Module 5 Quiz
A nurse is caring for a patient after abdominal surgery. The patient asks about the purpose for use of the incentive spirometer (IS) since using it causes pain in his abdomen. The nurse's best response is: a. "The incentive spirometer is used to encourage lung expansion to prevent collapse of the air sacs in the lungs." b. "The incentive spirometer is used to measure your tidal volume of air exhaled." c. "The incentive spirometer is not needed after surgery, it was to help build up your lungs before surgery." d. "The incentive spirometer is used to increase respirations following sedation."
a. "The incentive spirometer is used to encourage lung expansion to prevent collapse of the air sacs in the lungs." Incentive spirometry encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It promotes deep breathing and thought to prevent atelectasis in patients following thoracic or abdominal surgery.
Which patient would be most at risk for developing problems with oxygenation? a. A 60-year-old with a life-time exposure to second-hand smoke, works as a diesel mechanic, and eats fast-food most days. b. An active 55-year-old with a family history of lung cancer who works as a mail carrier and carries a water bottle continuously. c. A 35-year-old with a history of smoking for 3 years as a teenager, works as a park ranger, and packs sandwiches and fresh vegetables for lunches. d. A healthy 65-year-old who has worked as an accountant for 40 years with a family history coronary artery disease and follows a low-fat, low-sodium diet.
a. A 60-year-old with a life-time exposure to second-hand smoke, works as a diesel mechanic, and eats fast-food most days. The patient with the life-time exposure to second-hand smoke, exposure to chemicals as a diesel mechanic, and a probably high-fat diet is the patient most at risk. The other patients have a few risk factors that may lead to problems with oxygenation but the more risk factors, the more risk.
A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? a. Attach a humidifier bottle to the base of the flow meter. b. Remove the nasal cannula while the client eats. c. Secure the oxygen tubing to the bed sheet near the client's head. d. Apply petroleum jelly to the nares as needed to soothe mucous membranes.
a. Attach a humidifier bottle to the base of the flow meter. Oxygen therapy can dry the mucous membranes. The nurse should attach humidification for a client receiving oxygen greater than 4 L/min via nasal cannula. An advantage of the nasal cannula delivery system is that the client can continue to receive oxygen therapy while eating, drinking, and speaking. The nurse should maintain sufficient slack and secure the oxygen tubing to the client's clothing. The nurse should apply water-soluble lubricant, not petroleum jelly, as needed to soothe the mucous membranes.
A patient has a respiratory rate of 4 breaths/minute. The nurse's first action is: a. Attempt to rouse the patient b. Call the physician c. Auscultate breath sounds d. Obtain a pulse oximetry value
a. Attempt to rouse the patient The nurse should first attempt to rouse the patient to increase the respiratory rate. Breath sounds and pulse oximetry should be assessed and the provider informed of the findings.
After assessing the client's respiratory system, the nurse listens to his apical pulse. What location is used to listen to his apical pulse? a. Fifth intercostal space at left midclavicular line b. Fifth intercostal space at midsternal line c. Fourth intercostal space midsternal line d. Fourth intercostal space at left scapular line
a. Fifth intercostal space at left midclavicular line This is the location of the mitral valve and is known as the point of maximal impulse, so sound is best heard at this location.
An S3 heart sound is a normal finding in which of the following patients? a. A 40-year-old male b. A 14-year-old male c. An athletic 65-year old female d. A 50-year-old female
b. A 14-year-old male An S3 heart sound can often be heard normally in children and young adults. It can also be present among women in the later stages of pregnancy. S3 is considered abnormal in adults over the age of 31 years.
A nurse is caring for a patient experiencing an acute asthma attack. The nurse would expect to hear which adventitious breath sounds? a. Inspiratory stridor b. Inspiratory and expiratory wheezes c. Expiratory rhonchi d. Inspiratory crackles
b. Inspiratory and expiratory wheezes Inspiratory and expiratory wheezes are associated with an acute asthma attack.
Which of the following describes systole? (select all that apply) a. Systole is normally longer than diastole b. Systole is normally silent between S1 and S2 c. Systole is the period in which the ventricles relax d. Systole is the period in which the ventricles contract e. Systole begins with S1 and ends with S2
b. Systole is normally silent between S1 and S2; d. Systole is the period in which the ventricles contract; e. Systole begins with S1 and ends with S2 Systole is the period in which the ventricles contract and begins with S1 and ends with S2. Systole is shorter than diastole. There is normally a silent interval between S1 and S2.
Which of the following nursing interventions would promote effective airway clearance in a patient with acute respiratory distress? a. Administering oxygen every 2 hours b. Turning the client every 4 hours c. Administering sedatives to promote rest d. Suctioning if cough is ineffective
d. Suctioning if cough is ineffective Administering sedatives would not promote airway clearance. Turning is an intervention used to prevent skin breakdown. Giving oxygen may help a patient who is hypoxic, however, will not promote effective airway clearance. If a patient is unable to effectively clear their airway of secretions with coughing, then suctioning would be appropriate to clear their airway.
The nurse is educating a patient about the electrical conduction through the heart. Which of the following statements is true about the electrical conduction through the heart? a. The atrioventricular (AV) node of the heart is also called the "pacemaker" of the heart. b. The sinoatrial (SA) node initiates the electrical impulse that spreads through the atrial muscle, causing them to contract. c. The Bundle of His sends the electrical impulse to the atrioventricular (AV) node to transmit to the ventricles. d. The Purkinji fibers delay the electrical impulse to allow contraction of the right ventricle then left ventricle a second later.
b. The sinoatrial (SA) node initiates the electrical impulse that spreads through the atrial muscle, causing them to contract. The sinoatrial (SA) node is also called the "pacemaker" of the heart and initiates the electrical impulse that spreads to the atrial muscle causing them to contract. None of the other statements are correct.
A patient is brought to the emergency department with shortness of breath. The healthcare provider orders a stat hemoglobin and hematocrit level drawn. The patient questions why blood is being drawn when he is having trouble breathing. What is the nurse's best response? a. "We are just checking a baseline. However, hemoglobin has little to no effect on oxygenation." b. "We want to see if you have more hemoglobin because it can decrease your respiratory rate." c. "If we check your hemoglobin levels and they are low it tells us that you have reduced oxygen-carrying capacity." d. "If we check your hemoglobin levels and they are low it tells us you are at increased risk for developing a blood clot in your lungs."
c. "If we check your hemoglobin levels and they are low it tells us that you have reduced oxygen-carrying capacity." Hemoglobin is the component of blood that carries oxygen. If the hemoglobin is low, the amount of oxygen-carrying capacity is also low.
What is the most effective method for a patient to receive oxygen delivery at FiO2 of 85%? a. Nasal cannula b. Simple mask c. Mask with a reservoir bag (non-rebreather) d. Venturi mask
c. Mask with a reservoir bag (non-rebreather) A mask with a reservoir or non-rebreather mask administers up to 60-90% oxygen at a flow rate of 10-15 L/min. Maximum for a nasal cannula is 24-44%. Maximum for a simple mask is 35-50%. Maximum for a Venturi mask is 24-50%.
The nurse is preparing to assess a patient for jugular vein distension. How should the nurse position the patient? a. High Fowler's b. Supine with the head of the bed elevated 10 degrees c. Supine with the head of the bed elevated 45 degrees d. Prone with the feet elevated
c. Supine with the head of the bed elevated 45 degrees Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15-45 degrees.
The nurse is assessing the patient for abnormalities of the pulmonic valve. Where should the nurse auscultate the heart sounds? a. The second intercostal space, to the right of the sternum b. The fifth intercostal space in the midclavicular line c. The second left intercostal space along the left sternal border d. The third and fourth intercostal spaces along the left sternal border
c. The second left intercostal space along the left sternal border Abnormalities of the pulmonic valve are auscultated at the second left intercostal space along the left sternal border. Aortic valve abnormalities are heard at the second intercostal space, to the right of the sternum. Mitral valve abnormalities are heard at the fifth intercostal space in the midclavicular line. Tricuspid valve abnormalities are heard at the third and fourth intercostal spaces along the left sternal border.
The nurse is unable to palpate the patient's left pedal pulses. Which of the following actions would the nurse take next? a. Auscultate the pulses with a stethoscope b. Call the physician c. Use a Doppler ultrasound device d. Inspect the left lower extremity
c. Use a Doppler ultrasound device If no pulse is palpable, the next step to check to see if a pulse is present is to use a Doppler ultrasound device. This is within the nurse's scope and can be completed before contacting the physician. Inspecting will not help you determine if a pulse is present. Auscultating the pulses in the feet would not be appropriate nursing action.
The nurse is assessing the oxygenation risks for a patient. Which of the following would increase the patient risk for oxygenation problems? a. 45 minutes of daily exercise b. Maintains a vegetarian diet including seafood c. Works as a firefighter d. Drinks at least 64 ounces of fluids daily, avoiding caffeine
c. Works as a firefighter Working as a firefighter places the patient at risk for oxygenation problems due to stressful work environment and the potential for chemical exposure at work. The rest of the answers are healthy behaviors that will improve oxygenation.
The nurse is caring for a patient with chronic hypoxia. Which assessment finding would the nurse least expect? a. Pursed lip breathing b. Clubbing of the nails c. Cyanotic mucus membranes d. Asymmetrical chest expansion
d. Asymmetrical chest expansion Asymmetrical chest expansion is related to a chest injury. The rest of the assessment finding are congruent with chronic hypoxia.
A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first? a. Administer oxygen at 2 L/min. b. Administer prescribed analgesic medication. c. Encourage coughing and deep breathing. d. Raise the head of the bed.
d. Raise the head of the bed Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway. This is the first action the nurse should take and is the least invasive. The nurse should assess the client further and implement less invasive interventions before applying oxygen at 2 L/min. Pain management promotes increased participation by the client in coughing and deep breathing, frequent position changes and use of the incentive spirometer, but this is not the first action the nurse should take. Coughing and deep breathing promotes lung expansion and prevents respiratory infection, but these actions are not effective immediately in increasing oxygen saturation.
