NSG 100 Unit 2 Exam - Safety, Functional Ability, Gas Exchange

The intravenous (IV) pump has been identified as malfunctioning. The screen on the pump goes blank and cannot be reset. What should registered nurse (RN) do with the pump? A. Tag it and report the malfunction B. Put it in the soiled linen room C. Discontinue the patient's IV infusion D. Bang on the pump until function is restored

A. Tag it and report the malfunction

Which behavior by the nurse during medication administration is most likely to cause a medication error? (Select all that apply.) A. Verifies the patient's identity calling the patient by name. B. Calls the pharmacist to check on the medication dosage. C. Takes a telephone call while preparing the medication. D. Fails to weigh the patient prior to giving the medication. E. Double-checks the right route before administering medication.

A. Verifies the patient's identity calling the patient by name. C. Takes a telephone call while preparing the medication.

Indirect measurement of the oxygen content of blood is

Pulse oximetry (Sp02)

A patient with a diagnosis of anemia is at risk for impaired perfusion of oxygen True False

True

1. Which interventions would the nurse manager include in a fall prevention program to decrease the number of falls on the unit? (Select all that apply) a. Apply fall wristband b. Install bed safety alarms c. Establish a toileting schedule d. Allow client to ambulate to bathroom e. Use restraints to prevent the client from leaving the bed

a. Apply fall wristband b. Install bed safety alarms c. Establish a toileting schedule

Which questions would be included during a focused history on a cardiac patient to help the nurse determine the significance of the cues? (Select all that apply.) a. Are you having pain? b. Where is the pain located? c. Do you attend religious services regularly? d. Do you have increased fatigue? e. Do you have any episodes of dizziness?

a. Are you having pain? b. Where is the pain located? d. Do you have increased fatigue? e. Do you have any episodes of dizziness?

To promote safety, the nurse manager sensitive to point-of-care (sharp-end) and systems-level (blunt-end) exemplars works closely with administrators to address which organizational system exemplar? a. Care coordination b. Fall prevention c. Diagnostic workup d. Communication

a. Care coordination

1. Which strategies will promote safety and quality of client care on the unit? (Select all that apply) a. Communicate with clarity and precision when designing multidisciplinary plans of care b. Create a safety huddle so all health care professionals are aware of the clinical objectives c. Emphasize electronic communication is quick and most effective means of sharing information in all situations d. Conduct communication simulations to increase knowledge about expertise of other health care disciplines e. Explain effective communication will take more time and effort compared with ineffective communication

a. Communicate with clarity and precision when designing multidisciplinary plans of care b. Create a safety huddle so all health care professionals are aware of the clinical objectives d. Conduct communication simulations to increase knowledge about expertise of other health care disciplines

How does a nurse support a culture of safety? (Select ALL that apply) a. Completing an incident report for a near miss b. Identifying the person responsible for an incident c. Communicating product concerns to an immediate supervisor d. Participating in safety and health training

a. Completing an incident report for a near miss c. Communicating product concerns to an immediate supervisor d. Participating in safety and health training

The nurse is collecting data from an older adult (age >65) to determine the patient's functional ability to perform activities of daily living (ADLs). Which should the nurse acknowledge as normal physiological changes during her assessment? (Select all that apply.) a. Diminished visual acuity b. Crepitus c. Fast pulse rate d. Decreased reaction time e. Limited range of motion

a. Diminished visual acuity b. Crepitus d. Decreased reaction time e. Limited range of motion

A patient has been using herbal medication as part of her daily routine. Which actions should the nurse take? (Select all that apply.) a. Document the herbs as part of the medication history. b. Recommend a reputable company from which to buy herbs. c. Allow the patient to self-administer the herbs with her morning medications. d. Inform the primary care provider of the findings. e. Identify possible adverse effects of the herbal medications.

a. Document the herbs as part of the medication history. d. Inform the primary care provider of the findings. e. Identify possible adverse effects of the herbal medications.

The nurse is caring for a patient requiring parenteral anticoagulant therapy. Which of the following actions should the nurse take to maximize patient safety? (Select all that apply.) a. Double-check order and dosage with another RN. b. Administer medication using a smart IV infusion pump. c. Administer heparin only through a central venous catheter. d. Monitor glucose every 6 hours. e. Assess and document IV site every 8 hours.

a. Double-check order and dosage with another RN. b. Administer medication using a smart IV infusion pump.

The nurse is assessing a patient's ability to perform basic activities of daily living (BADLs). Which activities are considered in the BADLs assessment? (Select all that apply.) Select all that apply. a. Dressing oneself in the mornings b. Washing, drying, and folding laundry c. Calling family members d. Counting own pulse and taking heart pill e. Taking the bus to the park f. Brushing teeth or dentures

a. Dressing oneself in the mornings f. Brushing teeth or dentures

A patient is being discharged and several previous medications are being discontinued. The patient asks the nurse what she should do with unused medications. The nurse demonstrates knowledge of proper disposal of medications by which of the following? (Select all that apply.) a. Encouraging the patient to use a drug take-back location if available b. Telling the patient to check the label and, if approved, flush the medication down the toilet c. Encouraging the patient to donate the unused medication to a local hospital for use d. Teaching the patient to add coffee grounds to the medication, put in a sealed bag, and dispose in the trash e. Checking to see whether the patient's family members could benefit from the medication

a. Encouraging the patient to use a drug take-back location if available b. Telling the patient to check the label and, if approved, flush the medication down the toilet d. Teaching the patient to add coffee grounds to the medication, put in a sealed bag, and dispose in the trash

The nurse is in a patient's room ready to administer a new medication to the patient. Which action best demonstrates awareness of safe, skilled nursing practice? a. Identify the patient by comparing the patient's name and birth date to the medication administration record (MAR). b. Determine whether the medication and dose are appropriate for the patient. c. Make sure that the medication is in the medication cart. d. Check the accuracy of the dose with another nurse.

a. Identify the patient by comparing the patient's name and birth date to the medication administration record (MAR).

Which action should be taken when attempting to decrease falls in the hospital setting? a. Lower the height of the bed and the bottom two side rails before leaving the room. b. Ask patients on first encounter to use the bathroom and every 4 hours thereafter. c. Instruct patients to use the call light only if they think they need help getting out of bed. d. Encourage patients to not take any prescribed medicine that could cause drowsiness or light-headedness.

a. Lower the height of the bed and the bottom two side rails before leaving the room.

During handoff to the oncoming shift, the nurse includes in the SBAR report that the patient needs to be evaluated by speech therapy for which of the following reasons? a. Persistent aspiration of liquids b. Hypoventilation due to smoking c. Hyperventilation due to anxiety d. Decreased respiratory effort due to scoliosis

a. Persistent aspiration of liquids

The nurse implements the necessary safety precautions in an environment for a patient by doing which of the following? (Select all that apply.) a. Place bed in lowest position with brakes locked. b. Put both upper side rails up while patients are in bed. c. Move personal belongings within reach. d. Place bedside table between patient and the bathroom to use as a resting area. e. Ensure that all patients have bedside commode access.

a. Place bed in lowest position with brakes locked. b. Put both upper side rails up while patients are in bed. c. Move personal belongings within reach.

The nurse is caring for a patient with severe chronic obstructive pulmonary disease (COPD). The patient has albuterol treatments scheduled every 6 hours and PRN and is on 2 L/min of oxygen via nasal cannula. Respiratory therapy (RT) administered the last breathing treatment 1 hour ago. When entering the patient's room to administer medications, the nurse notes that the patient is in acute respiratory distress. Which priority interventions would the nurse take to safely manage the care of this patient? (Select all that apply.) a. Place patient in upright position. b. Call respiratory therapy. c. Increase oxygen to 7 L/min via nasal cannula. d. Assess vital signs. e. Listen to lung sounds. f. Administer metoprolol.

a. Place patient in upright position. b. Call respiratory therapy. d. Assess vital signs. e. Listen to lung sounds.

Which concepts should a nurse recognize have the strongest link to safety? (Select all that apply.) Select all that apply. a. Regulation b. Teamwork c. Communication d. Cognition e. Quality

a. Regulation b. Teamwork c. Communication e. Quality

When caring for a hearing-impaired patient, use of which action by the nurse would facilitate communication? a. Speaking clearly with distinct words b. Talking slowly to facilitate understanding c. Sitting behind the patient to decrease distractions d. Standing near the patient's affected ear to balance sound

a. Speaking clearly with distinct word

Which measures should the nurse suggest for​ toddler-proofing a​ home? (Select all that​ apply.) a. Storing and locking up cleaning supplies and medications out of reach b. Providing gym equipment on a hard surface c. Cutting foods properly to prevent choking hazards d. Choosing​ age-appropriate toys that do not pose a swallowing hazard or injury risk Placing toddlers on their backs in​ bed, without blankets and in warm clothing

a. Storing and locking up cleaning supplies and medications out of reach c. Cutting foods properly to prevent choking hazards d. Choosing​ age-appropriate toys that do not pose a swallowing hazard or injury risk Placing toddlers on their backs in​ bed, without blankets and in warm clothing

The nurse is developing a plan of care for a patient. What is the most appropriate goal for a patient related to medications? a. The patient will administer all medications correctly by discharge. b. The patient will be taught common side effects of prescribed medications. c. The patient will have a good understanding of prescribed medications. d. The patient will have all medications administered by staff as prescribed.

a. The patient will administer all medications correctly by discharge.

1. Which instruction would the nurse provide to a group of parents with small children to promote safety and prevent injury? (Select all that apply) a. Turn pot handles away from edges b. Install smoke detectors in the house c. Lock medication away in a safe place d. Place child safety latches on cabinets e. Verify water temperature before baths

a. Turn pot handles away from edges b. Install smoke detectors in the house c. Lock medication away in a safe place d. Place child safety latches on cabinets e. Verify water temperature before baths

When caring for an elderly patient who presents with acute confusion of sudden onset, which test would the nurse expect to be ordered? a. Urine culture and sensitivity testing b. Mini-Mental State Examination (MMSE) c. Swallow evaluation d. Magnetic resonance imaging (MRI) with contrast

a. Urine culture and sensitivity testing

The nurse is caring for a critically ill patient. What are the contraindications for administering medications by the oral route for this type of patient? (Select all that apply.) a. Vomiting b. Unconsciousness c. Diarrhea d. Penicillin allergy e. Intubation

a. Vomiting b. Unconsciousness e. Intubation

(Case Study) An 80-year-old male patient has been admitted to the medical surgical unit with a diagnosis of acute bronchitis. He has a history of hypertension, falls, dementia, and uses a cane to ambulate. Identify risk factors for fall in the scenario along with other factors discussed in your safety lesson

age, history of falls, dementia, ambulatory aid gender dizziness, vertigo any administered antiepileptics

Which statement by the patient with vertigo lets the nurse know that the patient has understood the home-going instructions? a. "I will buy a visual signal for my smoke detectors." b. "I will have grab bars installed in my bathtub." c. "I will change positions quickly to avoid vertigo." d. "I will get a home phone with amplified sound."

b. "I will have grab bars installed in my bathtub."

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD). Which significant finding does the nurse anticipate when inspecting the chest? a. A ratio of 1:2 when comparing the side and front views of the chest b. A barrel chest c. A concave shape to the sternum d. A severe lateral curvature of the spine

b. A barrel chest

Which of the following interventions by the nurse addresses a National Patient Safety Goal as indicated by The Joint Commission? a. Take a picture of the patient upon admission to verify patient identity. b. Answer patient call alarms in a timely manner. c. Provide patient a permanent marker to label all of their medications. d. Use hand sanitizer as the best option for hand hygiene.

b. Answer patient call alarms in a timely manner.

The nurse knows that which of the following nursing actions are indicated when suctioning a patient with a tracheostomy? (Select all that apply.) a. Decrease the patient's oxygen flow rate before beginning the deep suctioning. b. Assess heart rate, respiratory rate, oxygen saturation, and lung sounds prior to suctioning. c. Suction intermittently for no more than 10 to 15 seconds. d. Flush the artificial airway with 5 mL of normal saline to loosen secretions. e. Reassess heart rate, respiratory rate, oxygen saturation, and lung sounds after suctioning. f. Document time, amount, and characteristics of secretions.

b. Assess heart rate, respiratory rate, oxygen saturation, and lung sounds prior to suctioning. c. Suction intermittently for no more than 10 to 15 seconds. e. Reassess heart rate, respiratory rate, oxygen saturation, and lung sounds after suctioning. f. Document time, amount, and characteristics of secretions.

A post-op patient has been unwilling to ambulate despite the nurse's education on the benefits of early ambulation following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for what? a. Bronchitis b. Atelectasis c. Anemia d. Tachypnea

b. Atelectasis

The nurse is assessing a patient's ability to perform instrumental activities of daily living (IADLs). Which activities are considered in the IADLs assessment? (Select all that apply.) Select all that apply. a. Feeding oneself b. Balancing a checkbook c. Toileting d. Preparing a meal e. Grocery shopping f. Walking

b. Balancing a checkbook d. Preparing a meal e. Grocery shopping

What action should be taken by the nurse first when preparing to administer medications to a patient? a. Check the medication expiration date. b. Check the medication administration record (MAR). c. Call the pharmacy for administration instructions. d. Check the patient's name band.

b. Check the medication administration record (MAR).

Which intervention would help prevent falls in older adult clients? a. Check vision every five years. b. Exercise regularly. c. Place regular socks on feet. d. Check hearing every year.

b. Exercise regularly.

The nurse understands that which of the following is most likely occurring when caring for a pulmonary patient that has bluish discoloration around the lips? a. Increased PaCO2 levels b. Hemoglobin that is not saturated with oxygen c. Elevated white blood cell count d. Decreased PaCO2 levels

b. Hemoglobin that is not saturated with oxygen

What is the desired outcome related to the nursing diagnosis of Impaired Airway Clearance? a. Patient's respiratory secretions will become thicker so they are not moved when coughing. b. Patient's respiratory secretions will have a thinner consistency after being given a mucolytic agent. c. Patient will have improved range of motion while in bed. d. Patient's respiratory rate will increase from 16 to 28 breaths/min during hospitalization.

b. Patient's respiratory secretions will have a thinner consistency after being given a mucolytic agent.

Which nursing interventions would be necessary in caring for a patient with cognitive alterations who is hospitalized? (Select all that apply.) a. Apply wrist restraints for combativeness. b. Place a clock in the room for orientation. c. Keep floor free of clutter for safety. d. Identify staff with each interaction. e. Play loud music for distraction.

b. Place a clock in the room for orientation. c. Keep floor free of clutter for safety. d. Identify staff with each interaction.

Which interventions are priorities in a plan of care for a patient who had a stroke 30 days ago and is now in home care rehabilitation? (Select all that apply.) a. Promoting a diet rich in protein b. Promoting rest and sleep c. Promoting exercise and ambulation d. Limiting visitors and social contacts e. Assisting the patient with ADLs

b. Promoting rest and sleep c. Promoting exercise and ambulation

The nurse is providing discharge instructions on ways to prevent falls at home. Which of the following guidelines are helpful in preventing falls? (Select all that apply.) a. Always wear socks when walking to protect your feet when ambulating. b. Remove rugs that can slip; use rubber mats instead. c. Use your walker or cane even if only moving short distances. d. Use lightweight, easily moveable chairs to assist with mobility. e. Put frequently used items in easy-to-reach places. f. Use handrails when available.

b. Remove rugs that can slip; use rubber mats instead. c. Use your walker or cane even if only moving short distances. e. Put frequently used items in easy-to-reach places. f. Use handrails when available.

A student nurse receives an order for diazepam to be given intravenously. Diazepam tablets are available. The student nurse crushes a tablet and mixes it with sterile water for injection. The instructor notes that the solution is cloudy and asks to see the medication vial. When the student produces the vial of sterile water for injection and the instructor stops the medication from being given, what type of error is prevented? a. Preventive error b. Treatment error c. Diagnostic error d. Communication error

b. Treatment error

The nurse is teaching a patient about how to take a sublingual nitroglycerin tablet. Which statement by the patient best demonstrates understanding of the teaching? a. "I will take the tablet with plenty of water." b. "I will place the tablet inside my cheek." c. "I will put the tablet under my tongue." d. "I will take the tablet while I am eating."

c. "I will put the tablet under my tongue."

The nurse would understand the need for further safety education when a parent makes which of the following statements? a. "I secure my 8-month-old in a rear-facing car seat in the back seat." b. "My 10-year-old is angry that I still make him use a booster seat and he is not permitted to ride in the front seat." c. "My 2-month-old sleeps the longest when I put him in his crib on his stomach." d. "All of our household cleaners are stored in the upper cabinets in my home."

c. "My 2-month-old sleeps the longest when I put him in his crib on his stomach."

The nurse reviews a primary care provider's order and finds that the medication amount is greater than the standard dose. What action should the nurse take? a. Give the standard dose rather than the one that is ordered. b. Consult with the nursing supervisor to get a second opinion. c. Call the primary care provider to discuss the order in question. d. Administer the medication as ordered by the primary care provider.

c. Call the primary care provider to discuss the order in question.

A patient with chronic obstructive pulmonary disease (COPD) uses which drive to breathe? a. Increased PaCO2 b. Decreased hemoglobin c. Decreased PaO2 levels d. Increased PaO2 levels

c. Decreased PaO2 levels

A visually impaired diabetic patient states that he has lost the call light. What is the next action the nurse should take? a. Clip the call light closer to the patient. b. Tell the patient that the call light is clipped to the bed. c. Describe the call light location; then, take the patient's hand and guide it to that location. d. Instruct the patient to verbally call for a staff member because "someone is always nearby."

c. Describe the call light location; then, take the patient's hand and guide it to that location.

1. Which strategy would improve safety when the nurse manager institutes strategies to decrease the omission of important information during communication between staff nurses and health care providers? a. Require health care providers to print prescriptions instead of using cursive writing b. Use the "read-back" method when taking phone prescriptions from health care providers c. Employ SBAR (situation, background, assessment, and recommendation) communication d. Devise standing orders for the five most common admitting diagnoses on the client care unit

c. Employ SBAR (situation, background, assessment, and recommendation) communication

The nurse is caring for an 85-year-old woman 6 weeks following a hysterectomy secondary to ovarian cancer. The patient will need chemotherapy and irradiation on an outpatient basis. The nurse should identify and address which barriers to healing? (Select all that apply.) a. Can feed herself and prepare meals but cannot drive to the store b. Cannot participate in activities at the senior center c. Has no transportation to the oncology clinic d. Lives on a fixed income and can balance her checkbook e. Lives alone and has no nearby relatives f. Experiences stress incontinence

c. Has no transportation to the oncology clinic e. Lives alone and has no nearby relatives f. Experiences stress incontinence

which would the nurse teach the parents of an infant about the use of car seats? a. Infants should ride in a front-facing care safety seat b. Infants should ride in a car safety seat until 1 year of age c. Infants should be restrained properly in a federally approved car safety seat d. Infants should always ride in a car seat restrained to the front seat of the car

c. Infants should be restrained properly in a federally approved car safety seat

The health care provider prescribes a transdermal medication. The nurse understands what feature of the transdermal route? a. It is inhaled into the respiratory tract. b. It is dissolved inside the cheek. c. It is absorbed through the skin. d. It is inserted into the vaginal cavity.

c. It is absorbed through the skin.

When an error or patient safety issue is identified in an agency with a culture of safety, what does the individual who reports the problem know? a. The problem must be communicated to the patient. b. Details need to be shared in order to locate the individual at fault. c. Near misses in health care are used to improve care. d. Established protocols for discipline will be followed.

c. Near misses in health care are used to improve care.

Which goal statement is appropriate for a patient with the nursing diagnosis of Acute Confusion? a. Patient will remember nurse's name. b. Nurse will remind patient of his or her name each shift. c. Patient will state name and date with each nursing encounter. d. Nurse will remind patient of name and date with each nursing encounter.

c. Patient will state name and date with each nursing encounter.

The nurse is caring for a patient who is unable to hold a cup or spoon. How should the nurse administer oral medications to the patient? a. Crush the pills and mix them in pudding before administering. b. Ask the pharmacist to change all of the medications to a liquid form. c. Use a small paper cup to place the pills into the patient's mouth. d. Place the pills on the table and have the patient take the pills by hand.

c. Use a small paper cup to place the pills into the patient's mouth.

A patient comes to the emergency department complaining of difficulty breathing. An objective finding associated with the patient's complaints of dyspnea might include: a. Feeling of heaviness in the chest b. Complaints of shortness of breath c. Use of accessory muscles of respiration d. Statements about a sense of impending doom

c. Use of accessory muscles of respiration

The novice nurse knows that pulse oximetry is a(n) a. direct measurement of oxygen and carbon b. dioxide exchange c. percentage of inhalation and exhalation indirect measurement of the oxygen content of blood. d. peak expiratory flow rate (PEFR)

c. percentage of inhalation and exhalation indirect measurement of the oxygen content of blood.

The nurse is assigned a group of patients. Which patient would the nurse identify as being at increased risk for impaired gas exchange? A patient a. with a blood glucose of 350mg/dL b. who has been on anticoagulants for 7 days c. with a hemoglobin of 7.8g/dL d. with a heart rate of 100beats/min and BP of 100/60

c. with a hemoglobin of 7.8g/dL

1. After conducting a falls risk assessment education session for the staff and observing falls risk assessments on the unit, which staff action needs review for corrective action? a. Using a fall risk assessment tool b. Assessing the environment for fall hazards c. Inquiring about the client's history of falls d. Delegating fall assessments to assistive personnel

d. Delegating fall assessments to assistive personnel

1. Which nursing assessment supports a diagnosis of atelectasis in a postoperative client? a. Productive cough b. Clubbing of the fingertips c. Low-pitched expiratory rhonchi d. Diminished breath sounds on auscultation

d. Diminished breath sounds on auscultation

The nurse is teaching new mothers about safe sleeping for newborns. Which recommendation should the nurse​ include? a. Keep newborns on their stomachs while in the crib and cover them with a warm blanket. b. Place newborns on their sides and cover with a light blanket. c. Cover newborns up to the shoulder with a warm blanket and put them on their backs. d. Dress newborns in warm clothing and place them on their backs while in a crib.

d. Dress newborns in warm clothing and place them on their backs while in a crib.

1. Which action will the nurse take when a clients chest x-ray shows atelectasis? a. Administer oxygen b. Suction the upper airway c. Position for postural drainage d. Encourage incentive spirometer use

d. Encourage incentive spirometer use

What actions should be taken when caring for an 80-year-old postoperative patient with a history of Parkinson's disease? a. Ensure that all four side rails are elevated. b. Instruct family that they cannot leave the room. c. Place wrists in soft restraints to protect invasive lines. d. Include hourly rounding in the plan of care.

d. Include hourly rounding in the plan of care.

1. Which laboratory result of a client with chronic bronchitis would be most important for the nurse to communicate to the health care provider? a. PaO2 75mmHg b. PaCO2 48mmHg c. Hematocrit 52% (0.52) d. Leukocytes 16,000 mm ^3 (16x10^9/L)

d. Leukocytes 16,000 mm ^3 (16x10^9/L)

1. A child who is cognitively impaired and blind does not speak or respond to the nurse. Which would the nurse do when entering the child's room? a. Blink the room lights before starting care b. Start care and explain actions as care is given c. Nonverbally acknowledge the child before starting to give care d. Say the child's name and touch the child's arm before starting care

d. Say the child's name and touch the child's arm before starting care

can be caused by: decreased cardiac output, thrombus or emboli, vessel narrowing or vasoconstriction or blood loss is

impaired perfusion

Prescribed for postop patients as well as some with pulmonary alterations to expand lungs and clear mucus secretions is

incentive spirometry

sentential event example

tap H2O contaminated, pt fam member used H2O to humidify pt oxygen. pt contracts disease related to contamination and dies

fall assessment tools

- Morse fall scale - Hendricks II fall risk scale - john Hopkins Hospital fall risk scale -stopping elderly accidents, deaths, and injuries (STEADI) - humpty dumpty (in pediatric patients)

Partial rebreathing mask

-High concentration but still low flow -Delivers 60-80% O2 at flow rates of 6-15L/min -Flowrate must be sufficient to keep reservoir bag at least 2/3 full at peak inspiratio -No valves on mask -First part of patients exhaled gas enters the reservoir bag which is high in O2 -Mixes with O2 in bag

direct measurement of oxygen and carbon dioxide exchange is

ABG

volume of air expelled in 1 second from the beginning of the FVC; expected finding is 75-85% of FVC

Forced expiratory volume in 1 second (FEV1)

A patient admitted with a history of chronic obstructive pulmonary disease (COPD) admits to smoking 1 pack of cigarettes per day for the last 40 years. When developing a plan of care for the patient, the nurse includes smoking cessation as a priority education goal. Which interventions would the nurse include in the patient education? (Select all that apply.) a. Alternative therapies b. Nicotine replacements c. Support groups d. Switching to e-cigarettes e. Counseling f. Decreasing the number of cigarettes smoked by half g. Educating about the risks of smoking

a. Alternative therapies b. Nicotine replacements c. Support groups e. Counseling g. Educating about the risks of smoking

Which nursing diagnosis is most appropriate for a patient with expressive aphasia? a. Impaired Verbal Communication b. Acute Confusion c. Self-Care Deficit d. Impaired Mobility

a. Impaired Verbal Communication

The nurse knows that the primary function of the alveoli is to a. carry out gas exchange. b. store oxygen. c. regulate tidal volume. d. produce hemoglobin.

a. carry out gas exchange.

The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs is known as: a. Ventilation b. Perfusion c. Respiration d. Hypoxia

b. Perfusion

The nurse demonstrates proper use of a fire extinguisher by taking which action first? a. Sweep from side to side b. Pull the pin c. Squeeze the handles together d. Aim and approach the fire

b. Pull the pin

An oxygen Delivery system is prescribed for a client with COPD to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? a. Simple face mask b. Nasal cannula c. Venture mask d. Non-rebreather mask

c. Venture mask

difficulty or labored breathing. Shortness of breath (SOB) is

dyspnea

an airway clearance technique that uses gravity to drain mucus out of the lungs by changing positions is

postural drainage

near miss example

pt almost receives wrong dose of med

Hematocrit levels

reflects ratio of RBC's to plasma. Chronic hypoxemia= increased hematocrit male= 38.3-48.6% female= 35.5-44.9%

amount of air remaining in the lungs after forced expiration; expected finding is approximately 1 L In emphysema, the result may be up to 4x the expected value

residual volume (RV)

delivers flow rates from 5-8 L/min that administers 40-50% FiO2 is

simple face mask

education program addressing a significant individual risk factor for imparted gas exchange is

smoking cessation

helps to remove thick mucus and secretions from the trachea and lower airway that a patient is unable to clear by coughing is

suctioning

abnormally rapid breathing is

tachypnea

Gas exchange requires integration among the pulmonary, musculoskeletal and neurological systems. True False

true

impaired by the unavailability of oxygen as well as by any disorders affecting the nasopharynx and lungs is

ventilation

Simple face mask flow rate

6-10L/min

Venturi mask

A face mask and reservoir bag device that delivers specific concentrations of oxygen by mixing oxygen with inhaled air. can be adjusted to 24, 28, 31, 35, 40, & 50 percent oxygen

A nurse is contributing to the plan of care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse recommend for inclusion in the plan of care? (Select all that apply.) A. Encourage use of the incentive spirometer hourly B. Instruct the client to splint the incision when coughing and deep breathing. C. Reposition the client every 2 hr. D. Administer antibiotic therapy. E. Assist with early ambulation.

A. Encourage use of the incentive spirometer hourly B. Instruct the client to splint the incision when coughing and deep breathing. C. Reposition the client every 2 hr. E. Assist with early ambulation.

Which patient appears to be at greatest risk for falls? A. 66 year old post-op, oriented x 3, taking opioid pain meds B. 71 year old with pneumonia, oriented x 2, on oxygen and IV C. 76 year old with acute confusion, knows name, incontinent, has an IV D. 80 year old post-op, oriented x 3, has a cast, opioid pain medications

C. 76 year old with acute confusion, knows name, incontinent, has an IV

Identify two (or all) examples of the NPSG's

Identify patients correctly (using 2 ways of identification) use alarms safely prevent mistakes in surgery prevent infection

Partial pressure of carbon dioxide in the artery. The amount of carbon dioxide in plasma is

PaCO2

Noninvasive tests that show how well the lungs are working. Measure lung volume, capacity, rates of flow, and gas exchange is

Pulmonary function tests (PFTs)

adverse event & example

Unintended harm by an act of commission or omission rather than as a result of disease process NAP brings Pt tea and trips, burning the patients arm and legs

Both ventilation and perfusion are integral to the concept of gas exchange. This relationship is descried as

V (ventilation) - Q (perfusion) ratio (V-Q Ratio)

Delivers a known oxygen concentration to patients on controlled oxygen therapy is

Venturi mask

The nurse taught a group of high school students' actions to prevent injury. Which student comment indicates an understanding of the​ teaching? (Select all that​ apply.) a. "I hate​ it, but I will wear a helmet when riding my​ bike." ​b. "I do not need to wear a seat belt as a passenger in a​ car." c. "I should not get into a car when the driver has been​ drinking." d. "If I feel really​ down, I need to talk to my parents about​ it." ​e. "I can talk to a teacher if I am faced with peer pressure to use​ drugs."

a. "I hate​ it, but I will wear a helmet when riding my​ bike." c. "I should not get into a car when the driver has been​ drinking." d. "If I feel really​ down, I need to talk to my parents about​ it." ​e. "I can talk to a teacher if I am faced with peer pressure to use​ drugs."

Which nursing action is appropriate for a patient with sensory overload? a. Dimming the lights b. Performing care a little at a time c. Leaving the patient's door open d. Rushing to get care done quickly

a. Dimming the lights

The student nurse knows that an impairment in gas exchange due to altered transport may occur when a. the amount of hemoglobin is low (anemia) b. the patient has a thrombus or an emboli c. there is insufficient amount of white blood cells d. the amount of hemoglobin is elevated

a. the amount of hemoglobin is low (anemia)

which factor will the home health nurse use to assess an adolescent's safety in the home environment? (Select all that apply) a. use of helmets b. drug and alcohol use c. presence of weapons d. vehicle safety restraints e. number of people in home f. nutrition and food consumption

a. use of helmets b. drug and alcohol use c. presence of weapons

Non-rebreather mask

allows higher levels of oxygen to be added to the air taken in by the patient (60%-90%) cannot be used with high degree of humidity

Gas exchange occurs within the: a. bronchioles b. alveoli c. pleural space d. thoracic wall

b. alveoli

WBC levels

between 5,000 and 10,000

1. A client asks about the purpose of a pulse oximeter. Which measurement is a pulse oximeter used for? a. Respiratory rate b. Amount of oxygen in the blood c. Percentage of oxygen-carrying hemoglobin d. Amount of carbon dioxide in the blood

c. Percentage of oxygen-carrying hemoglobin

When administering oxygen to a patient, the nurse recognizes that using which oxygen delivery system places a patient in danger of receiving inadequate oxygen? a. Nasal cannula at a flow rate of 2 L/min b. Nasal cannula at a flow rate of 5 L/min c. Simple mask at a flow rate of 6 L/min d. Nonrebreather mask at a flow rate of 5 L/min

d. Nonrebreather mask at a flow rate of 5 L/min

A nurse is assessing a patient in restraints. The nurse observes correct use of restraints by checking which of the following? a. Restraint is tied in a secure knot. b. Restraint is secured to the bedrail. c. Restraint allows for 3 to 4 fingers' width between restraint and patient's wrist. d. Restraint is secured to the bedframe.

d. Restraint is secured to the bedframe.

Which recommendation in the home-going instructions is appropriate for a patient with damage to the chemoreceptors of the upper nasal passages? a. Arranging for lighted signals on doorbells and telephones b. Obtaining a thermometer for testing bath water temperature c. Installing amplification devices on televisions, doorbells, and telephones d. Scheduling yearly safety checks of gas hot water heaters and furnaces

d. Scheduling yearly safety checks of gas hot water heaters and furnaces

The nurse is caring for a patient with decreased sensation in the lower extremities. Which precaution does the nurse advise the patient to take? a. Use heat to warm hands during cold weather. b. Go barefoot at home to prevent blisters from shoes. c. Soak feet in cold water daily to decrease swelling. d. Test the bath water temperature to prevent burning injuries.

d. Test the bath water temperature to prevent burning injuries.

An array of assessment tools has been developed to assess activities of daily living (ADLs) as an indication of a person's functional ability. Some of these tools including the 24-Hour Functional Ability Questionnaire (24hFAQ) for outpatient postoperative patients, the Long Term Care Minimum Data Set (MDS) for nursing home patients, the Functional Status Scale (FSS) for hospitalized children, and the Edmonton Functional Assessment Tool for cancer patients are used to assess activities of daily living (ADLs). What is a disadvantage to these specific tools? a. The measurement of efficacy and reliability of the instruments are used to assess activities of daily living (ADLs). b. The instruments do not show a true measure of ability because of a lack of interactivity during the assessments. c. The information contained in the instruments is insufficient to make a determination about functional status in these populations. d. The variations in assessments and responses may be subjective because of self-reporting of functional activities.

d. The variations in assessments and responses may be subjective because of self-reporting of functional activities.

arterial blood gases (ABGs)

direct measurement of oxygen and carbon dioxide exchange measures SaO2, PaO2, PaCO2, HCO3-

sputum specimen

facilitate the selection of the proper antibiotic, antiviral, or antifungal

Hypoxemia refers to a decrease in the delivery of oxygen to the tissues. True False

false

amount of air that can be forcefully expelled or exhaled after the lungs are maximally inflated; average is 4 L for an adult

forced vital capacity (FVC)

The process by which oxygen is transported to cells and carbon dioxide is transported from cells is

gas exchange

the exchange of oxygen and carbon dioxide between the systemic circulatory system and the cells of the body is

internal respiration

spirometry

measures inhalation and exhalation

most common and comfortable device. Delivers flow rates from 2-6 L/min that administer 24-45% fraction of inspired oxygen or FiO2 is

nasal cannula

Before Transferring a patient from the bed to a chair, which assessment data does the nurse need to gather?

patients weight patients level of cooperation patients ability to assist (mobility) presence of transfer device

lung collapse caused by the collection of free air within the pleural space is

pneumothorax

A staff nurse reports a medication error due to failure to administer a medication at the scheduled time. What is the charge nurse's best response? A. "We'll conduct a root cause analysis." B. "That means you'll have to do continuing education." C. "Why did you let that happen?" D. "You'll need to tell the patient and family."

A. "We'll conduct a root cause analysis."

Pulse Oximetry (SpO2)

An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds.

A nurse is caring for a client who is postoperative and has developed atelectasis. Which of the following findings should the nurse expect? A. Facial flushing B. Increasing dyspnea C. Decreasing respiratory rate D. Dry Cough

B. Increasing dyspnea

maximum flow rate attained during the middle of the FVC maneuver; varies on pts body size ; emphysema is 25% of the predicted value based on pts size

Forced expiratory flow (FEF)

Volume of air that is left in the patients lung after normal expiration; predicted normal volume is 2.3 L in emphysema it may increase up to 200% over the expected amount due to air trapping

Functional residual capacity (FRC)

RBC levels

Male: 4.7-6.1 Female: 4.2-5.4

Hemoglobin levels (M&F)

Male= 13.2-16.6 g/dL Female= 11.6-15 g/dL

Necrosis death of heart muscles cells

Necrosis

FiO2 up to 70-80% can be achieved is

Nonrebreather Mask

a special nasal cannula that provides a higher luminal diameter in combination with an incorporated oxygen (O2) reservoir is

Oxymizer

The three elements of nursing competency described in the Quality and Safety for Nurses (QSEN) initiative are knowledge, skill, and which other element? a. Attitude b. Accountability c. Value d. Education

a. Attitude

1. Which nursing interventions would provide safe oxygen therapy? (Select all that apply) a. Check tubing for kinks b. Run wires under carpeting c. Post 'no smoking' sights in the clients rooms d. Place oxygen tanks flat in the carts when not in use e. Make sure the client is using oil-based products to lubricate the nose

a. Check tubing for kinks c. Post 'no smoking' sights in the clients rooms

occurs when there is an insufficient number and quality of erythrocytes or when the amount of hemoglobin is low is

altered transport

collapsed lung; incomplete expansion of alveoli

atelectasis

What is the most significant modifiable risk factor for the development of impaired gas exchange? a. Age b. Tobacco use c. Drug overdose d. Prolonged immobility

b. Tobacco use

1. The nurse is caring for a client in respiratory distress. The health care provider prescribes oxygen therapy with a venturi mask to be set at 35% oxygen. Which mask would the nurse use to implement the prescription? a. Simple face mask b. Partial rebreathing mask c. Nonrebreathing mask d. Venturi mask

d. Venturi mask

Ventilation and Respiration may be impaired due to: a. vasoconstriction b. bronchodilation c. vasodilation d. bronchoconstriction

d. bronchoconstriction

reduced oxygenation of arterial blood is

hypoxemia

insufficient oxygen reaching cells is

hypoxia

encouraged to decrease transmission of preventable diseases: influenza, pneumococcal pneumonia, pertussis, and rubella is

immunizations

Peak Expiratory Flow Rate (PEFR)

measures how fast a person can exhale

Saturation of arterial hemoglobin: percentage of oxygen bound to hemoglobin is

SaO2