Professional Documents
Culture Documents
I talk after the surgery? The best response by the n27 A patient
who had a total laryngectomy has a nursing diagnosis of hopele
You will have a permanent opening into your neck, and
you will need to have rehabilitation for some type of voice
restoration.
12.
27 A patient who had a total laryngectomy has a nursing
diagnosis of hopelessness related to loss of control of personal
care. Which information obtained by the nurse is the best
indicator that the problem identified in nursing diagnosis is
resolving? The patient asks how to clean the tracheostomy
stoma and tube.
13.
27 After completing discharge instructions for a patient
with a total laryngectomy, the nurse determines that additional
instruction is needed when the patient says,
I must keep the
stoma covered with a loose sterile dressing at all times.
14.
27 Which action should the nurse take first when a patient
develops a nosebleed? Pinch the lower portion of the nose for 10
minutes.
15.
27 When the nurse is caring for a patient who has had a
total laryngectomy and radical neck dissection during the first 24
hours after surgery, what is the priority nursing action?
Assess breath sounds.
16.
27 A patient with an uncuffed tracheostomy tube coughs
violently during suctioning and dislodges the tracheostomy tube.
Which action should the nurse take first? Insert the obturator
and attempt to reinsert the tracheostomy tube.
17.
27 Which of these patients in the respiratory disease clinic
should the nurse assess first? A 23-year-old, complaining of a
sore throat, who has a hot potato voice
18.
27 The nurse obtains the following assessment data in a
76-year-old patient who has influenza. Which information will be
most important to communicate to the health care provider?
Diffuse crackles in the lungs
19.
27 Which of these nursing actions can the RN working in a
long-term care facility delegate to an experienced LPN/LVN who
is caring for a patient with a permanent tracheostomy?
Suctioning the tracheostomy when needed
20.
The nurse is caring for a hospitalized 82-year-old patient
who has nasal packing in place to treat a nosebleed. Which of
the following assessment findings will require the most
immediate action by the nurse?
The oxygen saturation is
89%.
21.
27 The teaching plan for a patient with acute sinusitis will
need to include which of the following interventions (select all
that apply)?
hot shower will increase sinus drainage and
decrease pain,(OTC) antihistamines can be used to relieve
51.
28 A patient with a pleural effusion is scheduled for a
thoracentesis. Before the procedure, the nurse will plan to
position the patient sitting upright on the edge of the bed
and leaning forward
52.
28 After discharge teaching has been completed for a
patient who has had a lung transplant, the nurse will evaluate
that the teaching has been effective if the patient states
I will
call the health care provider right away if I develop a fever.
53.
28 Which of these orders will the nurse act on first for a
patient who has just been admitted with probable bacterial
pneumonia and sepsis? Obtain blood cultures from two sites
54.
28 Which assessment information obtained by the nurse
when caring for a patient who has just had a thoracentesis is
most important to communicate to the health care provider?
Oxygen saturation is 89%
55.
28 A patient who has just been admitted with
pneumococcal pneumonia has a temperature of 101.6 F with a
frequent cough and is complaining of severe pleuritic chest pain.
Which of these prescribed medications should the nurse give
first? azithromycin (Zithromax)
56.
28 Which information obtained by the nurse about a
patient who has been diagnosed with both human
immunodeficiency virus (HIV) and active tuberculosis (TB)
disease is most important to communicate to the health care
provider? The patient is being treated with antiretrovirals for
HIV infection.
57.
28 A patient with pneumonia has a fever of 101.2 F (38.5
C), a nonproductive cough, and an oxygen saturation of 89%.
The patient is very weak and needs assistance to get out of bed.
The priority nursing diagnosis for the patient is impaired gas
exchange related to respiratory congestion
58.
28 The nurse observes nursing assistive personnel (NAP)
doing all the following activities when caring for a patient with
right lower lobe pneumonia. The nurse will need to intervene
when NAP lower the head of the patients bed to 10 degrees
59.
28 A patient with a possible pulmonary embolism
complains of chest pain and difficulty breathing. The nurse finds
a heart rate of 142, BP reading of 100/60, and respirations of 42.
The nurses first action should be to
elevate the head of the
bed to 45 to 60 degrees
60.
28 After the nurse has received change-of-shift report
about the following four patients, which patient should be
assessed first?
A 46-year-old patient who has a deep vein
thrombosis and is complaining of sudden onset shortness of
breath
61.
28 The nurse is performing tuberculosis (TB) screening in a
clinic that has many patients who have immigrated to the United
States. Before doing a TB skin test on a patient, which question is
most important for the nurse to ask?
Have you received the
bacille Calmette-Gurin (BCG) vaccine for TB?
62.
28 A patient is admitted to the emergency department
with an open stab wound to the right chest. What is the first
action that the nurse should take? Tape a nonporous dressing on
three sides over the chest wound.
63.
28 The nurse notes that a patient has incisional pain, a
poor cough effort, and scattered rhonchi after a thoracotomy.
Which action should the nurse take first? Medicate the patient
with the prescribed morphine.
64.
28 The nurse is caring for a patient with primary
pulmonary hypertension who is receiving epoprostenol (Flolan).
Which assessment information requires the most immediate
action?
The patients central intravenous line is
disconnected.
65.
28 A patient who was admitted the previous day with
pneumonia complains of a sharp pain whenever I take a deep
breath. Which action will the nurse take next? Listen to the
patients lungs
66.
28 The nurse notes new onset confusion in an 89-year-old
patient in a long-term care facility. The patient is normally alert
and oriented. In which order should the nurse take the following
actions?
Obtain the oxygen saturation, Check the patients
pulse rate, Notify the health care provider, Document the change
in status
67.
29 A patient with chronic bronchitis who has a new
prescription for Advair Diskus (combined fluticasone and
salmeterol) asks the nurse the purpose of using two drugs. The
nurse explains that
one drug decreases inflammation, and
the other is a bronchodilator.
68.
29 The nurse has completed patient teaching about the
administration of salmeterol (Serevent) using a metered-dose
inhaler (MDI). Which action by the patient indicates good
understanding of the teaching?
The patient attaches a spacer
before using the MDI.
69.
29 When preparing a patient with possible asthma for
pulmonary function testing, the nurse will teach the patient to
withhold bronchodilators for 6 to 12 hours before the
examination.
70.
29 Which information will the nurse include when teaching
the patient with asthma about the prescribed medications?
Tremors are an expected side effect of rapidly acting
bronchodilators
71.
29 When the nurse is evaluating the effectiveness of
therapy for a patient who has received treatment during an
asthma attack, which finding is the best indicator that the
therapy has been effective? Oxygen saturation is >90%.
72.
29 A patient seen in the asthma clinic has recorded daily
peak flows that are 85% of the baseline. Which action will the
nurse plan to take?
Instruct the patient to continue to use
current medications
73.
29 Which action by a patient who has asthma indicates a
good understanding of the nurses teaching about peak flow
meter use? The patient uses the albuterol (Proventil) metereddose inhaler (MDI) for peak flows in the yellow zone.
74.
29 A 32-year-old patient who denies any history of smoking
is seen in the clinic with a new diagnosis of emphysema. The
nurse will anticipate teaching the patient about 1-antitrypsin
testing
75.
29 Which information about a newly admitted patient with
chronic obstructive pulmonary disease (COPD) indicates that the
nurse should consult with the health care provider before
administering the prescribed theophylline?
The patient takes
cimetidine (Tagamet) 150 mg daily
76.
29 A patient with chronic bronchitis has a nursing diagnosis
of impaired breathing pattern related to anxiety. Which nursing
action is most appropriate to include in the plan of care?
Teach
the patient how to effectively use pursed lip breathing.
77.
29 A patient with chronic obstructive pulmonary disease
(COPD) has a nursing diagnosis of imbalanced nutrition: less than
body requirements. An appropriate intervention for this problem
is to offer high calorie snacks between meals and at bedtime
78.
29 When the nurse is interviewing a patient with a new
diagnosis of chronic obstructive pulmonary disease (COPD),
which information will help most in confirming a diagnosis of
chronic bronchitis?
The patient complains about a productive
cough every winter for 3 months
79.
29 After the nurse has finished teaching a patient about
pursed lip breathing, which patient action indicates that more
teaching is needed?
The patient puffs up the cheeks while
exhaling
80.
29 Which finding by the nurse for a patient with a nursing
diagnosis of impaired gas exchange will be most useful in
evaluating the effectiveness of treatment?
Pulse oximetry
reading of 91%
81.
29 To evaluate the effectiveness of therapy for a patient
with cor pulmonale, the nurse will monitor the patient for
jugular vein distention
82.
29 When a hospitalized patient with chronic obstructive
pulmonary disease (COPD) is receiving oxygen, the best action
by the nurse is to maintain the pulse oximetry level at 90% or
greater
83.
Which information will the nurse include in teaching a
patient with chronic obstructive pulmonary disease (COPD) who
has a new prescription for home oxygen therapy?
Oxygen use
can improve the patients prognosis and quality of life.
84.
29 A patient is receiving 35% oxygen via a Venturi mask. To
ensure the correct amount of oxygen delivery, it is most
important that the nurse
keep the air entrainment ports
clean and unobstructed.
85.
29 Postural drainage with percussion and vibration is
ordered twice daily for a patient with chronic bronchitis. The
nurse will plan to carry out the procedure 3 hours after the
patient eats
86.
29 When developing a teaching plan to help increase
activity tolerance at home for a 70-year-old with severe chronic
obstructive pulmonary disease (COPD), the nurse should teach
the patient that an appropriate exercise goal is to
walk for a
total of 20 minutes daily
87.
29 A patient with severe chronic obstructive pulmonary
disease (COPD) tells the nurse, I wish I were dead! I cannot do
anything for myself anymore. Based on this information, which
nursing diagnosis is most appropriate?
Chronic low self-esteem
related to increased physical dependence
88.
29 A patient with chronic obstructive pulmonary disease
(COPD) is admitted to the hospital. How can the nurse best
position the patient to improve gas exchange? Sitting up at the
bedside in a chair and leaning slightly forward
89.
29 Which diagnostic test will the nurse plan to discuss with
a 54-year-old patient with progressively increasing dyspnea who
is being evaluated for a possible diagnosis of chronic obstructive
pulmonary disease (COPD)? Pulmonary function testing
90.
29 Which action will be included in the plan of care for a
23-year-old with cystic fibrosis (CF) who is admitted to the
hospital with increased dyspnea? Perform chest physiotherapy
every 4 hours
91.
29 A patient who is hospitalized with cystic fibrosis (CF)
coughs up large quantities of thick green mucus. The nurse will
plan to teach the patient about
aerosolized tobramycin
(TOBI)
92.
29 A 20-year-old patient with cystic fibrosis (CF) tells the
nurse that she is considering having a child. Which initial
response by the nurse is best?
Do you need any
information to help you with the decision?
93.
29 A patient with chronic obstructive pulmonary disease
(COPD) has rhonchi throughout the lung fields and a chronic,
nonproductive cough. Which nursing action will be most
effective? Educate the patient to use the Flutter airway
clearance device
94.
29 After the nurse has completed diet teaching for a
patient with chronic obstructive pulmonary disease (COPD) who
has a body mass index (BMI) of 20, which patient statement
indicates that the teaching has been effective? I will have ice
cream as a snack every day.
95.
29 When teaching the patient with chronic obstructive
pulmonary disease (COPD) about exercise, which information
should the nurse include?
Use the bronchodilator before you
start to exercise.
96.
29 Which information given by an asthmatic patient while
the nurse is doing the admission assessment is most indicative of
a need for a change in therapy?
The patients only
medications are albuterol (Proventil) and salmeterol (Serevent)
97.
29 When the nurse takes an admission history for a patient
with possible asthma who has new-onset wheezing and
shortness of breath, which information may indicate a need for a
change in therapy?
The patient takes propranolol (Inderal)
for hypertension
98.
29 Which topic will the nurse include in medication
teaching for a patient with newly-diagnosed persistent asthma?
Self-administration of inhaled corticosteroids
99.
29 A patient with cystic fibrosis (CF) has blood glucose
levels that are consistently 200 to 250 mg/dL. Which nursing
action will the nurse plan to implement? Educate the patient
about administration of insulin
100.
29 When caring for a patient with a history of asthma,
which assessment finding should the nurse communicate
immediately to the health care provider? Use of accessory
muscles in breathing
101.
29 Which action should the nurse anticipate taking first
when a patient who is experiencing an asthma attack develops
bradycardia and a decrease in wheezing? Assist with
endotracheal intubation
102.
29 A patient who is experiencing an acute asthma attack is
admitted to the emergency department. The nurses first action
should be to
listen to the patients breath sounds
103.
29 Which finding in a patient who has received
omalizumab (Xolair) is most important to report immediately to
the health care provider?
Flushing and dizziness
104.
29 The nurse in the emergency department receives
arterial blood gas results for four recently admitted patients with
147.
After the nurse has received change-of-shift report, which
of these patients should be assessed first?
A patient with
possible lung cancer who has just returned after bronchoscopy
148.
26 The nurse has just received arterial blood gas (ABG)
results on four patients. Which result is most important to report
rapidly to the health care provider? pH 7.31, PaO2 91 mm Hg,
PaCO2 50 mm Hg, and O2 sat 96%
149.
26 The nurse obtains this information when assessing a
patient with chronic obstructive pulmonary disease (COPD) who
has been admitted with increasing dyspnea over the last 3 days.
Which finding is most important to report to the health care
provider? Respirations are 36 breaths/minute
150.
26 When performing an assessment of the patients
respiratory system, the nurse uses the following illustrated
technique to evaluate chest expansion
151.
26 Which nursing actions will be included when sending a
patient for computed tomography (CT) of the chest with contrast
(select all that apply)? Question the patient about allergies to
iodine, Review the recent blood urea nitrogen (BUN) and
creatinine levels
152.
pH
7.35-7.45
153.
PCO2 35-45 mmHg
154.
HCO3 22-26 mEq/L
155.
PO2 80-100mmHg
156.
V/Q influenced by partial pressure of O2 and CO2
157.
pH <7.35 acidosis: increased hydrogen concentration in
blood
158.
pH>7.45
alkalosis: decreased ion concentration in blood
159.
PCO2 <35 alkalosis
160.
PCO2>45 acidosis