FUNDAMENTALS End Chapter Exam 3

Which skills can the nurse delegate to assistive personnel (AP)?

• Initiate oxygen therapy via nasal cannula

• Educate the pt about the use of an incentive spirometer

• Assist w/ the care of an established tracheostomy tube

• Reposition a pt w/ a chest tube

The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first?

• Start O2 at 2L/min via nasal cannula

• Elevate HOB to 45 degrees

• Encourage pt to use the incentive spirometer

• Notify the health care provider

The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). What statement, made by the patient, indicates the need for further teaching?

• “Pursed-lip breathing is like exercise for my lungs and will help me strengthen my breathing muscles.”

• “When I am sick, I should limit the amount of fluids I drink so that I don’t produce excess mucus.”

• “I will ensure that I receive an influenza vaccine every year, preferably in the fall.”

• “I will look for a smoking-cessation support group in my neighborhood.

Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention?

• SpO2 values of 95%

• Chest retractions

• Resp rate of 28 breaths per minute

• Nasal flaring

• Clubbing of finger

The nurse is caring for a patient with an artificial airway. What are reasons to suction the patient?

• The pt has visible secretions in the airway

• There is a sawtooth pattern on the pt's EtCO2 monitor

• The pt has clear breath sounds

• It has been 3 hrs since the pt was last suctioned

• The pt has excessive coughing

The nurse is caring for a patient with a chest tube for treatment of a right pneumothorax. Which assessment finding necessitates immediate notification of the health care provider?

• New, vigorous bubbling in the water seal chamber

• Scant amount of sanguineous drainage noted on the dressing

• Clear but slightly diminished breath sounds on the rt side of the chest

• Pain score of 2 one hr after admin of an analgesic

The nurse has just witnessed her patient go into cardiac arrest. The family is in the patient’s room at the time the cardiac arrest occurs. What priority interventions should the nurse perform at this time?

• Perform chest compressions

• Ask someone to bring the automatic external defibrillator (AED) to the room for immediate defibrillation

• Apply O2 via nasal cannula

• Place the patient supine

• Educate the family about the need for CPR

The nurse is performing tracheostomy care on a patient. What finding would indicate that the tracheostomy tube has become dislodged?

• Clear breath sounds

• Pt speaking to nurse

• SpO2 reading of 96%

• Resp rate of 18 breaths/min

Answer explanation

Pt phonation is a sign that the TT is not in its proper place

When planning patient education, it is important to remember that patients with which of the following illnesses may find relief in complementary therapies?

• Lupus and diabetes

• Ulcers and hepatitis

• Heart disease and pancreatitis

• Chronic back pain and arthritis

Which complementary therapies are most easily learned and applied by a nurse?

• Therapeutic massage therapy

• Traditional Chinese medicine

• Progressive relaxation

• Breath work and guided imagery

• Therapeutic touch