ASSESSMENT LEVEL 3
QUESTIONS AND ANSWERS
A patient with a possible PE complains of chest pain and difficulty
breathing. The nurse finds a HR of 142bpm, BP of 100/60, and
respirations of 42. Which action should the nurse take first? -
ANSWER ✔ ️ Elevate the head of the bed to a semi-Fowler's
position
While caring for a patient who has been admitted with a
pulmonary embolism, the nurse notes a change in the patient's
oxygen saturation (SpO2) from 94% to 88%. Which action should
the nurse take? - ANSWER ✔ ️ Increase the prescribed O2 flow
rate
Which information will the nurse include in the asthma teaching
plan for a patient being discharged? - ANSWER ✔ ️ Tremors are
an expected side effect of rapidly acting bronchodilators
The emergency department nurse is evaluating the effectiveness
of therapy for a patient who has received treatment during an
asthma attack. Which assessment finding is the best indicator that
the therapy has been effective? - ANSWER ✔ ️ O2 sat is >90
,A patient seen in the asthma clinic has recorded daily peak flow
rates that are 75% of the baseline. Which action will the nurse
plan to take next? - ANSWER ✔ ️ Administer a bronchodilator and
recheck the peak flow
The nurse teaches a patient who has asthma about peak flow
meter use. Which action by the patient indicates that teaching
was successful? - ANSWER ✔ ️ The patient uses an albuterol
(Ventolin HFA) inhaler for peak flows in the yellow zone.
A young adult patient with cystic fibrosis (CF) is admitted to the
hospital with increased dyspnea. Which intervention should the
nurse include in the plan of care? - ANSWER ✔ ️ Perform CPT
every 4 hours
A patient in the clinic with cystic fibrosis (CF) reports increased
sweating and weakness during the summer months. Which action
by the nurse would be most appropriate? - ANSWER ✔ ️ Have
patient add dietary salt to meals
A young adult female patient with cystic fibrosis (CF) tells the
nurse that she is considering getting married and wondering
, about having children. Which initial response by the nurse is
best? - ANSWER ✔ ️ Would you like more information to help you
with that decision?
The nurse completes an admission assessment on a patient with
asthma. Which information given by patient is indicates a need for
a change in therapy? - ANSWER ✔ ️ The patient's only
medications are albuterol (Ventolin HFAl) and salmeterol
The nurse takes an admission history on a patient with possible
asthma who has new-onset wheezing and shortness of breath.
Which information may indicate a need for a change in therapy? -
ANSWER ✔ ️ Patient takes propanolol for hypertension
A patient newly diagnosed with asthma is being discharged. The
nurse anticipates including which topic in the discharge teaching?
- ANSWER ✔ ️ Self administration of inhaled corticosteroids
A patient with cystic fibrosis (CF) has blood glucose levels that
are consistently between 180 to 250 mg/dL. Which nursing action
will the nurse plan to implement? - ANSWER ✔ ️ Teach patient
about administration of insulin