Exam 3 Ch. 38

18問 • 3年前

問題一覧

1. The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which oxygen delivery device will the nurse use for this patient?

b. Bag-valve-mask unit

2. The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient is breathing spontaneously but is minimally responsive and having difficulty maintaining a patent airway. Which intervention is the most appropriate for the patient to improve oxygenation?

a. Insert an oral airway.

3. The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient’s pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of the nurse?

a. Administer the ordered intravenous diuretic.

4. The nurse is caring for a patient who has been intubated with an oral endotracheal tube for several weeks. The physicians predict that the patient will need to remain on a ventilator for at least several more weeks before he will be able to maintain his airway and breathe on his own. What procedure does the nurse anticipate will be planned for the patient to facilitate recovery?

a. Placement of a tracheostomy tube

5. The nurse is caring for a patient with a chest tube who was transported to radiology for testing. When the patient returns to the nursing unit, the transporter shows the nurse the patient’s chest tube collection device, which was badly damaged after being caught in the elevator door. What is the priority action of the nurse?

a. Clamp the chest tube until the collection device is replaced.

6. The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has the highest priority?

c. Impaired airway clearance r/t thick secretions in trachea and bronchi

7. The nurse is caring for a patient who developed a pulmonary embolism after surgery. Which goal statement is the highest priority for the nurse to include in the patient’s care plan for the diagnosis impaired gas exchange r/t impaired pulmonary blood flow from embolus?

a. The patient will maintain pulse oximetry values of at least 95% on room air.

8. The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented. What is the priority action of the nurse?

a. Obtain an arterial blood gas to check for carbon dioxide retention.

9. The nurse is caring for a patient who has been prescribed warfarin (Coumadin) therapy after being diagnosed with atrial fibrillation. The patient asks the nurse what could happen if the prescription doesn’t get filled. What is the nurse’s best response?

a. “You could have a stroke.”

10. The preceptor is working with a new nurse to provide care for a patient with a chest tube to relieve a pneumothorax. Which action by the new nurse indicates need for additional teaching about chest tube care?

b. The collection device is emptied at the end of the shift and output recorded in the chart.

11. The nurse is caring for a postoperative patient who has just been diagnosed with a deep vein thrombosis (DVT) in the right leg. Which focused assessment question has the highest priority for this patient?

b. “Do you have any chest pain or shortness of breath?”

12. The nurse identifies which patient who would benefit from postural drainage?

d. A patient with chronic bronchitis and congested cough.

13. The nurse is caring for a patient who has a history of congestive heart failure with generalized pitting edema. Which laboratory results will the nurse expect to find in the patient’s chart?

c. Hematocrit 32%

14. The nurse is caring for a patient with high cholesterol who has been prescribed atorvastatin (Lipitor). Which laboratory result indicates that the patient has been taking the medication as ordered and following the physician’s dietary recommendations?

d. Total cholesterol level 185 mg/dL

15. The nurse is caring for a patient who has presented to the ER with chest pain. Which diagnostic test will best indicate if there is significant blockage of important blood vessels that provide oxygen to the heart muscle?

a. Cardiac catheterization

16. The nurse hears a loud murmur when listening to the patient’s heart. Which diagnostic test will best display the condition of the valves and structures within the patient’s heart that could be causing the murmur?

c. Echocardiogram

17. The nurse is caring for a patient who will be returning to the nursing unit following a cardiac catheterization via the right femoral artery. Which assessment is the highest priority for the nurse to perform when the patient arrives on the unit?

a. Checking the patient’s right pedal pulse and warmth of the right leg

18. The home care nurse is caring for a patient who has severe COPD and home oxygen therapy. The patient tells the nurse that she feels much better after increasing the oxygen flowmeter from 2 L to 5 L/min. The patient’s pulse oximetry is 98%. What is the priority action of the nurse?

a. Reduce the oxygen flow rate until the patient’s pulse oximetry value is more than 88%.

NUR 170 exam 4

V Farris · 50問 · 2年前

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