The nurse finds the patient in cardiopulmonary arrest with no b. Bag-valve-mask unit
pulse or respirations. Which oxygen delivery device will the
nurse use for this patient? The priority of the nurse is to ventilate the patient manually using a bag-valve-mask
(BVM) unit. This allows air to be forced into the patient's lungs when there are no
a. Non-rebreather mask spontaneous respirations. The non-rebreather mask and nasal cannula require the patient
b. Bag-valve-mask unit to breathe on his or her own. CPAP is used for patients who are awake, oriented, and in
c. Continuous positive airway pressure (CPAP) respiratory failure.
d. High-flow nasal cannula
The nurse is caring for a patient who is slow to awaken a. Insert an oral airway.
following general anesthesia. The patient is breathing
spontaneously but is minimally responsive and having An oral (oropharyngeal) airway will prevent the patient's tongue from falling back and
difficulty maintaining a patent airway. Which intervention is occluding the airway. Lowering the head of the bed will only increase airway occlusion
the most appropriate for the patient to improve oxygenation? 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
a. Insert an oral airway. improve oxygenation or clear the airway.
b. Lower the head of the bed.
c. Turn the patient's head to the side.
d. Monitor the patient's pulse oximetry.
The nurse is caring for a patient with a history of left-sided a. Administer the ordered intravenous diuretic.
congestive heart failure who is acutely short of breath. The
nurse hears fine crackles throughout both lung fields and notes The patient's respiratory distress is due to pulmonary edema and fluid overload from left-
that the patient's pulse oximetry is only 88% on 4 L of oxygen. sided congestive heart failure. A patient with heart failure may be on diuretics. A diuretic
What is the priority intervention of the nurse? 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
a. Administer the ordered intravenous diuretic. the lung and chest wall. Suctioning and use of an incentive spirometer will not address
b. Prepare for insertion of a chest tube. fluid overload or improve the patient's symptoms.
c. Suction secretions from the patient's respiratory tract.
d. Have the patient use the ordered incentive spirometer.
The nurse is caring for a patient who has been intubated with a. Placement of a tracheostomy tube
an oral endotracheal tube for several weeks. The physicians
predict that the patient will need to remain on a ventilator for Placement of a tracheostomy tube will secure the patient's airway directly through the
at least several more weeks before he will be able to maintain trachea, eliminating the need for the endotracheal tube. This will make the patient more
his airway and breathe on his own. What procedure does the comfortable and may allow eating while minimizing damage to the oropharynx from the
nurse anticipate will be planned for the patient to facilitate endotracheal tube.
recovery?
a. Placement of a tracheostomy tube
b. Diagnostic thoracentesis
c. Pulmonary angiogram
d. Lung transplantation surgery
The nurse is caring for a patient with a chest tube who was a. Clamp the chest tube until the collection device is replaced.
transported to radiology for testing. When the patient returns
to the nursing unit, the transporter shows the nurse the patient's The broken collection device may no longer be used to collect chest tube drainage.
chest tube collection device, which was badly damaged after Clamping the chest tube until the collection device is replaced will prevent air from
being caught in the elevator door. What is the priority action of entering the lung space until the new collection device is attached.
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.
The nurse is caring for a patient who is hospitalized for c. Impaired airway clearance r/t thick secretions in trachea and bronchi.
pneumonia. Which nursing diagnosis has the highest priority?
Airway maintenance and patency is the highest priority for all patients, especially
a. Activity intolerance r/t generalized weakness and patients with respiratory disorders. Oxygenation is the most important human need. The
hypoxemia other diagnoses can apply once the patient's airway is kept patent.
b. Impaired nutritional intake r/t poor appetite and increased
metabolic needs
c. Impaired airway clearance r/t thick secretions in trachea and
bronchi
d. Lack of knowledge r/t use of nebulizer and inhaled
bronchodilators
, The nurse is caring for a patient who developed a pulmonary a. The patient will maintain pulse oximetry values of at least 95% on room air.
embolism after surgery. Which goal statement is the highest
priority for the nurse to include in the patient's care plan for Oxygenation is the most important human need, so adequate oxygenation of tissues as
the diagnosis impaired gas exchange r/t impaired pulmonary evidenced by pulse oximetry values of at least 95% on room air is the highest priority
blood flow from embolus? goal. The other goals may be addressed once the oxygenation goal has been met.
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
to 10 scale.
d. The patient will ambulate 50 feet in hallway without
shortness of breath.
The nurse is caring for a patient with severe COPD who is a. Obtain an arterial blood gas to check for carbon dioxide retention.
becoming increasingly confused and disoriented. What is the
priority action of the nurse? Alteration of lung tissue may decrease delivery of oxygen to the alveoli, impede transfer
of oxygen from alveoli to the bloodstream, and hinder expulsion of carbon dioxide.
a. Obtain an arterial blood gas to check for carbon dioxide COPD causes impaired gas exchange, leading to decreased oxygen levels and higher
retention. circulating levels of carbon dioxide (i.e., respiratory acidosis). Confusion and
b. Increase the patient's oxygen until the pulse oximetry is disorientation in a patient with severe COPD may likely be due to carbon dioxide
greater than 98%. retention. An arterial blood gas should be drawn to determine if this is the case. COPD
c. Lower the head of the patient's bed and insert a nasal airway. patients should be kept on low oxygen flow rates whenever possible to avoid impeding
d. Administer a mild sedative and reorient the patient as the drive to breathe. Lowering the head of the bed will increase the difficulty of breathing
needed. as the abdominal contents press on the diaphragm. A sedative will cause respiratory
depression and should be avoided.
The nurse is caring for a patient who has been prescribed a. "You could have a stroke."
warfarin (Coumadin) therapy after being diagnosed with atrial
fibrillation. The patient asks the nurse what could happen if the A major complication of chronic atrial fibrillation is formation of blood clots within the
prescription doesn't get filled. What is the nurse's best atria due to sluggish blood flow. Anticoagulation therapy is common to prevent blood
response? clot formation that could travel to the brain, causing a stroke.
a. "You could have a stroke."
b. "Your kidneys could fail."
c. "You could develop heart failure."
d. "You could go into respiratory failure."
The preceptor is working with a new nurse to provide care for b. The collection device is emptied at the end of the shift and output recorded in the chart.
a patient with a chest tube to relieve a pneumothorax. Which
action by the new nurse indicates need for additional teaching The chest tube collection device is not emptied at the end of the shift. Instead, the amount
about chest tube care? of drainage present at the end of the shift (or specified time) is marked on the collection
device and the amount of drainage is documented in the patient's chart.
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.
The nurse is caring for a postoperative patient who has just b. "Do you have any chest pain or shortness of breath?"
been diagnosed with a deep vein thrombosis (DVT) in the
right leg. Which focused assessment question has the highest The highest risk of a DVT is the potential for the clot to break free and travel through the
priority for this patient? 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.
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?"
The nurse identifies which patient who would benefit from d. A patient with chronic bronchitis and congested cough.
postural drainage?
Patients who benefit from postural drainage therapy include those who are unable or
a. A patient with a heart murmur and jugular venous distention. reluctant to change body positions and patients with unilateral lung diseases that are
b. A patient with asthma and audible wheezing. related to poor oxygenation due to position. Patients who have diseases such as cystic
c. A patient with right-sided heart failure and pitting edema. fibrosis or bronchiectasis, COPD, abscesses, or difficulty removing secretions may
d. A patient with chronic bronchitis and congested cough. benefit from postural drainage therapy. A patient with chronic bronchitis and a congested,
productive cough would benefit from postural drainage because it would help clear the
airway.
pulse or respirations. Which oxygen delivery device will the
nurse use for this patient? The priority of the nurse is to ventilate the patient manually using a bag-valve-mask
(BVM) unit. This allows air to be forced into the patient's lungs when there are no
a. Non-rebreather mask spontaneous respirations. The non-rebreather mask and nasal cannula require the patient
b. Bag-valve-mask unit to breathe on his or her own. CPAP is used for patients who are awake, oriented, and in
c. Continuous positive airway pressure (CPAP) respiratory failure.
d. High-flow nasal cannula
The nurse is caring for a patient who is slow to awaken a. Insert an oral airway.
following general anesthesia. The patient is breathing
spontaneously but is minimally responsive and having An oral (oropharyngeal) airway will prevent the patient's tongue from falling back and
difficulty maintaining a patent airway. Which intervention is occluding the airway. Lowering the head of the bed will only increase airway occlusion
the most appropriate for the patient to improve oxygenation? 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
a. Insert an oral airway. improve oxygenation or clear the airway.
b. Lower the head of the bed.
c. Turn the patient's head to the side.
d. Monitor the patient's pulse oximetry.
The nurse is caring for a patient with a history of left-sided a. Administer the ordered intravenous diuretic.
congestive heart failure who is acutely short of breath. The
nurse hears fine crackles throughout both lung fields and notes The patient's respiratory distress is due to pulmonary edema and fluid overload from left-
that the patient's pulse oximetry is only 88% on 4 L of oxygen. sided congestive heart failure. A patient with heart failure may be on diuretics. A diuretic
What is the priority intervention of the nurse? 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
a. Administer the ordered intravenous diuretic. the lung and chest wall. Suctioning and use of an incentive spirometer will not address
b. Prepare for insertion of a chest tube. fluid overload or improve the patient's symptoms.
c. Suction secretions from the patient's respiratory tract.
d. Have the patient use the ordered incentive spirometer.
The nurse is caring for a patient who has been intubated with a. Placement of a tracheostomy tube
an oral endotracheal tube for several weeks. The physicians
predict that the patient will need to remain on a ventilator for Placement of a tracheostomy tube will secure the patient's airway directly through the
at least several more weeks before he will be able to maintain trachea, eliminating the need for the endotracheal tube. This will make the patient more
his airway and breathe on his own. What procedure does the comfortable and may allow eating while minimizing damage to the oropharynx from the
nurse anticipate will be planned for the patient to facilitate endotracheal tube.
recovery?
a. Placement of a tracheostomy tube
b. Diagnostic thoracentesis
c. Pulmonary angiogram
d. Lung transplantation surgery
The nurse is caring for a patient with a chest tube who was a. Clamp the chest tube until the collection device is replaced.
transported to radiology for testing. When the patient returns
to the nursing unit, the transporter shows the nurse the patient's The broken collection device may no longer be used to collect chest tube drainage.
chest tube collection device, which was badly damaged after Clamping the chest tube until the collection device is replaced will prevent air from
being caught in the elevator door. What is the priority action of entering the lung space until the new collection device is attached.
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.
The nurse is caring for a patient who is hospitalized for c. Impaired airway clearance r/t thick secretions in trachea and bronchi.
pneumonia. Which nursing diagnosis has the highest priority?
Airway maintenance and patency is the highest priority for all patients, especially
a. Activity intolerance r/t generalized weakness and patients with respiratory disorders. Oxygenation is the most important human need. The
hypoxemia other diagnoses can apply once the patient's airway is kept patent.
b. Impaired nutritional intake r/t poor appetite and increased
metabolic needs
c. Impaired airway clearance r/t thick secretions in trachea and
bronchi
d. Lack of knowledge r/t use of nebulizer and inhaled
bronchodilators
, The nurse is caring for a patient who developed a pulmonary a. The patient will maintain pulse oximetry values of at least 95% on room air.
embolism after surgery. Which goal statement is the highest
priority for the nurse to include in the patient's care plan for Oxygenation is the most important human need, so adequate oxygenation of tissues as
the diagnosis impaired gas exchange r/t impaired pulmonary evidenced by pulse oximetry values of at least 95% on room air is the highest priority
blood flow from embolus? goal. The other goals may be addressed once the oxygenation goal has been met.
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
to 10 scale.
d. The patient will ambulate 50 feet in hallway without
shortness of breath.
The nurse is caring for a patient with severe COPD who is a. Obtain an arterial blood gas to check for carbon dioxide retention.
becoming increasingly confused and disoriented. What is the
priority action of the nurse? Alteration of lung tissue may decrease delivery of oxygen to the alveoli, impede transfer
of oxygen from alveoli to the bloodstream, and hinder expulsion of carbon dioxide.
a. Obtain an arterial blood gas to check for carbon dioxide COPD causes impaired gas exchange, leading to decreased oxygen levels and higher
retention. circulating levels of carbon dioxide (i.e., respiratory acidosis). Confusion and
b. Increase the patient's oxygen until the pulse oximetry is disorientation in a patient with severe COPD may likely be due to carbon dioxide
greater than 98%. retention. An arterial blood gas should be drawn to determine if this is the case. COPD
c. Lower the head of the patient's bed and insert a nasal airway. patients should be kept on low oxygen flow rates whenever possible to avoid impeding
d. Administer a mild sedative and reorient the patient as the drive to breathe. Lowering the head of the bed will increase the difficulty of breathing
needed. as the abdominal contents press on the diaphragm. A sedative will cause respiratory
depression and should be avoided.
The nurse is caring for a patient who has been prescribed a. "You could have a stroke."
warfarin (Coumadin) therapy after being diagnosed with atrial
fibrillation. The patient asks the nurse what could happen if the A major complication of chronic atrial fibrillation is formation of blood clots within the
prescription doesn't get filled. What is the nurse's best atria due to sluggish blood flow. Anticoagulation therapy is common to prevent blood
response? clot formation that could travel to the brain, causing a stroke.
a. "You could have a stroke."
b. "Your kidneys could fail."
c. "You could develop heart failure."
d. "You could go into respiratory failure."
The preceptor is working with a new nurse to provide care for b. The collection device is emptied at the end of the shift and output recorded in the chart.
a patient with a chest tube to relieve a pneumothorax. Which
action by the new nurse indicates need for additional teaching The chest tube collection device is not emptied at the end of the shift. Instead, the amount
about chest tube care? of drainage present at the end of the shift (or specified time) is marked on the collection
device and the amount of drainage is documented in the patient's chart.
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.
The nurse is caring for a postoperative patient who has just b. "Do you have any chest pain or shortness of breath?"
been diagnosed with a deep vein thrombosis (DVT) in the
right leg. Which focused assessment question has the highest The highest risk of a DVT is the potential for the clot to break free and travel through the
priority for this patient? 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.
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?"
The nurse identifies which patient who would benefit from d. A patient with chronic bronchitis and congested cough.
postural drainage?
Patients who benefit from postural drainage therapy include those who are unable or
a. A patient with a heart murmur and jugular venous distention. reluctant to change body positions and patients with unilateral lung diseases that are
b. A patient with asthma and audible wheezing. related to poor oxygenation due to position. Patients who have diseases such as cystic
c. A patient with right-sided heart failure and pitting edema. fibrosis or bronchiectasis, COPD, abscesses, or difficulty removing secretions may
d. A patient with chronic bronchitis and congested cough. benefit from postural drainage therapy. A patient with chronic bronchitis and a congested,
productive cough would benefit from postural drainage because it would help clear the
airway.
