NUR 242 EXAM 3 STUDY QUESTIONS AND ANSWERS
1.The nurse immediately checks on the patient and
finds that she appears anxious and her vital signs are
as follows:
ØBlood pressure: 128/84
mm Hg ØHeart rate: 114
(sinus tachycardia)
ØRespiratory rate: 24, labored
and restless ØTemperature: 99.4°
F (axillary)
ØO2 saturation: 91% on 40% O2 via trach collar
Which of these findings are cause for concern?: ANS: **The
BP is within normal range and only slightly elevated. **The
temperature is only slightly elevated. **Her heart rate is elevated;
the nurse should check the patient's medications to see if she is
on a bronchodilator or other medication that could cause her
,heart rate
to increase. The priority concern is the RESTLESSNESS with
increased respiratory rate and the decreased oxygen saturation
despite the 40% oxygen setting.
A patient with a history of chronic obstructive
2.
pulmonary disease is admitted with shortness of
breath. Which nursing intervention is most
appropriate?
A. Do not administer oxygen.
B. Administer oxygen via Venturi mask.
C. Use nasal cannula to administer high flow oxygen.
D. Administer oxygen at 6L per simple face mask.: ANS: B
Oxygen therapy is prescribed at the lowest liter flow needed to
manage hypoxemia. A system that delivers more precise oxygen
levels (e.g., a Venturi mask) is preferred. Monitor the patient's
response to therapy closely to ensure adequate gas exchange and
correction of hypoxemia.
While suctioning a patient, vagal stimulation occurs.
3.
What is the appropriate nursing action?
,A. Instruct the patient to cough.
B. Place the patient in a high Fowler's position.
C. Oxygenate the patient with 100% oxygen.
D. Instruct the patient to breathe slowly and deeply.: ANS:
C
Vagal stimulation may occur during suctioning and result in severe
bradycardia, hypotension, heart block, ventricular
tachycardia, asystole, or other dysrhythmias. If vagal stimulation
occurs, stop suctioning immediately and oxygenate the patient
manually with 100% oxygen. Repositioning the patient, slow deep
breathing, and coughing will not address the cardiovascular
ettects of vagal stimulation.
The nurse recognizes that a patient with sleep
4.
apnea may benefit from which intervention(s)?
(Select all that apply.)
A. Weight loss
B. Nasal mask to deliver BiPAP
C. A change in sleeping position
D. Medication to increase daytime sleepiness
, E. Position-fixing device that prevents tongue subluxation:
ANS: A, B, C, E
All interventions listed are viable interventions that can be of
benefit to patients who have sleep apnea. Patients should work
with their providers of care to determine the severity of their
sleep apnea and which specific interventions would be of most
importance to them. Encouraging daytime sleepiness is the
opposite of the ettect needed for this patient.
Based on the patient's diagnosis, which clinical
5.
manifestations would the nurse expect to see when
assessing this patient? (Select all that apply.)
A. Bradycardia
B. Shortness of breath
C. Use of accessory muscles
D. Sitting in a forward posture
E. Barrel chest appearance: ANS: B, C, D, E
The patient with COPD often has a barrel chest appearance, is
short of breath, and may use accessory muscles when breathing.
1.The nurse immediately checks on the patient and
finds that she appears anxious and her vital signs are
as follows:
ØBlood pressure: 128/84
mm Hg ØHeart rate: 114
(sinus tachycardia)
ØRespiratory rate: 24, labored
and restless ØTemperature: 99.4°
F (axillary)
ØO2 saturation: 91% on 40% O2 via trach collar
Which of these findings are cause for concern?: ANS: **The
BP is within normal range and only slightly elevated. **The
temperature is only slightly elevated. **Her heart rate is elevated;
the nurse should check the patient's medications to see if she is
on a bronchodilator or other medication that could cause her
,heart rate
to increase. The priority concern is the RESTLESSNESS with
increased respiratory rate and the decreased oxygen saturation
despite the 40% oxygen setting.
A patient with a history of chronic obstructive
2.
pulmonary disease is admitted with shortness of
breath. Which nursing intervention is most
appropriate?
A. Do not administer oxygen.
B. Administer oxygen via Venturi mask.
C. Use nasal cannula to administer high flow oxygen.
D. Administer oxygen at 6L per simple face mask.: ANS: B
Oxygen therapy is prescribed at the lowest liter flow needed to
manage hypoxemia. A system that delivers more precise oxygen
levels (e.g., a Venturi mask) is preferred. Monitor the patient's
response to therapy closely to ensure adequate gas exchange and
correction of hypoxemia.
While suctioning a patient, vagal stimulation occurs.
3.
What is the appropriate nursing action?
,A. Instruct the patient to cough.
B. Place the patient in a high Fowler's position.
C. Oxygenate the patient with 100% oxygen.
D. Instruct the patient to breathe slowly and deeply.: ANS:
C
Vagal stimulation may occur during suctioning and result in severe
bradycardia, hypotension, heart block, ventricular
tachycardia, asystole, or other dysrhythmias. If vagal stimulation
occurs, stop suctioning immediately and oxygenate the patient
manually with 100% oxygen. Repositioning the patient, slow deep
breathing, and coughing will not address the cardiovascular
ettects of vagal stimulation.
The nurse recognizes that a patient with sleep
4.
apnea may benefit from which intervention(s)?
(Select all that apply.)
A. Weight loss
B. Nasal mask to deliver BiPAP
C. A change in sleeping position
D. Medication to increase daytime sleepiness
, E. Position-fixing device that prevents tongue subluxation:
ANS: A, B, C, E
All interventions listed are viable interventions that can be of
benefit to patients who have sleep apnea. Patients should work
with their providers of care to determine the severity of their
sleep apnea and which specific interventions would be of most
importance to them. Encouraging daytime sleepiness is the
opposite of the ettect needed for this patient.
Based on the patient's diagnosis, which clinical
5.
manifestations would the nurse expect to see when
assessing this patient? (Select all that apply.)
A. Bradycardia
B. Shortness of breath
C. Use of accessory muscles
D. Sitting in a forward posture
E. Barrel chest appearance: ANS: B, C, D, E
The patient with COPD often has a barrel chest appearance, is
short of breath, and may use accessory muscles when breathing.
