70 سؤال اختيارى على محاضرة oxygen administration

ملاحظة :فية اسئلة مش تبعنا فى المنهج 

لو عاوز تحمل الاسئلة وتحفظها على جهازك اضغط هنــــــا

This set has 78 terms

(1)The patient requires home oxygen therapy. When the home health nurse enters the patient's home for the initial visit, he observes several issues that are safety hazards related to the patient's oxygen therapy. What hazards do these include? (Select all that apply)
a. Bottle of wine in the kitchen area
b. Package of cigarettes on the coffee table
c. Several decorative candles on the mantlepiece
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

 (2)Before completing the morining assessment, the nurse concludes that the patient is experiencing inadequate oxygenation and tissue perfusion as a result of respiratory problems. Which assessment findings support the nurse's conclusion? (Select all that apply)
a. Inspiratory and expiratory effort is shallow, even, and quiet.
b. Patient must take a breath after every third or fourth word
c. Skin is pale, pink, and dry
d. Patient appears strained and fatigued
e. Pulse of 95 beats/min, respiratory rate of 30/min
f. Patient does not want to eat

 (3)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 physician about the mental status change
b. Take vital signs and check the pulse oximeter readings
c. Ask the patient's family when this behavior started
d. Perform a mental status examination

 (4)The nurse is caring for several patients on a general medical-surgical unit. The nurse would question the necessity of oxygen therapy for the patient with which condition?
a. Pulmonary edema with decreased arterial PO2 levels
b. Valve replacement with increased cardiac output
c. Anemia with adecreased hemoglobin and hematocrit
d. Sustained fever with an increased metabolic demand

 (5)When a patient is requiring oxygen therapy, what is important for the nurse to know?
a. Patients require 1 to 10L/min by nasal cannula in order for oxygen to be effective
b. Oxygen-induced hypoventilation is the priority when the 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

 (6)The patient with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with oxygen-induced hypoventilation. What is the respiratory stimulus t breathe for this patient?
a. High carbon dioxide (60 to 65 mm Hg) level in the blood that rose over time
b. Low level of carbon dioxide concentration in the blood, as sensed by the chemoreceptors in the brain
c. Low level of oxygen concentration in the blood, as sensed by the peripheral chemoreceptors
d. Oxygen narcosis which stimulates central chemoreceptors in the brain

 (7)The nurse is administering oxygen to the 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 to 4 L/min per nasal cannula
b. Venturi mask of 40% for the delivery of oxygen
c. Lower concentration of oxygen (1 to 2 L/min) per nasal cannula
d. Variable Fio2 via partial rebreather mask

The patient is at high risk or unknown risk for oxygen-induced hypoventilation. What must the nurse monitor for?
a. Signs of nonproductive cough, chest pain, crackles, and hypoxemia
b. Change of skin tone from pink to gray color after several minutes of oxygen therapy
c. Signs and symptoms of hypoventilation rather than hypoxemia
d. Changes in level of consciousness, apnea, and respiratory pattern

 (8)The 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 des not respond

 (9)Increased risk for oxygen toxicity is related to which factors? (Select all that apply)
a. Continuous delivery of oxygen at greater than 50% concentration
b. Delivery of high concentration of oxygen over 24 to 48 hours
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. Excluding measures such as continuous positive airway pressure (CPAP) or positive end-expiratory pressure (PEEP)

 (10)The patient is receiving humidified oxygen which places the patient at high risk for which nursing diagnosis?
a. Risk for injury related to the moisture in the tube
b. Risk for infection related to the condensation in the tubing
c. Impaired physical mobility related to reliance on equipment
d. Risk for impaired skin integrity related to the mask

 (11)The 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 respiratry isolation
b. Obtain an order for a sputum culture
c. Change the humidifier every 24 hours
d. Obtain an order to dicontinue the humidifier

 (12)Nursing interventions to prevent infection in patients with humidified oxygen include which actions?
a. Use sterile normal saline to provide moisture
b. Drain condensation into the humidifier
c. Drain condensation from the water trap
d. Maintain a sterile closed system at all times

 (13)Which factors are considered hazards associated with oxygen therapy? (Select all that apply)
a. Increased combustion
b. Oxygen narcosis
c. Oxygen toxicity
d. Absorption atelectasis
e. Hypoxic drive
f. Oxygen-induced hypoventilation

 (14)The 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 riskk of infection
c. To minimize the disturbance to the patient
d. To facilitate overall time management

 (15)What is the best description of the nurse's role in the deliver of oxygen therapy?
a. Receiving the therapy report from the respiratory therapist
b. Evaluating the response to oxygen therapy
c. Contacting respiratory therapy for the devices
d. Being familiar with the devices and techniques used in order to provide proper care

 (16)The patient with an oxygen delivery device would like to ambulate to the bathroom but the tubing is too short. Extension tubing is added. What is the maximum length of the tubing that can be added in order to deliver the amount of oxygen needed for that device?
a. 25 feet
b. 35 feet
c. 45 feet
d. 50 feet

 (17)The patient is being discharged and requires home oxygen therapy with a reservoir-type nasal cannula. He asks the nurse, "Why can't I just take this nasal cannula that I hve been using in the hospital?" What is the nurse's best response?
a. "The doctor ordered the cannula, so your insurance company should cover the cost."
b. "With the used cannula there is a risk of a hospital-acquired infection."
c. "This special nasal cannula allows you to decrease the oxygen flow by 50%."
d. "This nasal cannula is much better. It is more flexible and comfortable to wear.

 (18)The patient is receiving oxygen therapy through a non-rebreather mask. What is the correct nursing intervention?
a. Maintain liter flow so tat the reservoir bag is up to one-half full
b. Maintain 60% to 75% FiO2 at 6 to 11 L/min
c. Ensure that valves and rubber flaps are patent, functional, and not stuck
d. Assess for effctiveness and switch to partial rebreather for more precise FiO2.

 (19)The patient with 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 physician order for a nasal cannula at 5 L/min
d. Obtain a physician order to remove the mask at meals

 (20)The physician orders transtracheal oxygen therapy for the patient with respiratory difficulty. What does the nurse tell the patient's family is the purpose of this type oxygen deliver 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

 (21)The nursing diagnosis for the patient receiving oxygen therapy is risk for impaired skin integrity. Which nursing interventions are related to prevention of skin breakdown? (Select all that apply)
a. Assess the patient's ears, back of neck, and face at least every 4 to 8 hours for irritation
b. Apply padding on tubing to prevent pressure on skin
c. Use petroleum jelly on nostrils, face, and lips to relieve dryness
d. Assess nasal and mucous membranes for dryness and cracks
e. Obtain an order for humidification when oxygen is being delivered at 6 L/min or more
f. Provide mouth care every 8 hours and as needed
g. Position tubing so it will not pull on patient's ears

 (22)The patient is receiving oxygen therapy for respiratory problems. According to NIC interventions for administration and monitoring of its effectiveness, what does the nurse do?
a. Monitor the effectivenss of oxygen therapy at least once every 8 hours
b. Monitor for signs of oxygen toxicity and absorption atelectasis
c. Instruct the patient to replace the oxygen mask when the device is removed
d. Ask the respiratory therapist to monitor the oxygen flow and patient response

 (23)The patient requires long-term airway maintenance following surgery for cancer of the neck. The nurse is using a piece of equipment to explain the procedure nd mechanism that are associated with this long-term therapy. Which piece of equipment does the nurse most likely use for this patient teaching session?
a. Tracheostomy tube
b. Nasal trumpet
c. Endotracheal tube
d. Nasal cannula

 (24)The patient is receiving preoperative teaching for a partial laryngectomy and will have a tracheostomy postoperatively. How does the nurse define a tracheostomy to the patient?
a. Opening in the trachea that enables breathing
b. Temporary procedure that will be reversed at a later date
c. Technique using positive pressure to improve gas exchange
d. Procedure that holds open the upper airways

(25)The patient returns from the operating room and the nurse assessfor subcutaneous emphysema which is a potential complication associated with tracheostomy. How does the nurse assess for this complication?
a. Checking the volume of the pilot balloon
b. Listening for airflow through the tube
c. Inspecting and palpating for air under the skin
d. Assessing the tube for patency

The patient with a tracheostomy develops increased coughing, inability to expectorate secretions, and difficulty breathing. What are these assessment findings related to?
a. Overinflation of the pilot balloon
b. Tracheoesophageal fistula
c. Cuff leak and rupture
d. Tracheal stenosis

 (26)The patient returns from the operating room after having a tracheostomy. While assessing the patient, which observations made by the nurse warrant immediate notification of the physician?
a. Patient is alert but unable to speak and has difficulty communicating his needs.
b. Small amount of bleeding present at the incision
c. Skin is puffy at the neck area with a crackling sensation
d. Respirations are audible and noisy with an increased respiratory rate.

 (27)The patient was intubated for acute respiratory failure, and there is an endotracheal tube in place. Which nursing intervention is not appropriate for this patient?
a. Ensure that the oxygen is warme and humidified
b. Suction the airway, then the mouth, and give oral care
c. Suction the airway with the oral suction equipment
d. Position the tubing so it does not pull on the airway.

 (28)To prevent accidental decannulation of a tracheostomy rube, what does the nurse do?
a. Obtain an order for continuous upper extremity restraints
b. Secure te tube in place using ties or fabric fasteners
c. Allow some flexibility in motion of the tube while coughing
d. Instruct the patient to hold the tube with a tissue while coughing

 (29)The patient has a recent tracheostomy. What necessary equipment does the nurse ensure is kept at the bedside?
a. Pair of wire cutters
b. Pocket mask and code cart
c. Ambu bag and oxygen tubing
d. Tracheostomy tube with obturator

 (30)Which statement by the nursing student indicates an understanding of the deflation of the tracheostomy cuff?
a. "The cuff is deflated to allow the patient to speak."
b. "The cuff is deflated to permit suctioning more easily."
c. "The cuff should never be deflated because the patient will choke."
d. "The cuff should be deflated to facilitate access for tracheostomy care."

 (31)The patient has a temporary tracheostomy folling surgery to the neck area to remove a benign tumor. Which nursing intervention is performed to prevent obstruction f the tracheostomy tube?
a. Provide tracheal suctioning when there are noisy respirations
b. Provide oxygenation to maintain pulse oximeter readings
c. Inflate the cuff to maximum pressure and check it once per shift.
d. Suction regularly and PRN with a Yankauer suction

 (32)The patient sustained a serious crush injury to the neck and had a tracheostomy tube placed yesterday. As the nurse is performing tracheostomy care, the patient suddenly sneezes very forcefully and the tracheostomy tube falls out onto the bed linens. What does the nurse do?
a. Ventilate the patient with 100% oxygen and notify the physician
b. Quickly and gently replace the tube wth a clean cannula kept at the bedside
c. Quickly rinse the tube with sterile solution and gently replace it
d. Give the patient oxygen; call for assistance and a new tracheostomy kit.

 (33)The patient required emergency intubation and currently has an artificial airway in place. Oxygen is being administered directly from the wall source. Why would warmed and humidified oxygen be a more appropriate choice for this patient?
a. Helps prevent tracheal damage
b. Promotes thick secretions
c. Is more comfortable for the patient
d. Is less likely to cause oxygen toxicity

 (34)The patient has an endotracheal tube and requires frequent suctioning for copious secretions. What is a complication of tracheal suctioning?
a. Atelectasis
b. Hypoxia
c. Hypercarbia
d. Bronchodilation

 (35)While the nursing student changes the patient's tracheostomy dressing, the nurse observes the student using a pair of scissors to cut a 4 X 4 gauze pad to make a split dressing that will fit around the tracheostomy tube. What is the nurse's best action?
a. Give the student positive reinforcement for use of materials and technique
b. Report the student to the instructor for remediation of the skill
c. Change the dressing immediately after the student has left the room
d. Direct the student in the correct use of materials and explain the rationale

 (36)The nurse is caring for a patient with a tracheostomy who has recently been transferred from the ICU, but he has had no unusual occurrences related to the tracheostomy or his oxygenation status. What does the routine care for this patient include?
a. Thorough respiratory ssessment at least every 2 hours
b. Maintainin the cuff pressure between 50 and 100 mm Hg
c. Suctioning as needed; maximum suction time of 20 seconds
d. Changing the tracheostomy dressing once a day

 (37)The patient with a tracheostomy is being discharged to home. In patient teaching, what does the nurse instruct the patient to do?
a. Use sterile technique when suctioning
b. Instill tap water into the artificial airway
c. Clean the tracheostomy tube with soap and water
d. Increase the humidity in the home

 (38)The nurse has explained the endotracheal suctioning procedure to the patient, gathered equipment, washed hands, and set low wall suction. Indicate the correct steps of completing the suctioning procedure in order.
a. Open the suction kit
b. Pour sterile saline into sterile contaier
c. Preoxygenate the patient
d. Discard supplies, wash hands, and document
e. Put on sterile gloves
f. Keep catheter sterile; attach to suction
g. Withdraw catheter, applying suction and twirling catheter
h. Insert catheter into trachea without suctionin
i. Lubricate catheter tip in sterile saline solution

c. Suction tracheostomy tube if necessary
a. Remove old dressing and excess secretions
f. Open tracheostomy kit and pour peroxide into one side of container and saline into another
d. Put on sterile gloves
i. Remove inner cannula; place it in peroxide solution use brush to clean
h. Rinse inner cannula in sterile saline
e. Reinsert inner cannula into outer cannula
g. Clean stoma site and plate
j. Change tracheostomy ties if needed and place new tracheostomy dressing
b. Wash hands, dispose of equipment, and document

(39)The nurse has explained the tracheostomy care procedure to the patient, gathered equipment, and wased hands. Indicate the correct stops of completing the tracheostomy care procedure
a. Remove old dressing and excess secretions
b. Wash hands, dispose of equipment, and document
c. Suction tracheostomy tube if necessary
d. Put on sterile gloves
e. Reinsert inner cannula into outer cannula
f. Open tracheostomy kit and pour peroxide into one side of container and saline into another
g. Clean stoma site and plate
h. Rinse inner cannula in sterile saline
i. Remove inner cannula; place it in peroxide solution use brush to clean
j. Change tracheostomy ties if needed and place new tracheostomy dressing

 (40)The patient with a permanent tracheostomy is interested in developing an exercise regimen. Which activity does the nurse advise the patient to avoid?
a. Aerobics
b. Tennis
c. Golf
d. Swimming

 (41)The patient with an endotracheal tube in place has dry mucous membranes and lips related to the tube and the partial open mouth position. What techniques does the nurse use to provide this patient with frequent oral care?
a. Cleanses the mouth with glycerin swabs
b. Provides alcohol-based mouth rinse and oral suction
c. Cleanses with a mixture of hydrogen peroxide and water
d. Uses toothettes or a soft-bristled brush moistened in water

 (42)The patient with a tracheostomy tube is able to speak and is no longer on mechanical ventilation. Which type of tracheostomy tube does this patient have?
a. Cuffless tube
b. Standard cuffed tube
c. Cuffed fenestrated tube
d. Tube without an obturator

 (43)Tracheostomy tube that is used with patients who can speak while on a ventilator for a long-term basis.
a. Double-lumen tube
b. Cuffed fenestrated tube
c. Talking tracheostomy tube
d. Cuffed tube

 (44)Tracheostomy tube that has a cuff that seals airway when inflated.
a. Fenestrated tube
b. Metal tracheostomy tube
c. Single-lumen tube
d. Cuffed tube

 (45)Tracheostomy tube that is used for long-term management of patients not on mechanical ventilation or at high risk for aspiration
a. Cuffless tube
b. Single-lumen tube
c. Talking tracheostomy tube
d. Double-lumen tube

 (46)Tracheostomy tube that has three parts - outer cannula, inner cannula, and obturator
a. Cuffed fenestrated tube
b. Double-lumen tube
c. Cuffless tube
d. Metal tracheostomy tube

 (47)Tracheostomy tube that is used for permanent tracheostomy
a. Fenestrated tube
b. Single-lumen tube
c. Metal tracheostomy tube
d. Talking traheostomy tube

 (52)The patient has a cuffed tracheostomy tube without a pressure relief valve. To prevent tissue damage of the tracheal mucosa, what does the nurse do?
a. Deflate the cuff every 2 to 4 hours and maintain as needed
b. Change the tracheostomy tube every 3 days or per hospital policy
c. Assess and record cuff pressures each shift using the occlusive technique
d. Assess and record cuff pressures each shift using minimal leak technique

 (53)An older adult patient is at risk for aspirating food or fluids. What is the most appropriate nursing action to assess for and prevent this problem?
a. Monitor for increased amount of secretions when patient is coughing
b. Provide close supervision if the patient is self-feeding
c. Obtain an order for a clear liquid diet and offer small but frequent amounts
d. Obtain an order for a chest x-ray to determine the presence of aspiration pneumonia.

 (54)An older adult patient sustained a stroke several weeks ago and is having difficulty swallowing. To prevent aspiration during mealtimes, what does the nurse do?
a. Hyperextend the head to allow food to enter the stomach and not the lungs
b. Give thin liquids after each bite of food to help "wash the food down."
c. Encourage "dry swallowing" after each bite to clear residue from the throat
d. Maintain a low Fowler's position during eating and for 2 hours afterwards

 (55)The patient with a tracheostomy tube is currently alert and cooperative but seems to be coughing more frequently and producing more secretions than usual. The nurse determines that there is a need for suctioning. Which nursing intervention does the nurse use to prevent hypoxia for this patient?
a. Allow the patient to breathe room air prior to suctioning
b. Avoid prolonged suctioning time
c. Suction frequently when the patient is coughing
d. Use the largest available catheter

 (56)The nurse is suctioning the secretions from a patient's endotracheal tube. The patient demonstrates a vagal response by a drop in heart rate to 54 and a drop in blood pressure to 90/50. After stopping suctioning, what is the nurse's priority action?
a. Allow the patient to rest for at least 10 minutes
b. Monitor the patient and call the Rapid Response Team
c. Oxygenate with 100% oxygen and monitor the patient
d. Administer atropine according to standing orders

 (57)The patient with a tracheostomy is unable to speak. He is not in acute distress, but is gesturing and trying to communicate with the nurse. Which nursing intervention is (58)the best approach in this situation?
a. Rely on the family to interpret for the patient
b. Ask questions that can be answered with a "yes" or "no" response
c. Obtain an immediate consult with the speech therapist
d. Encourage the patient to rest rather than struggle with communication

 (59)Which clinical finding in the patient with a recent tracheostomy is the most serious and requires immediate intervention?
a. Increased cough and difficulty expectorating secretions
b. Food particles in the tracheal secretions
c. Pulsating traheostomy tube in synchrony with the heartbeat
d. Set tidal volume on the ventilator not being received by the patient

 (60)Following a motor-vehicle crash a client is admitted with multiple trauma, including significant bruising of the left chest from striking the steering wheel. The client is alert and reports severe left chest pain on inspiration. The nurse should assess the client for manifestations of pneumothorax, including which of the following?
a. Absence of breath sounds
b. Expiratory wheezing
c. Inspiratory stridor
d. Rhonchi

 (61)While changing soiled velcro ties for a client with a tracheostomy, the client suddenly coughs, dislodging a tracheostomy tube. Which of the following is the appropriate nursing action?
a. Provide ventilation with a manual resiscitation bag and face mask
b. Have a coworker call the emergency response team
c. Reinsert the tracheostomy tube
d. Cover the tracheostomy opening with a sterile dressing

 (62)A client is scheduled for a thoracentesis. Into what position should the nurse assist the client for the procedure?
a. Lying flat on the affected side
b. Prone with the arms raised over the head
c. Supine with the head of the bed elevated
d. Sitting while leaning forward over the bedside table

 (63)A nurse is caring for a client who is admitted in an extremely anxious state. The client's arterial blood gas (ABG) values are pH 7.47, PO2 94, PCO2 30, and HCO3 25. What should the nurse do?
a. Give supplemental oxygen via nasal cannula
b. Monitor the client's fluid and electrolyte balance closely.
c. Have the client breathe slowly into a paper bag
d. Administer sodium bicarbonate

 (64)An older adult client is admitted with respiratory acidosis as a complication of chronic obstruction pulmonary disease (COPD). The nurse suspects that this is related to which of the following?
a. Increased mucous secretions
b. Decreased exhalation of carbon dioxide
c. Increased respiratory rate
d. Recent vomiting and diarrhea

 (65)While the nurse is reinforcing preoperative teaching for a client scheduled for a right pneumonectomy, the client tells the nurse, "I cough all the time, and I'm really afraid it will hurt when I cough after the surgery." Which of the following is an appropriate nursing response?
a. "After the surgeon removes the lung, you will not need to cough."
b. "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough."
c. "Intravenious pain medication will keep you free of pain when you cough after the surgery."
d. "I will show you how to splint your incision while coughing."

b. Explain the procedure to the client
c. Increase the flow of oxygen via the tracheostomy collar
d. Insert the suction catheter into the tracheostomy
a. Apply Suction

(66)A nurse is assisting with the care of a client who has a tracheostomy in place. The nurse determines that the client's airway secretions require suctioning afte auscultating the lung fields and prepares to apply suction using the open method. Put the following steps in order:
a. Apply Suction
b. Explain the procedure to the client
c. Increase the flow of oxygen via the tracheostomy collar

d. Insert the suction catheter into the tracheostomy

A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation when palpating the skin on the client's right chest. (67)The nurse notifies the charge nurse and documents the presence of which of the following?
a. A friction rub
b. Crackles
c. Crepitus
d. Tactle fremitus

 (68)A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following indicates that the nurse should suction the client's airway secretions?
a. The client is unable to speak
b. The client's airway secretions were last suctioned 2 hr. ago
c. The client coughs and expectorates a large mucous plug
d. The nurse auscultates coarse crackles in the lung fields

 (69)A nurse is reinforcing teaching for a client with emphysema about pursed-lip breathing. The nurse reminds the client that pursed-lip breathing will help do which of the following?
a. Promote carbon dioxide elimination
b. Increase oxygen intake
c. Use the intercostal muscles
d. Strengthen the diaphragm

 (70)Following a bronchoscopy, a client is sleepy but asks for a drink. Which of the following should be the nurse's first action?
a. Auscultate the client's bowel sounds
b. Find out if a diet has been prescribed
c. Check the client's gag reflex
d. Ask the client which clear liquid she prefers

 (71)A nurse is reviewing the discharge teaching plan with a client hospitalized following an acute exacerbation of reactive airway disease. When reminding the client how to prevent acute asthma attacks, what should the nurse plan to discuss first?
a. Triggers that can precipitate an attack and how to eliminate them from the client's environment
b. the client's perception of the disease process and what may have triggered the current attack
c. The client's medication regimen, including the proper use of metered-dose inhalers
d. Manifestations of respiratory infections and the importance of avoiding people who have infections

 (72)When collecting data from a client with reactive airway disease who is experiencing an acute asthma attack, the nurse should expect to auscultate for which of the following?
a. An expiratory wheeze
b. A pleural friction rub
c. Inspiratory stridor
d. Subcutaneous emphysema

 (73)To meet the goal of maintaining an adequate nutritional status for a client who has pneumonia, which measure should the nurse include when assisting in planning care to promote oral intake?
a. Provide oral hygiene care after respiratory aerosol therapy treatments and before meals
b. Serve nutritious foods at mealtimes and discourage between-meal snacking
c. Schedule respiratory aerosol treatments and chest physiotherapy just before meals
d. Select meals for the client to ensure that the meals are well-balanced

 (74)A client diagnosed with pneumonia is prescribed chest physiotherapy (CPT) every 4 hrs. In planning the client's care, the nurse understands that the purpose of CPT is which of the following?
a. Encourage deep breaths
b. Mobilize secretions in the airways
c. Dilate the bronchioles
d. Stimulate the cough reflex

 (75)A pulse oximeter reading from a client diagnosed with smoke inhalation is 85% with a 40% face mask. The provider prescribes an increase of the oxygen to 50%. Because the client is a high risk for adult respiratory distress syndrome (ARDS), the nurse must observe the client for which of the following?
a. Substernal chest pain
b. Increased restlessness
c. Apnea
d. Oxygen saturation of 95%

 (76)A nurse is caring for a client who has acute respiratory failure and is being treated with mechanical ventilation. The low-pressure alarm on the ventilator begins to sound continuously. Which of the following is an appropriate nursing action?
a. Call the respiratory therapist
b. Look for loose connections
c. Suction the client's airway secretions
d. Increase the oxygen concentration

 (78)While observing a client who is unconscious following major trauma, the nurse notes that a portion of the client's chest pulls inward on inspiration. On expiration, the same portion expands outward. The nurse documents the presence of which of the following?
a. Symmetrical chest movement
b. Intercostal retractions
c. Flail chest
d. Cheyne-Stokes respirations 

                                                  انتهت الاسئلة

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30 سؤال اختيارى على محاضرة nursing process

ملاحظة :فية اسئلة مش تبعنا فى المنهج

 تحميل الاسئلة+شرح الاجابة بصيغة الورد اضغط هنـــــــا

This set has 30 terms

 (1)During which part of the client interview would it be best for the nurse to ask, "What's the weather forecast for today?"

A. Introduction
B. Body
C. Closing
D. Orientation

 (2)The nurse is most likely to collect timely, specific information by asking which of the following questions?

A. "Would you describe what you are feeling?"
B. "How are you today?"
C. "What would you like to talk about?"
D. "Where does it hurt?"

 (3)The nurse should avoid asking the client which of the following leading questions during a client interview?

A. "What medication do you take at home?"
B. "You are really excited about the plastic surgery, aren't you?"
C. "Were you aware I've has this same type of surgery?"
D. "What would you like to talk about?"

 (4)The nurse needs to validate which of the following statements pertaining to an assigned client?

A. The client has a hard, raised, red lesion on his right hand.
B. A weight of 185 lbs. is recorded in the chart
C. The client reported an infected toe
D. The client's blood pressure is 124/70. It was 118/68 yesterday.

 (5)Which of the following items of subjective client data would be documented in the medical record by the nurse?

A. Client's face is pale
B. Cervical lymph nodes are palpable
C. Nursing assistant reports client refused lunch
D. Client feel nauseated

 (6)A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift?

A. Nurse and client agree upon health care goals for the client
B. Nurse reviews the client's history on the medical record
C. Nurse explains to the client the purpose of each administered medication
D. Nurse rapidly reset priorities for client care based on a change in the client's condition

 (7)The client reports nausea and constipation. Which of the following would be the priority nursing action?

A. Collect a stool sample
B. Complete an abnormal assessment
C. Administer an anti-nausea medication
D. Notify the physician

 (8)The nurse suspects that a client is withholding health-related information out of fear of discovery and possible legal problems. The nurse formulates nursing diagnoses for the client carefully, being concerned about a diagnostic error resulting from which of the following?

A. Incomplete data
B. Generalize from experience
C. Identifying with the client
D. Lack of clinical experience

 (9)The nurse notes that the client often sighs and says in a monotone voice, "I'm never going to get over this." When encouraged to participate in care, the client says, "I don't have the energy." The nurse believes these cues are suggestive of which nursing diagnoses? Select all that apply.

A. Hopelessness
B. Powerlessness
C. Interrupted sleep pattern
D. Disturbed self esteem
E. Self care deficit

 (10)Which of the following descriptors is most appropriate to use when stating the "problem" part of a nursing diagnosis?

A. Grimacing
B. Anxiety
C. Oxygenation saturation 93%
D. Output 500 mL in 8 hours

 (11)Which desired outcome written by the nurse is correctly written and measurable?

A. Client will have a normal bowel pattern by April 2
B. The client will lose 4 lbs. within next 2 weeks
C. The nurse will provide skin care at least 3 times each day
D. The client will breathe better after resting for 10 minutes

 (12)The rehabilitation nurse wishes to make the following entry into a client's plan of care: "Client will reestablish a pattern of daily bowel movements without straining within two months." The nurse would write this statement under which section of the plan of care?

A. Nursing diagnosis/problem list
B. Nursing orders
C. Short-term goals
D. Long-term goals

 (13)Which of these is a correctly stated outcome goal written by the nurse?

A. The client will walk 2 miles daily by March 19
B. The client will understand how to give insulin by discharge
C. The client will regain their former state of health by April 1
D. The client achieve desired mobility by May 7

 (14)The nursing diagnosis is Risk for impaired skin integrity related to immobility and pressure secondary to pain and presence of a cast. Which of the following desired outcomes should the nurse include in the care plan?

A. Client will be able to turn self by day 3
B. Skin will remain intact and without redness during hospital stay
C. Client will state pain relieved within 30 minutes after medication
D. Pressure will be prevented by repositioning client every 2 hours

 (15)While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment?

A. Help client into the chair but more quickly
B. Document client's vital signs taken just prior to moving the client
C. Help client back to bed immediately
D. Observe client's skin color and take another set of vital signs

 (16)After instructing the client on crutch walking technique, the nurse should evaluate the client's understanding by using which of the following methods?

A. Return demonstration
B. Explanation
C. Achievement of 90 on written test
D. Have client explain produce to the family

 (17)The nurse would do which of the following during the implementation phase of the nursing process when working with a hospitalized adult?

A. Formulate a nursing diagnosis of impaired gas exchange
B. Record in the medical record the distance a client ambulate in the hall
C. Write individualized nursing orders in the care plan
D. Compare client responses to the desired outcomes for pain relief

 (18)A client on the nursing unit is terminally ill but remains alert and oriented. Three days after admission, the nurse observes signs of depression. The client states, "I'm tired of being sick. I wish I could end it all." What is the most accurate and informative way to record this data in a nursing progress note?

A. Client appears to be depressed, possibly suicidal
B. Client reports being tired of being ill and wants to die
C. Client does not want to live any longer and is tired of being ill
D. Client states, "I'm tired of being sick. I wish I could end it all."

 (19)The nurse evaluates the client's progress and determines that one of the nursing diagnoses on the client's care plan has been resolved. How should the nurse document this so that it is best communicated to the healthcare team?

A. Use Liquid PaperTM to "white out" the resolve diagnosis on the care plan
B. Recopy the care plan without the resolve diagnosis
C. Write a nursing process not indicating that the outcome goals have been achieved
D. Draw a single line through the diagnosis on the care plan and write the nurse's initials and date

 (20)The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress note to communicate to the LTC staff the client's outcome goals that were met and those that were not. To do this effectively, the nurse should:

A. Formulate post-discharge nursing diagnoses
B. Draw conclusion about resolution of current client problems
C. Assess the client for baseline data to be used at the LTC facility
D. Plan the care that is needed in the LTC facility

 (21)A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?

A. Help the client to get settled and do the interview the next morning when the client is rested
B. Do the interview immediately, directing the majority of the questions to the client's spouse
C. Do the interview as soon as some uninterrupted time is available in order to address the client's concerns
D. Ask the charge nurse to interview the client while the admitting

(22)The nurse overhears an unlicensed assistive person (UAP) who has just been accepted to nursing school say to a client, "You must be so pleased with your progress." The nurse later explains to the UAP that this is an example of what type of question?

A. Close-ended question
B. Open-ended question
C. Leading question
D. Neutral question

.

(23)The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply.

A. Collect and organize client information
B. Analyze data
C. Identify problems, risk, and client strengths
D. Develop nursing diagnoses
E. Develop client goals

(24)The functional health pattern assessment data states: "Eats three meals a day and is of normal weight for height." The nurse should draw which of the following conclusions about this data? Select all that apply.

A. Client has an actual health problem
B. Client has a wellness diagnosis
C. Collaborative health problem needs to be written
D. Possible nursing diagnosis exists
E. Specific questions about the diet should be asked next

 (25)For the nursing diagnostic statement, Self-care deficit: feeding related to bilateral fractured wrists in casts, what is the major related factor or risk factor identified by the nurse?

A. Discomfort
B. Deficit
C. Feeding
D. Fractured wrists

 (26)The nurse would make which of the following inferences after performing the appropriate client assessment?

A. Client is hypotensive
B. Respiratory rate of 20 breaths per minute
C. Oxygen saturation of 95%
D. Client relays anxiety about blood work

 (27)The nurse would write which of the following outcome statements for a client starting an exercise program?

A. Client will walk quickly three times a day
B. Client will be able to walk a mile
C. Client will have no alteration in breathing during the walk
D. Client will progress to walking a 20-minute mile in one month

 (28)The nurse decides it would be beneficial to the client to allow the client's infant granddaughter to visit before the client's scheduled heart transplant. Before implementing this intervention the nurse should collaborate with which of the following? Select all that apply.

A. Client and Family
B. Other nursing staff on the unit
C. Security department
D. Hospital administration
E. This is not a collaborative intervention so no collaboration will be needed prior to implementation

 (29)The nurse informs the physical therapy department that the client is too weak to use a walker and needs to be transported by wheelchair. Which step of the nursing process is the nurse engaged in at this time?

A. Assessment
B. Planning
C. Implementation
D. Evaluation

 (30)A desired outcome for a client immobilized in a long leg cast reads; Client will state three signs of impaired circulation prior to discharge. When the nurse evaluates the client's progress, the client is able to state that numbness and tingling are signs of impaired circulation. What would be an appropriate evaluation statement for the nurse to write?

A. Client understands the signs of impaired circulation
B. Goal met: Client cited numbness and tingling as sign of impaired circulation
C. Goal not met: Client able to name only two signs of impaired circulation
D. Goal not met: Client unable to describe signs of impaired circulation

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