NUR 282 Exam 3 Topics Revision
Questions With Solved Solutions.
The nurse is caring for a ct. w/ an acute asthma exacerbation What priority assessment would
concern the nurse most?
1. SOB and temp above 100* F.
2. An O2 sat of 90% and HR >80
3. Inspiratory wheezing and RR>30
4. Tachycardia and pursed-lip breathing - Answer 3. Inspiratory wheezing and RR>30
R: An acute asthma attack is characterized by wheezing, poor movement of the diaphragm,
increased RR, usually higher than 30 breaths/min and HR >120 BPM. W/ these findings the ct. is
forced to sit forward to allow for more effective breathing. Additionally an acute attack causes
the ct to use accessory muscles located in the neck to lift the diaphragm and when percussed,
hyperresonance can be heard in the lung fields. It's also common for the ct. to display agitation,
secondary to hypoxemia. Auscultation of the lungs indicates inspiratory or expiratory wheezing.
The home care nurse is analyzing the ct's understanding of caring for home O2 equipment to
treat COPD. What statement by the ct. indicates additional teaching is needed?
1. I wash the nasal cannula once a month w/ warm water and dish soap
2. I use mouthwash several times per day to deal w/ my dry mouth
3. The company sends mem new cannulas every couple of weeks
4. If I have a cold, I always replace my cannula as soon as I feel better - Answer 1. I wash the
nasal cannula once a month w/ warm water and dish soap
R: The highest risk for infection is the cannula because there's the potential for bacterial growth
due to the humidity. Washing the cannula w/ mild liquid soap and rinsing thoroughly at least
once per week is recommended.
The nurse is caring for ct. w/ pulmonary HTN who asks "Am I going to die?" What's the best
response by the nurse?
1. Of course you aren't going to die, we are taking good care of you.
2. Pulmonary HTN is a scary diagnosis but it won't kill you.
3. You sound frightened, can you tell me more about that?
4. We can give you meds to control your s/s - Answer 3. You sound frightened, can you tell me
more about that?
R: The TX of pulmonary HTN can be challenging and early diagnosis can prevent permanent
,The nurse is assessing a ct. w/ a diagnosis of asthma who reports having a dry cough and
episodic hoarseness. What information is the highest priority for the nurse to collect?
1. Potential seasonal allergies that may compound the asthma s/s
2. Whether a spacer is being used w/ inhalation corticosteroids
3. Any recent prescriptions for bronchodilators for cold s/s
4. Compliance w/ prescribed medications to control asthma s/s - Answer 2. Whether a spacer
is being used w/ inhalation corticosteroids
R: Chronic inflammation is a primary component of asthma which is treated w/ corticosteroid
inhalers. Hoarseness and a dry cough are frequent SE of inhaled corticosteroids and use of a
spacer can reduce or prevent these s/s
The nurse is instructing an UAP regarding the care of a male ct. w/ COPD. What's the highest
priority nursing action to share w/ the UAP?
1. Encourage the ct. to ambulate as much as possible
2. Keep the HOB elevated to 45 degrees
3. Never leave the ct. alone when he is out of bed
4. Offer to help the ct. w/ ADLs - Answer 2. Keep the HOB elevated to 45 degrees
R: Cts w/ COPD experience dyspnea even at rest. Keeping the HOB elevated to 45 degrees can
help the ct/ breathe easier
The clinic nurse is evaluating the OTC meds that a ct. w/ diagnosis of asthma reports taking on a
regular basis. Which meds should be of concern?
1. Multivitamin
2. Low dose aspirin
3. Probiotic
4. Ginseng - Answer 2. Low dose aspirin
R: Cts w/ asthma should avoid taking any meds that contain aspirin. ASpirin is known to be a
trigger for asthma attacks for many people
The nurse is planning care for a ct w/ a diagnosis of COPD w/ a high anxiety level that causes
SOB. Which action should the nurse take given the ct's reaction to anxiety?
1. Admin prescribed anti-anxiety meds prn
2. Teach pursed-lip breathing to use when feeling anxious
3. Discourage visitors who may cause anxiety to increase
, The nurse has completed the assessment for a ct/ in the clinic w/ diagnosis of chronic asthma.
What would be the priority goal the nurse should discuss w. the ct?
1. Maintaining a regular exercise routine
2. Complying w. med instructions
3. Recognizing triggers that cause asthma attacks
4. Understanding physical limitations caused by this disease - Answer 3. Recognizing triggers
that cause asthma attacks
R: The priority goal is asthma control AEB minimal s/s both during the day and at night. While
med compliance is important, recognizing triggers that cause s/s is the priority to control the
symptoms
The nurse is assessing a ct w/ secondary pulmonary HTN. What statement by the ct. requires
further assessment by the nurse?
1. There's no cure for this so I might as well give up now
2. I need to pay close attention to what causes me to be SOB
3. Regardless of how I feel, I need to make sure I drink plenty of fluids
4. My wife will be a big help at home so I don't have to exert myself - Answer 1. There's no
cure for this so I might as well give up now
R: Although there's no cure for pulmHTN, there are strategies to control s/s, as it is secondary
w/ treatment of the primary illness this could improve. Be wary of suicidal ideations, in people
w/ a chronic diagnosis that feel their life is over
The nurse is assessing a ct brought into the ED w/ respiratory distress and a provisional
diagnosis of asthma. What findings should the nurse anticipate w/ the asthma diagnosis? Select
all.
1. Wheezes
2. Friction rub on auscultation
3. Restlessness
4. Bradycardia
5. Intercostal retractions
6. Cyanosis - Answer 1. Wheezes
3. Restlessness
5. Intercostal retractions
Questions With Solved Solutions.
The nurse is caring for a ct. w/ an acute asthma exacerbation What priority assessment would
concern the nurse most?
1. SOB and temp above 100* F.
2. An O2 sat of 90% and HR >80
3. Inspiratory wheezing and RR>30
4. Tachycardia and pursed-lip breathing - Answer 3. Inspiratory wheezing and RR>30
R: An acute asthma attack is characterized by wheezing, poor movement of the diaphragm,
increased RR, usually higher than 30 breaths/min and HR >120 BPM. W/ these findings the ct. is
forced to sit forward to allow for more effective breathing. Additionally an acute attack causes
the ct to use accessory muscles located in the neck to lift the diaphragm and when percussed,
hyperresonance can be heard in the lung fields. It's also common for the ct. to display agitation,
secondary to hypoxemia. Auscultation of the lungs indicates inspiratory or expiratory wheezing.
The home care nurse is analyzing the ct's understanding of caring for home O2 equipment to
treat COPD. What statement by the ct. indicates additional teaching is needed?
1. I wash the nasal cannula once a month w/ warm water and dish soap
2. I use mouthwash several times per day to deal w/ my dry mouth
3. The company sends mem new cannulas every couple of weeks
4. If I have a cold, I always replace my cannula as soon as I feel better - Answer 1. I wash the
nasal cannula once a month w/ warm water and dish soap
R: The highest risk for infection is the cannula because there's the potential for bacterial growth
due to the humidity. Washing the cannula w/ mild liquid soap and rinsing thoroughly at least
once per week is recommended.
The nurse is caring for ct. w/ pulmonary HTN who asks "Am I going to die?" What's the best
response by the nurse?
1. Of course you aren't going to die, we are taking good care of you.
2. Pulmonary HTN is a scary diagnosis but it won't kill you.
3. You sound frightened, can you tell me more about that?
4. We can give you meds to control your s/s - Answer 3. You sound frightened, can you tell me
more about that?
R: The TX of pulmonary HTN can be challenging and early diagnosis can prevent permanent
,The nurse is assessing a ct. w/ a diagnosis of asthma who reports having a dry cough and
episodic hoarseness. What information is the highest priority for the nurse to collect?
1. Potential seasonal allergies that may compound the asthma s/s
2. Whether a spacer is being used w/ inhalation corticosteroids
3. Any recent prescriptions for bronchodilators for cold s/s
4. Compliance w/ prescribed medications to control asthma s/s - Answer 2. Whether a spacer
is being used w/ inhalation corticosteroids
R: Chronic inflammation is a primary component of asthma which is treated w/ corticosteroid
inhalers. Hoarseness and a dry cough are frequent SE of inhaled corticosteroids and use of a
spacer can reduce or prevent these s/s
The nurse is instructing an UAP regarding the care of a male ct. w/ COPD. What's the highest
priority nursing action to share w/ the UAP?
1. Encourage the ct. to ambulate as much as possible
2. Keep the HOB elevated to 45 degrees
3. Never leave the ct. alone when he is out of bed
4. Offer to help the ct. w/ ADLs - Answer 2. Keep the HOB elevated to 45 degrees
R: Cts w/ COPD experience dyspnea even at rest. Keeping the HOB elevated to 45 degrees can
help the ct/ breathe easier
The clinic nurse is evaluating the OTC meds that a ct. w/ diagnosis of asthma reports taking on a
regular basis. Which meds should be of concern?
1. Multivitamin
2. Low dose aspirin
3. Probiotic
4. Ginseng - Answer 2. Low dose aspirin
R: Cts w/ asthma should avoid taking any meds that contain aspirin. ASpirin is known to be a
trigger for asthma attacks for many people
The nurse is planning care for a ct w/ a diagnosis of COPD w/ a high anxiety level that causes
SOB. Which action should the nurse take given the ct's reaction to anxiety?
1. Admin prescribed anti-anxiety meds prn
2. Teach pursed-lip breathing to use when feeling anxious
3. Discourage visitors who may cause anxiety to increase
, The nurse has completed the assessment for a ct/ in the clinic w/ diagnosis of chronic asthma.
What would be the priority goal the nurse should discuss w. the ct?
1. Maintaining a regular exercise routine
2. Complying w. med instructions
3. Recognizing triggers that cause asthma attacks
4. Understanding physical limitations caused by this disease - Answer 3. Recognizing triggers
that cause asthma attacks
R: The priority goal is asthma control AEB minimal s/s both during the day and at night. While
med compliance is important, recognizing triggers that cause s/s is the priority to control the
symptoms
The nurse is assessing a ct w/ secondary pulmonary HTN. What statement by the ct. requires
further assessment by the nurse?
1. There's no cure for this so I might as well give up now
2. I need to pay close attention to what causes me to be SOB
3. Regardless of how I feel, I need to make sure I drink plenty of fluids
4. My wife will be a big help at home so I don't have to exert myself - Answer 1. There's no
cure for this so I might as well give up now
R: Although there's no cure for pulmHTN, there are strategies to control s/s, as it is secondary
w/ treatment of the primary illness this could improve. Be wary of suicidal ideations, in people
w/ a chronic diagnosis that feel their life is over
The nurse is assessing a ct brought into the ED w/ respiratory distress and a provisional
diagnosis of asthma. What findings should the nurse anticipate w/ the asthma diagnosis? Select
all.
1. Wheezes
2. Friction rub on auscultation
3. Restlessness
4. Bradycardia
5. Intercostal retractions
6. Cyanosis - Answer 1. Wheezes
3. Restlessness
5. Intercostal retractions
