Fundamentals Exam 2

A home health nurse is assessing the home for fire safety. Which information from the family will cause the nurse to intervene? (Select all that apply.) a. Smoking in bed helps me relax and fall asleep. b. We never leave candles burning when we are gone. c. We use the same space heater my grandparents used. d. We use the RACE method when using the fire extinguisher. e. There is a fire extinguisher in the kitchen and garage workshop.

A, C, D Incorrect information will cause the nurse to intervene. Accidental home fires typically result from smoking in bed. Advise family to only purchase newer model space heaters that have all of the current safety features. The PASS method is used for fire extinguishers.

The nurse is caring for a patient with respiratory problems. Which assessment finding indicates early sign of hypoxia? (select all that apply) a. Elevated blood pressure b. Increased pulse rate c. Restlessness d. Cyanosis

A,B,C Elevated blood pressure, increased pulse rate, and restlessness are early signs of hypoxia.

The nurse is assessing a patient with emphysema. Which assessment finding is the nurse likely to see? (select all that apply) a. Increased anterior-posterior diameter of the chest b. Accessory muscle used for breathing c. Clubbing of the fingers d. Hemoptysis

A,B,C clubbing of fingers, barrel chest( increased anterior-posterior chest diameter), and accessory muscle use are all normal findings in a patient with emphysema

A nurse is teaching a community health promotion class and discusses the flu vaccine. Which information will the nurse include in the teaching session? (Select all that apply.) a. It is given yearly. b. It is given in a series of four doses. c. It is safe for children allergic to eggs. d. It is safe for adults with acute febrile illnesses. e. The nasal spray is given to people over 50. f. The inactivated flu vaccine is given to people over 50.

A,F Annual fly vaccines are recommended for all people 6 months and older. The inactivated flu vaccine should be given to these individuals with chronic health problems and those 50 and older.

A nurse is caring for a group of patients. Which patient should the nurse see first? a. A patient with hypercapnia wearing an oxygen mask b. A patient with a chest tube ambulating with the chest tube unclamped c. A patient with thick secretions being tracheal suctioned first and then orally d. A patient with a new tracheostomy and tracheostomy obturator at bedside

A: A patient with hypercapnia wearing oxygen mask The mask is contraindicated for patients with carbon dioxide retention (hypercapnia) because retention can be worsened; the nurse must see the patient first to correct the problem.

The nurse is caring for a patient who needs oxygen via a nasal cannula. Which task can the nurse delegate to the nursing assistive personnel? a. Applying the nasal cannula b. Adjusting the oxygen flow c. Assessing lung sounds d. Setting up the oxygen

A: Applying the nasal cannula The skill of applying (not adjusting oxygen flow) a nasal cannula or oxygen mask can be delegated to nursing assistive personnel (NAP). the nurse is responsible for assessing the patients respiratory system, response to oxygen therapy, and setup of oxygen therapy, including adjustment of oxygen flow rate.

The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes affecting safety. Which question would be most important for the nurse to ask this group? a. "Are you able to hear the tornado sirens in your area?" b. "Are you able to read your favorite book?" c. "Are you able to taste spices like before?" d. "Are you able to open a jar of pickles?"

A: Are you able to hear the tornado sirens in your area The ability to hear safety alerts and seek shelter is imperative to life safety. Decreasing hearing acuity alters the ability to hear emergency vehicle sirens. Natural disasters such as flood, tsunamis, hurricanes, tornadoes, and wildfires are major causes of death and injury.

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous (IV) infusion. Which priority action will the nurse take? a. Assess the patient. b. Gather restraint supplies. c. Try alternatives to restraint. d. Call the health care provider for a restraint order.

A: Assess the patient When a patient becomes suddenly confused, the priority is to assess the patient, to identify the reason for change in behavior, and to try to eliminate the cause.

While performing an assessment, the nurse hears an irregular rhythm. Which condition will the nurse most likely observe written in the patient's medical record? a. Atrial fibrillation b. Myocardial ischemia c. Left-sided heart failure d. Right-sided heart failure

A: Atrial fibrillation Atrial fibrillation is often described as an irregularly irregular rhythm; rhythm is irregular because of multiple pacemaker sites

A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli's function will the nurse share with the patient? a. Carries out gas exchange b. Regulates tidal volume c. Produces hemoglobin d. Stores oxygen

A: Carries out gas exchange The alveolus is capillary membrane that allows gas exchange of oxygen and carbon dioxide during respiration. The alveoli do not store oxygen, regulate tidal volume or produce hemoglobin

The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination? a. Experiences chest pain after eating a heavy meal b. Experiences adequate oxygen saturation during exercise c. Experiences crushing chest pain for more than 20 minutes d. Experiences tingling in the left arm that lasts throughout the morning

A: Experiences chest pain after eating a heavy meal Angina pectoris is chest pain that results from limited oxygen supply. Often pain is precipitated by activities such as exercise, stress, and eating a heavy meal and lasts about 3 to 5 minutes. Symptoms of angina pectoris are relieved by rest and/ or nitroglycerin.

Which coughing technique will the nurse use to help a patient clear central airways? a. Huff b. Quad c. Cascade d. Incentive spirometry

A: Huff The huff cough stimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the word huff

The nurse is presenting an educational session on safety for parents of adolescents. Which information will the nurse include in the teaching session? a. Increased aggressiveness and blood spots on clothing may indicate substance abuse. b. Increased aggressiveness is an environmental clue that may indicate an adolescent is abusing. c. Adolescents need information about the effects of uncoordination on accidents. d. Adolescents need to be reminded to use seat belts primarily on long trips.

A: Increased aggressiveness and blood spots on clothing may indicate substance abuse Increased aggressiveness (psychosocial clue) and blood spots on clothing (environmental clue) may indicate substance abuse.

The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most likely expect? a. Increased preload b. Increased heart rate c. Decreased afterload d. Decreased tissue perfusion

A: Increased preload Preload refers to the amount of blood in the left ventricle at the end of diastole; increase in circulating volume would increase the preload of the heart. Afterload refers to resistance; increased pressure would lead to increased resistance and afterload would increase.

A patient has carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient? a. Low-carbohydrate b. Low-caffeine c. High-caffeine d. High-carbohydrate

A: Low carbohydrate A low-carbohydrate diet is best. Diets high in carbohydrates play a role increasing carbon dioxide load for patients with carbon dioxide retention. As carbohydrates are metabolized, an increased load of carbon dioxide is created and excreted via the lungs.

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen? a. Nasal cannula b. Simple face mask c. Non-rebreather mask d. Partial non-rebreather mask

A: Nasal cannula Nasal cannulas deliver oxygen from 1 to 6 L/min.

The patient has right-sided heart failure. Which finding will the nurse expect when performing an assessment? a. Peripheral edema b. Basilar crackles c. Chest pain d. Cyanosis

A: Peripheral edema Right-sided heart failure results from inability of the right side of the heart to pump effectively, leading to a systemic backup. Peripheral edema, distended neck veins, and weight gain are signs of right sided heart failure.

A nurse is teaching a community group of school-aged parents about safety. Which safety item is most important for the nurse to include in the teaching session? a. Proper fit of a bicycle helmet b. Proper fit of soccer shin guards c. Proper fit of swimming goggles d. Proper fit of baseball sliding shorts

A: Proper fit of a bicycle helmet Head injuries are a major cause of death, with bicycle accidents being one of the major causes of such injuries. Proper fit of the helmet helps to decrease head injuries resulting from these bicycle accidents.

A patient has an ankle restraint applied. Upon assessment the nurse finds the toes a light blue color. Which action will the nurse take next? a. Remove the restraint. b. Place a blanket over the feet. c. Immediately do a complete head-to-toe neurologic assessment. d. Take the patient's blood pressure, pulse, temperature, and respiratory rate.

A: Remove the restraint If the patient has altered neurovascular status of an extremity such as cyanosis, pallor, and coldness of skin or complains of tingling, pain, or numbness, remove the restraint immediately and notify the health care provider.

A confused patient is restless and continues to try to remove the oxygen cannula and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient? a. Risk for injury: Check on patient every 15 minutes. b. Risk for suffocation: Place "Oxygen in Use" sign on door. c. Disturbed body image: Encourage patient to express concerns about body. d. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.

A: Risk for Injury: Check on the patient every 15 minutes The priority nursing diagnosis is Risk for injury. The patient could cause harm to self by interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out. Before restraining, it is important to implement and exhaust alternatives to restraint.

A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave? a. SA node b. AV node c. Bundle of His d. Purkinje fibers

A: SA node The P wave represents the electrical conduction through both atria; the SA node initiates electrical conduction through the atria. The AV node conducts down through the bundle of His and the Purkinje fibers to cause ventricular contraction

The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires? a. Stimulation of chemical receptors in the aorta b. Reduction of arterial oxygen saturation levels c. Requirement of elastic recoil lung properties d. Enhancement of accessory muscle usage

A: Simulation of chemical receptors in the aorta Inspiration is an active process, stimulated by chemical receptors in the aorta.

The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal the patient could achieve? a. Sleeping on two to three pillows at night b. Limiting the diet to 1500 calories a day c. Running 30 minutes every morning d. Stopping smoking immediately

A: Sleeping on two or three pillows at night To achieve a short term goal, the nurse should plan a lifestyle change that the patient can make immediately that will have a quick effect. Sleeping on several pillows at night will immediately relieve orthopnea and open the patients airway, thereby reducing fatigue.

. The nurse is discussing about threats to adult safety with a college group. Which statement by a group member indicates understanding of the topic? a. "Smoking even at parties is not good for my body." b. "Our campus is safe; we leave our dorms unlocked all the time." c. "As long as I have only two drinks, I can still be the designated driver." d. "I am young, so I can work nights and go to school with 2 hours' sleep."

A: Smoking even at parties is not good for my body Lifestyle choices frequently affect adult safety. Smoking conveys risk for pulmonary and cardiovascular disease.

A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the nurse describe as modifiable? a. Stress b. Allergies c. Family history d. Gender

A: Stress Young and middle-aged adults are exposed to multiple cardiopulmonary risk factors; an unhealthy diet, lack of exercise, stress, over the counter and prescription drugs not used as intended, illegal substances, and smoking. Reducing these modifiable factors decreases a patients risk for cardiac or pulmonary diseases.

Which of these returns blood back to the heart? a. Superior vena cava b. Pulmonary artery c. Carotid artery d. Coronary artery

A: Superior vena cava the superior vena cava returns blood back to the heart

The nurse is caring for an older-adult patient admitted with nausea, vomiting, and diarrhea due to food poisoning. The nurse completes the health history. Which priority concern will require collaboration with social services to address the patient's health care needs? a. The electricity was turned off 3 days ago. b. The water comes from the county water supply. c. A son and family recently moved into the home. d. This home is not furnished with a microwave oven.

A: The electricity was turned off 3 days ago. Electricity is needed for refrigeration of food, and lack of electricity could have contributed to the nausea, vomiting's, and diarrhea due to food poisoning. This discussion about the patients electrical needs can be referred to social services.

The nurse is careful to monitor a patient's cardiac output. Which goal is the nurse trying to achieve? a. To determine peripheral extremity circulation b. To determine oxygenation requirements c. To determine cardiac dysrhythmias d. To determine ventilation status

A: To determine peripheral extremity circulation Cardiac output indicates how much blood is being circulated systemically throughout the body to the periphery. The amount of blood ejected from the left ventricle each minute is the cardiac output.

Which activity will cause the nurse to monitor for equipment-related accidents? a. Uses a patient-controlled analgesic pump b. Uses a computer-based documentation record c. Uses a measuring device that measures urine d. Uses a manual medication-dispensing device

A: Uses a patient-controlled analgesic pump Accidents that are equipment related result from malfunction, disrepair, or misuse of equipment or from an electrical hazard. To avoid rapid infusion of IV fluids, all general-use and patient-controlled analgesic pumps need to have free-flow protection devices

The nurse is teaching about the process of moving gases into and out of the lungs. Which term will the nurse use to describe this process? a. Ventilation b. Surfactant c. Perfusion d. Diffusion

A: Ventilation Ventilation is the process of moving gases into and out of the lungs

A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately? a. Ventricular tachycardia b. Atrial fibrillation c. Sinus rhythm d. Paroxysmal supraventricular tachycardia

A: Ventricular tachycardia Ventricular tachycardia and ventricular fibrillation are life-threatening rhythms that require immediate intervention. Ventricular tachycardia is a life-threatening dysrhythmia because of the decreased cardiac output and the potential to deteriorate into ventricular fibrillation or sudden cardiac death.

A nurse is teaching the patient and family about wound care. Which technique will the nurse teach to best prevent transmission of pathogens? a. Wash hands b. Wash wound c. Wear gloves d. Wear eye protection

A: Wash hands One of the most effective methods for limiting transmission of pathogens is the medically aseptic practice of hand hygiene.

A patient with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic? a. "Your disease doesn't send enough oxygen to your fingers." b. "Your disease affects both your lungs and your heart, and not enough blood is being pumped." c. "Your disease will be helped if you pursed-lip breathe." d. "Your disease often makes patients lose mental status."

A: Your disease doesn't send enough oxygen to your fingers Clubbing of the nail bed can occur with COPD and other disease that cause prolonged oxygen deficiency or chronic hypoxemia.

A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest? a. A cup of nonfat yogurt with granola and a handful of dried apricots b. Whole wheat toast with butter and a side of bacon c. A bowl of cereal with whole milk and a banana d. Omelet with sausage, cheese, and onions

A: a cup of nonfat yogurt with granola and a handful of dried apricots A 2000 calorie diet of fruits, vegetables, and low-fat dairy foods that are high in fiber, potassium, calcium, and magnesium and low in saturated and total fat helps prevent and reduce the effects of hypertension

Which activity will cause the nurse to monitor for procedure-related accidents? (select all that apply) a. Uses a patient-controlled analgesic pump b. Uses a computer-based documentation record c. Uses a measuring device that measures urine d. Uses a manual medication-dispensing device

B, C, D Measuring devices used by the nurse to measure urine, computer documentation, and manual dispensing devices can break or malfunction but are not used directly on a patient and are considered procedure-related accidents.

A nurse is following the Ventilator Bundle standards to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.) a. Head of bed elevation to 90 degrees at all times b. Daily oral care with chlorhexidine c. Cuff monitoring for adequate seal d. Clean technique when suctioning e. Daily "sedation vacations" f. Heart failure prophylaxis

B, C, E The key components of the Institute for Healthcare Improvement (IHI) Ventilator Bundle are: Elevation of the head of the bed (HOB)—elevation is 30 to 45 degrees Daily "sedation vacations" and assessment of readiness to extubate Peptic ulcer disease prophylaxis Deep venous thrombosis prophylaxis Daily oral care with chlorhexidine Monitor cuff pressure frequently to ensure that there is an adequate seal to prevent aspiration of secretions is also included. Sterile technique is used for suctioning when on ventilators. Heart failure prophylaxis is not a component.

The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat? a. 60° to 64° F b. 65° to 75° F c. 15° to 17° C d. 25° to 28° C

B: 65 to 75 A persons comfort zone is usually between 18.3 to 23.9 (65 to 75 F)

The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance? a. Suctioning respiratory secretions several times every hour b. Administering humidified oxygen through a tracheostomy collar c. Instilling normal saline into the tracheostomy to thin secretions before suctioning d. Deflating the tracheostomy cuff before allowing the patient to cough up secretions

B: Administering humified oxygen through a tracheostomy collar Humidification from air humidifiers or humidified oxygen tracheostomy collars can help prevent drying of secretions that cause occlusion.

An older-adult patient is using a wheelchair to attend a physical therapy session. Which action by the nurse indicates safe transport of the patient? a. Positions patient's buttocks close to the front of wheelchair seat b. Backs wheelchair into elevator, leading with large rear wheels first c. Places locked wheelchair on same side of bed as patient's weaker side d. Unlocks wheelchair for easy maneuverability when patient is transferring

B: Bacs wheelchair into elevator, leading with large rear wheels first A correct action when using a wheelchair is to back wheelchair into an elevator, leading with rear wheels first.

The patient has left-sided heart failure. Which finding will the nurse expect when performing an assessment? a. Peripheral edema b. Basilar crackles c. Chest pain d. Cyanosis

B: Basilar crackles Basilar crackles can indicate pulmonary congestion from left-sided heart failure.

The home health nurse recommends that a patient with respiratory problems install a carbon monoxide detector in the home. What is the rationale for the nurse's action? a. Carbon monoxide detectors are required by law in the home. b. Carbon monoxide tightly binds to hemoglobin, causing hypoxia. c. Carbon monoxide signals the cerebral cortex to cease ventilations. d. Carbon monoxide combines with oxygen in the body and produces a deadly toxin.

B: Carbon monoxide tightly binds to hemoglobin, causing hypoxia Carbon monoxide binds tightly to hemoglobin: therefore, oxygen is not able to bind to hemoglobin and be transported to tissues causing hypoxia.

The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient's plan of care? a. Risk for falls b. Deficient knowledge c. Risk for suffocation d. Impaired physical mobility

B: Deficient Knowledge The patient has a knowledge need and requires instruction regarding the device and its purpose and procedure. The nurse will intervene by teaching the patient about the sequential compression device and instructing the patient to call for assistance when getting up to go to the bathroom in the future, so that the nurse may assist with removal and proper reapplication.

The nurse needs to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change? a. Thinner heart valves cause lipid accumulation and fibrosis. b. Diminished respiratory muscle strength may cause poor chest expansion. c. Alterations in mental status prevent patients' awareness of ineffective breathing. d. An increased number of pacemaker cells make proper anesthesia induction more difficult.

B: Diminished respiratory muscle strength may cause poor chest expansion Age-related changes in the thorax that occur from ossification of costal cartilage, decreased space between vertebrae, and diminished respiratory muscle strength lead to problems with chest expansion and oxygenation, whereby the patient will have difficulty excreting anesthesia gas. The nurse needs to monitor the patients oxygen status carefully to make sure the patient does not retain too much of the drug.

A home health nurse is teaching a family to prevent electrical shock. Which information will the nurse include in the teaching session? a. Run wires under the carpet. b. Disconnect items before cleaning. c. Grasp the cord when unplugging items. d. Use masking tape to secure cords to the floor.

B: Disconnect items before cleaning A guide to prevent electrical shock is to disconnect items before cleaning.

The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient? a. Inform the patient of the importance of finishing the entire dose of antibiotics. b. Encourage the patient to stay up-to-date on all vaccinations. c. Schedule patient to get annual tuberculosis skin testing. d. Create an exercise routine to run 45 minutes every day.

B: Encourage the patient to stay up to date on all vaccinations Keeping up to date on vaccination is important because vaccine reduces the severity of illness and serious complications. Determine if and when the patient has had a pneumococcal or influenza vaccine. This is especially important when assessing older adults because of their increased risk for respiratory disease.

The nurse is educating a student nurse on caring for a patient with a chest tube. Which statement from the student nurse indicates successful learning? a. "I should clamp the chest tube when giving the patient a bed bath." b. "I should report if I see continuous bubbling in the water-seal chamber." c. "I should strip the drains on the chest tube every hour to promote drainage." d. "I should notify the health care provider first, if the chest tube becomes dislodged."

B: I should report if I see continuous bubbling in the water-seal chamber Correct care of a chest tube involves knowing normal and abnormal functioning of the tube. A constant or intermittent bubbling in the water-seal chamber indicates a leak in the drainage system, and the health care provider must be notified immediately.

A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority? a. Risk for skin breakdown b. Impaired gas exchange c. Activity intolerance d. Risk for infection

B: Impaired gas exchange The most important nursing intervention is to maintain airway and circulation for this patient; therefore impaired gas exchange is the first nursing priority

While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first? a. Press the emergency response button. b. Insert a spare tracheostomy with the obturator. c. Manually occlude the tracheostomy with sterile gauze. d. Place a face mask delivering 100% oxygen over the nose and mouth.

B: Insert a spare tracheostomy with the obturator The nurses first priority is to establish a stable airway by inserting a spare trach into the patients airway; ideally and obturator should be used.

A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis? a. "Atelectasis affects only those with chronic conditions such as emphysema." b. "It is important to do breathing exercises every hour to prevent atelectasis." c. "If I develop atelectasis, I will need a chest tube to drain excess fluid." d. "Hyperventilation will open up my alveoli, preventing atelectasis."

B: It is important to do breathing exercises every hour to prevent atelectasis Atelectasis develops when alveoli do not expand. Breathing exercises, especially deep breathing and incentive spirometry, increase lung volume and open the airways, preventing atelectasis. Deep breathing also opens the pores of Kohn between alveoli sharing oxygen between alveoli. Atelectasis can affect anyone who does not deep breathe. It is deep breathing, not hyperventilation, that prevents atelectasis.

The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take? a. Set suction regulator at 150 to 200 mm Hg. b. Limit the length of suctioning to 10 seconds. c. Apply suction while gently rotating and inserting the catheter. d. Liberally lubricate the end of the suction catheter with a water-soluble solution.

B: Limit the length of suctioning to 10 seconds Suctioning passes should be limited to 10 seconds to avoid hypoxemia. Suction for a tracheostomy should be set at 100 to 150 mm Hg.

What does the pulmonary artery supply deoxygenated blood to? a. Brain b. Lungs c. Heart

B: Lungs the pulmonary artery supplies deoxygenated blood to the lungs

The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority? a. Monitor for specific symptoms. b. Manage all patients using standard precautions. c. Transport patients quickly and efficiently through the elevators. d. Prepare for post-traumatic stress associated with this bioterrorism attack.

B: Manage all patients using standard precautions Manage all patients with suspected or confirmed bioterrorism-related illnesses using standard precautions. For certain diseases, additional precaution may be necessary. The early signs of a bioterrorism-related illness often include nonspecific symptoms (nausea, vomiting, diarrhea, skin rash, fever, confusion) that may persist for several days before the onset of a more severe disease.

A nurse auscultates heart sounds. When the nurse hears S1, which valves is the nurse hearing close? a. Aortic and mitral b. Mitral and tricuspid c. Aortic and pulmonic d. Mitral and pulmonic

B: Mitral and Tricuspid the mitral and tricuspid produce the first heart sound, S1

This happens when the supply of blood to the myocardium from the coronary arteries is insufficient to meet the myocardial oxygen demands, producing angina or myocardial infarction. a. Atrial fibrillation b. Myocardial ischemia c. Left-sided heart failure d. Right-sided heart failure

B: Myocardial ischemia Results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet myocardial oxygen demands, producing angina or myocardial infarction

The nurse discovers a patient on the floor. The patient states that he fell out of bed. The nurse assesses the patient and places the patient back in bed. Which action should the nurse take next? a. Do nothing, no harm has occurred. b. Notify the health care provider. c. Complete an incident report. d. Assess the patient.

B: Notify the provider Report immediately to physician or health care provider if the patients sustains a fall or an injury. The nurse must provide safe care. The scenario indicates that the nurse have already assessed the patient.

Which coughing technique will the nurse use for patients without abdominal muscle control such as those with spinal cord injuries ? a. Huff b. Quad c. Cascade d. Incentive spirometry

B: Quad The quad cough technique is for patients without abdominal muscle control such as those with spinal cord injuries . While the patient breathes out with a maximal expiratory effort, the patient or nurse pushes inward and upwards on the abdominal muscles toward the diaphragm, causing the cough

Upon auscultation of the patient's chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse? a. The beginning of the systolic phase b. Regurgitation of the mitral valve c. The opening of the aortic valve d. Presence of orthopnea

B: Regurgitation of the mitral valve When regurgitation occurs, there is a backflow of blood into an adjacent chamber. For ex, in mitral regurgiation the mitral leaflets do not close completely. When the ventricles contract, blood escapes back into the atria, causing a murmur, or "whooshing" sound. The systolic phase begins with ventricular filling and closing of the aortic valve, which is heard as the first heart sound, S1.

A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority? a. Pulse b. Respirations c. Temperature d. Blood pressure

B: Respiration Respiration and oxygen saturation are the priorities. Cervical trauma at the C3 to C5 usually results in paralysis of the phrenic nerve. When the phrenic nerve is damaged, the diaphragm does not descent properly, thus inspiratory lungs and volumes and causing hypoxemia.

The nurse is teaching about a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing. Which term will the nurse use to describe this process? a. Ventilation b. Surfactant c. Perfusion d. Diffusion

B: Surfactant Surfactant is a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing

The nurse is monitoring for Never Events. Which finding indicates the nurse will report a Never Event? a. No blood incompatibility occurs with a blood transfusion. b. A surgical sponge is left in the patient's incision. c. Pulmonary embolism after lung surgery d. Stage II pressure ulcer

B: Surgical sponge is left in the patients incision The Center for Medicare and Medicaid Services names select serious reportable events as Never Events (adverse events that should never occur in a health care setting). A surgical sponge left in a patients incision is a Never Event.

A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 106/56, apical pulse 58, and respiratory rate 12. Which vital sign should the nurse address immediately? a. Respiratory rate b. Temperature c. Apical pulse d. Blood pressure

B: Temperature The temperature indicates the patient is experiencing hypothermia. Homeless individuals are more at risk for hypothermia.

The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint? a. The patient refuses to call for help to go to the bathroom. b. The patient continues to remove the nasogastric tube. c. The patient gets confused regarding the time at night. d. The patient does not sleep and continues to ask for items.

B: The patient continues to remove the nasogastric tube Patients who are confused, disoriented, and wander or repeatedly fall or try to remove medical devices (oxygen equipment, IV lines, or dressings) often require the temporary use of restraints to keep them safe. Restraints can be used to prevent interruption of therapy such as traction, IV infusions, NG tube feedings or Foley catherization.

When making rounds the nurse observes a purple wristband on a patient's wrist. How will the nurse interpret this finding? a. The patient is allergic to certain medications or foods. b. The patient has do not resuscitate preferences. c. The patient has a high risk for falls. d. The patient is at risk for seizures.

B: The patient has do not resuscitate preferences AHA issued an advisory recommending that hospitals standardized wristband colors: red for patients is allergies, Yellow for fall risk, and Purple for do not resuscitate preferences.

During the admission assessment, the nurse assesses the patient for fall risk. Which finding will alert the nurse to an increased risk for falls? a. The patient is oriented. b. The patient takes a hypnotic. c. The patient walks 2 miles a day. d. The patient recently became widowed.

B: The patient takes a hypnotic Numerous factors increase the risk of falls, including a history of falling and the effects of various medications such as anticonvulsants, hypnotics, sedatives, and certain analgesics.

The nurse has placed a yellow armband on a 70-year-old patient. Which observation by the nurse will indicate the patient has an understanding of this action? a. The patient removes the armband to bathe. b. The patient wears the red nonslip footwear. c. The patient insists on taking a "water" pill in the evening. d. The patient who is allergic to penicillin asks the name of a new medicine.

B: The patient wears the red nonslip footwear A yellow armband is an alert for high risk of falls. Red nonslip footwear helps to grip the floor and decreases the chance of falling.

The nurse is assessing a patient for lead poisoning. Which patient is the nurse most likely assessing? a. Young infant b. Toddler c. Preschooler d. Adolescent

B: Toddler The incidence of lead poisonings is highest in late infancy and toddlerhood. Children at this stage explore the environment and, because of their increased level of oral activity, put objects in their mouths.

Which patient will the nurse see first? a. A 56-year-old patient with oxygen with a lighter on the bedside table b. A 56-year-old patient with oxygen using an electric razor for grooming c. A 1-month-old infant looking at a shiny, round battery just out of arm's reach d. A 1-month-old infant with a pacifier that has no string around the baby's neck

B: patient with oxygen using an electric razor for grooming Do not use oxygen around electrical equipment or flammable products. A lighter on the bedside table are potential problems not actual.

A nurse is caring for a patient with sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.) a. Assist-control (AC) b. Pressure support ventilation (PSV) c. Bilevel positive airway pressure (BiPAP) d. Continuous positive airway pressure (CPAP) e. Synchronized intermittent mandatory ventilation (SIMV)

C,D Ventilatory support is achieved using a variety of modes, including continuous positive airway pressure(CPAP) and bilevel positive airway pressure (BiPAP). The purpose of CPAP and BiPAP is to maintain a positive airway pressure and improve alveolar ventilation. This prevents or treats atelectasis by inflating the alveoli, reducing pulmonary edema by forcing fluid out of the lungs back into circulation, and improving oxygenation in those with sleep apnea.

A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close? a. Aortic and mitral b. Mitral and tricuspid c. Aortic and pulmonic d. Mitral and pulmonic

C: Aortic and pulmonic As the ventricles empty, the ventricular pressures decrease, allowing closure of the aortic and pulmonic valves, producing the second heart sound S2

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient? a. Discontinue the humidification delivery device to keep excess fluid from lungs. b. Monitor oxygen saturation, and frequently auscultate lung bases. c. Assist the patient to cough, turn, and deep breathe every 2 hours. d. Decrease fluid intake to 300 mL a shift.

C: Assist the patient to cough, turn, and deep breathe every 2 hours The goal of nursing action should be the prevention of pneumonia; the action that best addresses this is to cough, turn, and deep breathe to keep secretions from pooling at the base of the lungs.

A nurse is caring for a patient who is taking warfarin (Coumadin) and discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient? a. Increased cholesterol level b. Distended jugular vein c. Bleeding d. Angina

C: Bleeding Patients taking warfarin (coumadin) for anticoagulation prolong the prothrombin time(PT)/ international normalized ratio (INR) results if they are taking gingko biloba, garlic, or ginseng with the anticoagulant. The drug interaction can precipitate a life-threatening bleed.

The nurse suspects the patient has increased afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition? a. Pulse oximeter b. Oxygen cannula c. Blood pressure cuff d. Yankauer suction tip catheter

C: Blood pressure cuff A blood pressure cuff is needed. The diastolic aortic pressure is a good clinical measure of afterload. Afterload is the resistance to left ventricular ejection. In hypertension the afterload increases, making cardiac workload also increase.

What of these supplies blood to the brain? a. Superior vena cava b. Pulmonary artery c. Carotid artery d. Coronary artery

C: Carotid artery The carotid artery supplies blood to the brain

Which coughing technique will the nurse use to help a patient promote airway clearance and a patent airway in the patient with large volumes of sputum? a. Huff b. Quad c. Cascade d. Incentive spirometry

C: Cascade With the cascade cough the patient takes a slow, deep breath and holds it for two seconds while contacting expiratory muscles. Then he or she opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes

A patient has a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia? a. Superior vena cava b. Pulmonary artery c. Coronary artery d. Carotid artery

C: Coronary artery A myocardial infarction is the lack of blood flow due to obstruction to the coronary artery which supplies the heart with blood.

A patient's heart rate increased from 94 to 164 beats/min. What will the nurse expect? a. Increase in diastolic filling time b. Decrease in hemoglobin level c. Decrease in cardiac output d. Increase in stroke volume

C: Decreased in cardiac output With a sustained heart rate greater than 160 beats/min, diastolic filling time decreases, decreasing stroke volume and cardiac output.

A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation? a. Anxiety over illness b. Decreased drive to breathe c. Increased metabolic demands d. Infection destroying lung tissues

C: Increased metabolic demands Increased body temperature (fever) increases the metabolic rate, thereby increasing carbon dioxide production. The increased carbon dioxide levels stimulates and increase in the patients rate and depth of respiration causing hyperventilation.

While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record? a. Atrial fibrillation b. Myocardial ischemia c. Left-sided heart failure d. Right-sided heart failure

C: Left-sided heart failure Left sided heart failure results in pulmonary congestion, the signs and symptoms of which include shortness of breath, cough, crackles, and paroxysmal nocturnal dyspnea (difficulty breathing when lying flat)

A patient with a pneumothorax has a chest tube inserted and is placed on low constant suction. Which finding requires immediate action by the nurse? a. The patient reports pain at the chest tube insertion site that increases with movement. b. Fifty milliliters of blood gushes into the drainage device after the patient coughs. c. No bubbling is present in the suction control chamber of the drainage device. d. Yellow purulent discharge is seen leaking out from around the dressing site.

C: No bubbling is present in the suction control chamber of the drainage device No bubbling in the suction control chamber indicates an obstruction of the drainage system. An obstruction causes increased pressure, which can cause a tension pneumothorax, which can be life threatening. The nurse needs to determine whether the leak is inside the thorax or in the tubing and act from there.

The nurse is teaching about the ability of the cardiovascular system to carry oxygenated blood to tissues and return deoxygenated blood to the heart. Which term will the nurse use to describe this process? a. Ventilation b. Surfactant c. Perfusion d. Diffusion

C: Perfusion Perfusion is the ability of the cardiovascular system to carry oxygenated blood to tissues and return deoxygenated blood to the heart

A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium? a. Right ventricle, left ventricle, left atrium b. Left atrium, right ventricle, left ventricle c. Right ventricle, left atrium, left ventricle d. Left atrium, left ventricle, right ventricle

C: Right ventricle, left atrium, left ventricle Unoxygenated blood flows through the venae cavae into the right atrium, where it is pumped down to the right ventricle; the blood is then pumped out the pulmonary artery and is returned oxygenated via the pulmonary vein to the left atrium, where it flows to the left ventricle and is pumped out to the rest of the body via the aorta.

A patient has heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output? a. Myocardial contractility ´x Myocardial blood flow b. Ventricular filling time/Diastolic filling time c. Stroke volume x Heart rate d. Preload/Afterload

C: Stroke volume x heart rate Cardiac output can be calculated by multiplying the stroke volume and the heart rate.

A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident? a. Pathogenic asepsis b. Medical asepsis c. Surgical asepsis d. Clean asepsis

C: Surgical asepsis The potential for infection is reduced when surgical asepsis is used for sterile dressing changes or any invasive procedure such as insertion of a urinary catheter.

The nurse is trying to use alternatives rather than restrain a patient. Which finding will cause the nurse to determine the alternative is working? a. The patient continues to get up from the chair at the nurses' station. b. The patient gets restless when the sitter leaves for lunch. c. The patient folds three washcloths over and over. d. The patient apologizes for being "such a bother."

C: The patient folds three wash clothes over and over. Restraint alternatives include more frequent observations, social interaction such as involvement of family during visitations, frequent reorientation, regular exercise, and the introduction of familiar and meaningful stimuli (involve in hobbies such as knitting or crocheting or looking at family photos) within the environment or folding wash cloths

A nurse is providing care to a patient. Which action indicates the nurse is following the National Patient Safety Goals? a. Identifies patient with one identifier before transporting to x-ray department b. Initiates an intravenous (IV) catheter using clean technique on the first try c. Uses medication bar coding when administering medications d. Obtains vital signs to place on a surgical patient's chart

C: Uses medication bar coding when administering medications One of the National Patient Safety Goals us to use medicines safely. For example, proper preparation and administration of medications, use of patient and medication bar coding, and "smart" IV pump reduce medication errors. Identifying patients correctly is a national patient safety goal, and two identifiers are needed, not one. Another goal is to prevent invention.

The nurse is monitoring for the four categories of risk that have been identified in the health care environment. Which examples will alert the nurse that these safety risks are occurring? a. Tile floors, cold food, scratchy linen, and noisy alarms b. Dirty floors, hallways blocked, medication room locked, and alarms set c. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach d. Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms not functioning properly

D Specific risks to a patients safety within the health care environment include falls, patient-inherent accidents, procedure-related accidents, and equipment-related accidents. Wet floors contribute to falls, pinching finger in door is patient inherent, failure to use the lift is procedure related, and an alarm not functioning properly is equipment related.

A home health nurse is performing a home assessment for safety. Which comment by the patient will cause the nurse to follow up? a. "Every December is the time to change batteries on the carbon monoxide detector." b. "I will schedule an appointment with a chimney inspector next week." c. "If I feel dizzy when using the heater, I need to have it inspected." d. "When it is cold outside in the winter, I will use a nonvented furnace."

D Using a nonvented heater introduces carbon monoxide into the environment and decreases the available oxygen for human consumption and the nurse should follow up to correct this behavior

The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method? a. A 5-year-old with excessive drooling from epiglottitis b. A 5-year-old with an asthma attack following severe allergies c. A 24-year-old with a right pneumothorax following a motor vehicle accident d. A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation

D: A 24 year old with acute respiratory distress syndrome requiring mechanical ventilation Closed suctioning is most often used on patients who require invasive mechanical ventilation to support their respiratory efforts because it permits continuous delivery of oxygen while suction is performed and reduces the risk of oxygen desaturation.

A patient may need restraints. Which task can the nurse delegate to a nursing assistive personnel? a. Determining the need for restraints b. Assessing the patient's orientation c. Obtaining an order for a restraint d. Applying the restraint

D: Applying the restraint The application and routine checking of restraint can be delegated to nursing assistive personnel.

The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia? a. Elevated blood pressure b. Increased pulse rate c. Restlessness d. Cyanosis

D: Cyanosis Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. Elevated blood pressure, increased pulse rate, and restlessness are early signs of hypoxia.

The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process? a. Ventilation b. Surfactant c. Perfusion d. Diffusion

D: Diffusion Diffusion is the process of gas exchanging across the alveoli and capillaries of body tissues.

The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene? a. "The number for poison control is 800-222-1222." b. "Never induce vomiting if my grandchild drinks bleach." c. "I should call 911 if my grandchild loses consciousness." d. "If my grandchild eats a plant, I should provide syrup of ipecac."

D: If grandchild eats a plant, I should provide syrup of ipecac The administration of ipecac syrup or induction of vomiting is no longer recommended routine home treatment of poisoning. The nurse must intervene to provide additional teaching.

A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer? a. Diuretics b. Vasodilators c. Chest physiotherapy d. Intravenous (IV) fluids

D: Intravenous (IV) fluids Preload is affected by the circulating volume; if the patient has decreased fluid volume, it will need to be replaced with fluid or blood therapy. Preload is the amount of blood in the left ventricle at the end of diastole, often referred to as end-diastolic volume.

A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take? a. Check on the patient once a shift. b. Encourage visitors in the early evening. c. Place all four side rails in the "up" position. d. Keep the patient on fall risk until discharge.

D: Keep the patient on fall risk until discharge A fall-reduction program includes a fall risk assessment of every patient, conducted on admission and routinely until a patients discharge.

A nurse reviews the history of a newly admitted patient. Which finding will alert the nurse that the patient is at risk for falls? a. 55 years old b. 20/20 vision c. Urinary continence d. Orthostatic hypotension

D: Orthostatic hypotension Numerous factors increase the risk of falls, including a history of falling, being over 65 or over, reduced vision, orthostatic hypotension, lower extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, and the effects of various medications.

While performing an assessment, the nurse notices peripheral edema, weight gain, and distended neck veins. Which condition will the nurse most likely observe written in the patient's medical record? a. Atrial fibrillation b. Myocardial ischemia c. Left-sided heart failure d. Right-sided heart failure

D: Right sided heart failure Right sided heart failure is systemic and results in peripheral edema, weight gain and distended neck veins.

The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. Which nursing diagnosis will the nurse add to the care plan? a. Impaired home maintenance b. Deficient knowledge c. Risk for poisoning d. Risk for injury

D: Risk for injury The patients behaviors support the nursing diagnosis of risk for injury. The patient is confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury could result if the patient falls out of bed or begins to bleed from a pulled line.

The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider? a. Increased anterior-posterior diameter of the chest b. Accessory muscle used for breathing c. Clubbing of the fingers d. Hemoptysis

D: hemoptysis Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies needed to determine the cause of blood in the sputum.

A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning? a. Pulse 75 b. Pulse 80 c. Oxygen saturation 91% d. Oxygen saturation 88%

D: oxygen saturation 88% Stop when oxygen saturation is 88%. Monitor patients vital signs and oxygen saturation during procedure; note whether there is a change of 20 beats/min (either increase or decrease) or if pulse oximetry falls below 90% or 5% from baseline.

What does RACE stand for?

Rescue and Remove all patients in immediate danger Activate the alarm Confine the fire by closing doors and windows Extinguish the fire using appropriate extinguisher.