NUR 242 Exam 3 study questions Unit 7 & 8
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES ALREADY GRADED A+
The inurse iimmediately ichecks ion ithe ipatient iand ifinds ithat ishe iappears ianxious iand iher ivital isigns
iare ias ifollows:
ØBlood ipressure: i128/84 imm iHg
ØHeart irate: i114 i(sinus itachycardia)
ØRespiratory irate: i24, ilabored iand irestless
ØTemperature: i99.4° iF i(axillary)
ØO2 isaturation: i91% ion i40% iO2 ivia itrach icollar
Which iof ithese ifindings iare icause ifor iconcern? i- icorrect iAnswers i✔✔ i-ANS: i**The iBP iis iwithin
inormal irange iand ionly islightly ielevated. i**The itemperature iis ionly islightly ielevated. i**Her iheart
irate iis ielevated; ithe inurse ishould icheck ithe ipatient's imedications ito isee iif ishe iis ion ia
ibronchodilator ior iother imedication ithat icould icause iher iheart irate ito iincrease. iThe ipriority iconcern
iis ithe iRESTLESSNESS iwith iincreased irespiratory irate iand ithe idecreased ioxygen isaturation idespite
ithe i40% ioxygen isetting.
A ipatient iwith ia ihistory iof ichronic iobstructive ipulmonary idisease iis iadmitted iwith ishortness iof
ibreath. iWhich inursing iintervention iis imost iappropriate?
A. iDo inot iadminister ioxygen.
B. iAdminister ioxygen ivia iVenturi imask.
C. iUse inasal icannula ito iadminister ihigh iflow ioxygen.
D. iAdminister ioxygen iat i6L iper isimple iface imask. i- icorrect iAnswers i✔✔ i-ANS: iB
,Oxygen itherapy iis iprescribed iat ithe ilowest iliter iflow ineeded ito imanage ihypoxemia. iA isystem ithat
idelivers imore iprecise ioxygen ilevels i(e.g., ia iVenturi imask) iis ipreferred. iMonitor ithe ipatient's
iresponse ito itherapy iclosely ito iensure iadequate igas iexchange iand icorrection iof ihypoxemia.
While isuctioning ia ipatient, ivagal istimulation ioccurs. iWhat iis ithe iappropriate inursing iaction?
A. iInstruct ithe ipatient ito icough.
B. iPlace ithe ipatient iin ia ihigh iFowler's iposition.
C. iOxygenate ithe ipatient iwith i100% ioxygen.
D. iInstruct ithe ipatient ito ibreathe islowly iand ideeply. i- icorrect iAnswers i✔✔ i-ANS: iC
Vagal istimulation imay ioccur iduring isuctioning iand iresult iin isevere ibradycardia, ihypotension, iheart
iblock, iventricular itachycardia, iasystole, ior iother idysrhythmias. iIf ivagal istimulation ioccurs, istop
isuctioning iimmediately iand ioxygenate ithe ipatient imanually iwith i100% ioxygen. iRepositioning ithe
ipatient, islow ideep ibreathing, iand icoughing iwill inot iaddress ithe icardiovascular ieffects iof ivagal
istimulation.
The inurse irecognizes ithat ia ipatient iwith isleep iapnea imay ibenefit ifrom iwhich iintervention(s)? i(Select
iall ithat iapply.)
A. iWeight iloss
B. iNasal imask ito ideliver iBiPAP
C. iA ichange iin isleeping iposition
D. iMedication ito iincrease idaytime isleepiness
E. iPosition-fixing idevice ithat iprevents itongue isubluxation i- icorrect iAnswers i✔✔ i-ANS: iA, iB, iC, iE
All iinterventions ilisted iare iviable iinterventions ithat ican ibe iof ibenefit ito ipatients iwho ihave isleep
iapnea. iPatients ishould iwork iwith itheir iproviders iof icare ito idetermine ithe iseverity iof itheir isleep
iapnea iand iwhich ispecific iinterventions iwould ibe iof imost iimportance ito ithem. iEncouraging idaytime
isleepiness iis ithe iopposite iof ithe ieffect ineeded ifor ithis ipatient.
Based ion ithe ipatient's idiagnosis, iwhich iclinical imanifestations iwould ithe inurse iexpect ito isee iwhen
iassessing ithis ipatient? i(Select iall ithat iapply.)
, A. iBradycardia
B. iShortness iof ibreath
C. iUse iof iaccessory imuscles
D. iSitting iin ia iforward iposture
E. iBarrel ichest iappearance i- icorrect iAnswers i✔✔ i-ANS: iB, iC, iD, iE
The ipatient iwith iCOPD ioften ihas ia ibarrel ichest iappearance, iis ishort iof ibreath, iand imay iuse
iaccessory imuscles iwhen ibreathing. iThese ipatients itend ito imove islowly iand iare islightly istooped.
iUsually ithey isit iwith ia iforward-bending iposture. iWith isevere idyspnea, ithey iexhibit iactivity
iintolerance iand iactivities isuch ias ibathing iand igrooming iare iavoided.
When ithe ipatient iarrives ito ithe iunit, ishe iis iassessed iand iis iin iacute irespiratory idistress. iHer
irespirations iare ilabored iand iher irespiratory irate iis i34. iShe istates ithat ishe ihad ia ipeak iflow imeter
imeasurement iof i"Red iZone" ion ithe iway iand iis iseverely ishort iof iair. iHer ioxygen isaturation iis i82%
ion iO2 iat i2 iL ivia inasal icannula.
Based ion ithese ifindings, iwhat ishould ithe inurse ido inext? i- icorrect iAnswers i✔✔ i-ANS: iThe iRapid
iResponse iTeam ishould ibe inotified iimmediately. iAll iof ithese iassessment ifindings iindicate iacute
irespiratory idistress. iThe ipeak iflow imeter iis iin ithe iRED iZone. iThe ioxygen isaturation ishould ibe iat
ileast i90% ion i2 iL iper iNC.
While ithe iRapid iResponse iTeam iis iat ithe ibedside, ithe ipatient's ihealthcare iprovider iarrives. iThe
iprovider iwrites iseveral iorders.
Which iorder iis imost iimportant ifor ithe inurse ito iimplement iimmediately?
A. iTransfer ito iICU
B. iIncrease iO2 ito i3 iL iper inasal icannula
C. iABGs i30 iminutes iafter ioxygen iis iincreased
D. iMethylprednisolone isodium isuccinate i(Solu-Medrol) i40 img iIVP i- icorrect iAnswers i✔✔ i-ANS: iB
QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES ALREADY GRADED A+
The inurse iimmediately ichecks ion ithe ipatient iand ifinds ithat ishe iappears ianxious iand iher ivital isigns
iare ias ifollows:
ØBlood ipressure: i128/84 imm iHg
ØHeart irate: i114 i(sinus itachycardia)
ØRespiratory irate: i24, ilabored iand irestless
ØTemperature: i99.4° iF i(axillary)
ØO2 isaturation: i91% ion i40% iO2 ivia itrach icollar
Which iof ithese ifindings iare icause ifor iconcern? i- icorrect iAnswers i✔✔ i-ANS: i**The iBP iis iwithin
inormal irange iand ionly islightly ielevated. i**The itemperature iis ionly islightly ielevated. i**Her iheart
irate iis ielevated; ithe inurse ishould icheck ithe ipatient's imedications ito isee iif ishe iis ion ia
ibronchodilator ior iother imedication ithat icould icause iher iheart irate ito iincrease. iThe ipriority iconcern
iis ithe iRESTLESSNESS iwith iincreased irespiratory irate iand ithe idecreased ioxygen isaturation idespite
ithe i40% ioxygen isetting.
A ipatient iwith ia ihistory iof ichronic iobstructive ipulmonary idisease iis iadmitted iwith ishortness iof
ibreath. iWhich inursing iintervention iis imost iappropriate?
A. iDo inot iadminister ioxygen.
B. iAdminister ioxygen ivia iVenturi imask.
C. iUse inasal icannula ito iadminister ihigh iflow ioxygen.
D. iAdminister ioxygen iat i6L iper isimple iface imask. i- icorrect iAnswers i✔✔ i-ANS: iB
,Oxygen itherapy iis iprescribed iat ithe ilowest iliter iflow ineeded ito imanage ihypoxemia. iA isystem ithat
idelivers imore iprecise ioxygen ilevels i(e.g., ia iVenturi imask) iis ipreferred. iMonitor ithe ipatient's
iresponse ito itherapy iclosely ito iensure iadequate igas iexchange iand icorrection iof ihypoxemia.
While isuctioning ia ipatient, ivagal istimulation ioccurs. iWhat iis ithe iappropriate inursing iaction?
A. iInstruct ithe ipatient ito icough.
B. iPlace ithe ipatient iin ia ihigh iFowler's iposition.
C. iOxygenate ithe ipatient iwith i100% ioxygen.
D. iInstruct ithe ipatient ito ibreathe islowly iand ideeply. i- icorrect iAnswers i✔✔ i-ANS: iC
Vagal istimulation imay ioccur iduring isuctioning iand iresult iin isevere ibradycardia, ihypotension, iheart
iblock, iventricular itachycardia, iasystole, ior iother idysrhythmias. iIf ivagal istimulation ioccurs, istop
isuctioning iimmediately iand ioxygenate ithe ipatient imanually iwith i100% ioxygen. iRepositioning ithe
ipatient, islow ideep ibreathing, iand icoughing iwill inot iaddress ithe icardiovascular ieffects iof ivagal
istimulation.
The inurse irecognizes ithat ia ipatient iwith isleep iapnea imay ibenefit ifrom iwhich iintervention(s)? i(Select
iall ithat iapply.)
A. iWeight iloss
B. iNasal imask ito ideliver iBiPAP
C. iA ichange iin isleeping iposition
D. iMedication ito iincrease idaytime isleepiness
E. iPosition-fixing idevice ithat iprevents itongue isubluxation i- icorrect iAnswers i✔✔ i-ANS: iA, iB, iC, iE
All iinterventions ilisted iare iviable iinterventions ithat ican ibe iof ibenefit ito ipatients iwho ihave isleep
iapnea. iPatients ishould iwork iwith itheir iproviders iof icare ito idetermine ithe iseverity iof itheir isleep
iapnea iand iwhich ispecific iinterventions iwould ibe iof imost iimportance ito ithem. iEncouraging idaytime
isleepiness iis ithe iopposite iof ithe ieffect ineeded ifor ithis ipatient.
Based ion ithe ipatient's idiagnosis, iwhich iclinical imanifestations iwould ithe inurse iexpect ito isee iwhen
iassessing ithis ipatient? i(Select iall ithat iapply.)
, A. iBradycardia
B. iShortness iof ibreath
C. iUse iof iaccessory imuscles
D. iSitting iin ia iforward iposture
E. iBarrel ichest iappearance i- icorrect iAnswers i✔✔ i-ANS: iB, iC, iD, iE
The ipatient iwith iCOPD ioften ihas ia ibarrel ichest iappearance, iis ishort iof ibreath, iand imay iuse
iaccessory imuscles iwhen ibreathing. iThese ipatients itend ito imove islowly iand iare islightly istooped.
iUsually ithey isit iwith ia iforward-bending iposture. iWith isevere idyspnea, ithey iexhibit iactivity
iintolerance iand iactivities isuch ias ibathing iand igrooming iare iavoided.
When ithe ipatient iarrives ito ithe iunit, ishe iis iassessed iand iis iin iacute irespiratory idistress. iHer
irespirations iare ilabored iand iher irespiratory irate iis i34. iShe istates ithat ishe ihad ia ipeak iflow imeter
imeasurement iof i"Red iZone" ion ithe iway iand iis iseverely ishort iof iair. iHer ioxygen isaturation iis i82%
ion iO2 iat i2 iL ivia inasal icannula.
Based ion ithese ifindings, iwhat ishould ithe inurse ido inext? i- icorrect iAnswers i✔✔ i-ANS: iThe iRapid
iResponse iTeam ishould ibe inotified iimmediately. iAll iof ithese iassessment ifindings iindicate iacute
irespiratory idistress. iThe ipeak iflow imeter iis iin ithe iRED iZone. iThe ioxygen isaturation ishould ibe iat
ileast i90% ion i2 iL iper iNC.
While ithe iRapid iResponse iTeam iis iat ithe ibedside, ithe ipatient's ihealthcare iprovider iarrives. iThe
iprovider iwrites iseveral iorders.
Which iorder iis imost iimportant ifor ithe inurse ito iimplement iimmediately?
A. iTransfer ito iICU
B. iIncrease iO2 ito i3 iL iper inasal icannula
C. iABGs i30 iminutes iafter ioxygen iis iincreased
D. iMethylprednisolone isodium isuccinate i(Solu-Medrol) i40 img iIVP i- icorrect iAnswers i✔✔ i-ANS: iB
