ADULT HEALTH NURSING
(UNIT 1) EXAM
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High-Yield Qs
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,The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The
patient has been receiving high-flow oxygen therapy for an extended time. What symptoms
should the nurse anticipate if the patient were experiencing oxygen toxicity?
A) Bradycardia and frontal headache
B) Dyspnea and substernal pain
C) Peripheral cyanosis and restlessness
D) Hypotension and tachycardia - CORRECT ANSWER -B
Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an
extended period. Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness,
fatigue, and progressive respiratory difficulty. Bradycardia, frontal headache, cyanosis,
hypotension, and tachycardia are not symptoms of oxygen toxicity.
The nurse caring for a patient with an endotracheal tube recognizes several
disadvantages of an endotracheal tube. What would the nurse recognize as a
disadvantage of endotracheal tubes? A) Cognition is decreased.
B) Daily arterial blood gases (ABGs) are necessary.
C) Slight tracheal bleeding is anticipated.
D) The cough reflex is depressed. - CORRECT ANSWER -D
There are several disadvantages of an endotracheal tube. Disadvantages include suppression of
the patients cough reflex, thickening of secretions, and depressed swallowing reflexes.
Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected
finding. The tube should not influence cognition and daily ABGs are not always required.
What would the critical care nurse recognize as a condition that may indicate a patients need to
have a tracheostomy?
A) A patient has a respiratory rate of 10 breaths per minute.
B) A patient requires permanent ventilation.
C) A patient exhibits symptoms of dyspnea.
,D) A patient has respiratory acidosis. - CORRECT ANSWER -B
A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral
and gastric secretions in the unconscious or paralyzed patient. Indications for a tracheostomy
do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory
acidosis.
The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation.
What nursing action is most appropriate?
A) Keep the patient in a low Fowlers position.
B) Perform tracheostomy care at least once per day.
C) Maintain continuous bedrest.
D) Monitor cuff pressure every 8 hours. - CORRECT ANSWER -D
The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy
care at least every 8 hours because of the risk of infection. The patient should be encouraged to
ambulate, if possible, and a low Fowlers position is not indicated.
The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning
preoperative teaching, what information should the nurse communicate to the patient?
A) How to milk the chest tubing
B) How to splint the incision when coughing
C) How to take prophylactic antibiotics correctly
D) How to manage the need for fluid restriction - CORRECT ANSWER -B
Prior to thoracotomy, the nurse educates the patient about how to splint the incision with the
hands, a
pillow, or a folded towel. The patient is not taught how to milk the chest tubing because this is
performed by the nurse. Prophylactic antibiotics are not normally used and fluid restriction is
not indicated following thoracotomy.
, A nurse is educating a patient in anticipation of a procedure that will require a water-sealed
chest drainage system. What should the nurse tell the patient and the family that this drainage
system is used for?
A) Maintaining positive chest-wall
pressure B) Monitoring pleural fluid
osmolarity
C) Providing positive intrathoracic pressure
D) Removing excess air and fluid - CORRECT ANSWER -D
Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove
excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor
pleural fluid, or provide positive intrathoracic pressure.
A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a
chest tube into the anterior chest wall. What should the nurse tell the family is the primary
purpose of this chest tube?
A) To remove air from the pleural space
B) To drain copious sputum secretions
C) To monitor bleeding around the lungs
D) To assist with mechanical ventilation - CORRECT ANSWER -A
Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove
excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum
secretions, monitor bleeding, or assist with mechanical ventilation.
A patients plan of care specifies postural drainage. What action should the nurse perform when
providing this noninvasive therapy?
A) Administer the treatment with the patient in a high Fowlers or semi-Fowlers position.
B) Perform the procedure immediately following the patients meals.
C) Apply percussion firmly to bare skin to facilitate drainage.
(UNIT 1) EXAM
High-Yield Qs & Answers with Feedback
This Exam Description:
High-Yield Qs
Answers with Feedback
Multiple Choices
100% Guaranteed Pass
,The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The
patient has been receiving high-flow oxygen therapy for an extended time. What symptoms
should the nurse anticipate if the patient were experiencing oxygen toxicity?
A) Bradycardia and frontal headache
B) Dyspnea and substernal pain
C) Peripheral cyanosis and restlessness
D) Hypotension and tachycardia - CORRECT ANSWER -B
Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an
extended period. Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness,
fatigue, and progressive respiratory difficulty. Bradycardia, frontal headache, cyanosis,
hypotension, and tachycardia are not symptoms of oxygen toxicity.
The nurse caring for a patient with an endotracheal tube recognizes several
disadvantages of an endotracheal tube. What would the nurse recognize as a
disadvantage of endotracheal tubes? A) Cognition is decreased.
B) Daily arterial blood gases (ABGs) are necessary.
C) Slight tracheal bleeding is anticipated.
D) The cough reflex is depressed. - CORRECT ANSWER -D
There are several disadvantages of an endotracheal tube. Disadvantages include suppression of
the patients cough reflex, thickening of secretions, and depressed swallowing reflexes.
Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected
finding. The tube should not influence cognition and daily ABGs are not always required.
What would the critical care nurse recognize as a condition that may indicate a patients need to
have a tracheostomy?
A) A patient has a respiratory rate of 10 breaths per minute.
B) A patient requires permanent ventilation.
C) A patient exhibits symptoms of dyspnea.
,D) A patient has respiratory acidosis. - CORRECT ANSWER -B
A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral
and gastric secretions in the unconscious or paralyzed patient. Indications for a tracheostomy
do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory
acidosis.
The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation.
What nursing action is most appropriate?
A) Keep the patient in a low Fowlers position.
B) Perform tracheostomy care at least once per day.
C) Maintain continuous bedrest.
D) Monitor cuff pressure every 8 hours. - CORRECT ANSWER -D
The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy
care at least every 8 hours because of the risk of infection. The patient should be encouraged to
ambulate, if possible, and a low Fowlers position is not indicated.
The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning
preoperative teaching, what information should the nurse communicate to the patient?
A) How to milk the chest tubing
B) How to splint the incision when coughing
C) How to take prophylactic antibiotics correctly
D) How to manage the need for fluid restriction - CORRECT ANSWER -B
Prior to thoracotomy, the nurse educates the patient about how to splint the incision with the
hands, a
pillow, or a folded towel. The patient is not taught how to milk the chest tubing because this is
performed by the nurse. Prophylactic antibiotics are not normally used and fluid restriction is
not indicated following thoracotomy.
, A nurse is educating a patient in anticipation of a procedure that will require a water-sealed
chest drainage system. What should the nurse tell the patient and the family that this drainage
system is used for?
A) Maintaining positive chest-wall
pressure B) Monitoring pleural fluid
osmolarity
C) Providing positive intrathoracic pressure
D) Removing excess air and fluid - CORRECT ANSWER -D
Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove
excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor
pleural fluid, or provide positive intrathoracic pressure.
A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a
chest tube into the anterior chest wall. What should the nurse tell the family is the primary
purpose of this chest tube?
A) To remove air from the pleural space
B) To drain copious sputum secretions
C) To monitor bleeding around the lungs
D) To assist with mechanical ventilation - CORRECT ANSWER -A
Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove
excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum
secretions, monitor bleeding, or assist with mechanical ventilation.
A patients plan of care specifies postural drainage. What action should the nurse perform when
providing this noninvasive therapy?
A) Administer the treatment with the patient in a high Fowlers or semi-Fowlers position.
B) Perform the procedure immediately following the patients meals.
C) Apply percussion firmly to bare skin to facilitate drainage.
