NSG 3130 EXAM 4 TEST BANK QUESTIONS
The nurse finds the patient in cardiopulmonary arrest
b. Bag-valve-mask unit
with no 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
a.Non-rebreather mask
no spontaneous respirations. The non-rebreather mask and nasal cannula require
b.Bag-valve-mask unit
the patient to breathe on his or her own. CPAP is used for patients who are awake,
c. Continuous positive airway pressure (CPAP)
oriented, and in respiratory failure.
d.High-flow nasal cannula
The nurse is caring for a patient who is slow to
a. Insert an oral airway.
awaken following general anesthesia. The patient is
breathing spontaneously but is minimally responsive
An oral (oropharyngeal) airway will prevent the patient's tongue from falling back
and having difficulty maintaining a patent airway. Which
and occluding the airway. Lowering the head of the bed will only increase airway
intervention is the most appropriate for the patient to
occlusion and risk of aspiration. Turning the patient's head to the side will not clear
improve oxygenation?
the back of the patient's tongue from the airway. Monitoring the patient's pulse
oximetry will not improve oxygenation or clear the airway.
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.
, The nurse is caring for a patient with a history of left-
a. Administer the ordered intravenous diuretic.
sided congestive heart failure who is acutely short of
breath.
The patient's respiratory distress is due to pulmonary edema and fluid overload
The nurse hears fine crackles throughout both lung
from left-sided congestive heart failure. A patient with heart failure may be on
fields and notes that the patient's pulse oximetry is only
diuretics. A diuretic will pull the excess fluid out of the body through the urine and
88% on 4 L of oxygen. What is the priority
relieve the patient's distress. A chest tube is not needed as the fluid is within the
intervention of the nurse?
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
a. Administer the ordered intravenous diuretic.
symptoms.
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.
The nurse is caring for a patient who has been
a. Placement of a tracheostomy tube
intubated with an oral endotracheal tube for several
weeks. The physicians predict that the patient will need
Placement of a tracheostomy tube will secure the patient's airway directly through
to remain on a ventilator for at least several more
the trachea, eliminating the need for the endotracheal tube. This will make the
weeks before he will be able to maintain his airway
patient more comfortable and may allow eating while minimizing damage to the
and breathe on his own.
oropharynx from the endotracheal tube.
What procedure does the nurse anticipate will be
planned for the patient to facilitate
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
a. Clamp the chest tube until the collection device is replaced.
who was transported to radiology for testing. When the
patient returns to the nursing unit, the transporter shows
The broken collection device may no longer be used to collect chest
the nurse the patient's chest tube collection device,
tube drainage. Clamping the chest tube until the collection device is
which was badly damaged after being caught in the
replaced will prevent air from entering the lung space until the new
elevator door. What is the priority action of the
collection device is attached.
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
c. Impaired airway clearance r/t thick secretions in trachea and bronchi.
for pneumonia. Which nursing diagnosis has the
highest priority?
Airway maintenance and patency is the highest priority for all patients, especially
patients with respiratory disorders. Oxygenation is the most important human
a. Activity intolerance r/t generalized weakness
need. The other diagnoses can apply once the patient's airway is kept patent.
and hypoxemia
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 finds the patient in cardiopulmonary arrest
b. Bag-valve-mask unit
with no 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
a.Non-rebreather mask
no spontaneous respirations. The non-rebreather mask and nasal cannula require
b.Bag-valve-mask unit
the patient to breathe on his or her own. CPAP is used for patients who are awake,
c. Continuous positive airway pressure (CPAP)
oriented, and in respiratory failure.
d.High-flow nasal cannula
The nurse is caring for a patient who is slow to
a. Insert an oral airway.
awaken following general anesthesia. The patient is
breathing spontaneously but is minimally responsive
An oral (oropharyngeal) airway will prevent the patient's tongue from falling back
and having difficulty maintaining a patent airway. Which
and occluding the airway. Lowering the head of the bed will only increase airway
intervention is the most appropriate for the patient to
occlusion and risk of aspiration. Turning the patient's head to the side will not clear
improve oxygenation?
the back of the patient's tongue from the airway. Monitoring the patient's pulse
oximetry will not improve oxygenation or clear the airway.
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.
, The nurse is caring for a patient with a history of left-
a. Administer the ordered intravenous diuretic.
sided congestive heart failure who is acutely short of
breath.
The patient's respiratory distress is due to pulmonary edema and fluid overload
The nurse hears fine crackles throughout both lung
from left-sided congestive heart failure. A patient with heart failure may be on
fields and notes that the patient's pulse oximetry is only
diuretics. A diuretic will pull the excess fluid out of the body through the urine and
88% on 4 L of oxygen. What is the priority
relieve the patient's distress. A chest tube is not needed as the fluid is within the
intervention of the nurse?
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
a. Administer the ordered intravenous diuretic.
symptoms.
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.
The nurse is caring for a patient who has been
a. Placement of a tracheostomy tube
intubated with an oral endotracheal tube for several
weeks. The physicians predict that the patient will need
Placement of a tracheostomy tube will secure the patient's airway directly through
to remain on a ventilator for at least several more
the trachea, eliminating the need for the endotracheal tube. This will make the
weeks before he will be able to maintain his airway
patient more comfortable and may allow eating while minimizing damage to the
and breathe on his own.
oropharynx from the endotracheal tube.
What procedure does the nurse anticipate will be
planned for the patient to facilitate
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
a. Clamp the chest tube until the collection device is replaced.
who was transported to radiology for testing. When the
patient returns to the nursing unit, the transporter shows
The broken collection device may no longer be used to collect chest
the nurse the patient's chest tube collection device,
tube drainage. Clamping the chest tube until the collection device is
which was badly damaged after being caught in the
replaced will prevent air from entering the lung space until the new
elevator door. What is the priority action of the
collection device is attached.
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
c. Impaired airway clearance r/t thick secretions in trachea and bronchi.
for pneumonia. Which nursing diagnosis has the
highest priority?
Airway maintenance and patency is the highest priority for all patients, especially
patients with respiratory disorders. Oxygenation is the most important human
a. Activity intolerance r/t generalized weakness
need. The other diagnoses can apply once the patient's airway is kept patent.
and hypoxemia
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
