Question 1

The nurse is caring for a patient who has shallow breaths following abdominal surgery.Which respiratory complication is most likely to occur as a result of the patient's breathing pattern?

Accepted Answer

A)   Aspiration
B)   Atelectasis
C)   Cor pulmonale
D)   Pulmonary fibrosis B

Question 2

Which is the priority action of the nurse for a patient with ventricular tachycardia?

Accepted Answer

A)   Assess the patient for signs of digoxin toxicity.
B)   Draw serum electrolytes to check for hyperkalemia.
C)   Start chest compressions if there is no palpable pulse.
D)   Check the patient's BP and administer sublingual nitroglycerin. C

Question 3

Which assessment finding indicates why the patient does not have signs of respiratory alkalosis despite a respiratory rate of 30 breaths/minute?

Accepted Answer

A)   The patient's hematocrit is 28%.
B)   The patient's oral temperature is 99.2° F.
C)   The patient is experiencing a panic attack.
D)   The patient has a large pulmonary embolism. D

Question 4

How can the parents best protect their premature infant from developing respiratory syncytial virus (RSV)?

Accepted Answer

A)   Immunize the infant against RSV.
B)   Ensure that the infant's bottles are sterilized.
C)   Limit the baby's exposure to crowds of people.
D)   Daily administration of prophylactic antibiotics.

Question 5

The nursing staff is caring for a patient who collapsed in cardiac arrest.When will breaths be delivered via the bag-valve mask device?

Accepted Answer

A)   After the patient is intubated
B)   After every 30 chest compressions
C)   When the patient's lips start to become cyanotic
D)   When another nurse takes over chest compressions

Question 6

Which interventions are appropriate for the patient with the nursing diagnosis decreased cardiac output related to reduced stroke volume and contractility?

Accepted Answer

A)   Frequent lung sound assessment and continuous pulse oximetry.
B)   Strict intake and output monitoring with daily weights before breakfast.
C)   Administer oxygen to maintain pulse oximetry levels between 90% and 92%.
D)   Provide stool softeners and encourage dietary fiber to prevent constipation.
E)   Encourage the patient to consume additional salt to maintain blood pressure.

Question 7

Which laboratory finding indicates that the patient is likely to experience hypoxemia?

Accepted Answer

A)   Hematocrit 31%
B)   Serum creatinine 0.8 mg/dL
C)   Glycosylated hemoglobin 7%
D)   White blood cell count 4600/mm3

Question 8

Which assessment findings indicate to the nurse that the patient is hypoxic?

Accepted Answer

A)   Heart rate is 55 beats/minute and irregular.
B)   Urine output is 300 mL over the last 8 hours.
C)   The patient is drowsy and difficult to arouse.
D)   Hands and feet are pale and cool to the touch.
E)   Abdomen is soft with bowel sounds × 4 quadrants.

Question 9

Which assessment findings indicate that the patient is at risk for developing ventricular fibrillation?

Accepted Answer

A)   Serum potassium level 7.6 mEq/L
B)   Long history of coronary artery disease
C)   Impaired conduction through the SA node
D)   Recent incidents of ventricular tachycardia
E)   Vagal stimulation from removal of fecal impaction

Question 10

Which is the priority outcome for the patient with pulmonary embolism and the nursing diagnosis impaired gas exchange related to impaired pulmonary perfusion?

Accepted Answer

A)   The patient's pulse oximetry will stay at least 93%.
B)   The patient's lung sounds will remain clear bilaterally.
C)   The patient will verbalize understanding of oxygen therapy.
D)   The patient will walk 50 feet in the hallway without dyspnea.

Question 11

The nurse assesses distended neck veins in a patient sitting in a chair to eat.Which is the priority intervention of the nurse?

Accepted Answer

A)   Document the observation in the chart.
B)   Assess the patient's deep tendon reflexes.
C)   Measure urine specific gravity and volume.
D)   Check the patient's pulse and blood pressure.

Question 12

The nurse has orders to titrate the patient's oxygen to maintain a pulse oximetry level greater than 94%.The patient's pulse oximetry will not rise above 90% despite use of a nonrebreather mask.Which is the appropriate action of the nurse?

Accepted Answer

A)   Insert an oral airway and apply a full face oxygen mask.
B)   Call respiratory therapy to consider BiPAP support for the patient.
C)   Remove the nonrebreather mask and replace it with a Venturi mask.
D)   Place an oxygen nasal cannula underneath the patient's nonrebreather mask.

Question 13

The nurse assesses a patient during suctioning.Which finding indicates that the procedure should be stopped immediately?

Accepted Answer

A)   Pulse oximetry decreases from 98% to 92%.
B)   Heart rate decreases from 78 to 40 beats/minute.
C)   Respiratory rate increases from 16 to 20 breaths/minute.
D)   Blood pressure increases from 110/70 to 120/80 mm Hg.

Question 14

The patient's blood pressure is 180/100.Why does the patient's heart have to work harder due to the high blood pressure?

Accepted Answer

A)   Increased preload
B)   Increased afterload
C)   Decreased contractility
D)   Increased stroke volume

Question 15

Which intervention will most effectively maintain breathing function for a patient with muscle weakness due to amyotrophic lateral sclerosis (ALS)?

Accepted Answer

A)   Teaching pursed-lip breathing exercises
B)   BiPAP (bi-level positive airway pressure) 
C)   Administration of oxygen via nasal cannula
D)   CPAP (continuous positive airway pressure)

Question 16

Which assessment finding explains the patient's tachycardia?

Accepted Answer

A)   The patient drinks at least eight cans of diet cola every day.
B)   The patient takes digoxin 0.125 mg PO daily.
C)   The patient has a history of untreated hypothyroid disease.
D)   The patient takes metoprolol 50 mg PO daily.

Question 17

Which nursing diagnosis is appropriate for a patient using CPAP therapy to treat sleep apnea?

Accepted Answer

A)   Readiness for enhanced sleep related to desire for restful sleep
B)   Disturbed body image related to use of CPAP mask for sleeping
C)   Risk for disuse syndrome related to discomfort from CPAP mask
D)   Risk for impaired skin integrity related to tight-fitting mask on face

Question 18

Which assessment finding indicates that the sinoatrial node was damaged as a result of the patient's heart attack?

Accepted Answer

A)   The patient's jugular vein is distended.
B)   The patient's heart rate is 34 beats/minute.
C)   Faint wheezes are heard in the patient's lungs.
D)   The patient has developed a new heart murmur.

Question 19

Which patient would benefit from education about pursed-lip breathing?

Accepted Answer

A)   A patient with emphysema after many years of smoking
B)   A patient with a pneumothorax and a chest tube to suction
C)   A patient with a tracheostomy following throat cancer surgery
D)   A patient with respiratory muscle paralysis after spinal cord injury

Question 20

The nurse is caring for a dying patient in hospice.The patient's respirations are slow and uneven with deep breaths and long periods of apnea.Which term best describes this breathing pattern?

Accepted Answer

A)   Rhonchal bradypnea
B)   Forrest-Shiley breaths
C)   Kussmaul's respirations
D)   Cheyne-Stokes breathing

Exam 32: Oxygenation