NUR301 FINAL EXAM
PRACTICE questions fully
solved & updated
The nurse understands which is the cause of respiratory alkalosis?
A. hyperglycemia
b. hyperventilation
c. fluid loss
d. airway compromise - answer b. hyperventilation
the nurse instructs a pt how to use an incentive spirometer. which statement by
the pt shows that teaching is effective?
a. i should take a deep breathe and blow into the mouthpiece
b. im glad i only have to do this twice a day
c. i can ask for pain medication prior to using the spirometer
d. i should lie down to use the spirometer - answer c. i can ask for pain medication
prior to using the spirometer
rationale: the pt will put the mouthpiece in the mouth and close the lips tightly
around it. the pt will slowly exhale completely. the pt will then inhale slowly and
deeply to make the piston rise
the nurse identifies which client is most at risk for developing pneumonia?
a. a client with a urinary catheter
b. a client with an ng tube
c. a client with psoriasis
d. a client with paget disease - answer b. a client with an ng tube
when assessing a client for tactile remitUs, which part of the hand does the nurse
use?
a. fingertips and finger pads
,b. dorsal surface of the hand
c. ulnar and palmar surface of the hand
d. dorsiflexed surface of the wrist - answer c. ulnar and palmar surface of the
hand
rationale: the nurse asks the pt to say the number "99". tactile remits is palpable
vibrations that will increase when lung consolidation exists such as with
pneumonia, and decreased with pleural effusion, pneumothorax, bronchial
obstruction or air trapping occurs
a pt is admitted into the hospital with a diagnosis of acute right upper lobe
pneumonia. the pt has a history of chronic bronchitis. which symptom does the
nurse expect to see?
a. moist, cool skin
b. rust-colored sputum
c. bradycardia
d. decreased respiratory rate - answer b. rust-colored sputum
rationale: rust colored sputum, or blood-tinged due to inflammation is a typical
finding for pneumonia. the pt may also have increased respirations, dyspnea,
coughing, and pleuritic pain. treatment includes antibiotics, supplemental
oxygen, and chest pt. the nurse should assess breath sounds, VS including pulse
oximetry. the nurse should encourage coughing and deep breathing every 2 hours
and increased fluids
the nurse places a pulse oximetry probe on a pt. the pt asks "why do i have this
thing on me?" which response by the nurse is the best?
a. it enables your IV fluids to run
b. it monitors your pulse rate
c it tells us if your BP is within normal limits
d it measures the amount of oxygen circulating in your blood - answer d it
measures the amount of oxygen circulating in your blood
on the first post day, a pt developed a fever. the nurse auscultates crackles
bilaterally in the lower lobes. the nurse understands which complication of
surgery is probably developing?
a. HF
b. thromophlebitis
,c. PE
d. atelectasis - answer d. atelectasis
rationale: general anesthesia is a common cause of atelectasis. atelectasis occurs
when secretions block the bronchioles and the alveoli collapse, causing
hypoventilation. deep breathing excercies and coughing after surgery can reduce
the pt's risk of developing this
the nurse monitors a client receiving oxygen per face mask. the nurse is most
concerned with which observation
a. there is condensation in the tubing
b. the pulse oximetry reading is 92%
c. the client has a nonproductive cough
d. the skin under the elastic band is reddened - answer c. the client has a
nonproductive cough
rationale: this is a sign of lung oxygen toxicity
which objective data is most important when determining if a pt is hypoxic?
a. cool, bluish skin
b. abnormal blood gases
c. elevated temperature
d. increased sputum production - answer b. abnormal blood gases
rationale: arterial blood gases (ABG) measures tissue oxygenation, co2 removal,
and acid-base balance. if the pt has inadequate exchange of oxygen and co2,
respiratory acidosis occurs
the nurse identifies which type of food is most likely to present problems for a pt
with respiratory issues?
a fruits
b grains
c dairy
d fish - answer c dairy
, rationale: dairy products are mucus producing which can cause thick secretions
after receiving hand off shift report, the nurse assesses a pt who is having
cheyne-stokes respirations. which is the best description of this breathing
pattern?
a. regular but increased in rate and abnormally deep respirations
b. irregular patterns of shallow breathing alternating with periods of apnea
c. regular rapid and shallow breathing
d. gradual increase in depth of respirations, followed by a gradual decrease in
depth, then a period of apnea - answer d. gradual increase in depth of
respirations, followed by a gradual decrease in depth, then a period of apnea
after oxygen had been administered, the next priority intervention the nurse
would initiate for a pt with a pulmonary embolism is the administration of which
of the following therapies?
a. normal saline IV fluid
b. IV heparin
c. platelet administration
d. antibiotics for inflammatory fever - answer b. IV heparin
a pt diagnosed with pneumonia complains of a new onset slight SOB. for which of
the following assessment findings would the nurse call the doctor immediately?
(select all that apply
a. the pt is voiding, but amounts are decreasing
b. the pt is sleeping more than usual
c. there is pink coloration to the skin
d. the pt's secretions are thin and milky colored
e. the pt thought it was the 3rd instead of the 5th of the month - answer b. the pt
is sleeping more than usual
c. there is pink coloration to the skin
the nurse includes which nursing diagnosis in the plan of care for a pt with
pneumonia?
a anxiety related to hypoxia
b. deficient knowledge related to cause of disorder
PRACTICE questions fully
solved & updated
The nurse understands which is the cause of respiratory alkalosis?
A. hyperglycemia
b. hyperventilation
c. fluid loss
d. airway compromise - answer b. hyperventilation
the nurse instructs a pt how to use an incentive spirometer. which statement by
the pt shows that teaching is effective?
a. i should take a deep breathe and blow into the mouthpiece
b. im glad i only have to do this twice a day
c. i can ask for pain medication prior to using the spirometer
d. i should lie down to use the spirometer - answer c. i can ask for pain medication
prior to using the spirometer
rationale: the pt will put the mouthpiece in the mouth and close the lips tightly
around it. the pt will slowly exhale completely. the pt will then inhale slowly and
deeply to make the piston rise
the nurse identifies which client is most at risk for developing pneumonia?
a. a client with a urinary catheter
b. a client with an ng tube
c. a client with psoriasis
d. a client with paget disease - answer b. a client with an ng tube
when assessing a client for tactile remitUs, which part of the hand does the nurse
use?
a. fingertips and finger pads
,b. dorsal surface of the hand
c. ulnar and palmar surface of the hand
d. dorsiflexed surface of the wrist - answer c. ulnar and palmar surface of the
hand
rationale: the nurse asks the pt to say the number "99". tactile remits is palpable
vibrations that will increase when lung consolidation exists such as with
pneumonia, and decreased with pleural effusion, pneumothorax, bronchial
obstruction or air trapping occurs
a pt is admitted into the hospital with a diagnosis of acute right upper lobe
pneumonia. the pt has a history of chronic bronchitis. which symptom does the
nurse expect to see?
a. moist, cool skin
b. rust-colored sputum
c. bradycardia
d. decreased respiratory rate - answer b. rust-colored sputum
rationale: rust colored sputum, or blood-tinged due to inflammation is a typical
finding for pneumonia. the pt may also have increased respirations, dyspnea,
coughing, and pleuritic pain. treatment includes antibiotics, supplemental
oxygen, and chest pt. the nurse should assess breath sounds, VS including pulse
oximetry. the nurse should encourage coughing and deep breathing every 2 hours
and increased fluids
the nurse places a pulse oximetry probe on a pt. the pt asks "why do i have this
thing on me?" which response by the nurse is the best?
a. it enables your IV fluids to run
b. it monitors your pulse rate
c it tells us if your BP is within normal limits
d it measures the amount of oxygen circulating in your blood - answer d it
measures the amount of oxygen circulating in your blood
on the first post day, a pt developed a fever. the nurse auscultates crackles
bilaterally in the lower lobes. the nurse understands which complication of
surgery is probably developing?
a. HF
b. thromophlebitis
,c. PE
d. atelectasis - answer d. atelectasis
rationale: general anesthesia is a common cause of atelectasis. atelectasis occurs
when secretions block the bronchioles and the alveoli collapse, causing
hypoventilation. deep breathing excercies and coughing after surgery can reduce
the pt's risk of developing this
the nurse monitors a client receiving oxygen per face mask. the nurse is most
concerned with which observation
a. there is condensation in the tubing
b. the pulse oximetry reading is 92%
c. the client has a nonproductive cough
d. the skin under the elastic band is reddened - answer c. the client has a
nonproductive cough
rationale: this is a sign of lung oxygen toxicity
which objective data is most important when determining if a pt is hypoxic?
a. cool, bluish skin
b. abnormal blood gases
c. elevated temperature
d. increased sputum production - answer b. abnormal blood gases
rationale: arterial blood gases (ABG) measures tissue oxygenation, co2 removal,
and acid-base balance. if the pt has inadequate exchange of oxygen and co2,
respiratory acidosis occurs
the nurse identifies which type of food is most likely to present problems for a pt
with respiratory issues?
a fruits
b grains
c dairy
d fish - answer c dairy
, rationale: dairy products are mucus producing which can cause thick secretions
after receiving hand off shift report, the nurse assesses a pt who is having
cheyne-stokes respirations. which is the best description of this breathing
pattern?
a. regular but increased in rate and abnormally deep respirations
b. irregular patterns of shallow breathing alternating with periods of apnea
c. regular rapid and shallow breathing
d. gradual increase in depth of respirations, followed by a gradual decrease in
depth, then a period of apnea - answer d. gradual increase in depth of
respirations, followed by a gradual decrease in depth, then a period of apnea
after oxygen had been administered, the next priority intervention the nurse
would initiate for a pt with a pulmonary embolism is the administration of which
of the following therapies?
a. normal saline IV fluid
b. IV heparin
c. platelet administration
d. antibiotics for inflammatory fever - answer b. IV heparin
a pt diagnosed with pneumonia complains of a new onset slight SOB. for which of
the following assessment findings would the nurse call the doctor immediately?
(select all that apply
a. the pt is voiding, but amounts are decreasing
b. the pt is sleeping more than usual
c. there is pink coloration to the skin
d. the pt's secretions are thin and milky colored
e. the pt thought it was the 3rd instead of the 5th of the month - answer b. the pt
is sleeping more than usual
c. there is pink coloration to the skin
the nurse includes which nursing diagnosis in the plan of care for a pt with
pneumonia?
a anxiety related to hypoxia
b. deficient knowledge related to cause of disorder
