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.
Based on the patient’s diagnosis, which clinical 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. These patients tend to move slowly and are slightly
stooped. Usually they sit with a forward-bending posture. With severe dyspnea, they exhibit
activity intolerance and activities such as bathing and grooming are avoided.
When the patient arrives to the unit, she is assessed and is in acute respiratory distress. Her
respirations are labored and her respiratory rate is 34. She states that she had a peak flow
meter measurement of "Red Zone" on the way and is severely short of air. Her oxygen
saturation is 82% on O2 at 2 L via nasal cannula.
Based on these findings, what should the nurse do next?
ANS: The Rapid Response Team should be notified immediately. All of these assessment
findings indicate acute respiratory distress. The peak flow meter is in the RED Zone. The
oxygen saturation should be at least 90% on 2 L per NC.
While the Rapid Response Team is at the bedside, the patient's healthcare provider arrives. The
provider writes several orders.
Which order is most important for the nurse to implement immediately?
A. Transfer to ICU
B. Increase O2 to 3 L per nasal cannula
C. ABGs 30 minutes after oxygen is increased
D. Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP
ANS: B
All of the provider’s orders are very important, but based on the patient’s severe shortness of
breath, the first thing that should be done is to increase her oxygen. Once her oxygen is
increased, the nurse should note the time and remember to call for stat ABGs in 30 minutes.
The patient should then be transferred to the ICU as soon as possible. Once the patient arrives
in the ICU, they can administer the one-time dose of Solu-Medrol.
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.
Based on the patient’s diagnosis, which clinical 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. These patients tend to move slowly and are slightly
stooped. Usually they sit with a forward-bending posture. With severe dyspnea, they exhibit
activity intolerance and activities such as bathing and grooming are avoided.
When the patient arrives to the unit, she is assessed and is in acute respiratory distress. Her
respirations are labored and her respiratory rate is 34. She states that she had a peak flow
meter measurement of "Red Zone" on the way and is severely short of air. Her oxygen
saturation is 82% on O2 at 2 L via nasal cannula.
Based on these findings, what should the nurse do next?
ANS: The Rapid Response Team should be notified immediately. All of these assessment
findings indicate acute respiratory distress. The peak flow meter is in the RED Zone. The
oxygen saturation should be at least 90% on 2 L per NC.
While the Rapid Response Team is at the bedside, the patient's healthcare provider arrives. The
provider writes several orders.
Which order is most important for the nurse to implement immediately?
A. Transfer to ICU
B. Increase O2 to 3 L per nasal cannula
C. ABGs 30 minutes after oxygen is increased
D. Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP
ANS: B
All of the provider’s orders are very important, but based on the patient’s severe shortness of
breath, the first thing that should be done is to increase her oxygen. Once her oxygen is
increased, the nurse should note the time and remember to call for stat ABGs in 30 minutes.
The patient should then be transferred to the ICU as soon as possible. Once the patient arrives
in the ICU, they can administer the one-time dose of Solu-Medrol.
