Exam 4: NSG3130 / NSG 3130 (Latest )
Fundamental Concepts & Skills for Nursing
Practice II | 100% Correct Questions & Answers -
Galen
The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which
oxygen delivery device will the nurse use for this patient?
a. Non-rebreather mask
b. Bag-valve-mask unit
c. Continuous positive airway pressure (CPAP)
d. High-flow nasal cannula
b. Bag-valve-mask unit
The priority of the nurse is to ventilate the patient manually using a bag-valve-mask (BVM) unit.
This allows air to be forced into the patient's lungs when there are no spontaneous respirations.
The non-rebreather mask and nasal cannula require the patient to breathe on his or her own.
CPAP is used for patients who are awake, oriented, and in respiratory failure.
The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient
is breathing spontaneously but is minimally responsive and having difficulty maintaining a
patent airway. Which intervention is the most appropriate for the patient to improve
oxygenation?
a. Insert an oral airway.
b. Lower the head of the bed.
,c. Turn the patient's head to the side.
d. Monitor the patient's pulse oximetry.
a. Insert an oral airway.
An oral (oropharyngeal) airway will prevent the patient's tongue from falling back and occluding
the airway. Lowering the head of the bed will only increase airway occlusion and risk of
aspiration. Turning the patient's head to the side will not clear the back of the patient's tongue
from the airway. Monitoring the patient's pulse oximetry will not improve oxygenation or clear
the airway.
The nurse is caring for a patient with a history of left-sided congestive heart failure who is
acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that
the patient's pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of
the nurse?
a. Administer the ordered intravenous diuretic.
b. Prepare for insertion of a chest tube.
c. Suction secretions from the patient's respiratory tract.
d. Have the patient use the ordered incentive spirometer.
a. Administer the ordered intravenous diuretic.
The patient's respiratory distress is due to pulmonary edema and fluid overload from left-sided
congestive heart failure. A patient with heart failure may be on diuretics. A diuretic will pull the
excess fluid out of the body through the urine and relieve the patient's distress. A chest tube is not
needed as the fluid is within the alveoli rather than between the lung and chest wall. Suctioning
and use of an incentive spirometer will not address fluid overload or improve the patient's
symptoms.
,The nurse is caring for a patient who has been intubated with an oral endotracheal tube for
several weeks. The physicians predict that the patient will need to remain on a ventilator for at
least several more weeks before he will be able to maintain his airway and breathe on his own.
What procedure does the nurse anticipate will be planned for the patient to facilitate recovery?
a. Placement of a tracheostomy tube
b. Diagnostic thoracentesis
c. Pulmonary angiogram
d. Lung transplantation surgery
a. Placement of a tracheostomy tube
Placement of a tracheostomy tube will secure the patient's airway directly through the trachea,
eliminating the need for the endotracheal tube. This will make the patient more comfortable and
may allow eating while minimizing damage to the oropharynx from the endotracheal tube.
The nurse is caring for a patient with a chest tube who was transported to radiology for testing.
When the patient returns to the nursing unit, the transporter shows the nurse the patient's chest
tube collection device, which was badly damaged after being caught in the elevator door. What is
the priority action of the nurse?
a. Clamp the chest tube until the collection device is replaced.
b. Cover the insertion site with a new occlusive dressing.
c. Ensure that there is gentle bubbling in the water seal chamber.
d. Check the patient's lung sounds and pulse oximetry.
a. Clamp the chest tube until the collection device is replaced.
The broken collection device may no longer be used to collect chest tube drainage. Clamping the
chest tube until the collection device is replaced will prevent air from entering the lung space
until the new collection device is attached.
, The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has
the highest priority?
a. Activity intolerance r/t generalized weakness and hypoxemia
b. Impaired nutritional intake r/t poor appetite and increased metabolic needs
c. Impaired airway clearance r/t thick secretions in trachea and bronchi
d. Lack of knowledge r/t use of nebulizer and inhaled bronchodilators
c. Impaired airway clearance r/t thick secretions in trachea and bronchi.
Airway maintenance and patency is the highest priority for all patients, especially patients with
respiratory disorders. Oxygenation is the most important human need. The other diagnoses can
apply once the patient's airway is kept patent.
The nurse is caring for a patient who developed a pulmonary embolism after surgery. Which goal
statement is the highest priority for the nurse to include in the patient's care plan for the diagnosis
impaired gas exchange r/t impaired pulmonary blood flow from embolus?
a. The patient will maintain pulse oximetry values of at least 95% on room air.
b. The patient will verbalize understanding of ordered anticoagulants.
c. The patient will report chest pain of no greater than 3 on a 1 to 10 scale.
d. The patient will ambulate 50 feet in hallway without shortness of breath.
a. The patient will maintain pulse oximetry values of at least 95% on room air.
Oxygenation is the most important human need, so adequate oxygenation of tissues as evidenced
by pulse oximetry values of at least 95% on room air is the highest priority goal. The other goals
may be addressed once the oxygenation goal has been met.
Fundamental Concepts & Skills for Nursing
Practice II | 100% Correct Questions & Answers -
Galen
The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which
oxygen delivery device will the nurse use for this patient?
a. Non-rebreather mask
b. Bag-valve-mask unit
c. Continuous positive airway pressure (CPAP)
d. High-flow nasal cannula
b. Bag-valve-mask unit
The priority of the nurse is to ventilate the patient manually using a bag-valve-mask (BVM) unit.
This allows air to be forced into the patient's lungs when there are no spontaneous respirations.
The non-rebreather mask and nasal cannula require the patient to breathe on his or her own.
CPAP is used for patients who are awake, oriented, and in respiratory failure.
The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient
is breathing spontaneously but is minimally responsive and having difficulty maintaining a
patent airway. Which intervention is the most appropriate for the patient to improve
oxygenation?
a. Insert an oral airway.
b. Lower the head of the bed.
,c. Turn the patient's head to the side.
d. Monitor the patient's pulse oximetry.
a. Insert an oral airway.
An oral (oropharyngeal) airway will prevent the patient's tongue from falling back and occluding
the airway. Lowering the head of the bed will only increase airway occlusion and risk of
aspiration. Turning the patient's head to the side will not clear the back of the patient's tongue
from the airway. Monitoring the patient's pulse oximetry will not improve oxygenation or clear
the airway.
The nurse is caring for a patient with a history of left-sided congestive heart failure who is
acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that
the patient's pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of
the nurse?
a. Administer the ordered intravenous diuretic.
b. Prepare for insertion of a chest tube.
c. Suction secretions from the patient's respiratory tract.
d. Have the patient use the ordered incentive spirometer.
a. Administer the ordered intravenous diuretic.
The patient's respiratory distress is due to pulmonary edema and fluid overload from left-sided
congestive heart failure. A patient with heart failure may be on diuretics. A diuretic will pull the
excess fluid out of the body through the urine and relieve the patient's distress. A chest tube is not
needed as the fluid is within the alveoli rather than between the lung and chest wall. Suctioning
and use of an incentive spirometer will not address fluid overload or improve the patient's
symptoms.
,The nurse is caring for a patient who has been intubated with an oral endotracheal tube for
several weeks. The physicians predict that the patient will need to remain on a ventilator for at
least several more weeks before he will be able to maintain his airway and breathe on his own.
What procedure does the nurse anticipate will be planned for the patient to facilitate recovery?
a. Placement of a tracheostomy tube
b. Diagnostic thoracentesis
c. Pulmonary angiogram
d. Lung transplantation surgery
a. Placement of a tracheostomy tube
Placement of a tracheostomy tube will secure the patient's airway directly through the trachea,
eliminating the need for the endotracheal tube. This will make the patient more comfortable and
may allow eating while minimizing damage to the oropharynx from the endotracheal tube.
The nurse is caring for a patient with a chest tube who was transported to radiology for testing.
When the patient returns to the nursing unit, the transporter shows the nurse the patient's chest
tube collection device, which was badly damaged after being caught in the elevator door. What is
the priority action of the nurse?
a. Clamp the chest tube until the collection device is replaced.
b. Cover the insertion site with a new occlusive dressing.
c. Ensure that there is gentle bubbling in the water seal chamber.
d. Check the patient's lung sounds and pulse oximetry.
a. Clamp the chest tube until the collection device is replaced.
The broken collection device may no longer be used to collect chest tube drainage. Clamping the
chest tube until the collection device is replaced will prevent air from entering the lung space
until the new collection device is attached.
, The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has
the highest priority?
a. Activity intolerance r/t generalized weakness and hypoxemia
b. Impaired nutritional intake r/t poor appetite and increased metabolic needs
c. Impaired airway clearance r/t thick secretions in trachea and bronchi
d. Lack of knowledge r/t use of nebulizer and inhaled bronchodilators
c. Impaired airway clearance r/t thick secretions in trachea and bronchi.
Airway maintenance and patency is the highest priority for all patients, especially patients with
respiratory disorders. Oxygenation is the most important human need. The other diagnoses can
apply once the patient's airway is kept patent.
The nurse is caring for a patient who developed a pulmonary embolism after surgery. Which goal
statement is the highest priority for the nurse to include in the patient's care plan for the diagnosis
impaired gas exchange r/t impaired pulmonary blood flow from embolus?
a. The patient will maintain pulse oximetry values of at least 95% on room air.
b. The patient will verbalize understanding of ordered anticoagulants.
c. The patient will report chest pain of no greater than 3 on a 1 to 10 scale.
d. The patient will ambulate 50 feet in hallway without shortness of breath.
a. The patient will maintain pulse oximetry values of at least 95% on room air.
Oxygenation is the most important human need, so adequate oxygenation of tissues as evidenced
by pulse oximetry values of at least 95% on room air is the highest priority goal. The other goals
may be addressed once the oxygenation goal has been met.
