6001 EXAM QUESTIONS AND ANSWERS %
CORRECT.
1. A nurse caring for a patient with chronic obstructive pulmonary disease (COPD)
knows that hypoxia may occur in patients with respiratory problems. What are
signs of this serious condition?
Select all answers that apply.
A. Dyspnea
B. Hypotension
C. Small pulse pressure
D. Decreased respiratory rate
E. Pallor
F. Increased pulse rate Answer >>> 1. a, c, e, f. If a problem exists in ventilation,
respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an
inadequate amount of oxygen is available to cells. The most common symptoms
of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a
small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.
2. A nurse is suctioning the nasopharyngeal airway of a patient to maintain a
patent airway. For which condition would the nurse anticipate the need for a
nasal trumpet?
A. The patient vomits during suctioning.
,6001
B. The secretions appear to be stomach contents.
C. The catheter touches an unsterile surface.
D. Epistaxis is noted with continued suctioning. Answer >>>. d. When epistaxis is
noted with continued suctioning, the nurse should notify the physician and
anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal
mucosa from further trauma related to suctioning.
3. A nurse is inserting an oropharyngeal airway for a patient who vomits when it is
inserted. Which action would be the first that should be taken by the nurse
related to this occurrence?
A. Quickly position the patient on his or her side.
B. Put on disposable gloves and remove the oral airway.
C. Check that the airway is the appropriate size for the patient.
D. Put on sterile gloves and suction the airway. Answer >>> a. When a patient
vomits upon insertion of an oropharyngeal airway, the nurse should immediately
position the patient on his or her side to prevent aspiration, remove the oral
airway, and suction the mouth if needed
4. A nurse is choosing a catheter to use to suction a patient's endotracheal tube
via an open system. On which variable would the nurse base the size of the
catheter to use?
A. The age of the patient
B. The size of the endotracheal tube
C. The type of secretions to be suctioned
D. The height and weight of the patient Answer >>>. b. The nurse would base the
size of the suctioning catheter on the size of the endotracheal tube. The external
,6001
diameter of the suction catheter should not exceed half of the internal diameter
of the endotracheal tube. Larger catheters can contribute to trauma and
hypoxemia.
5. A nurse is caring for a 16-year-old male patient who has been hospitalized for
an acute asthma exacerbation. Which testing methods might the nurse use to
measure the patient's oxygen saturation? Select all that apply.
A. Thoracentesis
B. Spirometry
C. Pulse oximetry
D. Peak expiratory flow rate
E. Diffusion capacity
F. Maximal respiratory pressure Answer >>> b, c, d.
Spirometers are used to monitor the health status of patients with respiratory
disorders, such as asthma.
Pulse oximetry is used to obtain baseline information about the patient's oxygen
saturation level and is also performed for patients with asthma, along with PEFR
to monitor airflow. These three tests may be administered by the nurse.
Diffusion capacity estimates the patient's ability to absorb alveolar gases and
determines if a gas exchange problem exists. Maximal respiratory pressures help
evaluate neuromuscular causes of respiratory dysfunction. Both tests are usually
performed by a respiratory therapist. The physician or other advanced practice
professional can perform a thoracentesis at the bedside with the nurse assisting,
or in the radiology department.
, 6001
6. A patient with COPD is unable to perform activities of daily living (ADLs)
without becoming exhausted. Which nursing diagnosis best describes this
alteration in oxygenation as the etiology?
A. Decreased Cardiac Output related to difficulty breathing
B. Impaired Gas Exchange related to use of bronchodilators
C. Fatigue related to impaired oxygen transport system
D. Ineffective Airway Clearance related to fatigue Answer >>> c. Fatigue related to
an impaired oxygen transport system is an example of a nursing diagnosis with
alteration in oxygenation as the etiology or cause of other problems. Ineffective
Airway Clearance, Decreased Cardiac Output and Impaired Gas Exchange are
examples of nursing diagnoses indicating alterations in oxygenation as the
problem
7. A nurse working in a long-term care facility is providing teaching to patients
with altered oxygenation due to conditions such as asthma and COPD. Which
measures would the nurse recommend? Select all that apply.
A. Refrain from exercise.
B. Reduce anxiety.
C. Eat meals 1 to 2 hours prior to breathing treatments.
D. Eat a high-protein/high-calorie diet.
E. Maintain a High-Fowler's position when possible.
F. Drink 2 to 3 pints of clear fluids daily Answer >>> b, d, e. When caring for
patients with COPD, it is important to create an environment that is likely to
reduce anxiety and ensure that they eat a high-protein/high-calorie diet. People
with dyspnea and orthopnea are most comfortable in a high Fowler's position
because accessory muscles can easily be used to promote respiration. Patients
with COPD should pace physical activities and schedule frequent rest periods to