in pulmonary embolism or aspiration. ARDS involves an
exaggerated inflammatory response and does not normally result from factors
such as immobility and shallow breathing.
2. A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical
complication. The nurses assessment reveals that the patient has an increased work of
breathing due to copious tracheobronchial secretions. What should the nurse
encourage the patient to do?
A) Increase oral fluids unless contraindicated.
B) Call the nurse for oral suctioning, as needed.
C) Lie in a low Fowler's or supine position.
D) Increase activity.
Rationale:
Adequate hydration thins and loosens pulmonary secretions. Oral suctioning is
not sufficiently deep to remove tracheobronchial secretions. The patient
should have the head of the bed raised, and rest should be promoted to avoid
exacerbation of symptoms.
3. The public health nurse is administering Mantoux tests to children who are being
registered for kindergarten in the community. How should the nurse administer this
test?
A) Administer intradermal injections into the children's inner forearms.
B) Administer intramuscular injections into each child's vastus lateralis.
C) Administer a subcutaneous injection into each child s umbilical area.
D) Administer a subcutaneous injection at a 45-degree angle into each child's deltoid.
Rationale:
The purified protein derivative (PPD) is always injected into the intradermal
layer of the inner aspect of the forearm. The subcutaneous and intramuscular
routes are not utilized.
4. The nurse is caring for a patient who has been in a motor vehicle accident and the
care team suspects that the patient has developed pleurisy. Which of the nurses
assessment findings would best corroborate this diagnosis?
A) The patient is experiencing painless hemoptysis.
B) The patients arterial blood gases (ABGs) are normal, but he demonstrates
increased work of breathing.
C) The patients oxygen saturation level is below 88%, but he denies shortness of
breath.
D) The patients pain intensifies when he coughs or takes a deep breath.
Rationale:
,The key characteristic of pleuritic pain is its relationship to respiratory
movement. Taking a deep breath, coughing, or sneezing worsens the pain. The
patients ABGs would most likely be abnormal and shortness of breath would be
expected
5. The nurse caring for a patient recently diagnosed with lung disease encourages the
patient not to smoke. What is the primary rationale behind this nursing action?
A) Smoking decreases the amount of mucus production.
B) Smoke particles compete for binding sites on hemoglobin.
C) Smoking causes atrophy of the alveoli.
D) Smoking damages the ciliary cleansing mechanism.
Rationale:
In addition to irritating the mucous cells of the bronchi and inhibiting the
function of alveolar macrophage (scavenger) cells, smoking damages the ciliary
cleansing mechanism of the respiratory tract. Smoking also increases the amount
of mucus production and distends the alveoli in the lungs. It reduces the
oxygen-carrying capacity of hemoglobin, but not by directly competing for
binding sites.
6. A patient has been brought to the ED by the paramedics. The patient is suspected
of having ARDS. What intervention should the nurse first anticipate?
A) Preparing to assist with intubating the patient
B) Setting up oxygen at 5 L/minute by nasal cannula
C) Performing deep suctioning
D) Setting up a nebulizer to administer corticosteroids
Rationale:
A patient who has ARDS usually requires intubation and mechanical ventilation.
Oxygen by nasal cannula would likely be insufficient. Deep suctioning and
nebulizers may be indicated, but the priority is to secure the airway.
7. The nurse is caring for a patient who is scheduled for a lobectomy for a diagnosis
of lung cancer. While assisting with a subclavian vein central line insertion, the nurse
notes the clients oxygen saturation rapidly dropping. The patient complains of
shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has
developed. Further assessment findings supporting the presence of a
pneumothorax include what?
A) Diminished or absent breath sounds on the affected side
B) Paradoxical chest wall movement with respirations
C) Sudden loss of consciousness
D) Muffled heart sounds
Rationale:
In the case of a simple pneumothorax, auscultating the breath sounds will reveal
absent or diminished breath sounds on the affected side. Paradoxical chest wall
movements occur in flail chest conditions. Sudden loss of consciousness does not
typically occur. Muffled or distant heart sounds occur in pericardial tamponade.
8. The nurse is providing discharge teaching for a patient who developed a
pulmonary embolism after total knee surgery. The patient has been converted from
heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse
teach the client?
, A) Coumadin will continue to break up the clot over a period of weeks
B) Coumadin must be taken concurrent with ASA to achieve anticoagulation.
C) Anticoagulant therapy usually lasts between 3 and 6 months.
D) He should take a vitamin supplement containing vitamin K
Rationale:
Anticoagulant therapy prevents further clot formation, but cannot be used to
dissolve a clot. The therapy continues for approximately 3 to 6 months and is not
combined with ASA. Vitamin K reverses the effect of anticoagulant therapy and
normally should not be taken.
9. A new employee asks the occupational health nurse about measures to prevent
inhalation exposure of the substances. Which statement by the nurse will decrease the
patients exposure risk to toxic substances?
A) Position a fan blowing on the toxic substances to prevent the substance from
becoming stagnant in the air.
B) Wear protective attire and devices when working with a toxic substance.
C) Make sure that you keep your immunizations up to date to prevent respiratory
diseases resulting from toxins.
D) Always wear a disposable paper face mask when you are working with inhalable
toxins.
Rationale:
When working with toxic substances, the employee must wear or use protective
devices such as face masks, hoods, or industrial respirators. Immunizations do
not confer protection from toxins and a paper mask is normally insufficient
protection. Never position a fan directly blowing on the toxic substance as it will
disperse the fumes throughout the area.
10. An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed
with a small flail chest injury. Which intervention should the nurse include in the
patients plan of care?
A) Suction the patients airway secretions.
B) Immobilize the ribs with an abdominal binder.
C) Prepare the patient for surgery.
D) Immediately sedate and intubate the patient.
Rationale:
As with rib fracture, treatment of flail chest is usually supportive. Management
includes clearing secretions from the lungs, and controlling pain. If only a small
segment of the chest is involved, it is important to clear the airway through
positioning, coughing, deep breathing, and suctioning. Intubation
is required for severe flail chest injuries, and surgery is required only in rare
circumstances to stabilize the flail segment.
11. The nurse is caring for a patient who is receiving oxygen therapy for pneumonia.
How should the nurse best assess whether the patient is hypoxemic?
A) Assess the patients level of consciousness (LOC).
B) Assess the patients extremities for signs of cyanosis.
C) Assess the patients oxygen saturation level.
D) Review the patients hemoglobin, hematocrit, and red blood cell levels.
Rationale:
