NSG 3130 Exam 4 Test Questions
and Verified Answers- Galen
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. impaired nutritional intake r/t poor appetite and increased metabolic needs
C. impaired airway clearance r/t thick secretions in trachea and bronchi - correct
D. lack of knowledge r/t use of nebulizer and inhaled bronchodilators
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 - correct
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.
,The nurse is caring for a patient who has been prescribed warfarin (coumadin)
therapy after being diagnosed with atrial fibrillation... the patient asks the nurse
what could happen if the prescription doesn't get filled... what is the nurse's
best response?
A. “you could have a stroke.” - correct
B. “your kidneys could fail.”
C. “you could develop heart failure.”
D. “you could go into respiratory failure.”
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?” - correct
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?”
incentive spirometer use
every 2 hours or as needed
(another question was 10 times in the hour)
possible causes for hypoxia
, aspirated vomit, pulmonary fibrosis, high altitude, etc.
when a patient with a tracheostomy tube is taken care of at home by family,
tracheostomy care instructions from the nurse include: (select all that apply.)
A. avoid going to crowded theaters and malls
B. change catheters every 8 hours
C. keep the home environment free of dust
D. use bleach to clean suction equipment
E. All of the Above
when assessing the lungs of a patient, the nurse assesses a wheezing sound on
inspiration... this finding is documented as:
stridor
the nurse clarifies that the cough mechanism is stimulated when...
foreign substances are propelled by the cilia toward the respiratory tract
the nurse takes into consideration that a pulse oximeter may not give an
accurate reading if the patient is...
jaundiced
the nurse performing tracheotomy care will...
and Verified Answers- Galen
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. impaired nutritional intake r/t poor appetite and increased metabolic needs
C. impaired airway clearance r/t thick secretions in trachea and bronchi - correct
D. lack of knowledge r/t use of nebulizer and inhaled bronchodilators
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 - correct
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.
,The nurse is caring for a patient who has been prescribed warfarin (coumadin)
therapy after being diagnosed with atrial fibrillation... the patient asks the nurse
what could happen if the prescription doesn't get filled... what is the nurse's
best response?
A. “you could have a stroke.” - correct
B. “your kidneys could fail.”
C. “you could develop heart failure.”
D. “you could go into respiratory failure.”
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?” - correct
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?”
incentive spirometer use
every 2 hours or as needed
(another question was 10 times in the hour)
possible causes for hypoxia
, aspirated vomit, pulmonary fibrosis, high altitude, etc.
when a patient with a tracheostomy tube is taken care of at home by family,
tracheostomy care instructions from the nurse include: (select all that apply.)
A. avoid going to crowded theaters and malls
B. change catheters every 8 hours
C. keep the home environment free of dust
D. use bleach to clean suction equipment
E. All of the Above
when assessing the lungs of a patient, the nurse assesses a wheezing sound on
inspiration... this finding is documented as:
stridor
the nurse clarifies that the cough mechanism is stimulated when...
foreign substances are propelled by the cilia toward the respiratory tract
the nurse takes into consideration that a pulse oximeter may not give an
accurate reading if the patient is...
jaundiced
the nurse performing tracheotomy care will...
