Question 1

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.
B) The patient will verbalize understanding of ordered anticoagulants.
C) The patient will report chest pain of no greater than 3 on a 1-10 scale.
D) The patient will ambulate 50 feet in hallway without shortness of breath.

Accepted Answer

Oxygenation is the most important human need, so adequate oxygenation of tissues as evidenced by pulse oximetry values of at least 95% on room air is the highest priority goal. The other goals may be addressed once the oxygenation goal has been met.

Question 2

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 90% to 92%.
B) Inform the patient's physician and obtain an order for oxygen at 5 L/min.
C) Document the intervention and findings in the patient's medical record.
D) Listen to the patient's lung fields and reinforce pursed-lip breathing techniques.

Accepted Answer

The COPD patient should have a pulse oximetry value of approximately 90% to 92% to optimize oxygenation of tissues. High-flow oxygen may lead to respiratory suppression caused by loss of the patient's drive to breathe, so the oxygen flow rate should be kept at 2 L/min whenever possible. The nurse should reduce the oxygen flow rate until the patient's pulse oximetry is 90% to 92% and educate the patient about oxygen therapy for COPD.

Question 3

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?
A) "Do you have a headache or any dizziness?"
B) "Do you have any chest pain or shortness of breath?"
C) "When did you first notice the swelling and redness in your leg?"
D) "Do you have any cramping or muscle spasms in your leg?"

Accepted Answer

The highest risk of a DVT is the potential for the clot to break free and travel through the bloodstream to cause a pulmonary embolus (PE). The nurse should ask the patient about chest pain or shortness of breath to assess if a PE may have occurred.

Question 4

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.
B) Lower the head of the bed.
C) Turn the patient's head to the side.
D) Monitor the patient's pulse oximetry.

Accepted Answer

An oral airway will prevent the patient's tongue from falling back and occluding the airway. Lowering the head of the bed will only increase airway occlusion and risk of aspiration. Turning the patient's head to the side will not clear the back of the patient's tongue from the airway. Monitoring the patient's pulse oximetry will not improve oxygenation or clear the airway.

Question 5

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?
A) Chest x-ray
B) Cardiac catheterization
C) Echocardiogram
D) Electrocardiogram

Accepted Answer

Echocardiograms allow for ultrasound visualization of the structures of the heart along with function of the heart valves and cardiac musculature.

Question 6

The nurse is caring for a patient who has been prescribed warfarin (Coumadin) therapy after being diagnosed with atrial fibrillation. The patient tells the nurse that he doesn't want to take any more pills and asks what could happen if he doesn't fill the prescription. What is the nurse's best response?
A) "You could have a stroke."
B) "Your kidneys could fail."
C) "You could develop heart failure."
D) "You could go into respiratory failure."

Accepted Answer

A major complication of chronic atrial fibrillation is formation of blood clots within the atria as a result of sluggish blood flow. Anticoagulation therapy is common to prevent blood clot formation that could travel to the brain, causing a stroke.

Question 7

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.
B) Cover the insertion site with a new occlusive dressing.
C) Ensure that there is gentle bubbling in the water seal chamber.
D) Check the patient's lung sounds and pulse oximetry.

Accepted Answer

The broken collection device may no longer be used to collect chest tube drainage. Clamping the chest tube until the collection device is replaced will prevent air from entering into the lung space until the new collection device is attached.

Question 8

Which of the following patients would benefit from postural drainage?
A) A patient with a heart murmur and jugular venous distention
B) A patient with asthma and audible wheezing
C) A patient with right-sided heart failure and pitting edema
D) A patient with chronic bronchitis and congested cough

Accepted Answer

Postural drainage is used for patients who have difficulty removing thick secretions from the airway. A patient with chronic bronchitis and a congested, productive cough would benefit from postural drainage because it would help clear the airway.

Question 9

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
B) Checking pulse oximetry and listening to the patient's lung sounds
C) Checking bilateral radial pulses to check for a pulse deficit
D) Estimating the patient's jugular venous pressure

Accepted Answer

Cardiac catheterization includes the insertion of a large IV needle into the patient's femoral artery. Occlusion of the femoral artery may develop after the procedure leading to faint or absent pedal pulses and loss of warmth to the right leg. The nurse should check the patient's right pedal pulses and leg warmth to ensure that the femoral artery has not become occluded. The other assessments may be performed once the patient's right leg is found to be warm with strong pulses.

Question 10

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 certain important blood vessels that provide oxygen to the heart muscle?
A) Cardiac catheterization
B) Chest x-ray
C) Echocardiogram
D) Electrocardiogram

Accepted Answer

Cardiac catheterization includes the use of contrast dye to visualize the coronary arteries and determine blood flow to cardiac muscle. The other tests will not allow the physician to determine which (if any) coronary arteries are occluded.

Question 11

The nurse is caring for a patient who has just had a massive myocardial infarction. Which is the priority nursing diagnosis for this patient?
A) Impaired comfort r/t noisy ICU environment and need for frequent monitoring
B) Interrupted family processes r/t hospitalization of primary wage earner
C) Readiness for enhanced knowledge r/t cardiac rehabilitation options
D) Decreased cardiac output r/t weakened cardiac muscle and irregular heartbeat

Accepted Answer

Circulation and perfusion of body systems is the highest priority for patients who have suffered myocardial infarction. Decreased cardiac output can lead to poor oxygenation of tissues and organs. The other diagnoses may be addressed once cardiac output has increased and stabilized.

Question 12

The nurse is caring for a patient with advanced COPD who reports feeling short of breath. The nurse notes that the patient's lung sounds are diminished bilaterally and the patient's pulse oximetry is 91% on 2 L/min oxygen via nasal cannula. What actions will the nurse take to make the patient more comfortable? (Select all that apply.)
A) Increase the patient's oxygen to 4 L/min via nasal cannula.
B) Suction the patient's airway using sterile technique.
C) Maintain eye contact and provide calm reassurance.
D) Turn the patient onto the side for postural drainage.
E) Administer the ordered nebulized bronchodilator.
F) Elevate the head of the patient's bed to fully upright.

Accepted Answer

Patients who are acutely short of breath due to advanced COPD will benefit from nebulized bronchodilator medication to open the airways. Elevating the head of the bed will prevent pressure on the diaphragm from the abdominal contents. A caring demeanor with eye contact will help the patient remain calm until the medication begins to work and the shortness of breath is eased. Patients with COPD should be kept on low-flow oxygen to maintain pulse oximetry as close to 90% as possible.

Question 13

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?
A) Serum triglyceride level 325 mg/dL
B) High-density lipoproteins (HDL) 56 mg/dL
C) Low-density lipoproteins (LDL) 155 mg/dL
D) Total cholesterol level 185 mg/dL

Accepted Answer

Total cholesterol levels should be less than 200 mg/dL, so a cholesterol level of 185 mg/dL indicates that the patient has been compliant with the prescribed therapy. The other laboratory results are abnormal and would not indicate compliance.

Question 14

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 his recovery?
A) Placement of a tracheostomy tube
B) Diagnostic thoracentesis
C) Pulmonary angiogram
D) Lung transplantation surgery

Accepted Answer

Placement of a tracheostomy tube will secure the patient's airway directly through the trachea, eliminating the need for the endotracheal tube. This will make the patient more comfortable and may allow him to eat while minimizing damage to the oropharynx from the endotracheal tube.

Question 15

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?
A) The suction is discontinued when the patient is ambulated to the bathroom.
B) The collection device is emptied at the end of the shift and output recorded in the chart.
C) The patient's bed is placed in the semi-Fowler's position to facilitate lung reexpansion.
D) The patient is encouraged to use his incentive spirometer at least 10 times every hour.

Accepted Answer

The chest tube collection device is not emptied at the end of the shift. Instead, the amount of drainage present at the end of the shift (or specified time) is marked on the collection device and the amount of drainage entered into the patient's chart.

Question 16

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.
B) Increase the patient's oxygen until the pulse oximetry is greater than 98%.
C) Lower the head of the patient's bed and insert a nasal airway.
D) Administer a mild sedative and reorient the patient as needed.

Accepted Answer

Confusion and disorientation in a patient with severe COPD may likely be due to carbon dioxide retention. An arterial blood gas should be drawn to determine if this is the case. COPD patients should be kept on low oxygen flow rates whenever possible to avoid impeding the drive to breathe. Lowering the head of the bed will increase the difficulty of breathing as the abdominal contents press on the diaphragm. A sedative will cause respiratory depression and should be avoided.

Question 17

The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which oxygen delivery device will the nurse use for this patient?
A) Non-rebreather mask
B) Bag-valve-mask unit
C) Continuous positive airway pressure (CPAP)
D) High-flow nasal cannula

Accepted Answer

The priority of the nurse is to ventilate the patient manually using an Ambu bag-valve-mask unit. This allows air to be forced into the patient's lungs when there are no spontaneous respirations. The non-rebreather mask and nasal cannula require the patient to breathe on his own. CPAP is used for patients who are awake, oriented, and in respiratory failure.

Question 18

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.
B) Prepare for insertion of a chest tube.
C) Suction secretions from the patient's respiratory tract.
D) Have the patient use the ordered incentive spirometer.

Accepted Answer

The patient's respiratory distress is due to pulmonary edema and fluid overload from left-sided congestive heart failure. A diuretic will pull the excess fluid out of the body through the urine and relieve the patient's distress. A chest tube is not needed as the fluid is within the alveoli rather than between the lung and chest wall. Suctioning and use of an incentive spirometer will not address fluid overload or improve the patient's symptoms.

Question 19

The nurse is caring for a patient who has a history of congestive heart failure with generalized pitting edema. Which of the following laboratory results will the nurse expect to find in the patient's chart?
A) Glycosylated hemoglobin 12%
B) Platelet count 450,000/mmS1U1P13S1S1P0
C) Hematocrit 32%
D) Prothrombin time 8.8 seconds

Accepted Answer

Hemodilution is a common finding when patients are in fluid overload caused by congestive heart failure. A normal hematocrit result is 42% to 52% for a male and 37% to 47% for a female, so the patient's 32% hematocrit level is markedly low. The other laboratory results are not expected as a result of congestive heart failure or fluid overload.

Question 20

The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has the highest priority?
A) Activity intolerance r/t generalized weakness and hypoxemia
B) Imbalanced nutrition r/t poor appetite and increased metabolic needs
C) Ineffective airway clearance r/t thick secretions in trachea and bronchi
D) Knowledge deficit r/t use of nebulizer and inhaled bronchodilators

Accepted Answer

Airway maintenance and patency is the highest priority for all patients, especially patients with respiratory disorders. Oxygenation is the most important human need. The other diagnoses can apply once the patient's airway is kept patent.

Quiz 38: Oxygenation and Tissue Perfusion

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?

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?

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?

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?

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?

Which of the following patients would benefit from postural drainage?

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?

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 certain important blood vessels that provide oxygen to the heart muscle?

The nurse is caring for a patient who has just had a massive myocardial infarction. Which is the priority nursing diagnosis for this patient?

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?

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?

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?

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

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?

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

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