Exam 2 Practice Questions
A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his. statements would indicate a need for further education? A: "I'll make sure that I rest between activities so I don't get so short of breath." B: "I'll rest for 30 minutes before I eat my meal." C: "If I have trouble breathing at night, I'll use two to three pillows to prop up." D: "If I get short of breath, I'll turn up my oxygen level to 6 L/min."
"If I get short of breath, I'll turn up my oxygen level to 6 L/min."
Which statement made by the nurse demonstrates patient center care while focusing on alleviating the patient's fear and anxiety?
"Lets talk about the concerns you have about going home"
Which term is used to describe deteriorated skin condition related to prolonged, unrelieved pressure on a body part?
-Bed sore -Pressure sore -pressure ulcer -Decubitus
The nurse is preparing a diet plan for a patient admitted to a wound care unit. After the nurse explains the diet plan to the patient, the patient asks the reason for an increase in intake of citrus fruits. Which information would the nurse share with the patient?
-Citrus fruits have antioxidant properties -These fruits help in collagen synthesis -Citrus provides fuel for cell energy
The nurse is caring for older adult patients in a nursing home. The nurse understands that older adults are susceptible to development of pressure injuries and other wounds. Which factor makes older adults more vulnerable to developing pressure injuries?
-Diminished inflammatory response -Loss of collagen and thinning of muscles With age the skin loses elasticity, has decreased collagen, and the underlying muscles thin out, causing the skin to be easily torn with shearing and friction trauma. The decreased inflammatory response in older adults results in poor healing process because of slow epithelialization
Which finding is characteristic of a stage 3 pressure injury? (Select all that apply)
-It has full-thickness skin loss -The subcutaneous fat may be visible -Neither the bone, tendon, nor muscle is exposed A stage 3 pressure injury has a full-thickness skin loss involving epidermis and dermis. Because of this, the subcutaneous fat may be visible. The wound is NOT deep enough to expose the bone, tendon, or the muscle.
Which information would the nurse share with the patient about the normal mechanism of respiration?
-Normal breathing is quiet with minimum or no effort -Ventilation is the process of air moving in and out of the lungs -The diagram is an important muscle that helps in breathing
Which pulmonary manifestation would the nurse assess for in a patient with underlying left-sided heart failure?
-Paroxysmal nocturnal dyspnea -Difficulty in breathing -Crackles in base of lungs on auscultation In cases of underlying cardiac disease, such as left-sided heart failure, there can be associated paroxysmal nocturnal dyspnea, difficulty in breathing, and crackles that can be auscultated in the lungs.
Which parameter would the nurse monitor in a patient who has developed hypoxia as a result of severe anemia?
-Pulse rate -Respiratory rate -Skin color change Hypoxia presents as an increase in pulse rate and a rise in RR and depth of respiration. In late stages of hypoxia, the skin and mucous membranes may become bluish in color.
The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles ion both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? A: SpO2 levels B: Amount of sputum production C: Change in respiratory rate and pattern D: Pain in lower calf area
-SpO2 levels -Amount of sputum production -Change in respiratory rate and pattern
The nurse assesses a patient's abdominal wound and finds that the wound is in the proliferative phase of healing. Which change in the wound might have led the nurse to this conclusion?
-The wound is filled with granulation tissue -There is reepithelialization of the wound surface -The wound contracts to reduce the area that requires healing
which health care service is provided in secondary care?
-Urgent care -Outpatient surgery -Ambulatory care the aim of these services is to diagnose and treat the illness.
Which clinical manifestation occurs with right-sided heart failure?
-Weight gain -Distended neck veins -Pedal edema Weight gain, distended neck veins, and pedal edema indicate right-sided heart failure. The blood starts pooling in the systemic circulation, resulting in weight gain, distended neck veins, and pedal edema. Lung crackles occurs with left NOT right-sided heart failure.
Which patient group would be at increased risk of wound dehiscence?
-malnourished patients -obese patients -patients with wound infections A malnourished patient may have poor wound healing, which may lead to wound dehiscence. Obesity may increase strain on surgical incisions. Infection interferes with the wound healing process and may increase the risk of wound dehiscence.
A patient with a history of chronic obstructive pulmonary disease (COPD) is hospitalized with respiratory failure. Which laboratory values does the nurse assess to determine adequate oxygenation?
Arterial blood gases (ABGs) ABGs will provide information regarding the patient's oxygenation status including O2, CO@, and HCO3-
Which action would the nurse take first for the patient with chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min and becomes short of breath while in the supine position during a bath?
Assist the patient to a semi-Fowler's position The nurse would first assist the patient to a semi-Fowler's position. Breathing is easier in a semi-fowler's position because it permits greater expansion of the chest cavity. If repositioning does not improve the situation, then oxygenation and contacting the health care provider might be appropriate.
Which condition involves collapsed alveoli that prevent the normal exchange of oxygen and carbon dioxide
Atelectasis Atelectasis is a pulmonary condition that leads to a collapse of the alveoli, which prevents a normal exchange of oxygen and carbon dioxide.
A patient with a history of chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. The patient has pitting edema in both ankles, blood pressure (BP) of 170/100, an apical pulse rate of 92, and respirations 28. The most important assessment for the nurse to accomplish next is to
Auscultate the lung sounds
Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated?
Blanchable erythema Blanchable. erythema is an early identification of pressure that resolves without tissue loss if the pressure is removed
A long-term care facility encourages nurses to assess patients at risk of developing pressure injuries based on six sub scales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. Which tool is the long term care facility using for risk assessment of pressure injury development?
Braden Scale The Braden scale is a widely used tool for risk assessment of pressure injury development and is composed of six sub scales that are moisture, sensory perception, activity, mobility, nutrition, and friction or shear force.
Which information is correct regarding physiological factors that affect oxygenation?
Carbon monoxide (CO) poisoning decreases the oxygen-carrying capacity of the blood
After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first?
Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration.
Which clinical manifestation is a late sign. of hypoxia?
Cyanosis
Which assessment finding would indicate the patient needs airway suctioning?
Decreased independent ability to cough Impaired ability to cough up mucus caused by weakness or very thick secretions indicates a need for suctioning.
Which physiological process occurs in anemia?
Decreased oxygenation of blood. Anemia causes decreased oxygenation of blood. Anemia causes a decrease in hemoglobin, the oxygen-carrying substance, leading to a decreased oxygenation of blood
Which clinical manifestation would the nurse likely observe in a patient diagnosed with a pneumothorax?
Dyspnea Tachycardia Sharp pain in the chest
A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy, not cyanotic, the nurse understands that the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following
Forms a strong bond with hemoglobin, creating a functional anemia. CO strongly binds to hemoglobin, making it unavailable for oxygen binding and transport.
The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks off stasis of pulmonary secretions and decreased chest wall expansion? A: Antibiotics B: Frequent change of position C: Oxygen humidification D: Chest physiotherapy
Frequent change of position
Is red, moist tissue composed of new blood vessels, the presence of which indicates progression towards healing
Granulation
Which group or organization is directly affected by pay for performance reimbursement programs?
Health care providers Health care providers are directly affected by pay performance programs. Health care providers are compensated only if they meet certain benchmarks for quality and efficiency.
The nurse is caring for a patient who presents with an oxygen saturation of 85% on room air. Which assessment finding is most likely affecting this patient's oxygenation?
Heart rate 48 beats/min Bradycardia (heartbeat less than 60 beats/min) can decrease cardiac output, which decreases oxygenation
In which condition do the lungs remove carbon dioxide water than it is produced by cellular metabolism?
Hyperventilation
Which condition causes bluish discoloration of the skin and mucous membrane?
Hypoxia Bluish discoloration of the skin and mucous membrane is cyanosis, which is a clinical manifestation of hypoxia, or reduced tissue oxygenation
Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient?
Incentive spirometer encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It is a commonly used intervention that promotes deep breathing and it thought to prevent or treat atelectasis in the postoperative patient.
A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds?
Inspiratory crackles in lung bases In cases of underlying cardiac disease, such as left-sided heart failure, there can be associated paroxysmal nocturnal dyspnea, difficulty in breathing, and crackles that can be auscultated in the lungs.
A patient is admitted with a stage 2 pressure injury. Which characteristic of a pressure injury is the nurse likely to find during a wound assessment?
It has a reddish-pink wound bed without slough A stage 2 pressure injury has a partial thickness loss of dermis and is shallow. It has a reddish-pink wound bed without slough
Which statement is true regarding Magnet status recognition for a hospital?
Magnet is a special designation for hospitals that achieve excellence in nursing practice (pg 26)
The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen deliver systems should the nurse select to administer the oxygen to the patient?
Nasal Cannula
A patient who is hospitalized reports shortness of breath and extreme anxiety. The nurse performs an assessment and notes that the patient is sitting in an upright position and has an oxygen saturation of 86%. Which delivery device does the nurse select to administer oxygen to the patient?
Nonrebreather mask The patient's condition indicates the need for a higher concentration of oxygen for a short period of time. Partial rebreather and nonrebreather masks are simple masks with a reservoir bag that are capable of delivering concentrations of oxygen for a short period of time
When assessing a patient's respiratory status, which environmental factor would the nurse obtain?
Occupation Occupation is an environmental factor the nurse would assess. Many respiratory problems occur as a result of chronic exposure to inhalation irritants found in some work places.
Which option is an appropriate goal for restorative care?
Patient will walk 200 feet without shortness of breath Restorative interventions focus on returning a patient to his or her previous level of functioning or reaching a new level of function limited by his or her illness or disability. The goal of restorative care it to help individuals regain maximal function status and enhance quality of life by promoting independence
According to the Braden scale for predicting pressure injury risk, which factor most puts the patient at risk of developing a pressure injury?
Poor nutrition
The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first? A: Raise the head of the bed to 45 degrees. B: Take his oxygen saturation with a pulse oximeter. C: Take his blood pressure and respiratory rate. D: Notify the health care provider of his shortness of breath
Raise the head of the bed to 45 degrees
Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform?
Record the amount and continue to monitor drainage
Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? A: Record the amount and continue to monitor drainage B: Notify the health care provider C: Strip the chest tube starting at the chest D: Increase the suction by 10 mm Hg
Record the amount and continue to monitor drainage
Which service would the nurse suggest to a patient's caregiver who wants to know if there are support services that allow time off from caregiving?
Respite care
Which criteria does the Braden Scale evaluate?
Risk factors that place the patient at risk of pressure injury. The Braden scale measures factors in six sub scales that can predict the risk of pressure injury development.
Which reason would the nurse cite for increased risk of respiratory tract infections in infants?
Secondhand smoke exposure
Soft, yellow or white tissue is a characteristic of _______. stringy substance attached to the wound bed and it must be removed by a clinician or wound dressing.
Slough
Which condition would a patient with a respiratory rate of 25 breaths/min have?
Tachypnea Tachypnea is a condition in which the RR is greater than 20 breaths/min
Which parameter indicates a high quality of nursing care provided in the care unit?
The low rate of hospital-acquired infections. A low rate of hospital-acquired infections indicates that the quality of nursing care is high.
Which goal is the primary motive for why a nurse would perform pulse oximetry on a patient who is cyanotic?
To assess the oxygenation level
While assessing a patient who has a pressure injury, the nurse finds black wound tissue. In which stage is this pressure injury?
Unstageable Black tissue is characteristic of an eschar. Because the eschar obscures the depth of the wound, this pressure injury is unstageable
Which nutrient supports healing by promoting wound closure?
Vitamin A Vitamin A helps in wound closure, inflammatory response, and collagen formation
Which vitamin should be provided to a patient to promote wound healing?
Vitamin A and C -Vitamin A helps in wound closure, inflammatory response, collagen formation. -Vitamin C helps in collagen synthesis, immune function, and antioxidant
Which nutrient is an antioxidant that promotes wound healing?
Vitamin C
Which nursing activity is an example of tertiary care?
admitting a patient to the cardiovascular intensive care unit after open heart surgery Tertiary care is focused on highly specialized treatment of disease and illness.
