foundations exam 2
True or False: Alterations in the cardiovascular system can lead to impaired oxygenation
True
Residual Volume (RV)
amount of air in lungs at max expiration
The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which statement by the patient tells the nurse that the procedure is contraindicated.
"I just finished eating my lunch, I'm ready for my CPT now."
A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated, What action is next? A: open the windows to the client's room to allow smoke to escape B: obtain class C fire extinguisher to extinguish fire C: remove all electrical equipment from room D: place wet towels along base of door
D
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in prep for an invasive procedure. Which of the following flaps should the nurse unfold first? A: the flap closest to the body B: the right side flap C: the left side flap D: the flap furthest from body
D
A patient spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?
Ischial tuberosity
forced vital capacity (FVC)
Max air forcefully exhaled after full inspiration
Peak Expiratory Flow Rate (PEFR)
Max flow attained during the FVC
The patient has a tracheostomy tube. What action should the nurse take?
Secure new ties before removing old ties
What is an early sign of hypoxia
Tachypnea
A physician has ordered a moist saline packing for an infected pressure ulcer. The nurse knows that the primary reason for this treatment is to:
keep the wound moist.
A nurse is caring for a patient who recently underwent a tracheostomy. The first priority when caring for a patient with a tracheostomy is:
keeping his airway patent
total lung capacity
Amount of air contained in the lungs at max inspiration
A nurse provides care for a patient receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?
Assessing the patient's respiratory status, orientation, and skin color
A nurse manager is reviewing w the nurses on the unit in the care if a client who has a seizure. Which of the following statements by a nurse requires further instruction? A: "I will place client on their side" B: "I will go to nurse's station for assistance" C: "I will note the time that the seizure begins" D" I will prepare to insert an airway"
B
A nurse has prepared a sterile field for assisting a provider w a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? Select all that apply A: the provider drops a sterile instrument onto the near side of the sterile field B: the nurse moistens a cotton ball w sterile normal saline and places it on the sterile field C: the procedure is delayed 1 hr bc provider receives an emergency call D: the nurse turns to speak to someone who enters the door behind the nurse E: the client's hand brushes against the outer edge of sterile field
B, C, D
A gerontologic nurse is teaching a group of nursing students about integumentary changes that occur in older adults. How should these students best integrate these changes into care planning?
By protecting older adults against shearing injuries
A nurse observes smoke coming from under the door in staff's lounge. Which action is priority? A: Extinguish the fire B: activate fire alarm C move clients who are nearby D close all open doors on unit
C
When entering client's room to change dressing, nurse notes client is coughing & sneezing. When preparing sterile field, it's important the nurse... A: keep sterile field at least 6 ft away from client's bedside B: instruct client to not cough/sneeze during dressing change C: place mask on client to limit spread of microorganisms into surgical wound D: keep box of Kleenex nearby for client to use during dressing change
C
A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?
Encourage the patient to take approximately 10 breaths per hour.
What are crackles caused by?
Fluid in the lungs
vital capacity (VC)
Maximum air exhaled after maximum inspiration
A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention?
Measure the patient's oxygen saturation.
Spirometry
Measures the volume of air exhaled or inhaled
What respiratory complication are elderly patients at risk for?
Pneumonia
Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?
Proliferation phase
The nurse in the ED is caring for a patient who has returned to the ED 4 days after receiving sutures for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return to remove the packing and resuture the wound. The nurse is aware that the wound will now heal by what means?
Third intention
tidal volume (TV)
Total air inhaled and exhaled in 1 breath
While repositioning an immobile patient, a nurse notes that the patient's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to:
document the condition of the patient's skin.
A nurse is caring for a client who has a history of falls. Which of the following Is priority? A: complete fall-risk assessment B: educate client and family about fall risk C: eliminate safety hazards from client's environment D: make sure client uses assistive aids in their possession
A
A nurse is caring for a client who has sever acute respiratory syndrome. The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? Select all that apply A. Planning and evaluating control and prevention strategies B: deterring public health priorities C: ensuring proper medical treatment D: identifying endemic disease E: monitoring for comoon-source outbreaks
A, B, C, E
A charge nurse is reviewing with a newly hired nurse the difference between manifestations of localized vs systemic infections. Which of the following are manifestations of a systemic infection? Select all that apply A: fever B malaise C: edema D: pain or tenderness E: increase in pulse and respiratory rate
A, B, E
The patient is wearing an oxygen mask. What action should the nurse take?
Assess for skin breakdown
Which of the following uses the body's own digestive enzymes to break down necrotic tissues?
Autolytic debridement
A nurse is reviewing hand hygiene techniques with a group of assistive personnel. Which of the following instructions should the nurse include when discussing hand washing? Select all that apply A. Apply 3-5mL of liquid soap to dry hands B. Wash the hands w soap and water for at least 15 sec C. Rinse hands w hot water D. use clean paper towel to turn off water faucet E> allow hands to air dry after washing
B, C, D
A nurse is contributing to the plan of care for a client who is being admitted to the facility w a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? Select all that apply A: place client in a room that has negative air pressure of at least 6 exchanges per hour B: wear a mask when providing care within 3 ft of client C: place surgical mask on client if transporting to another department D: use sterile gloves when handling soiled items E: wear a gown when providing care that might result in contamination from secretions
B, C, E
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? Select all that apply A: place belt restraint on client when they are sitting on the bedside commode B: keep the bed in its lowest position with all side rails up C: make sure the client's call light is within reach D: provide client w nonskid footwear E: complete fall-risk assessment
C, D, E
A nurse is wearing sterile gloves in prep for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? Select all that apply A: a bottle containing sterile solution B: the edge of a sterile drape at the base of the field C: the inner wrapping of an item on the sterile field D: an irrigation syringe on the sterile field E: one gloved hand with the other gloved hand
C, D, E
The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient?
Correct and safe use of oxygen therapy equipment.
A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations about which of the following conditions? A: Allergic reaction B: tapeworm C: systemic lupus erythematosus D: Tuberculosis
D
A nurse is caring for a client who reports a sever sore throat, Ain when swelling, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A: prodromal B incubation C: convalescence D: illness
D
What is a potential early tracheostomy complication?
Hemorrhage
The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient?
How to splint the incision when coughing
An 82-year-old patient is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the patient's course of treatment?
Increased time required for wound healing
How should the nurse regulate the percentage of oxygen delivered to the patient?
Lowest amount to keep SPO2 adequate
A postoperative patient begins coughing forcefully while eating gelatin. The nurse notices an evisceration of the intestines. What should the nurse do first?
Place the patient in the low Fowler's position.
The nurse applies a moisture-retentive dressing to a patient's wound. The main advantage of this dressing, rather than a wet dressing, is its ability to:
Provide autolytic debridement.
After suctioning a tracheostomy tube, the nurse assesses the patient to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?
Respiratory rate of 16 breaths/minute through the established airway
Which position promotes lung expansion and improves gas exchange?
Semi-fowlers
Students are reviewing information about the stages of pressure ulcer development. They demonstrate understanding when they identify which stage as characterized by a full-thickness wound? Select all that apply.
Stage III Stage IV
The nurse suctions a patient through the endotracheal tube and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?
The patient is hypoxic from suctioning
In anticipation of a patient's scheduled surgery, the nurse is teaching her to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the patient?
The patient should take three deep breaths and exhale forcefully and then take a quick short breath and cough from deep in the lungs.
The nurse is providing preoperative teaching to a patient scheduled for surgery. The nurse is instructing the patient on the use of deep breathing, coughing, and the use of incentive spirometry when the patient states, "I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest." What rationale for these instructions should the nurse provide?
To promote optimal lung expansion
A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe?
Venturi mask
Which intervention best prevents pneumonia
incentive spirometer
