NURS 6700 Exam 1 (EAQ Style) Questions with
Correct Answers
A patient comes to a clinic for a regular checkup. The nurse is
performing a physical examination of the patient. Which interventions
should the nurse follow during inspection to get the best results? Select
all that apply. Correct Answer-Make sure that adequate lighting is
available.
Use a penlight or lamp to inspect body cavities.
Inspect each area for size, shape, color, symmetry, position, and
abnormality.
Check for side-to-side symmetry
A patient was admitted after a motor-vehicle accident with multiple
fractured ribs. During respiratory assessment, which signs and
symptoms of secondary pneumothorax would the nurse expect to find?
Correct Answer-Sharp pleuritic pain that worsens on inspiration.
A patient with chronic obstructive pulmonary disorder (COPD) is
administered oxygen therapy using a simple oxygen face mask. After
some time, the patient's blood analysis reveals abnormally high levels of
carbon dioxide. Which should be the nurse's immediate next step?
Correct Answer-Remove the mask and use a nasal cannula for oxygen
supply.
,Rationale:
Simple face masks are designed to deliver high-flow O2. In COPD
patients, this results in hypoventilation. Decreased O2 is the stimulus to
breathe with COPD, so excessive O2 destroys the stimulus. The
resulting hypoventilation causes excessive retention of carbon dioxide.
Additionally, the patient may inhale exhaled carbon dioxide retained in
the mask. Therefore, masks are contraindicated in patients with COPD..
When documenting a nursing assessment, which of the following uses
accurate terminology for respirations? Correct Answer-Bradypnea is less
than 12 breaths per minute.
Tachypnea is greater than 20 breaths per minute.
Apnea is the absence of respirations for some
While assessing a patient, the nurse notices bluish discoloration of the
skin and mucous membrane. Which condition might the nurse suspect
the patient is experiencing? Correct Answer-Hypoxia
Rationale:
Bluish discoloration of the skin and mucous membrane is cyanosis,
which is a clinical manifestation of hypoxia, or reduced tissue
oxygenation.
A patient comes to the clinic for a regular checkup. The nurse is
performing a physical examination on the patient. Which intervention
, should the nurse perform during palpation? Correct Answer-Warm the
hands and use a gentle approach.
A patient with chronic obstructive pulmonary disease (COPD) is
receiving oxygen at 2 L/min. While in the supine position for a bath, the
patient complains of shortness of breath. Which is the most appropriate
first nursing action?
A. Increase the flow of oxygen.
B. Perform tracheal suctioning.
C. Report this to the healthcare provider.
D. Assist the patient to semi-Fowler's position. Correct Answer-D.
Assist the patient to semi-Fowler's position.
Rationale:
LEAST invasive first; Manipulate position/environment first
A patient is admitted to the postanesthesia care unit (PACU)
immediately after undergoing surgery. The nurse finds shallow breathing
and the pulse oximetry value is 90%. Which intervention does the nurse
perform for effective treatment?
Correct Answers
A patient comes to a clinic for a regular checkup. The nurse is
performing a physical examination of the patient. Which interventions
should the nurse follow during inspection to get the best results? Select
all that apply. Correct Answer-Make sure that adequate lighting is
available.
Use a penlight or lamp to inspect body cavities.
Inspect each area for size, shape, color, symmetry, position, and
abnormality.
Check for side-to-side symmetry
A patient was admitted after a motor-vehicle accident with multiple
fractured ribs. During respiratory assessment, which signs and
symptoms of secondary pneumothorax would the nurse expect to find?
Correct Answer-Sharp pleuritic pain that worsens on inspiration.
A patient with chronic obstructive pulmonary disorder (COPD) is
administered oxygen therapy using a simple oxygen face mask. After
some time, the patient's blood analysis reveals abnormally high levels of
carbon dioxide. Which should be the nurse's immediate next step?
Correct Answer-Remove the mask and use a nasal cannula for oxygen
supply.
,Rationale:
Simple face masks are designed to deliver high-flow O2. In COPD
patients, this results in hypoventilation. Decreased O2 is the stimulus to
breathe with COPD, so excessive O2 destroys the stimulus. The
resulting hypoventilation causes excessive retention of carbon dioxide.
Additionally, the patient may inhale exhaled carbon dioxide retained in
the mask. Therefore, masks are contraindicated in patients with COPD..
When documenting a nursing assessment, which of the following uses
accurate terminology for respirations? Correct Answer-Bradypnea is less
than 12 breaths per minute.
Tachypnea is greater than 20 breaths per minute.
Apnea is the absence of respirations for some
While assessing a patient, the nurse notices bluish discoloration of the
skin and mucous membrane. Which condition might the nurse suspect
the patient is experiencing? Correct Answer-Hypoxia
Rationale:
Bluish discoloration of the skin and mucous membrane is cyanosis,
which is a clinical manifestation of hypoxia, or reduced tissue
oxygenation.
A patient comes to the clinic for a regular checkup. The nurse is
performing a physical examination on the patient. Which intervention
, should the nurse perform during palpation? Correct Answer-Warm the
hands and use a gentle approach.
A patient with chronic obstructive pulmonary disease (COPD) is
receiving oxygen at 2 L/min. While in the supine position for a bath, the
patient complains of shortness of breath. Which is the most appropriate
first nursing action?
A. Increase the flow of oxygen.
B. Perform tracheal suctioning.
C. Report this to the healthcare provider.
D. Assist the patient to semi-Fowler's position. Correct Answer-D.
Assist the patient to semi-Fowler's position.
Rationale:
LEAST invasive first; Manipulate position/environment first
A patient is admitted to the postanesthesia care unit (PACU)
immediately after undergoing surgery. The nurse finds shallow breathing
and the pulse oximetry value is 90%. Which intervention does the nurse
perform for effective treatment?
