ADULT HEALTH NURSING (UNIT ONE) EXAM
n n n n n
TEST BANK
n n n n
The nnurse nis ncaring nfor na npatient nwith nchronic nobstructive npulmonary ndisease n(COPD). nThe npatient
has nbeen nreceiving nhigh-flow noxygen ntherapy nfor nan nextended ntime. nWhat nsymptoms nshould nthe
n
nurse nanticipate nif nthe npatient nwere nexperiencing noxygen ntoxicity? n
n
A) Bradycardia nand nfrontal nheadache n
B) Dyspnea nand nsubsternal npain n
C) Peripheral ncyanosis nand nrestlessness n
D) Hypotension nand ntachycardia n- nCORRECT nANSWER n-B n
Oxygen ntoxicity ncan noccur nwhen npatients nreceive ntoo nhigh na nconcentration nof noxygen nfor nan
extended nperiod. nSymptoms nof noxygen ntoxicity ninclude ndyspnea, nsubsternal npain, nrestlessness,
n
fatigue, nand nprogressive nrespiratory ndifficulty. nBradycardia, nfrontal nheadache, ncyanosis, nhypotension,
n
and ntachycardia nare nnot nsymptoms nof noxygen ntoxicity. n
n
n
The nnurse ncaring nfor na npatient nwith nan nendotracheal ntube nrecognizes nseveral ndisadvantages
of nan nendotracheal ntube. nWhat nwould nthe nnurse nrecognize nas na ndisadvantage nof
n
endotracheal ntubes? nA) nCognition nis ndecreased. n
n
B) Daily narterial nblood ngases n(ABGs) nare nnecessary. n
C) Slight ntracheal nbleeding nis nanticipated. n
D) The ncough nreflex nis ndepressed. n- nCORRECT nANSWER n-D n
There nare nseveral ndisadvantages nof nan nendotracheal ntube. nDisadvantages ninclude nsuppression nof
the npatients ncough nreflex, nthickening nof nsecretions, nand ndepressed nswallowing nreflexes. nUlceration
n
and nstricture nof nthe nlarynx nor ntrachea nmay ndevelop, nbut nbleeding nis nnot nan nexpected nfinding. nThe
n
tube nshould nnot ninfluence ncognition nand ndaily nABGs nare nnot nalways nrequired. n
n
n
,What nwould nthe ncritical ncare nnurse nrecognize nas na ncondition nthat nmay nindicate na npatients nneed nto
nhave na ntracheostomy? n
A) A npatient nhas na nrespiratory nrate nof n10 nbreaths nper nminute. n
B) A npatient nrequires npermanent nventilation. n
C) A npatient nexhibits nsymptoms nof ndyspnea. n
D) A npatient nhas nrespiratory nacidosis. n- nCORRECT nANSWER n-B n
A ntracheostomy npermits nlong-term nuse nof nmechanical nventilation nto nprevent naspiration nof noral nand
gastric nsecretions nin nthe nunconscious nor nparalyzed npatient. nIndications nfor na ntracheostomy ndo nnot
n
include na nrespiratory nrate nof n10 nbreaths nper nminute, nsymptoms nof ndyspnea, nor nrespiratory
n
acidosis. n
n
n
The nmedical nnurse nis ncreating nthe ncare nplan nof nan nadult npatient nrequiring nmechanical nventilation.
What nnursing naction nis nmost nappropriate? n
n
A) Keep nthe npatient nin na nlow nFowlers nposition. n
B) Perform ntracheostomy ncare nat nleast nonce nper nday. n
C) Maintain ncontinuous nbedrest. n
D) Monitor ncuff npressure nevery n8 nhours. n- nCORRECT nANSWER n-D n
The ncuff npressure nshould nbe nmonitored nevery n8 nhours. nIt nis nimportant nto nperform ntracheostomy
care nat nleast nevery n8 nhours nbecause nof nthe nrisk nof ninfection. nThe npatient nshould nbe nencouraged
n
to nambulate, nif npossible, nand na nlow nFowlers nposition nis nnot nindicated. n
n
n
The nnurse nis ncaring nfor na npatient nwho nis nscheduled nto nhave na nthoracotomy. nWhen nplanning
preoperative nteaching, nwhat ninformation nshould nthe nnurse ncommunicate nto nthe npatient? n
n
A) How nto nmilk nthe nchest ntubing n
B) How nto nsplint nthe nincision nwhen ncoughing n
C) How nto ntake nprophylactic nantibiotics ncorrectly n
,D) How nto nmanage nthe nneed nfor nfluid nrestriction n- nCORRECT nANSWER n-B n
Prior nto nthoracotomy, nthe nnurse neducates nthe npatient nabout nhow nto nsplint nthe nincision nwith nthe
hands, na n
n
pillow, nor na nfolded ntowel. nThe npatient nis nnot ntaught nhow nto nmilk nthe nchest ntubing nbecause nthis nis
performed nby nthe nnurse. nProphylactic nantibiotics nare nnot nnormally nused nand nfluid nrestriction nis
n
not nindicated nfollowing nthoracotomy. n
n
n
A nnurse nis neducating na npatient nin nanticipation nof na nprocedure nthat nwill nrequire na nwater-sealed
chest ndrainage nsystem. nWhat nshould nthe nnurse ntell nthe npatient nand nthe nfamily nthat nthis ndrainage
n
system nis nused nfor? n
n
A) nMaintaining npositive nchest-wall npressure
B) nMonitoring npleural nfluid nosmolarity n
n
C) Providing npositive nintrathoracic npressure n
D) Removing nexcess nair nand nfluid n- nCORRECT nANSWER n-D n
Chest ntubes nand nclosed ndrainage nsystems nare nused nto nre-expand nthe nlung ninvolved nand nto nremove
excess nair, nfluid, nand nblood. nThey nare nnot nused nto nmaintain npositive nchest-wall npressure, nmonitor
n
pleural nfluid, nor nprovide npositive nintrathoracic npressure. n
n
n
A npatient nis nexhibiting nsigns nof na npneumothorax nfollowing ntracheostomy. nThe nsurgeon ninserts na
chest ntube ninto nthe nanterior nchest nwall. nWhat nshould nthe nnurse ntell nthe nfamily nis nthe nprimary
n
purpose nof nthis nchest ntube? n
n
A) To nremove nair nfrom nthe npleural nspace n
B) To ndrain ncopious nsputum nsecretions n
C) To nmonitor nbleeding naround nthe nlungs n
D) To nassist nwith nmechanical nventilation n- nCORRECT nANSWER n-A n
, Chest ntubes nand nclosed ndrainage nsystems nare nused nto nre-expand nthe nlung ninvolved nand nto nremove
excess nair, nfluid, nand nblood. nThe nprimary npurpose nof na nchest ntube nis nnot nto ndrain nsputum
n
secretions, nmonitor nbleeding, nor nassist nwith nmechanical nventilation. n
n
n
A npatients nplan nof ncare nspecifies npostural ndrainage. nWhat naction nshould nthe nnurse nperform nwhen
providing nthis nnoninvasive ntherapy? n
n
A) Administer nthe ntreatment nwith nthe npatient nin na nhigh nFowlers nor nsemi-Fowlers nposition. n
B) Perform nthe nprocedure nimmediately nfollowing nthe npatients nmeals. n
C) Apply npercussion nfirmly nto nbare nskin nto nfacilitate ndrainage. n
D) Assist nthe npatient ninto na nposition nthat nwill nallow ngravity nto nmove nsecretions. n- nCORRECT
ANSWER n-D n
n
Postural ndrainage nis nusually nperformed ntwo nto nfour ntimes nper nday. nThe npatient nuses ngravity nto
facilitate npostural ndraining. nThe nskin nshould nbe ncovered nwith na ncloth nor na ntowel nduring npercussion
n
to nprotect nthe nskin. nPostural ndrainage nis nnot nadministered nin nan nupright nposition nor ndirectly
n
following na nmeal. n
n
n
The ncritical ncare nnurse nis nprecepting na nnew nnurse non nthe nunit. nTogether nthey nare ncaring nfor na
patient nwho nhas na ntracheostomy ntube nand nis nreceiving nmechanical nventilation. nWhat naction nshould
n
the ncritical ncare nnurse nrecommend nwhen ncaring nfor nthe ncuff? n
n
A) Deflate nthe ncuff novernight nto nprevent ntracheal ntissue ntrauma. n
B) Inflate nthe ncuff nto nthe nhighest npossible npressure nin norder nto nprevent naspiration. n
C) Monitor nthe npressure nin nthe ncuff nat nleast nevery n8 nhours n
D) Keep nthe ntracheostomy ntube nplugged nat nall ntimes. n- nCORRECT nANSWER n-C n
Cuff npressure nmust nbe nmonitored nby nthe nrespiratory ntherapist nor nnurse nat nleast nevery n8 nhours nby
nattaching n
a nhandheld npressure ngauge nto nthe npilot nballoon nof nthe ntube nor nby nusing nthe nminimal nleak nvolume
or nminimal nocclusion nvolume ntechnique. nPlugging nis nonly nused nwhen nweaning nthe npatient nfrom
n
n n n n n
TEST BANK
n n n n
The nnurse nis ncaring nfor na npatient nwith nchronic nobstructive npulmonary ndisease n(COPD). nThe npatient
has nbeen nreceiving nhigh-flow noxygen ntherapy nfor nan nextended ntime. nWhat nsymptoms nshould nthe
n
nurse nanticipate nif nthe npatient nwere nexperiencing noxygen ntoxicity? n
n
A) Bradycardia nand nfrontal nheadache n
B) Dyspnea nand nsubsternal npain n
C) Peripheral ncyanosis nand nrestlessness n
D) Hypotension nand ntachycardia n- nCORRECT nANSWER n-B n
Oxygen ntoxicity ncan noccur nwhen npatients nreceive ntoo nhigh na nconcentration nof noxygen nfor nan
extended nperiod. nSymptoms nof noxygen ntoxicity ninclude ndyspnea, nsubsternal npain, nrestlessness,
n
fatigue, nand nprogressive nrespiratory ndifficulty. nBradycardia, nfrontal nheadache, ncyanosis, nhypotension,
n
and ntachycardia nare nnot nsymptoms nof noxygen ntoxicity. n
n
n
The nnurse ncaring nfor na npatient nwith nan nendotracheal ntube nrecognizes nseveral ndisadvantages
of nan nendotracheal ntube. nWhat nwould nthe nnurse nrecognize nas na ndisadvantage nof
n
endotracheal ntubes? nA) nCognition nis ndecreased. n
n
B) Daily narterial nblood ngases n(ABGs) nare nnecessary. n
C) Slight ntracheal nbleeding nis nanticipated. n
D) The ncough nreflex nis ndepressed. n- nCORRECT nANSWER n-D n
There nare nseveral ndisadvantages nof nan nendotracheal ntube. nDisadvantages ninclude nsuppression nof
the npatients ncough nreflex, nthickening nof nsecretions, nand ndepressed nswallowing nreflexes. nUlceration
n
and nstricture nof nthe nlarynx nor ntrachea nmay ndevelop, nbut nbleeding nis nnot nan nexpected nfinding. nThe
n
tube nshould nnot ninfluence ncognition nand ndaily nABGs nare nnot nalways nrequired. n
n
n
,What nwould nthe ncritical ncare nnurse nrecognize nas na ncondition nthat nmay nindicate na npatients nneed nto
nhave na ntracheostomy? n
A) A npatient nhas na nrespiratory nrate nof n10 nbreaths nper nminute. n
B) A npatient nrequires npermanent nventilation. n
C) A npatient nexhibits nsymptoms nof ndyspnea. n
D) A npatient nhas nrespiratory nacidosis. n- nCORRECT nANSWER n-B n
A ntracheostomy npermits nlong-term nuse nof nmechanical nventilation nto nprevent naspiration nof noral nand
gastric nsecretions nin nthe nunconscious nor nparalyzed npatient. nIndications nfor na ntracheostomy ndo nnot
n
include na nrespiratory nrate nof n10 nbreaths nper nminute, nsymptoms nof ndyspnea, nor nrespiratory
n
acidosis. n
n
n
The nmedical nnurse nis ncreating nthe ncare nplan nof nan nadult npatient nrequiring nmechanical nventilation.
What nnursing naction nis nmost nappropriate? n
n
A) Keep nthe npatient nin na nlow nFowlers nposition. n
B) Perform ntracheostomy ncare nat nleast nonce nper nday. n
C) Maintain ncontinuous nbedrest. n
D) Monitor ncuff npressure nevery n8 nhours. n- nCORRECT nANSWER n-D n
The ncuff npressure nshould nbe nmonitored nevery n8 nhours. nIt nis nimportant nto nperform ntracheostomy
care nat nleast nevery n8 nhours nbecause nof nthe nrisk nof ninfection. nThe npatient nshould nbe nencouraged
n
to nambulate, nif npossible, nand na nlow nFowlers nposition nis nnot nindicated. n
n
n
The nnurse nis ncaring nfor na npatient nwho nis nscheduled nto nhave na nthoracotomy. nWhen nplanning
preoperative nteaching, nwhat ninformation nshould nthe nnurse ncommunicate nto nthe npatient? n
n
A) How nto nmilk nthe nchest ntubing n
B) How nto nsplint nthe nincision nwhen ncoughing n
C) How nto ntake nprophylactic nantibiotics ncorrectly n
,D) How nto nmanage nthe nneed nfor nfluid nrestriction n- nCORRECT nANSWER n-B n
Prior nto nthoracotomy, nthe nnurse neducates nthe npatient nabout nhow nto nsplint nthe nincision nwith nthe
hands, na n
n
pillow, nor na nfolded ntowel. nThe npatient nis nnot ntaught nhow nto nmilk nthe nchest ntubing nbecause nthis nis
performed nby nthe nnurse. nProphylactic nantibiotics nare nnot nnormally nused nand nfluid nrestriction nis
n
not nindicated nfollowing nthoracotomy. n
n
n
A nnurse nis neducating na npatient nin nanticipation nof na nprocedure nthat nwill nrequire na nwater-sealed
chest ndrainage nsystem. nWhat nshould nthe nnurse ntell nthe npatient nand nthe nfamily nthat nthis ndrainage
n
system nis nused nfor? n
n
A) nMaintaining npositive nchest-wall npressure
B) nMonitoring npleural nfluid nosmolarity n
n
C) Providing npositive nintrathoracic npressure n
D) Removing nexcess nair nand nfluid n- nCORRECT nANSWER n-D n
Chest ntubes nand nclosed ndrainage nsystems nare nused nto nre-expand nthe nlung ninvolved nand nto nremove
excess nair, nfluid, nand nblood. nThey nare nnot nused nto nmaintain npositive nchest-wall npressure, nmonitor
n
pleural nfluid, nor nprovide npositive nintrathoracic npressure. n
n
n
A npatient nis nexhibiting nsigns nof na npneumothorax nfollowing ntracheostomy. nThe nsurgeon ninserts na
chest ntube ninto nthe nanterior nchest nwall. nWhat nshould nthe nnurse ntell nthe nfamily nis nthe nprimary
n
purpose nof nthis nchest ntube? n
n
A) To nremove nair nfrom nthe npleural nspace n
B) To ndrain ncopious nsputum nsecretions n
C) To nmonitor nbleeding naround nthe nlungs n
D) To nassist nwith nmechanical nventilation n- nCORRECT nANSWER n-A n
, Chest ntubes nand nclosed ndrainage nsystems nare nused nto nre-expand nthe nlung ninvolved nand nto nremove
excess nair, nfluid, nand nblood. nThe nprimary npurpose nof na nchest ntube nis nnot nto ndrain nsputum
n
secretions, nmonitor nbleeding, nor nassist nwith nmechanical nventilation. n
n
n
A npatients nplan nof ncare nspecifies npostural ndrainage. nWhat naction nshould nthe nnurse nperform nwhen
providing nthis nnoninvasive ntherapy? n
n
A) Administer nthe ntreatment nwith nthe npatient nin na nhigh nFowlers nor nsemi-Fowlers nposition. n
B) Perform nthe nprocedure nimmediately nfollowing nthe npatients nmeals. n
C) Apply npercussion nfirmly nto nbare nskin nto nfacilitate ndrainage. n
D) Assist nthe npatient ninto na nposition nthat nwill nallow ngravity nto nmove nsecretions. n- nCORRECT
ANSWER n-D n
n
Postural ndrainage nis nusually nperformed ntwo nto nfour ntimes nper nday. nThe npatient nuses ngravity nto
facilitate npostural ndraining. nThe nskin nshould nbe ncovered nwith na ncloth nor na ntowel nduring npercussion
n
to nprotect nthe nskin. nPostural ndrainage nis nnot nadministered nin nan nupright nposition nor ndirectly
n
following na nmeal. n
n
n
The ncritical ncare nnurse nis nprecepting na nnew nnurse non nthe nunit. nTogether nthey nare ncaring nfor na
patient nwho nhas na ntracheostomy ntube nand nis nreceiving nmechanical nventilation. nWhat naction nshould
n
the ncritical ncare nnurse nrecommend nwhen ncaring nfor nthe ncuff? n
n
A) Deflate nthe ncuff novernight nto nprevent ntracheal ntissue ntrauma. n
B) Inflate nthe ncuff nto nthe nhighest npossible npressure nin norder nto nprevent naspiration. n
C) Monitor nthe npressure nin nthe ncuff nat nleast nevery n8 nhours n
D) Keep nthe ntracheostomy ntube nplugged nat nall ntimes. n- nCORRECT nANSWER n-C n
Cuff npressure nmust nbe nmonitored nby nthe nrespiratory ntherapist nor nnurse nat nleast nevery n8 nhours nby
nattaching n
a nhandheld npressure ngauge nto nthe npilot nballoon nof nthe ntube nor nby nusing nthe nminimal nleak nvolume
or nminimal nocclusion nvolume ntechnique. nPlugging nis nonly nused nwhen nweaning nthe npatient nfrom
n
