NURS 309 Quiz 7

The nurse is reviewing lab results for a patient with a new-onset pulmonary embolism (PE). What is the INR therapeutic range? A. 1.0-1.5 B. 2.5-3.0 C. 3.1-4.5 D. 4.6-5.0

B. 2.5-3.0

A nurse assess that several clients have low oxygen saturation levels. Which client would benefit the most from receiving oxygen via a nasal cannula? A. Has an upper respiratory infection B. Receives many visitors while sitting in a chair C. Has a nasogastric tube for gastric decompression D. Exhibits dry oral mucous membranes from mouth breathing

. Receives many visitors while sitting in a chair

Levofloxacin (Levaquin) 750 mg IVPB is prescribed for a client with pneumonia. The dose is available in 150 mL of 5% dextrose and is to infuse over 90 minutes. The administration set has a drop factor of 15 drops per mL. At how many drops per minute should the nurse regulate the IVPB to infuse? _______ gtt/minute

25 gtt/minute

A client is admitted to the hospital with a diagnosis of pneumonia. List the following nursing actions in the order they should be accomplished. 1. Check the peak and trough levels of the antiboitic 2. Insert an IV catheter to establish venous access 3. Collect a sputum sample for culture and sensitivity 4. Administer prescribed antibiotic intravenous piggyback 5. Obtain data about the client's history and physical status

5, 2, 3, 4, 1

A patient requires oxygen therapy with a nasal cannula. Which interventions will the nurse teach the student nurse providing care for this patient? SATA A. "Make sure that the prongs on the nasal cannula are properly positioned in the nares" B. "Apply a water-soluble gel to the nares as needed" C. "Adjust the flow rate between 1 and 8 liters/minute based on how the patient is feeling" D. "Be sure to assess the patency of both nares" E. "Assess the patient for any changes in respiratory rate and pattern" F. "Nasal cannula can provide a patient with between 24% and 50% oxygen flow"

A. "Make sure that the prongs on the nasal cannula are properly positioned in the nares" B. "Apply a water-soluble gel to the nares as needed" D. "Be sure to assess the patency of both nares" E. "Assess the patient for any changes in respiratory rate and pattern"

A nurse is caring for a variety of clients. For which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? A. 59-year-old who had a knee replacement B. 60-year-old who has bacterial pneumonia C. 68-year-old who had emergency dental surgery D. 76-year-old who has a history of thrombocytopenia

A. 59-year-old who had a knee replacement

The nurse is caring for a patient who had a nasoseptoplasty. Which action is the best to assign to the licensed practical nurse? A. Administer a stool softener to ease bowel movements B. Assess the patient's airway and breathing after general anesthesia C. Evaluate the patient's emotional reaction to the facial edema and bruising D. Take vital signs every 4 hours as ordered by the physician

A. Administer a stool softener to ease bowel movements

After being treated in the emergency department for posterior nosebleed, the patient is admitted to the hospital. The nasal packaging is in place and vital signs are stable. The patient has an IV of normal saline at 125 mL/hr. What is the priority for nursing care? A. Airway management B. Managing potential dehydration C. Managing potential decreased cardiac output D. Monitoring for potential infection

A. Airway management

A patient enters the emergency department after being punched in the throat. What does the nurse monitor for? A. Aphonia B. Dry cough C. Crepitus D. Loss of gag reflex

A. Aphonia

The nurse is providing postoperative nursing care for a patient with surgical correction of a deviated septum. Which intervention is part of the standard care for this patient? A. Apply ice to the nasal area and eyes to decrease swelling and pain B. Encourage deep coughing to prevent atelectasis and clear secretions C. Administer NSAIDs or Tylenol every 4-6 hours for pain relief D. Apply moist heat and humidity to the nasal area for comfort and circulation

A. Apply ice to the nasal area and eyes to decrease swelling and pain

A nurse is instructing a client to use an incentive spirometer. What client action indicates the need for further instruction? A. Blowing vigorously into the mouthpiece B. Getting into a chair to use the spirometer C. Coughing deeply after using the spirometer D. Using lips to form a seal around the mouthpiece

A. Blowing vigorously into the mouthpiece

The patient has a diagnosis of mild sleep apnea. Which interventions will the nurse teach the patient that may correct this condition? SATA A. Change sleeping positions B. Use continuous positive airway pressure (CPAP) every night C. Look into a weight loss program D. A position fixing device can prevent tongue subluxation E. You may need surgery to remodel your posterior oropharynx F. A prescription for modafinil may help promote wakefulness during the day

A. Change sleeping positions C. Look into a weight loss program D. A position fixing device can prevent tongue subluxation

Increased risk for oxygen toxicity is related to which factors? SATA A. Continuous delivery of oxygen at greater than 50% concentration B. Family members smoking while patient is receiving oxygen therapy C. The severity and extent of lung disease D. Neglecting to monitor the patient's status and reducing oxygen concentration as soon as possible E. Adding continuous positive airway pressure (CPAP) or positive end-expiratory pressure (PEEP) F. Delivery of a high concentration of oxygen over 24-48 hours

A. Continuous delivery of oxygen at greater than 50% concentration C. The severity and extent of lung disease D. Neglecting to monitor the patient's status and reducing oxygen concentration as soon as possible F. Delivery of a high concentration of oxygen over 24-48 hours

A patient has been diagnosed with airway obstruction during sleep. The nurse will likely include patient education about which device for home use? A. Continuous positive airway pressure (CPAP) to deliver a positive airway pressure B. Oxygen via face mask to prevent hypoxia C. Neck brace to support the head and facilitate breathing D. Nebulizer treatments with bronchodilators

A. Continuous positive airway pressure (CPAP) to deliver a positive airway pressure

The provider orders transtracheal oxygen therapy for a patient with respiratory difficulty. What does the nurse tell the patient's family about the purpose of this type of oxygen delivery system? A. Delivers oxygen directly into the lungs B. Keeps the small air sacs open to improve gas exchange C. Prevents the need for an endotracheal tube D. Provides high humidity with oxygen delivery

A. Delivers oxygen directly into the lungs

On postoperative assessment, the nurse notes that the patient with a rhinoplasty repeatedly swallows. What is the nurse's first action? A. Examine the throat for bleeding B. Provide ice chips to ease swallowing C. Notify the health care provider D. Ask if the patient is hungry

A. Examine the throat for bleeding

Which side effects would a patient with obstructive sleep apnea report? SATA A. Excessive daytime sleepiness B. Excessive daytime hyperactivity C. Inability to concentrate D. Excessive production of sputum E. Irritability F. Heavy snoring

A. Excessive daytime sleepiness C. Inability to concentrate E. Irritability F. Heavy snoring

A client states that the health care provider said the tidal volume is slightly diminished and asks the nurse what this means. Which explanation should the nurse provide about the volume of air being measured to determine tidal volume? A. Exhaled after there is a normal inspiration B. Exhaled forcibly after a regular expiration C. Inspired forcibly above a typical inspiration D. Trapped in the alveoli after a maximum expiration

A. Exhaled after there is a normal inspiration

A patient with an active nosebleed (epistaxis) is admitted to the emergency department. Which intervention does the nurse use first? A. Have the patient sit upright with the head forward B. Insert nasal packing C. Apply direct lateral pressure to the nose D. Place a nasal catheter

A. Have the patient sit upright with the head forward

The unlicensed assistive personnel (UAP) tells the nurse that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should the nurse suggest to the UAP to improve the patient's comfort for this problem? A. Humidify the patient's oxygen B. Use a simple face mask instead of a nasal cannula C. Provide the patient with an extra pillow D. Have the patient sit up in a chair at the bedside

A. Humidify the patient's oxygen

Which parameters does the nurse monitor to ensure that a patient's response to oxygen therapy gas exchange is adequate? SATA A. Level of consciousness B. Respiratory pattern C. Oxygen flow rate D. Pulse oximetry E. Respiratory rate F. Blood pressure

A. Level of consciousness B. Respiratory pattern D. Pulse oximetry E. Respiratory rate

Which instructions must the nurse give to a patient after rhinoplasty to prevent bleeding? SATA A. Limit or avoid straining during bowel movements (e.g. Valsalva maneuver) B. Do not sniff upwards or blow your nose C. Sneeze with your mouth closed for a few days after packing is removed D. Forceful coughing should be done to keep the airways clear E. Avoid aspirin-containing products of NSAIDs F. Use a humidifier to prevent mucosal dyring

A. Limit or avoid straining during bowel movements (e.g. Valsalva maneuver) B. Do not sniff upwards or blow your nose E. Avoid aspirin-containing products of NSAIDs F. Use a humidifier to prevent mucosal dyring

Which conditions are related to acute respiratory distress syndrome (ARDS)? SATA A. Lung fluid increases B. A systemic inflammatory response occurs C. The lungs dry out and become stiff D. Lung volume is decreased E. Hypoxemia results F. Surfactant production is increased

A. Lung fluid increases B. A systemic inflammatory response occurs D. Lung volume is decreased E. Hypoxemia results

A patient has an inner maxillary fixation. The nurse encourages the patient to eat which kind of food? A. Milkshakes B. Cottage cheese C. Tea and toast D. Tuna and noodle casserole

A. Milkshakes

The nurse is caring for a patient with acute hypoxemia. Which nursing interventions are best for the care of this patient? SATA A. Minimal self-care B. Sedatives prn C. Upright position D. Oxygen therapy E. Remain NPO while dyspneic F. Prescribed metered-dose inhalers

A. Minimal self-care C. Upright position D. Oxygen therapy F. Prescribed metered-dose inhalers

The nurse is caring for a patient receiving humidified oxygen. Which precaution does the nurse take to prevent bacterial contamination and infection? A. Never drain fluid from the water trap back into the nebulizer B. Always wear gloves when cleaning the patient's nasal cannula C. Do not allow live or cut flowers into the patients room D. Administer ordered antibiotic therapy

A. Never drain fluid from the water trap back into the nebulizer

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism? A. Obese client with leg trauma B. Pregnant client with acute asthma C. Client with diabetes who ha cholecystitis D. Client with pneumonia who is immunodeficient

A. Obese client with leg trauma

A patient with facial trauma has undergone surgical intervention to wire the jaw shut. In performing discharge teaching with this patient, which topics does the nurse cover? SATA A. Oral care B. Activity C. Use of wire cutters D. Communication E. Aspiration prevention F. Dental liquid diet

A. Oral care C. Use of wire cutters D. Communication E. Aspiration prevention F. Dental liquid diet

The patient is prescribed home oxygen. Which criteria are important when choosing the oxygen delivery system? SATA A. Oxygen concentration required by the patient B. Importance of accuracy and control of the oxygen concentration C. Importance of humidity D. Need to teach patient to suction self E. Patient pain medication administration F. Patient mobility

A. Oxygen concentration required by the patient B. Importance of accuracy and control of the oxygen concentration C. Importance of humidity F. Patient mobility

What are the hazards of administering oxygen therapy? SATA A. Oxygen supports and enhances combustion B. Oxygen itself can burn C. Each electrical outlet in the room must be covered if not in use D. All electrical equipment in the room must be grounded to prevent fires E. Solutions with high concentrations of alcohol or oil cannot be used in the room F. Alcohol-based hand rubs should be removed from rooms with oxygen therapy

A. Oxygen supports and enhances combustion D. All electrical equipment in the room must be grounded to prevent fires E. Solutions with high concentrations of alcohol or oil cannot be used in the room

A patient is at risk for aspiration. Which instructions must the nurse provide to the unlicensed assistive personnel (UAP) prior to the feeding the patient? SATA A. Position the patient in the most upright position possible B. Provide adequate time; do not "hurry" the patient C. Provide sips of water or milk between bites of food to help with swallowing D. Encourage the patient to "tuck" his or her chin down and move the forehead forward while swallowing E. If the patient coughs, stop the feeding until he or she indicates that the airway has been cleared F. Allow the patient to indicate when he or she is ready for the next bite

A. Position the patient in the most upright position possible B. Provide adequate time; do not "hurry" the patient D. Encourage the patient to "tuck" his or her chin down and move the forehead forward while swallowing E. If the patient coughs, stop the feeding until he or she indicates that the airway has been cleared F. Allow the patient to indicate when he or she is ready for the next bite

The nurse is caring for a patient with a postoperative complication of pulmonary embolism (PE). The nurse determines the patient has adequate perfusion by which data? SATA A. Pulse oximetry of 95% B. Arterial blood gas, pH of 7.28 C. Patient's subjective desire to go home D. Absence of pallor or cyanosis E. Mental status at patient's baseline F. Palpable peripheral pulses

A. Pulse oximetry of 95% D. Absence of pallor or cyanosis E. Mental status at patient's baseline F. Palpable peripheral pulses

A patient demonstrates chest pain, dyspnea, dry cough, and change in level of consciousness. The nurse suspects pulmonary embolism (PE) and notifies the health care provider, who orders and arterial blood gas (ABG). In the early stage of a PE, what would ABG results probably indicate? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory alkalosis

A patient has been diagnosed with sleep apnea. Which assessment findings indicate that the patient is having complications associated with sleep apnea? A. Side effects of hypoxemia, hypercapnia, and sleep deprivation B. Decrease in arterial carbon dioxide levels and sleep deprivation C. Respiratory alkalosis with retention of carbon dioxide D. Irritability, obesity, and enlarged tonsils or adenoids

A. Side effects of hypoxemia, hypercapnia, and sleep deprivation

Which factors contribute to sleep apnea? SATA A. Smoking B. A short neck C. Athletic lifestyle D. Small uvula E. Enlarged tonsils or adenoids F. Underweight for height and gender

A. Smoking B. A short neck E. Enlarged tonsils or adenoids

The nurse is caring for several postoperative patients at risk for developing pulmonary embolism (PE). Which intervention does the nurse use to help prevent the development of PE in these patients? SATA A. Start passive and active range-of-motion exercises for the extremities B. Ambulate postoperative patients soon after surgery C. Use anti embolism devices postoperatively D. Elevate legs in an extended position E. Change patient position every 4-6 hours F. Administer stool softeners to prevent constipation

A. Start passive and active range-of-motion exercises for the extremities B. Ambulate postoperative patients soon after surgery C. Use anti embolism devices postoperatively F. Administer stool softeners to prevent constipation

Which are extrapulmonary causes of ventilatory failure? SATA A. Stroke B. Use of opioid analgesics C. Pulmonary edema D. Chronic obstructive pulmonary disease E. Massive obesity F. Increased intracranial pressure

A. Stroke B. Use of opioid analgesics E. Massive obesity F. Increased intracranial pressure

The nurse is admitting a patient for whom a diagnosis of pulmonary embolism must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolism? A. The patient was recently in a motor vehicle crash B. The patient participated in an aerobic exercise program for 6 months C. The patient gave birth to her youngest child 1 year ago D. The patient was on bed rest for 6 hours after a diagnostic procedure

A. The patient was recently in a motor vehicle crash

A client is scheduled for a pulmonary function test. The nurse explains that during the test one of the instructions the respiratory therapist will give the client is to breathe normally. What should the nurse teach is being measured when the client follows these directions? A. Tidal volume B. Vital capacity C. Expiratory reserve D. Inspiratory reserve

A. Tidal volume

A patient is receiving warmed and humidified oxygen. In discarding the moisture formed by condensation, why does the nurse minimize the time that the tubing is disconnected? A. To prevent the patient from desaturating B. To reduce the patient's risk of infection C. To minimize the disturbance to the patient D. To facilitate overall time management

A. To prevent the patient from desaturating

In what situations is oxygen therapy needed for a patient? SATA A. To treat hypoxia B. To treat hypothermia C. To treat hypoxemia D. When the normal 35% oxygen level in the air is in adequate E. When the normal 21% oxygen level in the air is inadequate F. To treat acute and chronic respiratory illness

A. To treat hypoxia C. To treat hypoxemia E. When the normal 21% oxygen level in the air is inadequate F. To treat acute and chronic respiratory illness

Packing has been removed from a patient with epistaxis. Which discharge instructions would the nurse be sure to teach the patient and his family? SATA A. Use saline spray to add moisture and prevent rebleeding B. Use lots of petrolatum jelly to coat the inside and outside of the nasal passages for comfort C. Avoid vigorous nose blowing D. Do not take aspirin-containing products or NSAIDs E. No strenuous lifting for at least a month F. Consume only small meals for 2 weeks

A. Use saline spray to add moisture and prevent rebleeding C. Avoid vigorous nose blowing D. Do not take aspirin-containing products or NSAIDs E. No strenuous lifting for at least a month

Which conditions define respiratory failure? SATA A. Ventilatory failure B. Circulatory failure C. Oxygenation failure D. Severe anemia E. Combination of ventilatory and oxygenation failure F. Chronic emphysema

A. Ventilatory failure C. Oxygenation failure E. Combination of ventilatory and oxygenation failure

The nurse is teaching a patient about post-rhinoplasty care. Which patient statement indicates an understanding of the instruction? A. "I will have a very large dressing on my nose" B. "I will have bruising around my eyes, nose, and face" C. "There will be swelling that will cause a loss of sense of smell" D. "My nose will be three times its normal size for 3 weeks"

B. "I will have bruising around my eyes, nose, and face"

The nurse is reviewing the arterial blood gas (ABG) result for a patient. The latest ABGs show pH 7.48, HCO3- 23 mEq/L, PaCO2 25 mm Hg, and PaO2 98 mm Hg. What is the correct interpretation of these lab findings? A. Chronic respiratory alkalosis with compensation B. Acute respiratory alkalosis and hyperventilation C. Acute respiratory acidosis and hypoventilation D. Chronic respiratory acidosis and hypoventilation

B. Acute respiratory alkalosis and hyperventilation

Which are major risk factors for venous thromboembolism (VTE) leading to pulmonary embolism (PE)? SATA A. Malnutrition B. Central venous catheters C. Chronic obstructive pulmonary disease (COPD) D. Obesity E. Prolonged immobility F. Conditions that decrease blood clotting

B. Central venous catheters D. Obesity E. Prolonged immobility

The home health nurse has been caring for a patient with a chronic respiratory disorder. Today the patient seems confused when she is normally alert and oriented x 3. What is the priority nursing action? A. Notify the provider about the mental status change B. Check the pulse oximeter reading C. Ask the patient's family when this behavior started D. Perform a mental status examination

B. Check the pulse oximeter reading

What does the nurse monitor for in a patient with pulmonary embolism (PE)? SATA A. Vomiting B. Cyanosis C. Rapid heart rate D. Dyspnea E. Paradoxical chest movement F. Crackles in lung fields

B. Cyanosis C. Rapid heart rate D. Dyspnea F. Crackles in lung fields

What is the most common site of origin for a clot to occur, causing a pulmonary embolism? A. Right side of heart B. Deep veins of legs and pelvis C. Antecubital vein in upper extremities D. Subclavian veins

B. Deep veins of legs and pelvis

Ventilatory failure is the result of what processes? SATA A. Hematologic disease B. Defect in the respiratory control center of the brain C. Physical problems of the lungs D. Poor function of the diaphragm E. Physical problem of the chest wall F. Infectious disease such as pneumonia

B. Defect in the respiratory control center of the brain C. Physical problems of the lungs D. Poor function of the diagphragm E. Physical problem of the chest wall

What is the best description of the nurse's role in the delivery of oxygen therapy? A. Receiving the therapy report from the respiratory therapist B. Evaluating the patient's response to oxygen therapy C. Contracting respiratory therapy for devices D. Being familiar with the devices and techniques in order to provide proper care

B. Evaluating the patient's response to oxygen therapy

A patient is admitted for a posterior nosebleed. Posterior packing is in place and the patient is on oxygen therapy. What is the priority assessment? A. Tolerance of packing or tubes B. Gag and cough reflex C. Mouth breathing D. Skin breakdown around the nares

B. Gag and cough reflex

The patient receiving oxygen at 5 L/min by nasal cannula. What priority intervention must the nurse use at this time? A. Switch to a mask delivery system B. Humidify the oxygen with sterile water C. Monitor for manifestations of oxygen toxicity D. Add extension tubing for patient mobility

B. Humidify the oxygen with sterile water

Which conditions will increase the body's need for more oxygen? SATA A. Hypothyroid state B. Infection in the blood C. Diabetes mellitus D. Body temperature of 101 E. Hemoglobin level of 8.7 g/dL F. Heart failure

B. Infection in the blood D. Body temperature of 101 E. Hemoglobin level of 8.7 g/dL F. Heart failure

The patient with a nasal fracture has clear fluid draining from the nose that dries on a piece of filter paper and leaves a yellow "halo" ring at the dried edge of the fluid. What is the nurse's first action? A. Document the finding B. Notify the health care provider C. Send a sample to the lab D. Place the patient in a supine position

B. Notify the health care provider

A patient is being treated with heparin therapy for a pulmonary embolism (PE). What does the nurse monitor in relation to the heparin therapy and potential for bleeding? A. Lab values for any elevation of prothrombin time (PT) or partial thromboplastin time (PTT) value B. PTT values for greater than 2.5 times the control and/or the patient for bleeding C. Occurence of a pulmonary infarction by blood in sputum D. PT values for International Normalized Ratio (INR) for a therapeutic range of 2 to 3 and/or the patient for bleeding

B. PTT values for greater than 2.5 times the control and/or the patient for bleeding

Acute respiratory failure is classified by which critical arterial blood gas (ABG) values? SATA A. PaCO2 39 mm Hg B. PaCO2 52 mm Hg C. PaO2 78 mm Hg D. PaO2 55 mm Hg E. pH value of < 7.3 F. SaO2 90%

B. PaCO2 52 mm Hg D. PaO2 55 mm Hg E. pH value of < 7.3

A patient requires home oxygen therapy. When the home health nurse enters the patient's home for the initial visit, the nurse observes several issues that are safety hazards related to the patient's oxygen therapy. What hazards do these include? SATA A. Bottle of wine in the kitchen area B. Package of cigarettes on the coffee table C. Several decorative candles on the mantelpiece D. Grounded outlet with a green dot on the plate E. Electric fan with a frayed cord in the bathroom F. Computer with a three-pronged plug

B. Package of cigarettes on the coffee table C. Several decorative candles on the mantelpiece E. Electric fan with a frayed cord in the bathroom

An older adult with dehydration has altered mental status and inspissated (thickly crusted) oral and nasopharyngeal secretions. What priority instruction would the nurse give to the unlicensed assistive personnel (UAP) when providing care for this patient? A. Bathe the patient twice a day B. Provide comprehensive oral care every 2 hours C. Ambulate the patient in the hall every 4 hours D. Check vital signs including temperature every 6 hours

B. Provide comprehensive oral care every 2 hours

The nurse suspects a patient has a pulmonary embolism (PE) and notifies the provider, who orders an arterial blood gas. The health care provider is on the way to the facility. The nurse anticipates and prepares the patient for which additional diagnostic test? A. Ultrasound B. Pulmonary angiography C. 12-lead ECG D. Venous Dopplers

B. Pulmonary angiography

To improve a patient's oxygenation to a normal level, the amount of oxygen administered is based on which factors? SATA A. Symptom management only B. Pulse oximetry reading C. Respiratory assessment D. The patient's subjective complaints E. The arterial blood gas results F. Presence of chronic hypercarbia

B. Pulse oximetry reading C. Respiratory assessment E. The arterial blood gas results F. Presence of chronic hypercarbia

The health care provider orders heparin therapy for a patient with a relatively small pulmonary embolism (PE). The patient states, "I didn't tell the doctor my complete medical history." Which condition may affect the health care provider's decision to immediately start heparin therapy? A. Type 2 Diabetes mellitus B. Recent cerebral hemorrhage C. Newly diagnosed osteoarthritis D. Asthma since childhood

B. Recent cerebral hemorrhage

A nurse uses abdominal-thoracic thrusts (Heimlich maneuver) when an older adult in a senior center chokes on a piece of meat. Which volume of air is the basis for the efficacy of the abdominal thrusts to expel a foreign object in the larynx? A. Tidal B. Residual C. Vital capacity D. Inspiratory reserve

B. Residual

The nurse is assessing a patient with significant and obvious facial trauma after being struck repeatedly in the face. Which finding is the priority and requires immediate intervention? A. Asymmetry of the mandible B. Restlessness with high-pitched respirations C. Nonparallel extraocular movements D. Pain upon palpation over the nasal bridge

B. Restlessness with high-pitched respirations

An older adult patient on anticoagulation therapy for a pulmonary embolism (PE) is somewhat confused and requires assistance with activities of daily living (ADLs). Which instruction specific to this therapy does the nurse give to the unlicensed assistive personnel (UAP) A. Count and report episodes of urinary incontinence B. Use a lift sheet when moving or turning the patient in bed C. Assist with ambulation because the patient is likely to have dizziness D. Give the patient an extra blanket, because the patient is likely to feel cold

B. Use a lift sheet when moving or turning the patient in bed

The nurse is caring for several patients on a general medical-surgical unit. The nurse would question the need for oxygen therapy for a patient with which condition? A. Pulmonary edema with decreased arterial PO2 levels B. Valve replacement with increased cardiac output C. Anemia with a decreased hemoglobin and hematocrit D. Sustained fever with an increased metabolic demand

B. Valve replacement with increased cardiac output

A patient has an inner maxillary fixation for a mandibular fracture. Which piece of equipment should be kept at the bedised at all times? A. Waterpik B. Wire cutters C. Pair of hemostats D. Emesis basin

B. Wire cutters

A patient has sustained a mandible fracture and the surgeon has explained that the repair will be made using a resorbable plate. The patient discloses to the nurse that he has not told the surgeon about his substance abuse and illicit drug dependence. What is the nurse's best response? A. "Why didn't you talk to your surgeon about this issue?" B. "You should tell the surgeon, but it is your choice." C. "It is important for your surgeon to know about this information." D. "You shouldn't be ashamed; your surgeon will still repair your fracture."

C. "It is important for your surgeon to know about this information."

The nurse is caring for several patients who are at risk because of problems related to the upper airway. Which are the priority assessments and actions for these patients? A. Thickness of oral secretions; encourage ingestion of oral fluids B. Anxiety and pain; provide reassurance and NSAIDs C. Adequacy of oxygenation; ensure an unobstructed airway D. Evidence of spinal cord injuries; obtain orders for x-rays

C. Adequacy of oxygenation; ensure an unobstructed airway

What is the most common cause of an embolism? A. Amniotic fluid B. Bolus of air C. Blood clot D. Arterial plaque

C. Blood clot

A patient is receiving warmed and humidified oxygen. The respiratory therapist informs the nurse that several other patients on other units have developed hospital-acquired infections and Pseudomonas aeruginosa has been identified as the organism. What does the nurse do? A. Place the patient in respiratory isolation B. Obtain an order for a sputum culture C. Change the humidifier every 24 hours D. Obtain an order to discontinue the humidifier

C. Change the humidifier every 24 hours

The nurse's young neighbor who smokes is going on an overseas flight. The neighbor knows he is at risk for a deep vein thrombosis (DVT) and pulmonary embolism (PE) and asks the nurse for advice. What does the nurse suggest? A. Exercise regularly and walk around before boarding the flight B. Get a prescription for heparin therapy and take it before the flight C. Drink water and get up every hour for at least 5 minutes during the flight D. Elevate legs as much as possible during and after the flight

C. Drink water and get up every hour for at least 5 minutes during the flight

A patient is receiving oxygen therapy through a nonrebreather mask. What is the correct nursing intervention? A. Maintain oxygen liter flow so that the reservoir bag is up to one-half full B. Maintain 60%-75% FiO2 at 6-11 L/min C. Ensure that valves and rubber flaps are patent, functional, and not stuck D. Assess for effectiveness and switch to partial rebreather mask for more precise FiO2

C. Ensure that valves and rubber flaps are patent, functional, and not stuck

The nurse is caring for several postoperative patients with high risk for a pulmonary embolism (PE). All of these patients have pre-existing chronic respiratory problems. Which assessment findings suggest that a patient has developed a PE with pulmonary infarction? A. Dyspnea B. Sudden dry cough C. Hemoptysis D. Audible wheezing

C. Hemoptysis

A patient is following up on a postoperative complication of pulmonary embolism (PE). The patient must have blood drawn to determine the therapeutic range for warfarin (Coumadin). Which lab test determines this therapeutic range? A. Partial thromboplastin time (PTT) level B. Platelets C. International Normalized Ratio (INR) D. Coumadin peak and trough

C. International Normalized Ratio (INR)

The nurse is administering oxygen to a patient who is hypoxic and has chronic high levels of carbon dioxide. Which oxygen therapy prevents a respiratory complication for this patient? A. FiO2 higher than the usual 2-4 L/min per nasal cannula B. Venturi mask of 40% for the delivery of oxygen C. Lower concentration of oxygen (1-2 L/min) per nasal cannula D. Variable FiO2 via partial rebreather mask

C. Lower concentration of oxygen (1-2 L/min) per nasal cannula

A patient is receiving a high concentration of oxygen as a temporary emergency measure. Which nursing action is the most appropriate to prevent complications associated with high-flow oxygen? A. Auscultate the lungs every 4 hours for oxygen toxicity B. Increase the oxygen if the PaO2 level is less than 93 mm Hg C. Monitor the prescribed oxygen level and length of therapy D. Decrease the oxygen if the patient's condition does not improve

C. Monitor the prescribed oxygen level and length of therapy

A patient receiving oxygen via a face mask at 5 L/min is able to eat. Which nursing intervention is performed at mealtimes? A. Change the mask to a nasal cannula of 6 L/min or more B. Have the patient work around the face mask as best as possible C. Obtain a provider order for a nasal cannula at 5 L/min D. Obtain a provider order to remove the mask at meals

C. Obtain a provider order for a nasal cannula at 5 L/min

The patient has been on oxygen therapy at 70% for over 48 hours. For which complication must the nurse monitor? A. Oxygen-induced hypoventilation B. Hypercarbia C. Oxygen toxicity D. Absorptive atelectasis

C. Oxygen toxicity

A nurse identifies that a client's hemoglobin level is decreasing and is concerned about tissue hypoxia. An increase in what diagnostic test result indicates an acceleration in oxygen dissociation from hemoglobin? A. pH B. PO2 C. PCO2 D. HCO3

C. PCO2

A patient arrives in the emergency department with a severe crush injury to the face with blood gurgling from the mouth and nose and obvious respiratory distress. The nurse prepares to assist the physician with which procedure to manage the airway? A. Performing a needle thoractomy B. Inserting an endotracheal tube C. Performing a tracheotomy D. Inserting a nasal airway and giving oxygen

C. Performing a tracheotomy

A patient returns from surgery following a rhinoplasty. The unlicensed assistive personnel (UAP) places the patient in a supine position to encourage rest and sleep. Which action should the nurse take first? A. Teach the patient how to use the bed controls to position herself B. Explain the purpose of the semi-Fowler's position to the nursing assistant C. Place the patient in a semi-Fowler's position and assess for aspiration D. Post a notice at the head of the bed to remind personnel about positioning

C. Place the patient in a semi-Fowler's position and assess for aspiration

The nurse is caring for several patients at risk for deep vein thrombosis (DVT) and pulmonary embolism (PE). Which condition causes the patient to be a candidate for placement of a vena cava filter? A. Presence of symptoms of shock B. Signs of deteriorating cardiopulmonary status C. Recurrent bleeding while receiving anticoagulants D. No response to oxygen therapy

C. Recurrent bleeding while receiving anticoagulants

A patient with a diagnosis of sleep apnea has a problem with sleep deprivation related to a disrupted sleep cycle. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)? A. Discussing weight-loss strategies such as diet and exercise with the patient B. Teaching the patient how to set up the bilevel positive airway pressure (BiPAP) machine before sleeping C. Reminding the patient to sleep on his side instead of his back D. Administering modafinil to promote daytime wakefulness

C. Reminding the patient to sleep on his side instead of his back

A patient had a rhinoplasty and is preparing for discharge home. A family member is instructed by the nurse to monitor the patient for postnasal drip by using a flashlight to look in the back of the throat. If bleeding is noted, what does the nurse tell the family member to do? A. Place ice packs on the back of the neck and apply pressure to the nose B. Hyperextend the neck and apply pressure and ice packs as needed C. Seek immediate medical attention for the bleeding D. Monitor for 24 hours if the bleeding appears to be a small amount

C. Seek immediate medical attention for the bleeding

While playing football at school, a patient injured his nose, resulting in a possible simple fracture. The patient's parents call the nurse seeking advice. What does the nurse tell the parents to do? A. Ask the school nurse to insert a nasal airway to ensure patency B. Apply an ice pack and allow the patient to rest in a supine position C. Seek medical attention within 24 hours to minimize further complications D. Monitor the symptoms for 24 hours and contact the physician if there is bleeding

C. Seek medical attention within 24 hours to minimize further complications

After surgery a client develops a deep vein thrombosis and a pulmonary embolism. Heparin via a continuous drip at 1200 units/hr is prescribed. Several hours later, vancomycin (Vancocin) 500 mg intravenously every 12 hours is prescribed. The client has one IV site: a peripheral line in the left forearm. What action should the nurse take? A. Stop the heparin, flush the line, and administer the vancomycin B. Use a piggyback setup to administer the vancomycin into the heparin C. Start another IV line for the vancomycin and continue heparin as prescribed D. Hold the vancomycin and tell the provider that the drug is incompatible with heparin

C. Start another IV line for the vancomycin and continue heparin as prescribed

A patient in the hospital is receiving a continuous infusion of heparin for a pulmonary embolism (PE). When the nurse enters the room, the patient has blood on the front of his chest and is holding a tissue saturated with blood to his nose. What is the first priority action the nurse must take? A. Have the patient sit up and lean forward, pinching the nostril B. Have a UAP set up oral suctioning to suction excess blood from the patient's mouth C. Stop the heparin IV infusion D. Obtain laboratory results from prothrombin time and complete blood count

C. Stop the heparin IV infusion

A patient recently received anticoagulant therapy for complications of pulmonary embolism (PE) after knee surgery. The patient is now in a rehabilitation facility and is receiving warfarin (coumadin). What is the nursing responsibility related to warfarin (Coumadin)? A. Have protamine sulfate as an antidote B. Administer NSAIDs or aspirin for pain related to the knee C. Teach the patient about foods high in vitamin K D. Monitor platelets for thrombocytopenia

C. Teach the patient about foods high in vitamin K

What is the most important interrelated medical-surgical concept for nursing care of patients requiring oxygen therapy? A. Gas exchange B. Perfusion C. Tissue integreity D. Cellular regulation

C. Tissue integrity

After receiving heparin anticoagulant therapy, patients are often discharged from the hospital with a prescription and instructions for which drug? A. Protamine sulfate B. Prednisone C. Warfarin D. Oral heparin

C. Warfarin

When a patient is requiring oxygen therapy, what is important for the nurse to know? A. Patients require 1-10 L/min by nasal cannula in order for oxygen to be effective B. Oxygen-induced hypoventilation is the priority when PACO2 levels are unknown C. Why the patient is receiving oxygen, expected outcomes, and complications D. The goal is the highest FIo2 possible for the particular device being used

C. Why the patient is receiving oxygen, expected outcomes, and complications

A patient with a pulmonary embolism (PE) asks for an explanation of heparin therapy. What is the nurse's best response? A. "It keeps the clot from getting larger by preventing platelets from sticking together to improve blood flow" B. "It will improve your breathing and decrease chest pain by dissolving the clot in your lung" C. "It promotes the absorption of the clot in your leg that originally caused the PE" D. "It increases the time it takes for blood to clot, therefore prevent further clotting and improving blood flow"

D. "It increases the time it takes for blood to clot, therefore prevent further clotting and improving blood flow"

The nurse is monitoring a patient receiving oxygen therapy. On auscultation, the nurse notes that the patient developed new onset of crackles and decreased breath sounds. Which condition does the nurse recognize? A. Oxygen toxicity B. Hypoxemia C. Hypercarbia D. Absorptive atelectasis

D. Absorptive atelectasis

Upon diagnosis of a submassive pulmonary embolism (PE), the nurse expects to perform which therapeutic intervention for the patient? A. Provide oral anticoagulant therapy B. Maintain bedrest in the supine position C. GIve oxygen therapy via mechanical ventilator D. Administer parenteral low molecular weight heparin (LMWH)

D. Administer parenteral low molecular weight heparin (LMWH)

Which intervention for a patient with a pulmonary embolism would the RN assign to the LPN/LVN on the patient care team? A. Evaluating the patient's reports of chest pain B. Monitoring laboratory values for changes in oxygenation C. Assessing for symptoms of respiratory failure D. Auscultating the lungs for crackles

D. Auscultating the lungs for crackles

A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client? A. Slow, deep respirations B. Normal oral temperature C. Dry, unproductive cough D. Diminished breath sounds

D. Diminished breath sounds

A patient with a massive pulmonary embolism (PE) has hypotension and shock and is receiving IV crystalloids. The patient's cardiac output does not improve. The nurse anticipates an order for which drug? A. Hydromorphone B. Alteplase C. Diltiazem D. Dobutamine

D. Dobutamine

A patient with a pulmonary embolism (PE) is receiving anticoagulant therapy. Which assessment related to the therapy does the nurse perform? A. Measure abdominal girth because the medication causes fluid retention B. Check skin turgor because dehydration contributes to anticoagulation C. Monitor for nausea, vomiting, and diarrhea D. Examine skin every 2 hours for evidence of bleeding

D. Examine skin every 2 hours for evidence of bleeding

The nurse is assessing a patient who reports being struck in the face and head several times. During the assessment, pink-tinged drainage from the nares is observed. Which nursing action provides relevant assessment data? A. Have the patient gently blow the nose and observe for bloody mucous B. Check the drainage with a reagent to check the pH C. Ask the patient to describe the appearance of the face before the incident D. Place a drop of the drainage on a filter paper and look for a yellow ring

D. Place a drop of the drainage on a filter paper and look for a yellow ring

The nurse is caring for a patient with a nasal fracture. The patient has clear secretions that react positively when tested for glucose. Which complication does the nurse suspect? A. Jaw fracture B. Facial fracture C. Vertebral fracture D. Skull fracture

D. Skull fracture

Which high flow oxygen delivery system delivers the most accurate concentration of oxygen without intubation? A. Partial rebreather mask B. Nonrebreather mask C. High flow nasal cannula D. Venturi mask

D. Venturi mask