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WorksheetsNSG 100 Oxygenation/Tissue Integrity
Total questions: 105
Worksheet time: 3hrs 53mins
Name
Class
Date
1.
While caring for a patient with respiratory disease, the nurse observes that the patient’s SpO2drops from 93% to 88% while the patient is ambulating in the hallway. What is the priorityaction of the nurse?
a)
Notify the health care provider.
b)
Document the response to exercise.
c)
Administer the PRN supplemental O2.
d)
Encourage the patient to pace activity.
2.
The nurse is caring for a client with orders for oxygen at 5 L/min. Approximately how much FiO2 is the client receiving?
a)
24%
b)
28%
c)
36%
d)
40%
3.
A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. What does the nurse do first?
a)
Notify the health care provider.
b)
Assess the client’s pulse oximetry.
c)
Document the observation.
d)
Raise the head of the bed.
4.
The nurse assesses a client who is receiving oxygen via a partial rebreather mask. Which assessment finding does the nurse intervene to correct?
a)
The bag is two thirds inflated during inhalation.
b)
The client’s pulse oximetry reading is 93%.
c)
The oxygen flow rate is 2 L/min.
d)
The arterial oxygen level is 90%.
5.
A client is 24 hours postoperative after a tracheostomy has been performed. The nurse finds the client cyanotic, with the tracheostomy tube lying on his chest. Which action by the nurse takes priority?
a)
Auscultate breath sounds bilaterally.
b)
Ventilate with a resuscitation bag and mask.
c)
Call a code or the Rapid Response Team.
d)
Insert a new obturator into the neck.
6.
A client is 24 hours postoperative after a tracheostomy has been performed. The nurse finds the client cyanotic, with the tracheostomy tube lying on his chest. Which action by the nurse takes priority?
a)
Auscultate breath sounds bilaterally.
b)
Ventilate with a resuscitation bag and mask.
c)
Call a code or the Rapid Response Team.
d)
Insert a new obturator into the neck.
7.
While suctioning a client who had a tracheostomy placed 4 days ago, the nurse notes particles of food in the tracheal secretions. Which action by the nurse is most appropriate?
a)
Increase the inflation pressure in the tracheostomy cuff.
b)
Add blue dye to a beverage to assess for aspiration.
c)
Make the client NPO and notify the health care provider.
d)
Perform a more thorough assessment of the client.
8.
The nurse observes a nursing student suctioning a client. Which intervention by the student nurse requires the supervising nurse to intervene?
a)
Checking oxygen saturation post suctioning
b)
Hyperoxygenating the client after removal of the catheter
c)
Applying intermittent suction during catheter removal
d)
Applying suction when the catheter is inserted
9.
The nurse assesses a client during suctioning. Which finding indicates that the procedure should be stopped?
a)
Heart rate increases from 86 to 102 beats/min.
b)
Respiratory rate increases from 16 to 20 breaths/min.
c)
Blood pressure increases from 110/70 to 120/80 mm Hg.
d)
Heart rate decreases from 78 to 40 beats/min.
10.
A client receiving high-flow oxygen has new crackles and diminished breath sounds since the last assessment 1 hour ago. Which action by the nurse is most appropriate?
a)
Call respiratory therapy and request a bronchodilator treatment.
b)
Instruct the client to use the spirometer and to cough and deep breathe.
c)
Consult with the health care provider and request an order for diuretics.
d)
Ensure that the ordered FiO2 is what is being provided.
11.
The nurse is preparing to receive a postoperative client who just had a tracheostomy. Which action by the nurse takes priority?
a)
Obtain report from the postanesthesia care unit.
b)
Place a second tracheostomy tube and obturator at the bedside.
c)
Review orders for postoperative pain medications.
d)
Order supplies for tracheostomy care for 24 hours.
12.
The nurse is caring for an older adult client with a pulmonary infection. Which nursing action is a priority with this client?
a)
Encouraging the client to increase fluid intake
b)
Assessing the client’s level of consciousness
c)
Raising the head of the bed to at least 45 degrees
d)
Providing the client with humidified oxygen
13.
A client has a long-standing history of chronic obstructive pulmonary disease (COPD). Which laboratory finding does the nurse correlate with this condition?
a)
White blood cell count, 7500/mm3
b)
Hemoglobin, 22 g/dL
c)
Neutrophils, 6000/ mm3
d)
Monocytes, 600/mm3
14.
A client with a history of chronic obstructive pulmonary disease (COPD) presents to the clinic with increased cough and low-grade temperature. Which question by the nurse elicits the most useful information?
a)
“How long have you been sick?”
b)
“Has your sputum changed color?”
c)
“Is anyone else in your house sick?”
d)
“Do you take any medications?”
15.
A client says to the nurse, “It’s hard for me to breathe; I feel winded all the time.” The nurse would record this subjective feeling on the chart as
a)
apnea
b)
dyspnea
c)
respiratory fatigue
d)
tachypnea
16.
A 44-year-old man with active pulmonary tuberculosis is experiencing hemoptysis, which the nurse understands describes
a)
bloody sputum.
b)
chest pain.
c)
constant cough.
d)
dyspnea.
17.
The nurse would explain to a client with complaints of wheezing and chest tightness that wheezing occurs when
a)
air is passing through a narrowed airway.
b)
air is trapped in the alveoli.
c)
an allergic reaction is taking place.
d)
sputum production is increased.
18.
The nurse clinician performing percussion of the chest on a client assesses a low-pitched, hollow sound over the middle lobe. The nurse would record this finding as
a)
dull, and refer the client to an allergist.
b)
hyperresonant, and refer to a physician for work-up.
c)
resonant and document the finding, taking no other action.
d)
tympany, and refer the client to radiology for a chest x-ray.
19.
A patient with chronic obstructive pulmonary disease requires low flow oxygen. How will the oxygen be administered?
a)
Nasal cannula
b)
Simple oxygen mask
c)
Venturi mask
d)
Partial rebreather mask
20.
The home care nurse visits a patient with compromised lung function. She has greenish-yellow sputum with a musty odor. This is indicative of
a)
allergy
b)
congestive heart failure
c)
asthma
d)
infection
21.
Which of the following medications are administered in the home or the hospital to relieve inflammation in the lung tissue?
a)
Antibiotics
b)
Bronchodilators
c)
Expectorants
d)
Corticosteroids
22.
Which of the following dietary guidelines would be appropriate for the elderly homebound patient with advanced respiratory disease who informs the nurse that she has no energy to eat?
a)
Snack on high-carbohydrate foods frequently
b)
Eat smaller meals that are high in protein
c)
Contact the physician for Ensure
d)
Eat one large meal at noon
23.
The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on . The nurse correctly recognizes this condition as which of the following?
a)
dyspnea
b)
apnea
c)
orthopnea
d)
hypercapnia
24.
When the nurse observes a newborn infant demonstrating an irregular abdominal breathing pattern, with a respiratory rate of 50 breaths/minute with occasional pauses in breathing of 5-second durations, the most appropriate action by the nurse is to
a)
Begin resuscitation efforts
b)
Elevate the head of the crib
c)
Continue to assess the infant
d)
Position the infant side-lying
25.
Oxygen and carbon dioxide move between the alveoli and the blood by
a)
Osmosis
b)
Hyperosmolar pressure
c)
Diffusion
d)
Negative pressure
26.
The nurse is reviewing the results of a patient’s pulmonary function tests. Which result describes the air remaining in lungs after normal expiration?
a)
Tidal volume
b)
Expiratory reserve
c)
Forced vital capacity
d)
Functional residual capacity
27.
The nurse is reviewing the exchange of gases in the blood stream with a patient prescribed oxygen therapy. How should the nurse explain the transport of carbon dioxide in the blood?
a)
As CO2 in plasma
b)
As bicarbonate ions in plasma
c)
As hydrogen ions in red blood cells
d)
As part of hemoglobin in red blood cells
28.
A patient is having problems with oxygenation of body tissues. What is important for the nurse to consider about the transport of oxygen in the blood?
a)
It is in blood plasma as free oxygen.
b)
It travels on red blood cell membranes.
c)
It is bonded to hemoglobin in blood plasma.
d)
It is bonded to hemoglobin in red blood cells.
29.
A patient has a low oxygen level. Which body structure should the nurse consider as being responsible for this low level?
a)
larynx
b)
alveoli
c)
bronchi
d)
nasal passages
30.
While providing care for a patient with asthma, the nurse notes the patient’s shoulders are rising with each breath. What should the nurse realize this action represents?
a)
Hyperinflation of the chest
b)
The use of accessory muscles to aid breathing
c)
Shoulder muscle fatigue related to difficulty breathing
d)
Effective use of a breathing exercise to increase ventilation
31.
An adult patient has a respiratory rate of 36 breaths per minute. Which term should the nurse use to document this finding?
a)
apnea
b)
bradypnea
c)
tachypnea
d)
within normal limits
32.
A patient with pulmonary edema has moist, bubbling lung sounds. How should the nurse describe this finding?
a)
wheezing
b)
fine crackles
c)
coarse crackles
d)
pleural friction rub
33.
A patient is making a loud crowing sound caused by an obstruction of the airways by a foreign body. How should the nurse document this patient’s lung sound?
a)
stridor
b)
wheeze
c)
crackles
d)
pleural friction rub
34.
A patient’s oxygen saturation value is 92% on room air. What does this value mean to the nurse?
a)
The percentage of oxygen in the lungs
b)
The partial pressure of the oxygen in the blood
c)
The amount of oxygen saturating the lymphocytes
d)
The percentage of hemoglobin that is saturated with oxygen
35.
A patient’s oxygen saturation is 89%. Which actions should the nurse take first?
a)
Raise the head of the patient’s bed.
b)
Call the respiratory therapist STAT.
c)
Place the patient in a supine position.
d)
No action; this is a normal oxygen saturation.
36.
The nurse is assigned to monitor a patient with chronic lung disease who is receiving oxygen via a non-rebreathing mask. Which observation indicates to the nurse that the system is functioning as expected?
a)
Both side vents open, reservoir bag inflated
b)
Both side vents open, reservoir bag deflated
c)
Both side vents closed, reservoir bag inflated
d)
Both side vents closed, reservoir bag deflated
37.
A postoperative patient is taking shallow breaths because of fear of incisional pain. Which action should the nurse take first?
a)
Instruct the patient on the use of an incentive spirometer.
b)
Measure peak expiratory flow rate with a peak flow meter.
c)
Call respiratory therapy to provide a metered-dose inhaler (MDI).
d)
Contact the physician to request nebulized mist treatments (NMTs).
38.
After providing chest physiotherapy, the nurse notes the patient has loose secretions and a slight rattle with expiration. Which action should the nurse take first?
a)
Administer an expectorant.
b)
Suction the patient’s airway.
c)
Keep the patient on bedrest for 4 hours.
d)
Encourage the patient to cough and deep breathe.
39.
The nurse explains that the purpose of mucus is to:
a)
warm the air entering the lungs.
b)
trap particles and bacteria.
c)
protect the cilia.
d)
clean the sinus cavity.
40.
The nurse uses a visual aid to show the mechanics of inhaling which correctly illustrates:
a)
the diaphragm moves down.
b)
the negative pressure of the lung converts to positive pressure.
c)
muscles contract, pulling the rib cage down.
d)
bronchi enlarge.
41.
The nurse explains that the substance that decreases the surface tension of the alveolar walls is:
a)
plasma
b)
surfactant
c)
cilia
d)
mucus
42.
Using animation, the nurse demonstrates how most of the inspired oxygen is carried to the tissues by the:
a)
plasma
b)
lymphatic system
c)
red blood cells
d)
white blood cells
43.
When the nurse places the diaphragm of the stethoscope over one of the main bronchi, the expected normal breath sound heard is:
a)
bronchovesicular
b)
bronchial
c)
rhonchi
d)
vesicular
44.
The nurse performing tracheal suctioning of the patient with a respiratory disorder should suction no longer than _____ seconds.
a)
2 to 5
b)
5 to 10
c)
10 to 15
d)
15 to 20
45.
While reviewing the results of the pulmonary functions test, the nurse is aware that the maximum amount of gas that can be displaced (expired) from the lung is called:
a)
Vital capacity (VC)
b)
Total lung capacity
c)
Functional capacity
d)
Residual volume
46.
A patient requires a precise concentration of 40% oxygen. Which of the following devices would best allow for this?
a)
A simple face mask
b)
A non-rebreather mask
c)
A partial rebreathing mask
d)
Venturi mask
took five deep breaths slowly every 4 hours.A Venturi mask
took five deep breaths slowly every 4 hours.A Venturi mask
47.
The nurse recognizes that a post-operative patient who can breathe independently but has trouble maintaining an airway because of the tongue falling back into the throat would be best benefited by a(n):
a)
pharyngeal airway.
b)
endotracheal tube.
c)
tracheostomy.
d)
partial rebreather oxygen mask.
48.
A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:
a)
monitoring the rate of respirations.
b)
determining the last time the patient was suctioned.
c)
examining the character of the sputum.
d)
auscultating the breath sounds.
49.
The nurse takes into consideration that while caring for a patient on oxygen therapy, safety precautions should be observed, which include:
a)
using clothing of synthetic cloth for the patient.
b)
removing any adhesive from the patient’s skin with acetone.
c)
assessing equipment in room for frayed cords.
d)
reducing humidification on the oxygen delivery device.
50.
The nurse would determine that this patient is aware of how to use the incentive spirometer device properly when the patient:
a)
took 10 slow, deep breaths every hour.
b)
took five quick “huffs” and then coughed vigorously.
c)
exhaled deeply and then inhaled quickly and forcefully three times.
d)
took five deep breaths slowly every 4 hours.
51.
An obese patient on the unit has demonstrated difficulty healing a large pressure ulcer. The nurse correctly recognizes that this is most likely because of which of the following factors?
a)
The patient’s size limits his activity level.
b)
Adipose tissue is poorly vascularized.
c)
Obesity is linked to impaired white blood cell function.
d)
The amount of tissue needing healing will increase the amount of time needed to adequately heal the wound.
52.
A patient has been admitted to the acute care unit after surgery to debride an infected skin ulceration. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing?
a)
Primary intention
b)
Secondary intention
c)
Tertiary intention
d)
Quadratic intention
53.
A patient has a small wound with moderate drainage. The nurse should apply
a)
Hydrophilic polyurethane
b)
Collagens
c)
Hydrogels
d)
Silver dressings
54.
Which of the following activities should the nurse implement to decrease shearing force on the patient with a stage II pressure ulcer?
a)
Support the patient from sliding in bed
b)
Lubricate the area with skin oil
c)
Improve the patient’s hydration
d)
Pull patient up under the arms
55.
A nursing student is providing a complete bed bath to a 60-year-old diabetic patient. The student is conducting an assessment during the bath. The student observes a red raised rash under the patient’s breasts. This manifestation is most consistent with which of the following conditions?
a)
An allergic reaction to medications
b)
An allergic reaction to detergent
c)
A rash related to a yeast infection
d)
A rash related to immobility
56.
The cells in the epidermis that provide protection from microorganisms are
a)
Macrophages and mast cells
b)
Melanin and sebum
c)
Langerhans and keratinocytes
d)
Granulocytes and agranulocytes
57.
Which of the following statements accurately describes a developmental consideration when assessing skin integrity of patients?
a)
In children younger than 2 years, the skin is thicker and stronger than it is in adults.
b)
An infant’s skin and mucous membranes are injured easily and are subject to infection.
c)
A child’s skin becomes increasingly at risk for injury and infection.
d)
In the older adult, circulation and collagen formation are increased.
58.
What is the most accurate definition of a wound?
a)
a disruption in normal skin and tissue integrity
b)
a change in the function of internal organs
c)
any injury that results in changes in nervous tissue
d)
any trauma resulting in serious damage and pain
59.
Which of the following best describes an unintentional wound?
a)
clean wound edges, controlled bleeding
b)
jagged wound edges, uncontrolled bleeding
c)
little risk for infection, shorter healing time
d)
the result of surgery, intravenous therapy
60.
A nurse documents a closed wound on a patient chart. Which of the following is an example of a closed wound?
a)
abrasion
b)
ecchymosis
c)
incision
d)
puncture wound
61.
What are the two major processes involved in the inflammatory phase of wound healing?
a)
bleeding is stimulated, epithelial cells are deposited
b)
granulation tissue is formed, collagen is deposited
c)
collagen is remodeled, avascular scar forms
d)
blood clotting is initiated, WBCs move into the wound
62.
A nurse is teaching a postoperative patient about essential nutrition for healing. What statement by the patient would indicate a need for more information?
a)
“I will drink a lot of orange juice and drink milk too.”
b)
“I will take the zinc supplement the doctor recommended.”
c)
“I will restrict my diet to fats and carbohydrates.”
d)
“I will drink 8 to 10 glasses of water every day.”
63.
A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one would be most at risk?
a)
an 83-year-old who is mobile
b)
a 92-year-old who uses a walker
c)
a 75-year-old who uses a cane
d)
an 86-year-old who is bedfast
64.
The nurse assesses a patient’s surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate?
a)
Obtain wound cultures.
b)
Document the assessment.
c)
Notify the health care provider.
d)
Assess the wound every 2 hours.
65.
A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How would the nurse document this wound?
a)
Red wound
b)
Yellow wound
c)
Full-thickness wound
d)
Stage III pressure ulcer
66.
The nurse should plan to use a wet-to-dry dressing for which patient?
a)
A patient who has a pressure ulcer with pink granulation tissue
b)
A patient who has a surgical incision with pink, approximated edges
c)
A patient who has a full-thickness burn filled with dry, black material
d)
A patient who has a wound with purulent drainage and dry brown areas
67.
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer?
a)
Stage I
b)
Stage II
c)
Stage III
d)
Stage IV
68.
A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are mostimportant for the nurse to teach the mother?
a)
Change the patient’s bedding frequently.
b)
Use a hydrocolloid dressing over the ulcer.
c)
Record the size and appearance of the ulcer weekly.
d)
Change the patient’s position at least every 2 hours.
69.
A nurse is changing a dressing over a client’s abdominal surgical incision. Which action by the nurse is most important?
a)
Apply dressings using aseptic or sterile technique.
b)
Irrigate the wound with copious amounts of solution.
c)
Use strict sterile technique, including sterile gloves.
d)
Wash the suture line carefully to remove debris.
70.
The edges of a client’s appendectomy incision are approximated, and no drainage is noted. The nurse documents on the client’s wound record that the incision appears to be healing by
a)
granulation.
b)
primary intention.
c)
secondary intention.
d)
tertiary intention.
71.
A client must do dressing changes at home on a clean, but open, surgical wound. The nurse determines that goals for discharge instructions have been met when the client says:
a)
“I will be sure to keep the skin surrounding the wound dry.”
b)
“I will sit under a heat lamp for 30 minutes a day to help dry up the drainage.”
c)
“If I run out of saline, I can irrigate the wound with half strength peroxide.”
d)
”
“Pulling out the dried up dressings will help clean the wound out.”
“Pulling out the dried up dressings will help clean the wound out.”
72.
On removing a dressing from a client on the third postoperative day, the nurse notes thin, pink-colored drainage and documents this as
a)
serous.
b)
sanguineous.
c)
serosanguineous.
d)
purulent.
73.
When caring for a client with a wound healing by secondary intention, the nurse considers during care planning that this type of wound is
a)
healed with skin grafts.
b)
prone to dehiscence.
c)
sealed with sutures.
d)
susceptible to infection.
74.
A client is being discharged with a large wound on the right ankle that has cellulitis. The client is obese, smokes 2 packs of cigarettes a day, and is sedentary. In the discharge instructions, which lifestyle modification would be most important for the nurse to include? The client should
a)
drink more water.
b)
lose weight.
c)
start an exercise routine.
d)
stop smoking.
75.
To assist in the healing of a large leg ulcer, the nurse applies wet dressings to the wound to promote
a)
angiogenesis.
b)
chemotaxis.
c)
epithelialization.
d)
wound contraction.
76.
What is the primary difference between acute and chronic wounds? Chronic wounds:
a)
Are full-thickness wounds, but acute wounds are superficial.
b)
Result from pressure, but acute wounds result from surgery.
c)
Are usually infected, whereas acute wounds are contaminated.
d)
Exceed the typical healing time, but acute wounds heal readily.
77.
A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it?
a)
Partial-thickness wound
b)
Penetrating wound
c)
Superficial wound
d)
Full-thickness wound
78.
A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is:
a)
Primary intention healing.
b)
Secondary intention healing.
c)
Tertiary intention healing.
d)
Approximation healing.
79.
What is the primary goal that the nurse should establish for a patient with an open wound?
a)
The wound will remain free of infection throughout the healing process.
b)
Client completes antibiotic treatment as ordered.
c)
The wound will remain free of scar tissue at healing.
d)
Client increases caloric intake throughout the healing process.
80.
Pressure ulcers are directly caused by which of the following conditions at the site?
a)
Compromised blood flow
b)
Edema
c)
Shearing forces
d)
Inadequate venous return
81.
Which nursing intervention can help a client maintain healthy skin?
a)
Keep the client well hydrated.
b)
Avoid bathing the client with mild soap.
c)
Remove adhesive tape quickly from the skin.
d)
Recommend wearing tight-fitting clothes in hot weather.
82.
Nurse Meredith is caring for a wheelchair-bound client. Which piece of equipment impedes circulation to the area it’s meant to protect?
a)
Polyurethane foam mattress
b)
Ring or donut
c)
Gel flotation pad
d)
Water bed
83.
Nurse Rudolf documents the presence of a scab on a client’s deep wound. The nurse identifies this as which phase of wound healing?
a)
inflammatory
b)
migratory
c)
proliferative
d)
maturation
84.
Nurse Jay is performing wound care. Which of the following practices violates surgical asepsis?
a)
Holding sterile objects above the waist
b)
Considering a 1″ edge around the sterile field as being contaminated
c)
Pouring solution onto a sterile field cloth
d)
Opening the outermost flap of a sterile package away from the body
85.
Nurse Kate is changing a dressing and providing wound care. Which activity should she perform first?
a)
Assess the drainage in the dressing.
b)
Slowly remove the soiled dressing
c)
Wash hands thoroughly.
d)
Put on latex gloves.
86.
The nurse is assessing for the presence of cyanosis in a male dark-skinned client. The nurse understands that which body area would provide the best assessment?
a)
lips
b)
sacrum
c)
earlobes
d)
back of hands
87.
Which of the following clients would least likely be at risk of developing skin breakdown?
a)
A client incontinent of urine or feces
b)
A client with chronic nutritional deficiencies
c)
A client with decreased sensory perception
d)
A client who is unable to move about and is confined to bed
88.
The evening nurse reviews the nursing documentation in the male client’s chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client’s sacral area?
a)
Intact skin
b)
Full-thickness skin loss
c)
Exposed bone, tendon, or muscle
d)
Partial-thickness skin loss of the dermis
89.
The nurse is reviewing the health care record of a male clients scheduled to be seen at the health care clinic. The nurse determines that which of the following individuals is at the greatest risk for development of an integumentary disorder?
a)
An adolescent
b)
An older female
c)
A physical education teacher
d)
An outdoor construction worker
90.
The nurse is teaching a female client with a leg ulcer about tissue repair and wound healing. Which of the following statements by the client indicates effective teaching?
a)
“I’ll limit my intake of protein.”
b)
“I’ll make sure that the bandage is wrapped tightly.”
c)
“My foot should feel cold.”
d)
“I’ll eat plenty of fruits and vegetables.”
91.
A female client exhibits s purplish bruise to the skin after a fall. The nurse would document this finding most accurately using which of the following terms?
a)
purpura
b)
petechiae
c)
ecchymosis
d)
erythema
92.
When repositioning a patient with several risk factors for developing a pressure ulcer, the nurse notices redness over the sacral area. After helping the patient to a side-lying position, the nurse presses a finger over the red area, and the area blanches. What is the significance of this finding?
a)
The patient has sensitive skin and requires the use of a special bed linen.
b)
The redness indicates cellulitis, and antibiotics need to be ordered.
c)
The reddened area may be from unrelieved pressure and could resolve with repositioning.
d)
This is a stage II pressure ulcer requiring a wound-care dressing for healing.
93.
What is the mechanism of injury of a pressure ulcer?
a)
Blood vessel damage from repeated injections causing tissue loss
b)
Continual exposure of the skin to fecal or urinary incontinence
c)
Compression of the skin by two hard surfaces for a prolonged period of time
d)
Excessive dryness of the epidermis, stripping the skin and causing damage to the dermis
94.
A patient comes into the clinic complaining of a runny nose and facial pain. What should the nurse’s initial assessment include?
a)
Assessment for nasal drainage and sinus tenderness
b)
Transillumination and nasal speculum examination
c)
Palpation of the frontal and maxillary sinuses and tonsillar inspection
d)
Turbinate assessment and assessment for patency of the nares
95.
Which assessment should indicate the necessity for a nurse to suction a patient with a tracheostomy?
a)
Becomes restless and has increases in vital signs
b)
Has decreased peak airway pressure
c)
Shows diaphoresis
d)
Is coughing frothy mucus
96.
To auscultate breath sounds in the right middle lobe from the anterior aspect, the nurse should place the diaphragm of the stethoscope at which intercostal space?
a)
second
b)
third
c)
fourth
d)
fifth
97.
What should the nurse suspect regarding the bronchus when auscultating coarse crackles in the lower right lobe?
a)
Partially filled with fluid
b)
Narrowed by spasm
c)
Partially filled with thick mucus
d)
Completely obstructed
98.
A nurse is caring for a patient with asthma with a nursing diagnosis of “Impaired gas exchange, related to air trapping.” Which intervention is the most appropriate to add to the nursing care plan?
a)
Provide postural drainage.
b)
Administer oxygen (O2) at 8 L/min.
c)
Position the patient flat in bed with small pillow.
d)
Increase fluid intake.
99.
What is a characteristic of chronic obstructive pulmonary disease that places a patient at risk for the nursing diagnosis of “Imbalanced nutrition: Less than body requirements”?
a)
Increased metabolism
b)
Anxiety
c)
Chronic constipation
d)
Excessive respiratory effort
100.
What should a nurse focus on when assessing for major sources of infection in a patient with COPD?
a)
Stasis of respiratory secretions
b)
Low body weight
c)
Episodes of postural hypotension
d)
Delayed antigen-antibody response
101.
The nurse palpates the posterior chest while the patient says “99” and notes that no vibration is felt. How should this be charted?
a)
Diminished expansion
b)
Dullness to percussion
c)
Absent tactile fremitus
d)
Decreased breath sounds
102.
While caring for a patient with respiratory disease, the nurse observes that the patient’s SpO2 drops from 92% to 88% while the patient is ambulating in the hallway. Which action should the nurse take next?
a)
Notify the health care provider.
b)
Document the response to exercise.
c)
Administer the PRN supplemental O2.
d)
Encourage the patient to pace activity.
103.
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?
a)
No wheezes are audible.
b)
Oxygen saturation is >90%.
c)
Accessory muscle use has decreased.
d)
Respiratory rate is 16 breaths/minute.
104.
After the nurse has finished teaching a patient about pursed lip breathing, which patient action indicates that more teaching is needed?
a)
The patient inhales slowly through the nose.
b)
The patient puffs up the cheeks while exhaling.
c)
The patient practices by blowing through a straw.
d)
The patient’s ratio of inhalation to exhalation is 1:3.
105.
Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic bronchitis. The nurse will plan to
a)
carry out the procedure 3 hours after the patient eats.
b)
maintain the patient in the lateral position for 20 minutes.
c)
perform percussion before assisting the patient to the drainage position.
d)
give the ordered albuterol (Proventil) after the patient has received the therapy.
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