Chapter 21 Workbook NCLEX style questions

A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for? A. Anemic hypoxia B. Histotoxic hypoxia C. Hypoxic hypoxia D. Stagnant hypoxia

A. Anemic hypoxia

A new ICU nurse is observed by her preceptor entering her patients room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned? A. Auscultate the lung for adventitious sounds B. Have the patient inform the nurse of the need to be suctioned C. Assess the CO2 level to determine if the patient requires suctioning. D. Have the patient cough

A. Auscultate the lung for adventitious sounds

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does in-line suction have for the patient. (Select all that apply) A. Decreases hypoxemia B. Decreases patient anxiety C. Sustains positive end expiratory pressure (PEEP) D. Increases oxygen consumption E. Prevents aspiration

A. Decreases hypoxemia B. Decreases patient anxiety C. Sustains positive end expiratory pressure (PEEP)

The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply) A. Hold the breath at the end of inspiration for a few seconds B. Cough frequently C. Take rapid, deep breaths D. Frequently evaluate progress E. Prolong the expiratory phase after using the nebulizer

A. Hold the breath at the end of inspiration for a few seconds B. Cough frequently D. Frequently evaluate progress

The nurse is educating a patient with COPD about the technique for performing pursed lip breathing. What does the nurse inform the patient is the importance of using this technique? A. It prolongs exhalation B. It increases the respiratory rate to improve oxygenation C. It will assist with widening the airway D. It will prevent the alveoli from overexpanding

A. It prolongs exhalation

The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber? A. Notify the healthcare provider B. Place the head of the patient's bed flat C. Milk the chest tube D. Disconnect the system and get another

A. Notify the healthcare provider

The nurse is admitting a patient with chronic obstructive pulmonary disorder (COPD). The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxia? A. PaO2 B. pH C. PCO2 D. HCO3

A. PaO2

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient? A. The patient is hypoxic from suctioning B. The patient is having a stress reaction C. The patient is having a myocardial infarction D. The patient is in a hypermetabolic state.

A. The patient is hypoxic from suctioning

A patient with emphysema informs the nurse, "The surgeon wil lbe removing about 30% of my lung so that I will not be so short of breath and will have an improved quality of life." What surgery does the nurse understand the surgeon will perform? A. A sleeve resection B. A long volume reduction C. A wedge resection D. Lobectomy

B. A long volume reduction

The nurse assesses a patient with a heart rate of 42 bpm and a blood pressure of 70/46 mmHg. What type of hypoxia does the nurse determine this patient is displaying? A. Anemic hypoxia B. Circulatory hypoxia C. Histotoxic hypoxia D. Hypoxic hypoxia

B. Circulatory hypoxia

The nurse hears the patient's ventilator alarm sound and attempts the find the cause. What is the priority action of the nurse what the cause of the alarm is not able to be determined? A. Call respiratory therapy and wait until they arrive to determine what is happening B. Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. C. Stop the ventilator by pressing the off button, wait 15 seconds, and then turn it on again to see if the alarm stops. D. Suction the patient since the patient may be obstructed by secretions

B. Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.

A patient has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the patient reports tingling in the fingers and shortness of breath, is extremely restless and describes pain beneath the breastbone. What condition should the nurse suspect? A. Oxygen-induced hypoventilation B. Oxygen toxicity C. Oxygen-induced atelectasis D. Hypoxia

B. Oxygen toxicity

A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration A. A nasal cannula B. A oropharyngeal catheter C. A partial rebreather mask D. A Venturi mask

C. A partial rebreather mask

A patient is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this patient. A. Surgery to remove the tonsils and adenoids B. Medications to assist the patient with sleep at night C. Continuous positive airway pressure D. Bi-level positive airway pressure.

C. Continuous positive airway pressure

The nurse is transporting a patient with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse? A. Immediately reconnect the chest tube to the drainage apparatus B. Clamp the chest tube close to the connection site. C. Cut the contaminated tip of the tube and insert a sterile connector and reattach. D. Call the healthcare provider

C. Cut the contaminated tip of the tube and insert a sterile connector and reattach.

A patient in the ICU has been orally intubated an on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the healthcare provider will take now that the patient has been intubated for this length of time? A. The patient will be extubated and another endotracheal tube will be inserted B. The patient will be extubated and a nasotracheal tube will be inserted C. The patient will have an insertion of a tracheostomy tube D. The patient will begin the weaning process.

C. The patient will have an insertion of a tracheostomy tube

A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25mmHg. The nurse is aware of what complications that can be caused by this pressure? (Select all that apply) A. Tracheal aspiration B. Hypoxia C. Tracheal ischemia D. Tracheal bleeding E. Pressure necrosis

C. Tracheal ischemia D. Tracheal bleeding E. Pressure necrosis

A patient with COPD requires oxygen administration. What method of delivery does the nurse know would produce optimal results for this patient? A. A nasal cannula B. An oropharyngeal catheter C. A nonrebreathing mask D. A Venturi mask

D. A Venturi mask

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education? A. Have the patient lie in a supine position during the use of the spirometer B. Encourage the patient to try to stop coughing during and after using the spirometer C. Inform the patient that using the spirometer is not necessary if the patient is experiencing pain D. Encourage the patient to take approximately 10 breaths per hour while awake.

D. Encourage the patient to take approximately 10 breaths per hour while awake.

a patient with emphysema is placed on continuous oxygen at 2L per minute at home. Why is it important for the nurse ro educate the patient and family that they must have NO SMOKING signs placed on the doors? A. Oxygen is combustible B. Oxygen is explosive C. Oxygen prevents the dispersion of smoke particles D. Oxygen supports combustion

D. Oxygen supports combustion