The nurse is providing care for a patient diagnosed with laryngeal cancer who is receiving
radiation therapy. The patient tells the nurse that he is experiencing hoarseness and difficulty
with speaking. What is the nurse's best response? - Answers "Your voice should improve in 6 to
8 weeks after completion of the radiation."
The nurse is supervising a nursing student providing care for a patient with shortness of breath
who has expressed interest in smoking cessation.
Which questions would the nurse suggest the student ask to determine nicotine dependence? -
Answers - How soon after you wake up in the morning do you smoke?
- Do you smoke when you are ill?
- Do you wake up in the middle of your sleep time to smoke?
- Do you have a difficult time not smoking in places where it is not allowed?
The RN clinical instructor is discussing a patient's oxygen-hemoglobin dissociation curve with a
student (Figure 6.1). The student states that the patient's oral body temperature is elevated at
100.8°F (38.2°C). Which statement by the student indicates correct understanding of this
patient's curve shift? - Answers "When the patient's body temperature is elevated, there is a shift
to the right so that hemoglobin will dissociate oxygen faster."
An experienced LPN/LVN, under the supervision of the team leader RN, is assigned to provide
nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope
of practice of an experienced LPN/LVN? Select all that apply. - Answers - Auscultating breath
sounds
- Administering medications via metered-dose inhaler (MDI)
- Checking oxygen saturation using pulse oximetry
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? - Answers Respiratory rate of 8 breaths/min
The assistive personnel (AP) tells the nurse that a patient who is receiving oxygen at a flow rate
of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should the
nurse suggest to the AP to improve the patient's comfort? - Answers Apply water-soluble jelly to
the nares.
The RN is teaching an assistive personnel (AP) to check oxygen saturation by pulse oximetry.
What will the nurse be sure to tell the AP about patients with darker skin? - Answers "Usually
dark-skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light-
, skinned patients."
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. - Answers - Check vital signs every
15 minutes for 1 hour.
- Remind the patient to take deep breaths.
- Take the specimens to the laboratory.
The nurse is supervising a student nurse who is performing tracheostomy care for a patient.
Which action by the student would cause the nurse to intervene? - Answers Removing the inner
cannula and cleaning using standard precautions
The nurse is supervising an RN who floated from the medical-surgical unit to the emergency
department. The float nurse is providing care for a patient admitted with anterior epistaxis
(nosebleed). Which directions would the supervising nurse clearly provide to the RN? Select all
that apply. - Answers - Apply direct lateral pressure to the nose
for 5 minutes.
- Maintain standard body substance precautions.
- Apply ice or cool compresses to the nose.
- Instruct the patient not to blow the nose for several hours.
- Teach the patient to avoid vigorous nose blowing.
A patient with a diagnosis of sleep apnea has a problem with sleep deprivation related to a
disrupted sleep cycle. Which action should the nurse delegate to the assistive personnel (AP)? -
Answers Reminding the patient to sleep on his side instead of his back
The nurse is acting as 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. - Answers - A 38-year-old patient with moderate persistent
asthma awaiting discharge
- A 63-year-old patient with a tracheostomy needing tracheostomy care every shift
- A 69-year-old patient with emphysema to be discharged tomorrow
The nurse is providing care for a patient with recently diagnosed asthma. Which key points
would the nurse be sure to include in the teaching plan for this patient? Select all that apply. -
Answers - Avoid potential environmental asthma triggers such as smoke.
- Use the inhaler 30 minutes before exercising to prevent bronchospasm.