NUR301 FINAL EXAM PRACTICE
QUESTIONS correctly answered
The nurse understands which is the cause of respiratory alkalosis?
A. hyperglycemia
b. hyperventilation
c. fluid loss
d. airway compromise - correct answer ✔✔b. hyperventilation
the nurse instructs a pt how to use an incentive spirometer. which statement by the pt shows that
teaching is effective?
a. i should take a deep breathe and blow into the mouthpiece
b. im glad i only have to do this twice a day
c. i can ask for pain medication prior to using the spirometer
d. i should lie down to use the spirometer - correct answer ✔✔c. i can ask for pain medication prior to
using the spirometer
rationale: the pt will put the mouthpiece in the mouth and close the lips tightly around it. the pt will
slowly exhale completely. the pt will then inhale slowly and deeply to make the piston rise
the nurse identifies which client is most at risk for developing pneumonia?
a. a client with a urinary catheter
b. a client with an ng tube
c. a client with psoriasis
d. a client with paget disease - correct answer ✔✔b. a client with an ng tube
when assessing a client for tactile remitUs, which part of the hand does the nurse use?
a. fingertips and finger pads
,b. dorsal surface of the hand
c. ulnar and palmar surface of the hand
d. dorsiflexed surface of the wrist - correct answer ✔✔c. ulnar and palmar surface of the hand
rationale: the nurse asks the pt to say the number "99". tactile remits is palpable vibrations that will
increase when lung consolidation exists such as with pneumonia, and decreased with pleural effusion,
pneumothorax, bronchial obstruction or air trapping occurs
a pt is admitted into the hospital with a diagnosis of acute right upper lobe pneumonia. the pt has a
history of chronic bronchitis. which symptom does the nurse expect to see?
a. moist, cool skin
b. rust-colored sputum
c. bradycardia
d. decreased respiratory rate - correct answer ✔✔b. rust-colored sputum
rationale: rust colored sputum, or blood-tinged due to inflammation is a typical finding for pneumonia.
the pt may also have increased respirations, dyspnea, coughing, and pleuritic pain. treatment includes
antibiotics, supplemental oxygen, and chest pt. the nurse should assess breath sounds, VS including
pulse oximetry. the nurse should encourage coughing and deep breathing every 2 hours and increased
fluids
the nurse places a pulse oximetry probe on a pt. the pt asks "why do i have this thing on me?" which
response by the nurse is the best?
a. it enables your IV fluids to run
b. it monitors your pulse rate
c it tells us if your BP is within normal limits
d it measures the amount of oxygen circulating in your blood - correct answer ✔✔d it measures the
amount of oxygen circulating in your blood
on the first post day, a pt developed a fever. the nurse auscultates crackles bilaterally in the lower lobes.
the nurse understands which complication of surgery is probably developing?
a. HF
b. thromophlebitis
,c. PE
d. atelectasis - correct answer ✔✔d. atelectasis
rationale: general anesthesia is a common cause of atelectasis. atelectasis occurs when secretions block
the bronchioles and the alveoli collapse, causing hypoventilation. deep breathing excercies and coughing
after surgery can reduce the pt's risk of developing this
the nurse monitors a client receiving oxygen per face mask. the nurse is most concerned with which
observation
a. there is condensation in the tubing
b. the pulse oximetry reading is 92%
c. the client has a nonproductive cough
d. the skin under the elastic band is reddened - correct answer ✔✔c. the client has a nonproductive
cough
rationale: this is a sign of lung oxygen toxicity
which objective data is most important when determining if a pt is hypoxic?
a. cool, bluish skin
b. abnormal blood gases
c. elevated temperature
d. increased sputum production - correct answer ✔✔b. abnormal blood gases
rationale: arterial blood gases (ABG) measures tissue oxygenation, co2 removal, and acid-base balance. if
the pt has inadequate exchange of oxygen and co2, respiratory acidosis occurs
the nurse identifies which type of food is most likely to present problems for a pt with respiratory issues?
a fruits
b grains
c dairy
, d fish - correct answer ✔✔c dairy
rationale: dairy products are mucus producing which can cause thick secretions
after receiving hand off shift report, the nurse assesses a pt who is having cheyne-stokes respirations.
which is the best description of this breathing pattern?
a. regular but increased in rate and abnormally deep respirations
b. irregular patterns of shallow breathing alternating with periods of apnea
c. regular rapid and shallow breathing
d. gradual increase in depth of respirations, followed by a gradual decrease in depth, then a period of
apnea - correct answer ✔✔d. gradual increase in depth of respirations, followed by a gradual decrease
in depth, then a period of apnea
after oxygen had been administered, the next priority intervention the nurse would initiate for a pt with
a pulmonary embolism is the administration of which of the following therapies?
a. normal saline IV fluid
b. IV heparin
c. platelet administration
d. antibiotics for inflammatory fever - correct answer ✔✔b. IV heparin
a pt diagnosed with pneumonia complains of a new onset slight SOB. for which of the following
assessment findings would the nurse call the doctor immediately? (select all that apply
a. the pt is voiding, but amounts are decreasing
b. the pt is sleeping more than usual
c. there is pink coloration to the skin
d. the pt's secretions are thin and milky colored
e. the pt thought it was the 3rd instead of the 5th of the month - correct answer ✔✔b. the pt is sleeping
more than usual
c. there is pink coloration to the skin
the nurse includes which nursing diagnosis in the plan of care for a pt with pneumonia?
QUESTIONS correctly answered
The nurse understands which is the cause of respiratory alkalosis?
A. hyperglycemia
b. hyperventilation
c. fluid loss
d. airway compromise - correct answer ✔✔b. hyperventilation
the nurse instructs a pt how to use an incentive spirometer. which statement by the pt shows that
teaching is effective?
a. i should take a deep breathe and blow into the mouthpiece
b. im glad i only have to do this twice a day
c. i can ask for pain medication prior to using the spirometer
d. i should lie down to use the spirometer - correct answer ✔✔c. i can ask for pain medication prior to
using the spirometer
rationale: the pt will put the mouthpiece in the mouth and close the lips tightly around it. the pt will
slowly exhale completely. the pt will then inhale slowly and deeply to make the piston rise
the nurse identifies which client is most at risk for developing pneumonia?
a. a client with a urinary catheter
b. a client with an ng tube
c. a client with psoriasis
d. a client with paget disease - correct answer ✔✔b. a client with an ng tube
when assessing a client for tactile remitUs, which part of the hand does the nurse use?
a. fingertips and finger pads
,b. dorsal surface of the hand
c. ulnar and palmar surface of the hand
d. dorsiflexed surface of the wrist - correct answer ✔✔c. ulnar and palmar surface of the hand
rationale: the nurse asks the pt to say the number "99". tactile remits is palpable vibrations that will
increase when lung consolidation exists such as with pneumonia, and decreased with pleural effusion,
pneumothorax, bronchial obstruction or air trapping occurs
a pt is admitted into the hospital with a diagnosis of acute right upper lobe pneumonia. the pt has a
history of chronic bronchitis. which symptom does the nurse expect to see?
a. moist, cool skin
b. rust-colored sputum
c. bradycardia
d. decreased respiratory rate - correct answer ✔✔b. rust-colored sputum
rationale: rust colored sputum, or blood-tinged due to inflammation is a typical finding for pneumonia.
the pt may also have increased respirations, dyspnea, coughing, and pleuritic pain. treatment includes
antibiotics, supplemental oxygen, and chest pt. the nurse should assess breath sounds, VS including
pulse oximetry. the nurse should encourage coughing and deep breathing every 2 hours and increased
fluids
the nurse places a pulse oximetry probe on a pt. the pt asks "why do i have this thing on me?" which
response by the nurse is the best?
a. it enables your IV fluids to run
b. it monitors your pulse rate
c it tells us if your BP is within normal limits
d it measures the amount of oxygen circulating in your blood - correct answer ✔✔d it measures the
amount of oxygen circulating in your blood
on the first post day, a pt developed a fever. the nurse auscultates crackles bilaterally in the lower lobes.
the nurse understands which complication of surgery is probably developing?
a. HF
b. thromophlebitis
,c. PE
d. atelectasis - correct answer ✔✔d. atelectasis
rationale: general anesthesia is a common cause of atelectasis. atelectasis occurs when secretions block
the bronchioles and the alveoli collapse, causing hypoventilation. deep breathing excercies and coughing
after surgery can reduce the pt's risk of developing this
the nurse monitors a client receiving oxygen per face mask. the nurse is most concerned with which
observation
a. there is condensation in the tubing
b. the pulse oximetry reading is 92%
c. the client has a nonproductive cough
d. the skin under the elastic band is reddened - correct answer ✔✔c. the client has a nonproductive
cough
rationale: this is a sign of lung oxygen toxicity
which objective data is most important when determining if a pt is hypoxic?
a. cool, bluish skin
b. abnormal blood gases
c. elevated temperature
d. increased sputum production - correct answer ✔✔b. abnormal blood gases
rationale: arterial blood gases (ABG) measures tissue oxygenation, co2 removal, and acid-base balance. if
the pt has inadequate exchange of oxygen and co2, respiratory acidosis occurs
the nurse identifies which type of food is most likely to present problems for a pt with respiratory issues?
a fruits
b grains
c dairy
, d fish - correct answer ✔✔c dairy
rationale: dairy products are mucus producing which can cause thick secretions
after receiving hand off shift report, the nurse assesses a pt who is having cheyne-stokes respirations.
which is the best description of this breathing pattern?
a. regular but increased in rate and abnormally deep respirations
b. irregular patterns of shallow breathing alternating with periods of apnea
c. regular rapid and shallow breathing
d. gradual increase in depth of respirations, followed by a gradual decrease in depth, then a period of
apnea - correct answer ✔✔d. gradual increase in depth of respirations, followed by a gradual decrease
in depth, then a period of apnea
after oxygen had been administered, the next priority intervention the nurse would initiate for a pt with
a pulmonary embolism is the administration of which of the following therapies?
a. normal saline IV fluid
b. IV heparin
c. platelet administration
d. antibiotics for inflammatory fever - correct answer ✔✔b. IV heparin
a pt diagnosed with pneumonia complains of a new onset slight SOB. for which of the following
assessment findings would the nurse call the doctor immediately? (select all that apply
a. the pt is voiding, but amounts are decreasing
b. the pt is sleeping more than usual
c. there is pink coloration to the skin
d. the pt's secretions are thin and milky colored
e. the pt thought it was the 3rd instead of the 5th of the month - correct answer ✔✔b. the pt is sleeping
more than usual
c. there is pink coloration to the skin
the nurse includes which nursing diagnosis in the plan of care for a pt with pneumonia?
