Fundamentals success quiz 7

A primary HCP orders chest physiotherapy with percussion and vibration for a patient. After the HCP leaves, the patient says "I still don't understand the purpose of the therapy." Which statement should be included in the nurses response.

"It helps clear the airway of excessive secretions"

Which physical examination method should a nurse use when assessing for borborygmi? `

Auscultation

A patient has a thick tenacious respiratory secretion. Which should the nurse do to liquify the patient's respiratory secretions?

Encourage the patient to drink more fluids.

Which nursing action is common to all instruments when taking a temperature?

Ensure that the instrument is clean

A nurse is assessing a post-op patient. Which complaint has occurred when the patient experiences purulent sputum, dyspnea, and chest pain?

Hypostatic pneumonia

An unconscious patient who had oral surgery is admitted to the post-anesthesia care unit. In which position should the nurse place the patient?

Lateral

A patient had a 101 F fever. How often should the nurse monitor this patient's temperature.

Every 4 hours.

A nurse is caring for a patient who is experiencing an increase in signs and symptoms associated with MS. Which term describes the recurrence of signs and symptoms associated with a chronic disease?

Exacerbation

For which clinical manifestation should the nurse monitor the patient when concerned about a potential for respiratory distress?

Orthopnea

A primary HCP orders chest physiotherapy with percussion and vibration for a newly admitted patient. Which information obtained by the nurse during the health history should alert the nurse to question the provider's orders?

Osteoporosis.

An obese patient has limited mobility after an open reduction and internal fixation of a fractured hip. For which human response related to an increased blood coagulability should the nurse monitor the patient?

Pain in the calf

A patient is admitted with the diagnosis of lower extremity arterial disease (LEAD). Which is a specific desirable outcome for a patient with this diagnosis?

Palpable peripheral pulses

A nurse plans to take a patient's radial pulse. Which method of examination should be used by the nurse?

Palpation

Which method of examination is being used when the nurse's hands are used to assess the temperature of a patients skin?

Palpation

A meal tray arrives for a patient who is receiving 24% oxygen via a Venturi mask. To meet this patient's needs, the nurse should:

Request an order to use a nasal cannula during meals

A primary HCP's order reads "6 L oxygen via facemark." The patient, who has been extremely confused since being in the unfamiliar environment of the hospital, becomes agitated and repeatedly pulls off the mask. Which should the nurse do?

Request that the order for oxygen be changed to a nasal cannula.

A nurse is assessing a patient who states "i feel cold." Which mechanism that helps regulate body temperature will increase body heat?

Shivering

A nurse is teaching a patient how to use an incentive spirometer. Which positions should the nurse assist the patient to assume during this procedure?

Sitting

A nurse is caring for a patient receiving oxygen via nasal cannula. Which actions should the nurse implement? *Select all that apply.*

- Adjust the flow meter to the ordered oxygen flow rate - Reassess nares, cheeks, and ears for signs of pressure every 2 hours

A nurse concludes that a patient has inadequate nutrition. Which patient adaptations support this conclusion? *Select all that apply.*

- Cachetic appearance - Spoon-shaped nails

A nurse is concerned about the risk for thrombophlebitis when caring for a patient with impaired mobility. For which clinical manifestation associated with thrombophlebitis should the nurse monitor the patient? *Select all that apply.*

- Difficulty breathing - Acute chest pain

A nurse is caring for a patient who has a chest tube after a thoracic surgery. Which action should the nurse implement when caring for this patient? *Select all that apply.*

- Encourage the patient to cough and deep breathe at regular intervals - Maintain an airtight dressing over the puncture wound - Avoid using pins to secure tubing

A nurse identifies that a patient with a fever has cool skin. Which additional signs confirm the onset (cold or chill phase) of a fever? *Select all that apply.*

- Goose bumps on the skin - Cyanotic nail beds

A nurse is caring for a male patient. Which lab results place this patient at risk for impaired ability to tolerate activity? *Select all that apply.*

- Hb of 10 g/dL - O2 saturation of 90% - RBC count of 3.8 x 10^6 / mm^3

A nurse is assessing a post-op patient for signs of a hemorrhage. Which clinical manifestations are indicative of shock? *Select all that apply.*

- Hypotension - Fast respirations - Cold, clammy skin

A nurse in a clinic must obtain the vital signs of each patient via a electronic thermometer before patients are assessed by the primary health-care provider. Which patient characteristics indicate that the nurse should take the patient's temperature via the rectal, rather than the oral route? *Select all that apply.*

- Mouth breather - Presence of confusion

A patient has an elevated temperature and reports feeling cold. Which additional physical changes should the nurse expect during the onset of phase (cold or chill phase) of a fever? *Select all that apply.*

- Pale, cold skin - Shivering

A patient with HTN is given discharge instructions to take the BP everyday. A nurse is evaluating a family member taking the patient's BP as part of the discharge teaching plan. Which behaviors indicate that the family member needs additional teaching? *Select all that apply.*

- Positions the arm higher than the level of the heart - Releases the valve on the manometer so that the gauge drops 10 mm HG per heart beat - Inserts the earpieces of the stethoscope into the ears so that they tilt slightly backwards

A patient has lost approximately 2 units of blood during a vaginal delivery. For which responses to this blood loss should the nurse assess this patient? *Select all that apply.*

- Rapid, shallow breathing - Tachycardia

A nurse in the operative suite is preparing an older adult for surgery. Which physiological factors place the adult at *greater* risk for life-threatening complications associated with surgery for which the nurse should be aware? *Select all that apply.*

- Respiratory excursion - Cardiovascular capacity

A nurse is interviewing a newly admitted patient. Which words used by the patient describe data associated with the defervescence phase (fever abatement, flush phase) of a fever? *Select all that apply.*

- Warm -Sweaty

A patient has a serious vitamin K deficiency. For which clinical manifestations should the nurse assess the patient? *Select all that apply.*

- bleeding gums - ecchymotic area

A nurse is assessing a patient with a respiratory problem.. Which clinical manifestations are *most* reflective of an early response to hypoxia? *Select all that apply.*

- restlessness - irritability

A nurse obtains the BP of several adults. Which BP result should cause the most concern.

140/90 mm Hg

When evaluating the vital signs of a group of patients, the nurse takes into consideration the circadian rhythm of body temperature. Which time of day is the body temperature usually at its lowest?

4 a.m. to 6 a.m.

Which assessment requires the nurse to assess the patient further?

65-year-old man with a RR of 10

When evaluating vital signs of a group of patients, the nurse takes into consideration the circadian rhythm of body temperature. At which time of day is body temperature usually at the highest?

8 p.m. to 10 p.m.

A nurse identifies that a patient's hands are edematous when attempting to apply a pulse oximetry probe. Which action should the nurse implement?

Connect the probe to one of the patient's earlobes.

A primary HCP orders bedrest for a patient. Which should the nurse explain to the patient is the *primary* purpose of bedrest?

Conserve energy

Which outcome *best* reflects achievement of the goal, "The patient will expectorate lung secretions with no signs of respiratory complications?"

Absence of adventitious breath sounds

A nurse in the ED is engaging in an initial assessment of a patient. Which assessment takes priority?

Airway clearance

A nurse concludes that a patient is experiencing pyrexia. Which assessment precipitated this conclusion?

Rectal temperature of 101 F

Which of the following can cause urine to appear red?

Beets

Which is usually *unrelated* to a nursing physical assessment?

Blood and urine values

An adult patients vital signs are: oral temp 99F, pulse 88 bpm with regular rhythm, respirations 16 breaths per minute, and BP 180/110 mm HG. Which sign should cause concern?

Blood pressure

A nurse is assessing a patient's bilateral pulses for symmetry. Which pulse site should not be assessed on both sides of the body at the same time?

Carotid

Which action should the nurse implement to increase both the respiratory and the circulatory functions of a patient in a coma?

Change the patient's position every 2 hours

A nurse is teaching a cancer prevention community health class. Which recommended cancer screening guideline for asymptomatic people not at risk for cancer should the nurse include?

Colonoscopy of 50 years of age and every 10 years thereafter

Which should the nurse do if an adult is choking on food?

Determine if the patient can make any verbal sounds

Which should the nurse do *first* when caring for a nonverbal patient who is agitated and irritable?

Determine patency of the airway

Which are effective leg exercises the nurse should encourage a patient to perform to prevent circulatory complications during the postoperative period?

Dorsiflexion exercises

Which clinical manifestation is of *most* concern when the nurse assesses a patient who has impaired mobility?

Gurgling sounds when breathing

A nurse is monitoring the status of post-op patients. Which vital signs will change when a post-op patient has internal bleeding?

Heart rate

A nurse evaluates that the patient understood teaching about the purpose of pursed-lip breathing when the patient includes which information when explaining its purpose to a relative?

Helps maintain open airways

A nurse is reviewing the lab results of a patient with the preliminary diagnosis of anemia. An abnormal response of which diagnostic test reflects iron deficiency anemia?

Hemoglobin

A nurse in the ED is caring for a patient who is diagnosed with hypothermia. The presence of which factor in the patient's history may have precipitated this condition?

High alcohol intake

A primary HCP orders oxygen for a patient to be delivered at a high flow rate. Which additional nursing action is necessary when implementing a high-liter flow as opposed to a low-liter flow?

Humidifying oxygen before it is delivered to the patient

A nurse teaches a patient how to use an incentive spirometer. Which projected patient outcome will support the conclusion that the use of the incentive spirometer was a effective?

Inspiratory volume will be increased.

A patient is admitted to the ED with difficulty breathing. Which patient response identified by the nurse causes the *most* concern?

Low pulse oximetry

Which is the *most* important action by the nurse after a patient has a thoracotomy?

Maintain the integrity of the patient's chest tube

A nurse is planning care for a patient who has intolerance to activity. Which is the *first* assessment that should be made by the nurse?

Pattern of vital signs.

A nurse must assess for the presence of bowel sounds in a postoperative patient. Which technique should the nurse employ to obtain accurate results when auscultating the patient's abdomen?

Perform auscultation before palpation of the abdomen

A nurse raises the head of the bed for a patient who has difficulty breathing. Which science includes the principle that explains how this intervention facilitates respirations?

Physics

The nurse is obtaining a patient's BP. Which information is *most* important for the nurse to document?

Position of the patient if the patient is not in a sitting position

A nurse is assessing a patient's HR by palpating the carotid artery. Which action should the nurse implement when assessing a pulse at this site?

Press gently when palpating the site.

Which action is effective in meeting the needs of a patient experiencing laryngospasm after extubation?

Providing positive- pressure ventilation

A patient sucking on hard candy inhales while laughing and develops a total airway obstruction. Which is the nurse attempting to do when implementing an abdominal thrust?

Push air out of the lungs

A nurse is unable to palpate the patient's brachial pulse. Which pulse should the nurse assess to determine adequate brachial flow in this patient?

Radial

A patient's hemoglobin saturation via pulse oximetry indicates inadequate oxygenation. Which should the nurse do *first.*

Raise the head of the bed

A nurse teaches a patient to make a series of short, forceful exhalations (huffing) just before actually coughing. Which information should the nurse include when explaining the purpose of the action?

Raises sputum to a level where it can be expectorated

The nurse in the Post-Anesthesia Care Unit is monitoring several patients who received general anesthesia. Which patient adaptation causes the *most* concern?

Stridor

Which is common to the collection of specimens for culture and sensitivity tests regardless of their source?

Surgical asepsis must be maintained

The nurse takes a rectal temperature. Which should the nurse do?

Wear gloves throughout the entire procedure.

A nurse is planning to teach one patient pursed-lip breathing and another patient diaphragmatic breathing. Which technique associated with diaphragmatic breathing is different from pursed-lip breathing that the nurse should include in the teaching plan?

Tighten the abdominal muscles while exhaling

A nurse is performing a psych assessment. Which assessment should be identified as a subtle indicator of depression?

Unkempt apperance

Which nursing assessment *best* indicated a patient's ability to tolerate activity?

Vital signs that take three minutes to return pre activity level.