Ch. 28, 40-41

Front 1

A nurse performing oral suctioning on an adult patient should set the wall suction machine so that the suction pressure is between _____ mm Hg. Select one:

a. 50 and 75

b. 80 and 120

c. 25 and 50

d. 120 and 180

Back 1

The range of suction pressure for an adult patient is between 80 and 120 mm Hg

Front 2

The nurse uses a diagram to show that when the diaphragm moves:

Select one:

a. down, the negative pressure in the thoracic space pulls air into the lungs.

b. down, the intercostal muscles retract, forcing air out of the lungs.

c. up, the decreased negative pressure allows air to enter the lungs.

d. up, the increased negative pressure in the thoracic space forces air into the lungs.

Back 2

The correct answer is: down, the negative pressure in the thoracic space pulls air into the lungs.:

When the diaphragm moves down, increasing the size of the thoracic space, air is pulled into the lungs. The respiratory action is controlled by the spinal cord.

Front 3

The nurse instructing the patient to perform forceful exhalation coughing would teach the patient to take in:

Select one:

a. two breaths and force the air out quickly.

b. two deep breaths, then inhale deeply again and force out the air quickly.

c. one deep breath and quickly exhale.

d. one breath, hold it for 3 seconds, then forcefully exhale three times with mouth open.

Back 3

Proper coughing procedure is to take in two deep breaths, inhale deeply again and to forcibly exhale (cough) at the end of the third breath.

This technique is very effective in moving secretions up the bronchial tree.

Front 4

The nurse loosens mucus plugs by using percussion on a patient over the area of the: Select one:

a. sternum.

b. spine between the scapulae.

c. thorax.

d. midaxillary line on the rib cage

Back 4

Percussion, a rhythmic clapping with cupped hands over the thoracic area, will loosen mucus plugs. This technique is both useless and painful when applied over bony areas.

Front 5

When obtaining a sputum specimen, the nurse should provide the patient with a sterile sputum cup and teach the patient to rinse her mouth with

Back 5

water

Front 6

The nurse clarifies that the cough mechanism is stimulated when: Select one:

a. foreign substances are propelled by the cilia toward the respiratory tract.

b. dehumidified air enters the upper airway passages

.c. more than 250 mL of air moves in and out of the lungs with each breath.

d. the blood transports carbon dioxide to the lungs.

Back 6

The correct answer is: foreign substances are propelled by the cilia toward the respiratory tract.

: Cilia work to propel foreign substances toward the entrance of the respiratory tract, and the cough reflex works to expel the secretions.

Front 7

A patient requires a precise concentration of 40% oxygen. Which of the following devices would best allow for this? Select one:

a. A non-rebreather mask

b. A simple face mask

c. A Venturi mask

d. A partial rebreathing mask

Back 7

A Venturi mask is useful when accuracy of delivery is essential.

Front 8

A patient has a history of chronic obstructive pulmonary disease. The patient's oxygen flow rate should be set to no more than _____ L/min. Select one:

a. 2 to 3

b. 1 to 2

c. 4 to 5

d. 5 to 10

Back 8

Patients with obstructive lung disease are given only 2 to 3 L/min of oxygen, because over time they adjust to high carbon dioxide levels, and their stimulus to breathe comes from low arterial oxygen levels. Higher amounts of oxygen could reduce or eliminate the respiratory drive.

Front 9

A nurse is aware that adequate hydration is necessary to mobilize respiratory secretions. To thin respiratory secretions for easier expectoration, the patient should consume at least _____ mL/day. Select one:

a. 2500 to 3000

b. 500 to 1000

c. 1000 to 1500

d. 1500 to 2000

Back 9

A fluid intake of at least 1500 to 2000 mL/day is needed to thin respiratory secretions for easier removal by coughing

Front 10

The nurse administering cardiopulmonary resuscitation (CPR) would administer chest compressions at the rate of

Back 10

100 compressions/minute.

Front 11

A patient has collapsed and cannot be aroused by asking loudly, "Are you okay?" The next action should be to:

Select one:

a. tilt the head by placing one hand on the forehead and lift the chin.

b. call for help or, if there is assistance, have that person get help.

c. deliver two quick short breaths into the patient's airway.

d. position the fingers over the carotid artery to feel for a pulse.

Back 11

The correct answer is: call for help or, if there is assistance, have that person get help

: The sequence for resuscitative interventions is to check for responsiveness; if no response, activate emergency medical services, check for pulse at carotid, begin compressions, then open the airway and check for breathing.

Front 12

The multiple causes for hypoxia include:

(Select all that apply.)

a. aspirated vomit.

b. extreme fright.

c. high altitude.

d. pulmonary fibrosis.

e. hiccoughs.

Back 12

The correct answer is: aspirated vomit., pulmonary fibrosis., high altitude.

: Among the many causes of hypoxia are aspirated vomit, pulmonary fibrosis, and high altitude.

Front 13

The nurse takes into consideration that a pulse oximeter may not give an accurate reading if the patient is:Select one:

a. jaundiced.

b. obese.

c. febrile.

d. dark skinned.

Back 13

An accurate reading is dependent on light passing through the vascular bed. Jaundice may cause an inaccurate reading.

Front 14

When assessing the lungs of a patient, the nurse assesses a wheezing sound on inspiration. This finding is documented as:

Select one:

a. retractions.

b. dyspnea.

c. stridor.

d. apnea

Back 14

Stridor is a wheezing sound that can be heard on auscultation or even with the naked ear and indicates respiratory obstruction.

Front 15

The nurse monitoring patients eating in the dining room of a skilled nursing facility notes that a patient begins choking. As the nurse prepares to deliver the Heimlich maneuver, the fist should be positioned:

Select one:

a. directly over the umbilicus.

b. halfway between the xiphoid process and the umbilicus.

c. directly over the sternum.

d. between the umbilicus and the symphysis pubis.

Back 15

Proper placement of the fist is halfway between the xiphoid process and the umbilicus

Front 16

The nurse clarifies to a family of a resident with Alzheimer's that dementia differs from confusion and delirium in that dementia is:

Select one:

a. effectively treatable.

b. caused by depression.

c. usually rapid in onset.

d. permanent.

Back 16

Dementia is generally a permanent condition characterized by cognitive deficits with a slow onset. It is primarily seen in Alzheimer's patients but also occurs in persons with brain tumors

Front 17

The nurse would question a new order for a tricyclic antidepressant for a patient who has had a recent:

Select one:

a. myocardial infarct.

b. abdominal surgery.

c. peptic ulcer.

d. diagnosis of diabetes.

Back 17

Tricyclics are contraindicated in patients with recent myocardial infarctions because these drugs may cause cardiac arrhythmias

Front 18

The 64-year-old resident newly admitted to a long-term care facility refuses to sit down and eat, preferring to wander aimlessly through the facility. The initial intervention by the nursing staff should be to:

Select one:

a. offer high-protein malts to drink on the go.

b. feed the patient rapidly before he begins to wander.

c. apply an alarm bracelet to monitor wandering.

d. feed the resident in his room away from other residents

Back 18

The offering of high-protein drinks or nutritious snacks to eat on the go may be an initial approach to the problem.

Front 19

A home health nurse working with an elderly patient assesses an early indication that this patient is developing Alzheimer's disease. This early indication would be:

Select one:

a. difficulty learning new things.

b. deteriorating speech.

c. wandering behavior.

d. agitation.

Back 19

arly signs of Alzheimer's disease are mild short-term memory loss, difficulty learning new things, and mild depression.

Front 20

When a patient becomes violent and hits a table with his cane, the initial appropriate nursing approach is to:

Select one:

a. direct the patient in a loud authoritarian voice to sit down

.b. medicate the patient to help control his anxiety.

c. attempt to distract the patient.

d. call for assistance to apply restraints.

Back 20

A behavioral approach such as distraction might diffuse the situation until the cause can be determined. Chemical restraint (medication) or a restrictive restraint should not be the first intervention. Loud voices frequently increase the violent behavior.

Front 21

The home health nurse initiates an inexpensive noninvasive treatment that can decrease depression by the use of:

Select one:

a. arrangements to have a high-calorie drink twice a day.

b. subscriptions to travel or hobby-oriented magazines.

c. placing the patient in front of a high action TV show for 1 hour.

d. shining lights on the patient for 30 minutes a day

Back 21

se of a light therapy box that allows the patient to absorb the light for 20 to 30 minutes in the morning my help decrease depression.

Front 22

The family of a patient with Alzheimer's indicates that they want to keep the patient at home but are not sure how much longer they can care for the patient because of stress on family members. A helpful suggestion by the home health nurse would be to:

Select one:

a. encourage family counseling.

b. encourage the hiring of a full-time caregiver.

c. consider use of respite services.

d. face the reality of need for long-term care.

Back 22

Respite care or adult day services can provide for much-needed psychological and physical rest for caregivers.

Front 23

The nurse in a long-term care facility emphasizes to the family of a resident recently admitted that one of the purposes of the creative behavioral therapies is to:

Select one:

a. slow the rate of deterioration.

b. keep the residents out of their rooms.

c. stimulate an avid interest in music or art.

d. entertain the residents who have become bored.

Back 23

The creative behavioral therapies of art, music, dancing, and humor are designed to delay the deterioration of the resident.

Front 24

When the nurse determines that an elderly patient has a reasonable risk of being physically abused by family members, it is the nurse's legal obligation to

:Select one:

a. advise the patient to leave the family home.

b. refer the family for counseling.

c. tell the family to stop or face legal consequences.

d. report the suspected abuse to the proper authority.

Back 24

It is a legal obligation under state-mandated reporting laws for suspected abuse for nurses to report instances in which there is a reasonable belief that an individual has been or is likely to be abused, neglected, or exploited.

Front 25

When the nurse plans to use reminiscence as a psychosocial approach to managing confusion with cognitively impaired patients, the nurse should:

Select one:

a. encourage individual and group sharing of information about previous life experiences.

b. use plants, pictures, and animals to encourage interactions in the group.

c. use memory aids such as television, radio, clock, and calendar.

d. increase socialization roles in the group, such as serving each other refreshments.

Back 25

Reminiscence involves individual and group sharing about previous life experiences.

Front 26

When assessing the lungs of a patient, the nurse assesses a wheezing sound on inspiration. This finding is documented as:

Select one:

a. stridor.

b. retractions.

c. apnea.

d. dyspnea.

Back 26

Stridor is a wheezing sound that can be heard on auscultation or even with the naked ear and indicates respiratory obstruction.

Front 27

The nurse clarifies that the condition in which there is a decreased amount of oxygen in the blood is:Select one:

a. dyspnea.

b. hypercapnia.

c. hypoxia.

d. hypoxemia.

Back 27

Hypoxemia is a condition in which there is a decreased amount of oxygen in the blood, hypoxia is inadequate oxygen to meet cellular needs, hypercapnia is increased level of carbon dioxide in the blood, and dyspnea is difficulty breathing.

Front 28

# of aveoli in the lungs

Back 28

300 million to 1 Billion

Front 29

.....mL of air moves in and out of the lungs with each breath

Back 29

500 mL

Front 30

The elderly Pt. has (oxygen wise)

Back 30

1. less respiratory reserve
2. decreased elasticity of the thorax and respiratory tissues
   
3. total body water loss resulting in dry membranes and thicker secretions
4. cilia experience some degree of impairment
5. loss of elastic recoil during expiration
6. decrease of gas diffusion across the membrane

Front 31

increased level of carbon dioxide in the blood

Back 31

hypercapnia

Front 32

sings of hypoxia

Back 32

1. restlessness, mental dullness, sits up to breath
2. b.p. pulse and respirations +
3. ---use of accessory muscles, stridor
4. cyanosis and muscle retractions

Front 33

sputum specimen best obtained when (2)

Back 33

1. Pt. has just awoken
2. Pt. has just finished a nebuilzer treatment

Front 34

do not perform chest percussions over

Back 34

spine or sternum

Front 35

You observe the patient for early signs of hypoxia. You know that the first signs of hypoxia include.

Select all

1. + restlessness or irritability

2. + respiratory rate

3. cyanosis of the nail beds of the fingers

4. retraction of muscles used in breathing

Back 35

1,2 :

+ restlessness or irritability

+ respiratory rate

Front 36

In providing nursing care for this patient, who is having difficulty, it is important to reduce her anxiety because it:

1. + the pulse and blood pressure

2. causes tense muscles, which need +oxygen.

3. causes needless fear and worry

4. delays recovery and healing of inj. tissues.

Back 36

2:

causes tense muscles, which need +oxygen.

Front 37

The patient is in pain but does not want to take pain medication. You know that is important to keep her comfortable because:

1. when breathing causes pain, she won't take deep breaths to open alveoli.

2. the surgeon ordered pain medication for her.

3. She needs to sleep a lot in order to heal

4. she may become irritable and confused

Back 37

1 :

when breathing causes pain, she won't take deep breaths to open alveoli.

Front 38

There is continuous bubbling in the suction chamber of the disposable water-seal chest drainage unit, with 120 mL of drainage in the last hour. What should you do?

1. Document the drainage and continue to monitor Pt.

2. Check the suction tubing for leaks.

3. Check the Pt.'s vital signs

4. Call the Physician

Back 38

4 :

Call the Physician 100 mL of drainage per hour is max

Front 39

When performing nasopharyngeal suctioning, you should (SELECT ALL THAT APPLY)

1. Raise the head of the bed 30 to 45 degrees

2. Set suction at 100 mm Hg

3. Deflate the cuff before deciding to do nasopharyngeal suctioning.

4. Moisten the catheter before suctioning

Back 39

1,2,4

: Raise the head of the bed 30 to 45 degrees, Set suction at 100 mm Hg, Moisten the catheter before suctioning

Front 40

When administering oxygen by nasal cannula, it is important to: (SELECT ALL THAT APPLY)

1. Monitor the Pt.'s Pao2 and PacO2 levels in the blood.

2. + the flow rate when the patient becomes short of breath.

3. Decrease the flow rate, per the physician's order, when oxygen levels are in normal range.

4. Verify the physician's order and recognize oxygen as a drug treatment.

5. Educate the Pt. about the need for oxygen and how to use it

Back 40

3,4,5

1. Decrease the flow rate, per the physician's order, when oxygen levels are in normal range.
2. Verify the physician's order and recognize oxygen as a drug treatment.
3. Educate the Pt. about the need for oxygen and how to use it
   

Front 41

The most effective way to clear a Pt.'s respiratory tract of secretions after a thoracotomy and lung resection is to :

1. Position Pt. for postural drainage

2. use pharyngeal suctioning

3. Teach Pt. to cough effectively

4. Use endotracheal suctioning

Back 41

3:

Teach Pt. to cough effectively

Front 42

Older people are more prone to respiratory problems because aging causes what changes?

Select all the apply

1. Thinning of the alveolar membrane

2. Decreased elasticity of respiratory tissues

3. + secretion production

4. Decreased efficiency of the immune system

Back 42

2, 4

Decreased elasticity of respiratory tissues and Decreased efficiency of the immune system

Front 43

In normal individuals, the drive to breath and the control of respiratory rate are dependent on:

1. the elasticity of the lungs

2. the PaO2 level in the blood

3. The cerebral cortex

4. PacO2 level in the blood

Back 43

4

: PacO2 level in the blood

Front 44

One nursing measure that can prevent respiratory insufficiency is to :

1. Assist the Pt. to turn, cough & deep breathe

2. Administer low-flow oxygen continuously

3. Allow the Pt. to rest as much as possible

4. Perform postural drainage at least three times a day

Back 44

1

: Assist the Pt. to turn, cough & deep breathe

Front 45

Regarding HIV, sexuality and the older adult :

Back 45

health care providers are less likely to ask the older Pt. about their sex practices

Front 46

Your neighbor asks your advice on nutrition for her aging parents. You consider your response based on the fact that:

Back 46

In general older adults require fewer calories

Front 47

One of the most common reasons that elder adults are placed in long-term care is

Back 47

Incontinence

Front 48

What is true regarding sensory deficits in the older adult?

Back 48

cleaning excess cerumen can improve hearing

Front 49

Dietary recommendations for the elderly include:

Back 49

between 46-56 g/day of protein