NUR 242 Exam 3 study questions Unit 7 & 8

NUR 242 Exam 3 study questions Unit 7 & 8 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 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. 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 effects of vagal stimulation. The nurse recognizes that a patient with sleep 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 effect needed for this patient.