NUR 326 exam 3
a serious complication of a group A beta-hemolytic streptococcal infection is rheumatic fever
true
lungs with decreased compliance require greater-than-normal energy expenditure by the patient to achieve normal levels of ventilation
true
the venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means
true
viruses, the most common cause of URI's, affect the upper respiratory passages and lead to subsequent mucous membrane inflammation
true
a patient in the ED has been experiencing upper abdominal pain after meals for the past several months. she reports pain after napping or sleeping at night. she has been taking OTC antacids with some relief. the nurse understands that which assessment finding places the patient at risk for peptic ulcer disease?
use of NSAIDs to control arthritis pain
An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease (COPD) to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the patient?
venturi mask
___, the most common cause of upper respiratory infections, affect the upper respiratory passages and lead to subsequent mucous membrane inflammation
viruses
an oxygen saturation of less than ____% using pulse oximetry, indicates that tissues are not receiving enough oxygen
90
a nurse is caring for a patient on oxygen therapy while in the hospital. which assessment finding indicates that outcomes for patient safety are being met?
intact skin behind ears
the nurse is caring for a patient with peptic ulcer disease (PUD). which patient statement requires nursing teaching?
"My doctor said to take ibuprofen for my aches and pain"
a 23-year-old female patient reports having red, raised lesions at the base of her tongue and on the inside of her mouth for the past 3 weeks. what priority assessment question should the nurse ask?
"do you have a history of human papillomavirus?'
after abdominal surgery, which question should the nurse ask the patient to determine whether peristaltic movement is returning?
"have you passed flatus?"
which patient statement alerts the nurse to perform a thorough GI history and focused assessment?
"i take ibuprofen three times daily for arthritis"
What is gas exchange between the lungs and blood and between the blood and tissues? A.Diffusion B.Perfusion C.Respiration D.Ventilation
C.Respiration
What should the nurse palpate when assessing for an upper respiratory tract infection? Neck lymph nodes Nasal mucosa Tracheal mucosa All of the above
Neck lymph nodes
Is the following statement true or false? Acute pharyngitis of a bacterial nature is most commonly caused by group A beta-hemolytic streptococci
True Rationale: Acute pharyngitis of a bacterial nature is most commonly caused by group A beta-hemolytic streptococci
Is the following statement true or false? An early sign of cancer of the larynx includes changes in speech, the voice may sound harsh, raspy, and lower in pitch
True Rationale: An early sign of cancer of the larynx includes changes in speech, the voice may sound harsh, raspy, and lower in pitch
Is the following statement true or false? Wheezes are considered an adventitious breath sound
True Wheezes are considered an adventitious breath sound
which of these patients would be a priority for the nurse to assess immediately following shift report?
a post-op patient presenting with sudden onset of pleuretic pain and acute dyspnea
a nurse is assessing a patient who has suffered a nasal fracture. which assessment would the nurse perform first?
airway patency (ABCs)
a home health nurse is visiting a new patient that uses oxygen at home. for which factors does the nurse assess when determining if the patient is using the oxygen safely. select all that apply
the patient does not allow smoking in the house all electrical cords are in good working order flammable liquids are stored in the garage
when administering a new GI medication to an older patient, the nurse anticipates what?
close monitoring is needed because toxic levels may develop
a nurse assesses a patient with a nasal fracture. the patient reports having a constant nasal drainage, a headache, and difficulty with vision. what action would the nurse take next?
collect the nasal drainage on filter paper (could be spinal fluid)
what EARLY symptom would an older adult present with when experiencing hypoxia?
confusion
which assessment finding for an older patient does the nurse attribute to the natural aging process?
decrease in respiratory muscle strength
sudden ____ in a healthy person may indicate pneumothorax (air in pleural cavity), acute respiratory obstruction, allergic reaction, or myocardial infarction
dyspnea (difficult or labored breathing)
oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (generally longer than 48 hours)
false, 24 hours
a gradual incline in respiratory function begins in early to middle adulthood and affects the structure and function of the respiratory system
false, decline
esophageal speech is the most widely used communication technique for patients who have undergone laryngectomy
false, it is much harder
Cyanosis is a reliable and early sign of hypoxia.
false, late
the nurse is caring for a patient with a long history of osteoarthritis. which risk factors will the nurse teach the patient that may contribute to development of gastroesophageal reflux disease (GERD)?
frequently takes NSAIDs for pain
the most serious postoperative complication of a tonsillectomy is _____
hemorrhage
which position would be most effective for a patient who is in respiratory distress?
high-fowler's
an older patient with poor oral hygiene was admitted after a fall which he sustained a fractured hip. what is the priority nursing intervention?
implement aspiration precautions
which diagnostic results does the nurse recognize that support the diagnosis of peptic ulcer disease (PUD)? select all that apply
low hemoglobin (hgb) low hematocrit (hct) positive for H. pylori bacteria
which nursing intervention is the priority in the care of a patient with hiatal hernia?
providing nutrition education
a partial ____ oxygen mask has a reservoir bag that must remain inflated during both inspiration and expiration
rebreather
which assessment variable requires immediate nursing intervention post esophagectomy?
respiratory rate of 28
Which of these clinical assessment finding would indicate a patient is experiencing early signs of hypoxia? Select all that apply
restlessness tachycardia tachypnea (breathing fast)
BiPAP is most often used for patients who require ventilator assistance at night, such as those with severe COPD or ____
sleep apnea
a patient is scheduled to start chemotherapy. what oral cavity problem does the nurse teach the patient that may occur?
stomatitis