NURS 355 Exam 2 Questions and Answers| New Update with 100% Correct Answers
Which information obtained by the nurse in the endocrine clinic about a patient who has been
taking prednisone 40 mg daily for 3 weeks is most important to report to the health care
provider?
a. Patient's blood pressure is 148/94 mm Hg.
b. Patient has bilateral 2+ pitting ankle edema.
c. Patient stopped taking the medication 2 days ago.
d. Patient has not been taking the prescribed vitamin D. Answer: Patient stopped taking the
medication 2 days ago.
Rationale: Sudden cessation of corticosteroids after taking the medication for a week or more
can lead to adrenal insufficiency, with problems such as severe hypotension and hypoglycemia.
The patient will need immediate evaluation by the health care provider to prevent or treat
adrenal insufficiency. The other information will also be reported but does not require rapid
treatment.
Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse
should contact the health care provider before administering levothyroxine (Synthroid)?
a. Increased thyroxine (T4) level
b. Blood pressure 112/62 mm Hg
c. Distant and difficult to hear heart sounds
d. Elevated thyroid stimulating hormone level Answer: Increased thyroxine (T4) level
Rationale: An increased thyroxine level indicates the levothyroxine dose needs to be decreased.
The other data are consistent with hypothyroidism and the nurse should administer the
levothyroxine.
,The nurse teaches a patient about pulmonary spirometry testing. Which statement by the
patient indicates teaching was effective?
a. "I should use my inhaler right before the test."
b. "I won't eat or drink anything 8 hours before the test."
c. "I will inhale deeply and blow out hard during the test."
d. "My blood pressure and pulse will be checked every 15 minutes." Answer: "I will inhale
deeply and blow out hard during the test."
Rationale: For spirometry, the patient should inhale deeply and exhale as long, hard, and fast as
possible. The other actions are not needed. The administration of inhaled bronchodilators
should be avoided 6 hours before the procedure.
A patient with acute shortness of breath is admitted to the hospital. Which action should the
nurse take during the initial assessment of the patient?
a. Ask the patient to lie down for complete a full physical assessment.
b. Complete the health history and check for allergies before treatment.
c. Briefly ask specific questions about this episode of respiratory distress.
d. Delay the physical assessment to first complete pulmonary function tests. Answer: Briefly
ask specific questions about this episode of respiratory distress
Rationale: When a patient has severe respiratory distress, only information pertinent to the
current episode is obtained, and a more thorough assessment is deferred until later. Obtaining
a comprehensive health history or full physical examination is unnecessary until the acute
distress has resolved. Brief questioning and a focused physical assessment should be done
rapidly to help determine the cause of the distress and suggest treatment. Checking for
allergies is important, but it is not appropriate to complete the entire admission database at
,this time. The initial respiratory assessment must be completed before any diagnostic tests or
interventions can be ordered.
The nurse prepares a patient who has a left-sided pleural effusion for a thoracentesis. How
should the nurse position the patient?
a. High-Fowler's position with the left arm extended
b. Supine with the head of the bed elevated 30 degrees
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table Answer: Sitting upright with
the arms supported on an over bed table
Rationale: The upright position with the arms supported increases lung expansion, allows fluid
to collect at the lung bases, and expands the intercostal space so that access to the pleural
space is easier. The other positions would increase the work of breathing for the patient and
make it more difficult for the health care provider performing the thoracentesis.
A patient with diabetes has arterial blood gas (ABG) results pH 7.28; PaCO2 34 mm Hg; PaO2 85
mm Hg; HCO3?2- 18 mEq/L. The nurse would expect which finding?
a. Intercostal retractions
b. Kussmaul respirations
c. Low oxygen saturation (SpO2)
d. Decreased venous O2 pressure Answer: Kussmaul respirations
Rationale: Kussmaul (deep and rapid) respirations are a compensatory mechanism for
metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Acidosis
, does not cause intercostal retractions, a low oxygen saturation rate, and a decrease in venous
O2 pressure.
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during
inhalation in the lower third bilaterally. How should the nurse document this finding?
a. Inspiratory crackles at the bases
b. Expiratory wheezes in both lungs
c. Abnormal lung sounds in the apices of both lungs
d. Pleural friction rub in the right and left lower lobes Answer: Inspiratory crackles at the
bases
Rationale: Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are
high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the
respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs
are grating sounds that are usually heard during both inspiration and expiration.
The nurse palpates the posterior chest and notes absent fremitus while the patient says "99".
Which action should the nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally. Answer: Auscultate anterior
and posterior breath sounds bilaterally
Which information obtained by the nurse in the endocrine clinic about a patient who has been
taking prednisone 40 mg daily for 3 weeks is most important to report to the health care
provider?
a. Patient's blood pressure is 148/94 mm Hg.
b. Patient has bilateral 2+ pitting ankle edema.
c. Patient stopped taking the medication 2 days ago.
d. Patient has not been taking the prescribed vitamin D. Answer: Patient stopped taking the
medication 2 days ago.
Rationale: Sudden cessation of corticosteroids after taking the medication for a week or more
can lead to adrenal insufficiency, with problems such as severe hypotension and hypoglycemia.
The patient will need immediate evaluation by the health care provider to prevent or treat
adrenal insufficiency. The other information will also be reported but does not require rapid
treatment.
Which finding for a patient who has hypothyroidism and hypertension indicates that the nurse
should contact the health care provider before administering levothyroxine (Synthroid)?
a. Increased thyroxine (T4) level
b. Blood pressure 112/62 mm Hg
c. Distant and difficult to hear heart sounds
d. Elevated thyroid stimulating hormone level Answer: Increased thyroxine (T4) level
Rationale: An increased thyroxine level indicates the levothyroxine dose needs to be decreased.
The other data are consistent with hypothyroidism and the nurse should administer the
levothyroxine.
,The nurse teaches a patient about pulmonary spirometry testing. Which statement by the
patient indicates teaching was effective?
a. "I should use my inhaler right before the test."
b. "I won't eat or drink anything 8 hours before the test."
c. "I will inhale deeply and blow out hard during the test."
d. "My blood pressure and pulse will be checked every 15 minutes." Answer: "I will inhale
deeply and blow out hard during the test."
Rationale: For spirometry, the patient should inhale deeply and exhale as long, hard, and fast as
possible. The other actions are not needed. The administration of inhaled bronchodilators
should be avoided 6 hours before the procedure.
A patient with acute shortness of breath is admitted to the hospital. Which action should the
nurse take during the initial assessment of the patient?
a. Ask the patient to lie down for complete a full physical assessment.
b. Complete the health history and check for allergies before treatment.
c. Briefly ask specific questions about this episode of respiratory distress.
d. Delay the physical assessment to first complete pulmonary function tests. Answer: Briefly
ask specific questions about this episode of respiratory distress
Rationale: When a patient has severe respiratory distress, only information pertinent to the
current episode is obtained, and a more thorough assessment is deferred until later. Obtaining
a comprehensive health history or full physical examination is unnecessary until the acute
distress has resolved. Brief questioning and a focused physical assessment should be done
rapidly to help determine the cause of the distress and suggest treatment. Checking for
allergies is important, but it is not appropriate to complete the entire admission database at
,this time. The initial respiratory assessment must be completed before any diagnostic tests or
interventions can be ordered.
The nurse prepares a patient who has a left-sided pleural effusion for a thoracentesis. How
should the nurse position the patient?
a. High-Fowler's position with the left arm extended
b. Supine with the head of the bed elevated 30 degrees
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table Answer: Sitting upright with
the arms supported on an over bed table
Rationale: The upright position with the arms supported increases lung expansion, allows fluid
to collect at the lung bases, and expands the intercostal space so that access to the pleural
space is easier. The other positions would increase the work of breathing for the patient and
make it more difficult for the health care provider performing the thoracentesis.
A patient with diabetes has arterial blood gas (ABG) results pH 7.28; PaCO2 34 mm Hg; PaO2 85
mm Hg; HCO3?2- 18 mEq/L. The nurse would expect which finding?
a. Intercostal retractions
b. Kussmaul respirations
c. Low oxygen saturation (SpO2)
d. Decreased venous O2 pressure Answer: Kussmaul respirations
Rationale: Kussmaul (deep and rapid) respirations are a compensatory mechanism for
metabolic acidosis. The low pH and low bicarbonate result indicate metabolic acidosis. Acidosis
, does not cause intercostal retractions, a low oxygen saturation rate, and a decrease in venous
O2 pressure.
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during
inhalation in the lower third bilaterally. How should the nurse document this finding?
a. Inspiratory crackles at the bases
b. Expiratory wheezes in both lungs
c. Abnormal lung sounds in the apices of both lungs
d. Pleural friction rub in the right and left lower lobes Answer: Inspiratory crackles at the
bases
Rationale: Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are
high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the
respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs
are grating sounds that are usually heard during both inspiration and expiration.
The nurse palpates the posterior chest and notes absent fremitus while the patient says "99".
Which action should the nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally. Answer: Auscultate anterior
and posterior breath sounds bilaterally
