NUR 111 - Exam 3 QA
NUR 111 - Exam 3
Study online at https://quizlet.com/_c3qnz0
1. Which should the nurse do d. Determine patency of the airway.
first when caring for a nonver-
bal patient who is restless, ag- REMEMBER ABCs COME FIRST!!!!!
itated, and irritable?
Early signs of hypoxia are restlessness, agitation, and irritability
a. Reduce environmental
resulting from reduced oxygen to brain cells. A partial or com-
stimuli.
pletely obstructed airway prevents the passage of gases into
b. Administer oxygen.
and out of the lungs. The ABCs (Airway, Breathing, Circulation)
c. Suction the oropharynx.
of emergency care identify airway as the priority.
d. Determine patency of the
airway.
Administering oxygen may or may not be necessary. The need
for oxygen administration will depend on the results of other
interventions that should be done first.
Suctioning the oropharynx is premature. Mucus or sputum may
not be the cause of the problem.
Reducing environmental stimuli will serve no purpose at this
time and is not the priority.
2. A meal tray arrives for a pa- a. Request an order to use a nasal cannula during meals
tient who is receiving 24% oxy-
gen via a Venturi mask. Which A Venturi mask interferes with eating because it covers the nose
should the nurse do to meet and mouth. Using a nasal cannula during meals will help meet
this patient's needs? both the nutritional and oxygen needs of the client. A nasal
a. Request an order to use a cannula delivers oxygen via prongs placed in the client's nares,
nasal cannula during meals. leaving the mouth unobstructed, which promotes talking and
b. Discontinue the oxygen eating. Specific oxygen delivery systems require an order and
when the client is eating are a dependent function of the nurse, except in emergency
meals. situations.
c. Obtain an order to change
Discontinuing oxygen when the client is eating is unsafe be-
the mask to a nonrebreather
cause it can compromise the client's respiratory status while the
mask during meals.
oxygen is disconnected.
d. Arrange for liquid supple-
A Venturi mask and a nonrebreather mask are both masks that
8/25/2026, 8:37:45 AM
, NUR 111 - Exam 3 QA
NUR 111 - Exam 3
Study online at https://quizlet.com/_c3qnz0
ments that can be adminis- cover the mouth, which interferes with eating.
tered via a straw through a Liquid supplements are unnecessary. The client should eat the
valve in the mask. diet ordered by the health care provider.
3. The nurse is caring for a client a. Venturi mask.
with chronic obstructive pul-
monary disease who is pre- A Venturi mask delivers a precise concentration of oxygen de-
scribed a precise oxygen con- spite client variations in respiratory rate, depth or tidal volume.
centration. Which oxygen de- It is a high flow delivery device that can deliver precise concen-
livery system will the nurse se- trations of oxygen up to 50% FIO2.
lect as the best option for the Face mask can be used but does not deliver a precise amount
client? of oxygen.
a. Venturi mask. Nasal cannula delivers approximate concentrations of oxygen
b. Nasal cannula. that can ran from 24-44% at rates of 1L to 6L/min flow rate. The
c. Nasogastric tube. concentration is dependent on flow rates and client respiratory
d. Face mask. depth and rate of breathing.
A nasogastric (NG) tube is not an oxygen delivery device.
4. The nurse is caring for a a. Tachypnea more than 60 breaths/minute.
neonate with respiratory dis-
tress. Which sign appears ear- Tachypnea and expiratory grunting occur early in respiratory
ly for the neonate with respi- distress syndrome to help improve oxygenation.
ratory distress syndrome?
Poor capillary filling time, a later manifestation, occurs if signs
a. Tachypnea more than 60 and symptoms aren't treated.
breaths/minute. A pale gray skin color obscures earlier cyanosis as respiratory
b. Pale gray skin color. distress symptoms persist and worsen.
c. Bilateral crackles. Crackles occur as the respiratory distress progressively worsens.
d. Capillary filling time four
seconds.
5.
8/25/2026, 8:37:45 AM
, NUR 111 - Exam 3 QA
NUR 111 - Exam 3
Study online at https://quizlet.com/_c3qnz0
The nursing is performing a d. Assess respirations while the infant is being held by the
respiratory assessment on a parent.
three-month-old. Which tech-
nique will the nurse use to REMEMBER HOW THIS RELATES TO THE STAGES OF DEVELOP-
obtain an accurate respiratory MENT AND COMFORT
rate?
The most accurate respiratory rate is obtained before disturbing
a. Place the infant flat on the the infant or child. This can often be done easily when the
bed with the chest exposed. parent/caregiver is holding the child before any clothing is
b. Assess respirations after removed.
checking temperature and
The infant's respirations should be taken before disturbing the
blood pressure.
infant. Respiratory rate often changes when infants or young
c. Assess respirations while
children cry, feed, or become more active. They also tend to
the infant is crying.
breathe faster when they are anxious or scared. Count the
d. Assess respirations while
respiratory rate for a full minute to ensure accuracy. Infants' res-
the infant is being held by the
pirations are primarily diaphragmatic, so count the abdominal
parent.
movements. After 1 year of age, count the thoracic movements.
6. A client with COPD reports c. Imbalanced nutrition: Less than body requirements related to
steady weight loss and being fatigue.
"too tired from just breathing
to eat." Which of the following The client's problem is altered nutrition—specifically, less than
nursing diagnoses would be required. The cause, as stated by the client, is the fatigue as-
most appropriate when plan- sociated with the disease process. Instruct the patient to fre-
ning nutritional interventions quently eat high caloric foods in smaller portions. Encourage
for this client? rest before and after meals. COPD patients expend an extraor-
a. Ineffective breathing pat- dinary amount of energy simply on breathing and require high
tern related to alveolar hy- caloric meals to maintain body weight and muscle mass.Activity
poventilation. intolerance is a likely diagnosis but is not related to the client's
b. Weight loss related to nutritional problems.Weight loss is not a nursing diagnosis.Inef-
COPD. fective breathing pattern may be a problem, but this diagnosis
8/25/2026, 8:37:45 AM
NUR 111 - Exam 3
Study online at https://quizlet.com/_c3qnz0
1. Which should the nurse do d. Determine patency of the airway.
first when caring for a nonver-
bal patient who is restless, ag- REMEMBER ABCs COME FIRST!!!!!
itated, and irritable?
Early signs of hypoxia are restlessness, agitation, and irritability
a. Reduce environmental
resulting from reduced oxygen to brain cells. A partial or com-
stimuli.
pletely obstructed airway prevents the passage of gases into
b. Administer oxygen.
and out of the lungs. The ABCs (Airway, Breathing, Circulation)
c. Suction the oropharynx.
of emergency care identify airway as the priority.
d. Determine patency of the
airway.
Administering oxygen may or may not be necessary. The need
for oxygen administration will depend on the results of other
interventions that should be done first.
Suctioning the oropharynx is premature. Mucus or sputum may
not be the cause of the problem.
Reducing environmental stimuli will serve no purpose at this
time and is not the priority.
2. A meal tray arrives for a pa- a. Request an order to use a nasal cannula during meals
tient who is receiving 24% oxy-
gen via a Venturi mask. Which A Venturi mask interferes with eating because it covers the nose
should the nurse do to meet and mouth. Using a nasal cannula during meals will help meet
this patient's needs? both the nutritional and oxygen needs of the client. A nasal
a. Request an order to use a cannula delivers oxygen via prongs placed in the client's nares,
nasal cannula during meals. leaving the mouth unobstructed, which promotes talking and
b. Discontinue the oxygen eating. Specific oxygen delivery systems require an order and
when the client is eating are a dependent function of the nurse, except in emergency
meals. situations.
c. Obtain an order to change
Discontinuing oxygen when the client is eating is unsafe be-
the mask to a nonrebreather
cause it can compromise the client's respiratory status while the
mask during meals.
oxygen is disconnected.
d. Arrange for liquid supple-
A Venturi mask and a nonrebreather mask are both masks that
8/25/2026, 8:37:45 AM
, NUR 111 - Exam 3 QA
NUR 111 - Exam 3
Study online at https://quizlet.com/_c3qnz0
ments that can be adminis- cover the mouth, which interferes with eating.
tered via a straw through a Liquid supplements are unnecessary. The client should eat the
valve in the mask. diet ordered by the health care provider.
3. The nurse is caring for a client a. Venturi mask.
with chronic obstructive pul-
monary disease who is pre- A Venturi mask delivers a precise concentration of oxygen de-
scribed a precise oxygen con- spite client variations in respiratory rate, depth or tidal volume.
centration. Which oxygen de- It is a high flow delivery device that can deliver precise concen-
livery system will the nurse se- trations of oxygen up to 50% FIO2.
lect as the best option for the Face mask can be used but does not deliver a precise amount
client? of oxygen.
a. Venturi mask. Nasal cannula delivers approximate concentrations of oxygen
b. Nasal cannula. that can ran from 24-44% at rates of 1L to 6L/min flow rate. The
c. Nasogastric tube. concentration is dependent on flow rates and client respiratory
d. Face mask. depth and rate of breathing.
A nasogastric (NG) tube is not an oxygen delivery device.
4. The nurse is caring for a a. Tachypnea more than 60 breaths/minute.
neonate with respiratory dis-
tress. Which sign appears ear- Tachypnea and expiratory grunting occur early in respiratory
ly for the neonate with respi- distress syndrome to help improve oxygenation.
ratory distress syndrome?
Poor capillary filling time, a later manifestation, occurs if signs
a. Tachypnea more than 60 and symptoms aren't treated.
breaths/minute. A pale gray skin color obscures earlier cyanosis as respiratory
b. Pale gray skin color. distress symptoms persist and worsen.
c. Bilateral crackles. Crackles occur as the respiratory distress progressively worsens.
d. Capillary filling time four
seconds.
5.
8/25/2026, 8:37:45 AM
, NUR 111 - Exam 3 QA
NUR 111 - Exam 3
Study online at https://quizlet.com/_c3qnz0
The nursing is performing a d. Assess respirations while the infant is being held by the
respiratory assessment on a parent.
three-month-old. Which tech-
nique will the nurse use to REMEMBER HOW THIS RELATES TO THE STAGES OF DEVELOP-
obtain an accurate respiratory MENT AND COMFORT
rate?
The most accurate respiratory rate is obtained before disturbing
a. Place the infant flat on the the infant or child. This can often be done easily when the
bed with the chest exposed. parent/caregiver is holding the child before any clothing is
b. Assess respirations after removed.
checking temperature and
The infant's respirations should be taken before disturbing the
blood pressure.
infant. Respiratory rate often changes when infants or young
c. Assess respirations while
children cry, feed, or become more active. They also tend to
the infant is crying.
breathe faster when they are anxious or scared. Count the
d. Assess respirations while
respiratory rate for a full minute to ensure accuracy. Infants' res-
the infant is being held by the
pirations are primarily diaphragmatic, so count the abdominal
parent.
movements. After 1 year of age, count the thoracic movements.
6. A client with COPD reports c. Imbalanced nutrition: Less than body requirements related to
steady weight loss and being fatigue.
"too tired from just breathing
to eat." Which of the following The client's problem is altered nutrition—specifically, less than
nursing diagnoses would be required. The cause, as stated by the client, is the fatigue as-
most appropriate when plan- sociated with the disease process. Instruct the patient to fre-
ning nutritional interventions quently eat high caloric foods in smaller portions. Encourage
for this client? rest before and after meals. COPD patients expend an extraor-
a. Ineffective breathing pat- dinary amount of energy simply on breathing and require high
tern related to alveolar hy- caloric meals to maintain body weight and muscle mass.Activity
poventilation. intolerance is a likely diagnosis but is not related to the client's
b. Weight loss related to nutritional problems.Weight loss is not a nursing diagnosis.Inef-
COPD. fective breathing pattern may be a problem, but this diagnosis
8/25/2026, 8:37:45 AM
