NUR220: Exam III Review

Which is the primary goal of community health nursing?

• to support and supplement the efforts of the medical profession in the promotion of health

• to enhance the capacity of individuals, families, and communities to cope with their health needs

• to increase productivity of the people by providing them with services that will increase their level of health

• to contribute to national development through the promotion of family welfare

Which questions would be included during a focused history on a cardiac patient to help the nurse determine the significance of the cues? (Select all that apply.)

• Are you having pain?

• Where is the pain located?

• Do you attend religious services regularly?

• Do you have increased fatigue?

• Do you have any episodes of dizziness?

A patient with chronic obstructive pulmonary disease (COPD) uses which drive to breathe?

• Increased PaCO2

• Decreased hemoglobin

• Decreased PaO2 levels

• Increased PaO2 levels

During handoff to the oncoming shift, the nurse includes in the SBAR report that the patient needs to be evaluated by speech therapy for which of the following reasons?

• Persistent aspiration of liquids

• Hypoventilation due to smoking

• Hyperventilation due to anxiety

• Decreased respiratory effort due to scoliosis

The nurse understands that which of the following is most likely occurring when caring for a pulmonary patient who has bluish discoloration around the lips?

• Increased PaCO2 levels

• Hemoglobin that is not saturated with oxygen

• Elevated white blood cell count

• Decreased PaCO2 levels

A patient admitted with a history of chronic obstructive pulmonary disease (COPD) admits to smoking 1 pack of cigarettes per day for the last 40 years. When developing a plan of care for the patient, the nurse includes smoking cessation as a priority education goal. Which interventions would the nurse include in the patient education? (Select all that apply.)

• alternative therapies

• nicotine replacements

• support groups

• counseling

• educating about the risks of smoking

The nurse knows that which of the following nursing actions are indicated when suctioning a patient with a tracheostomy? (Select all that apply.)

• Assess heart rate, respiratory rate, oxygen saturation, and lung sounds prior to suctioning.

• Suction intermittently for no more than 10 to 15 seconds.

• Flush the artificial airway with 5 mL of normal saline to loosen secretions.

• Reassess heart rate, respiratory rate, oxygen saturation, and lung sounds after suctioning.

• Document time, amount, and characteristics of secretions.

When administering oxygen to a patient, the nurse recognizes that using which oxygen delivery system places a patient in danger of receiving inadequate oxygen?

• Nasal cannula at a flow rate of 2 L/min

• Nasal cannula at a flow rate of 5 L/min

• Simple mask at a flow rate of 6 L/min

• Nonrebreather mask at a flow rate of 5 L/min

The nurse is caring for a patient with severe chronic obstructive pulmonary disease (COPD). The patient has albuterol treatments scheduled every 6 hours and PRN and is on oxygen 2L/min via nasal cannula. Respiratory therapy (RT) administered the last breathing treatment 1 hour ago. When entering the patient’s room to administer medications, the nurse notes that the patient is in acute respiratory distress. Which priority interventions would the nurse take to safely manage the care of this patient? (Select all that apply.)

• place the patient in an upright position

• increase oxygen to 7 L/min per nasal cannula

• assess vital signs

• listen to lung sounds

• call respiratory therapy

What is the desired outcome related to the nursing diagnosis of Impaired Airway Clearance?

• Patient’s respiratory secretions will become thicker so they are not moved when coughing.

• Patient’s respiratory secretions will have a thinner consistency after being given a mucolytic agent.

• Patient will have improved range of motion while in bed.

• Patient’s respiratory rate will increase from 16 to 28 breaths/min during hospitalization.