NSG3130/ NSG 3130 Exam 4 Final Prep 2026/ 2027 | Nursing Practice II (Galen) | Full Study Guide & Practice Questions

NSG3130/ NSG 3130 Exam 4 Final Prep 2026/ 2027 | Nursing Practice II (Galen) | Full Study Guide & Practice Questions Match the correct term on the left with the definition on the right. Group of answer choices 1. Systolic Pressure 2. Diastolic Pressure 3. Mean Arterial Pressure 4. Pulse Pressure maximum pressure when heart contracts lowest pressure when myocardium is relaxed average pressure in the arteries calculated by subtracting diastolic from systolic pressure Systolic Pressure- maximum pressure when heart contracts Diastolic Pressure- lowest pressure when myocardium is relaxed Mean Arterial Pressure- average pressure in the arteries Pulse Pressure- calculated by subtracting diastolic from systolic pressure The two parts of an at-risk nursing diagnosis statement are (select all that apply) 1. Etiology 2.Problem 3.Time 4.Signs and symptoms 1. Etiology 2. Problem The nurse continues to modify, or terminates the client's care plan during which phase of the nursing process? 1. Diagnosis 2. Evaluation 3. Implementing 4. Planning 5. Assessment 2. Evaluation The spouse of a client is recalling the modifiable risk factors for coronary heart disease. Which statement by the client's spouse indicates a need for further teaching? 1. "My wife's age is a modifiable risk factor." 2. "My wife's sedentary lifestyle is a modifiable risk factor." 3. "Diabetes is a modifiable risk factor." 4. "Obesity is a modifiable risk factor." 1. "My wife's age is a modifiable risk factor." A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the nurse describe as modifiable? 1. stress 2. allergies 3. family history 4. gender 1. stress A nurse is caring for a group of patients. Which patient should the nurse see first? 1. A patient with a chest tube ambulating with the chest tube unclamped 2. A patient with a new tracheostomy and tracheostomy obturator at bedside 3. A patient with thick secretions being tracheal suctioned first and then orally 4. A patient with hypercapnia wearing an oxygen mask 4. A patient with hypercapnia wearing an oxygen mask The nurse is discussing nutrition with a patient that has been diagnosed with hypertension. Which of the following, if stated by the patient, would show a correct understanding of the types of food that this patient can eat for lunch? 1. "I will prepare a grilled chicken breast on a wheat bun with low fat mayonnaise, mustard, and skim milk for lunch." 2. "I will prepare a bacon, lettuce, and tomato sandwich on whole wheat bread with low-fat mayonnaise and low-fat cheese with a diet soda." 3. "I will prepare canned soup, crackers, and unsweetened tea for lunch." 4. "I will prepare a ham sandwich on wheat bread with mayonnaise and mustard, lettuce, and tomatoes." 1. "I will prepare a grilled chicken breast on a wheat bun with low fat mayonnaise, mustard, and skim milk for lunch." Who can do the following task? (Select all that apply...may be one, two or three of the choices.) Insert a NG tube 1. LPN/ LPN 2. Registered Nurse (RN) 3. UAP 2. Registered Nurse (RN) Who can do the following task? (Select all that apply...may be one, two or three of the choices.) Central line insertion and management 1. LPN/ LPN 2. UAP 3. Registered Nurse (RN) 3. Registered Nurse (RN) Who can do the following task? (Select all that apply...may be one, two or three of the choices.) Blood glucose check by finger stick 1. LPN/LVN 2. UAP 3. Registered Nurse (RN) 1. LPN/LVN 2. UAP 3. Registered Nurse (RN) Who can do the following task? (Select all that apply...may be one, two or three of the choices.) Admission assessment 1. UAP 2. LPN/ LPN 3. Registered Nurse (RN) 3. Registered Nurse (RN) The nurse is caring for a patient who is having issues with their mitral valve. The nurse is explaining to the patient about the mitral valve. Which of the following is accurate? (Select all that apply.) 1. This valve is also known as the left atrioventricular valve because it sits between the left atrium and the left ventricle. 2. It is also known as the bicuspid valve. 3. Just like all valves, it has chordae tendineae which help the valves operate appropriately. 4. This valve is also known as the left atrioventricular valve because it sits between the left atrium and the pulmonary valve 1. This valve is also known as the left atrioventricular valve because it sits between the left atrium and the left ventricle. 2. It is also known as the bicuspid valve. 3. Just like all valves, it has chordae tendineae which help the valves operate appropriately. Match the term on the left with the appropriate definition on the right. Group of answer choices 1. endocardium 2. epicardium 3. mediastinum 4. murmur [ Choose ] Region between the lungs and the organs and vessels it contains. The inner layer of the heart which includes the valves. Abnormal heart sound. Membrane that forms the heart wall's outermost layer and is continuous with the lining of the fibrous pericardium; visceral pericardium. endocardium- The inner layer of the heart which includes the valves Abnormal heart sound. epicardium- Membrane that forms the heart wall's outermost layer and is continuous with the lining of the fibrous pericardium; visceral pericardium. mediastinum Region between the lungs and the organs and vessels it contains. murmur- Abnormal heart sound. Which client heart rate would cause the nurse to document bradycardia in the medical record? 1. 78 beats per minute 2. 58 beats per minute 3. 88 beats per minute 4. 68 beats per minute 58 beats per minute There are many vessels in the body. Where in the body would the nurse assess the renal and suprarenal veins? 1. arm 2. brain 3. abdomen 4. kidneys arm The patient has experienced a myocardial infarction resulting in damage to the left ventricle. A possible complication the patient may experience that the nurse is alert to is 1. peripheral edema 2. jugular neck vein distention 3. liver enlargement 4. pulmonary congestion pulmonary congestion Normal changes of aging may contribute to problems of circulation in older adults, even when there is no actual pathology. Which of the following is not a correct statement regarding the aging process and cardiovascular system? 1. An increase in baroreceptor response to blood pressure changes makes the heart and blood vessels more responsive to exercise and stress. 2. Blood vessels become less elastic and have an increase in calcification. 3. A decrease of muscle tone in the heart results in a decrease in cardiac output. 4. Impaired valve function in the heart is often the result of increased stiffness and calcification and results in a decrease in cardiac output. An increase in baroreceptor response to blood pressure changes makes the heart and blood vessels more responsive to exercise and stress. A nurse is planning a seminar on promoting a healthy heart. Which of the following statements is incorrect? 1. Eat a diet low in total fat, saturated, fats, cholesterol, and sodium. 2. Exercise at least 20 minutes, three times per week 3. Reduce stress and manage anger. 4. Do not smoke. Exercise at least 20 minutes, three times per week You are caring for a client who needs to eat what is known as a DASH diet. Which of the following would be appropriate to tell the client to eat? (Select all that apply.) 1. Full-fat dairy products 2. Foods rich in calcium and magnesium 3. Eating plenty of fruits and vegetables 4. Plenty of whole grains, nuts and seeds Foods rich in calcium and magnesium Eating plenty of fruits and vegetables Plenty of whole grains, nuts and seeds Match the term on the left with the appropriate definition on the right. Group of answer choices 1. systole 2. tachycardia 3. valve 4. ventricle [ Choose ] Structure that prevents fluid from flowing backward, as in the heart, veins, and lymphatic vessels. Contraction; adj., systolic Cavity or chamber. One of the heart's two lower chambers. One of the brain's four chambers in which cerebrospinal fluid is produced; adj., ventricular. Heart rate more than 100 beats per minute in an adult. systole Contraction; adj., systolic tachycardia Heart rate more than 100 beats per minute in an adult. valve Structure that prevents fluid from flowing backward, as in the heart, veins, and lymphatic vessels. ventricle Cavity or chamber. One of the heart's two lower chambers. One of the brain's four chambers in which cerebrospinal fluid is produced; adj., ventricular. Which is the only vein within the circulatory system that carries freshly oxygenated blood to the heart? 1. pulmonary vein 2. superior vena cava 3. jugular vein 4. inferior vena cava pulmonary vein The nurse is caring for a patient who is having issues with their pulmonary valve. The nurse is explaining to the patient about the pulmonary valve. Which of the following is accurate? (Select all that apply.) 1. This valve is located between the right ventricle and the pulmonary trunk portion of the pulmonary artery 2. This valve opens as the heart pumps oxygenated blood to the lungs 3. This valve sits between the right atrium and the right ventricle 4. This valve is also known as the pulmonic valve 5. This valve opens as the heart pushes de-oxygenated blood to the lungs 6. This valve is located between the right ventricle and the pulmonary vein This valve is located between the right ventricle and the pulmonary trunk portion of the pulmonary artery This valve is also known as the pulmonic valve This valve opens as the heart pushes de-oxygenated blood to the lungs Cardiac output equals the rate of the heart rate multiplied by stroke volume. In other words: CO= [ Select ] 1. RR 2. HR 3. BP X [ Select ] 1. SV 2. CO 3. HR. HR; SV There are 4 chambers of the heart. Which of the following is accurate regarding the right atrium? (Select all that apply.) 1. Receives blood from the inferior vena cava 2. Thick walled chamber 3. Receives blood from the superior vena cava 4. Delivers blood to the right ventricle through the mitral valve 5. Delivers blood to the right ventricle through the tricuspid valve Receives blood from the inferior vena cava Receives blood from the superior vena cava Delivers blood to the right ventricle through the tricuspid valve Match the blood components on the left and the proper patients who would receive them on the right. 1. Plasma 2. Whole blood [ Choose ] For clients who need the fluid (volume). Good in emergencies when there isn't time to type and cross. Is all the parts of the blood, requires a type and cross. For clients who need the fluid (volume). Good in emergencies when there isn't time to type and cross. Is all the parts of the blood, requires a type and cross. A nurse is providing care to a client who comes to the Emergency Department with a very large cut on their leg which is bleeding. The nurse explains that the healthcare team will assist with stopping the bleeding and to assist the body with wound healing. Which of the following responses would be correct for the nurse to share with the client? (Select all that apply.) 1. Your body will form a plug of platelets to help stop the bleeding until the full healing occurs. 2. Your body will form a clot by the process of coagulation. 3. Your body to going to vasoconstrict the blood vessels (make them smaller) which will decrease the bleeding. 4. Your body will form a clot by the process called immunity. 5. Your body is going to vasodilate or widen the diameter of the vessels which will decrease bleeding. Your body will form a plug of platelets to help stop the bleeding until the full healing occurs. Your body will form a clot by the process of coagulation. Your body to going to vasoconstrict the blood vessels (make them smaller) which will decrease the bleeding. The nurse is aware that blood type O is considered the universal donor. This means all patients can receive blood type O. Knowing this, which of the following statements is correct. (Select all that apply.) 1. The client with blood type AB can receive type O. 2. A client with the blood type AB can receive blood type A. 3. The client with blood type AB can receive blood type B. 4. The client with AB can receive blood type ABO. The client with blood type AB can receive type O. A client with the blood type AB can receive blood type A. The client with blood type AB can receive blood type B. The client with AB can receive blood type ABO. Complete the sentences with the appropriate explanation. 1. The erythrocyte 2, The leukocyte 3. The platelets [ Select ] are cell fragments and are involved in blood clotting are cell fragments and are involved in the oxygen are white blood cells and help fight infections and cancer are cell fragments and are involved in the oxygen are white blood cells and help fight infections and cancer are cell fragments and are involved in blood clotting The nurse is caring for someone with a low red blood cell (erythrocyte) count. The nurse explains the function of the erythrocyte is to (select all that apply.) 1. carry some carbon dioxide 2. assist with immunity 3. assist with clotting 4. carry oxygen bound to hemoglobin carry some carbon dioxide carry oxygen bound to hemoglobin Match the term on the left with the appropriate meaning on the right. Group of answer choices 1. erythrocytes 2. leukocytes 3. platelets [ Choose ] form platelet plugs and start clotting (coagulation) carry oxygen and carbon dioxide assist in immunity carry oxygen and carbon dioxide assist in immunity form platelet plugs and start clotting (coagulation) The spouse of a client is recalling the modifiable risk factors for coronary heart disease. Which statement by the client's spouse indicates a need for further teaching? a. "My wife's age is a modifiable risk factor." b. "Diabetes is a modifiable risk factor." c. "Obesity is a modifiable risk factor." d. "My wife's sedentary lifestyle is a modifiable risk factor." "My wife's age is a modifiable risk factor." The nurse is teaching a client about methods to decrease the client's homocysteine level. Which statement by the client indicates a need for further teaching? a. "Homocysteine is an amino acid that may increase my risk for developing heart disease." b. "Homocysteine levels may be decreased by taking a multivitamin with folate." c. "Homocysteine is an enzyme that increases my cholesterol level, which increases by risk for developing heart disease." d. "Homocysteine levels may be decreased by taking a multivitamin with B6 and B12." "Homocysteine is an enzyme that increases my cholesterol level, which increases by risk for developing heart disease." Normal changes of aging may contribute to problems of circulation in older adults, even when there is no actual pathology. Which of the following is not a correct statement regarding the aging process and cardiovascular system? a. A decrease of muscle tone in the heart results in a decrease in cardiac output. b. Blood vessels become less elastic and have an increase in calcification. c. Impaired valve function in the heart is often the result of increased stiffness and calcification and results in a decrease in cardiac output. d. An increase in baroreceptor response to blood pressure changes makes the heart and blood vessels more responsive to exercise and stress. (There is a decrease in baroreceptor response) An increase in baroreceptor response to blood pressure changes makes the heart and blood vessels more responsive to exercise and stress. (There is a decrease in baroreceptor response) A nurse is planning a seminar on promoting a healthy heart. Which of the following statements is incorrect? a. Reduce stress and manage anger. b. Exercise at least 20 minutes, three times per week c. Do not smoke. d. Eat a diet low in total fat, saturated, fats, cholesterol, and sodium. Exercise at least 20 minutes, three times per week Which of the following would be a sign of heart failure? a. Pulmonary congestion; adventitious lungs sound b. Decreased respiratory rate c. Warm, red extremities d. Decreased heart rate S/S of heart failure are: #1, SOB, increased heart rate, increased respiratory rate, peripheral vasoconstriction, cold, pale extremities, distended neck veins Pulmonary congestion; adventitious lungs sound The nurse is discussing nutrition with a patient that has been diagnosed with hypertension. Which of the following, if stated by the patient, would show a correct understanding of the types of food that this patient can eat for lunch? a. "I will prepare canned soup, crackers, and unsweetened tea for lunch." b. "I will prepare a ham sandwich on wheat bread with mayonnaise and mustard, lettuce, and tomatoes." c. "I will prepare a grilled chicken breast on a wheat bun with low fat mayonnaise, mustard, and skim milk for lunch." d. "I will prepare a bacon, lettuce, and tomato sandwich on whole wheat bread with low-fat mayonnaise and low-fat cheese with a diet soda." "I will prepare a grilled chicken breast on a wheat bun with low fat mayonnaise, mustard, and skim milk for lunch." The home health nurse has developed a teaching guide for a client with cardiovascular risk factors that focuses on the importance of regular physical activity with gradually increasing activity levels. This teaching guide specifically promotes which topic? a. Cardiac output and tissue perfusion b. Renal perfusion and formation of urine c. Oxygen-carrying capacity of white blood cells d. Effective breathing and airway clearance Cardiac output and tissue perfusion Rationales a. Correct. Regular physical activity will help promote healthy cardiac functioning and will also promote tissue perfusion. b. Improving tissue perfusion may also improve renal perfusion but it is not the primary goal. c. Red blood cells carry oxygen. d. Cardiac output and tissue perfusion improve the respiratory system performance. Which would most likely be included in the evaluation of the client goal of "Demonstrate adequate tissue perfusion"? a. Symmetrical chest expansion b. Uses pursed-lip breathing c. Brisk capillary refill d. Activity intolerance Brisk capillary refill Rationales a. Symmetrical chest expansion is an assessment of respiratory function. b. Pursed-lip breathing is a technique used to assist clients with obstructive lung diseases to keep alveoli open during respirations. c. Correct. Capillary refill is an assessment of capillary blood flow and thus tissue perfusion. d. Activity intolerance can occur because of low cardiac output (e.g., heart failure). Activity tolerance would indicate adequate tissue perfusion. Which client is most likely to experience poor cardiac output? a. A client who has recently completed exercising and is talking easily with an exercise partner b. A client who has a stroke volume of 70 mL per beat and a heart rate of 70 beats/minute c. A client with a sustained heart rate of 150 beats/minute d. A client who receives a positive inotropic medication A client with a sustained heart rate of 150 beats/minute Rationales a. Option A is normal. b. Option B is a normal cardiac output of 4900 mL/min. The formula is SV × HR CO is about 5 L/min. c. Correct. Very rapid heart rates do not allow adequate time for the ventricles to fill, causing cardiac output to fall. d. Option D: Positive inotropic drugs (e.g., digoxin) increase contractility of the cardiac muscle and thus increase stroke volume, which increases cardiac output. Which set of assessment data best validates that the nurse should initiate cardiopulmonary resuscitation on a comatose client? a. Cool, pale skin; unconsciousness; absence of radial pulse b. Cyanosis, slow pulse, dilated pupils c. Absent pulses, flushed skin, pinpoint pupils d. Apnea, absence of carotid or femoral pulses, dilated pupils Apnea, absence of carotid or femoral pulses, dilated pupils Rationales a. Incorrect. b. Incorrect. c. Incorrect. d. Correct. The three cardinal signs of cardiac arrest are absence of heart beat, cessation of breathing(apnea), and the absence of circulation reflected in dilated pupils. The surgeon ordered sequential compression devices (SCDs) to be applied postoperatively. The client asks why the SCDs are needed. Which is the best response by the nurse when teaching the client about the purpose of SCDs? a. They promote arterial circulation. b. They promote venous return from the legs. c. They decrease afterload. d. They decrease postoperative pain. They promote venous return from the legs. Rationales a. Arterial flow is from the heart to the general circulation. b. Correct. The sequential compression devices promote venous return from the legs to the heart. They inflate and deflate plastic sleeves wrapped around the legs to promote venous flow. This sequential inflation and deflation counteracts blood stasis in the lower extremities. c. Afterload is related to the ventricles' ability to eject blood forward. These devices affect peripheral circulation. d. No relationship between pain and the purpose of the devices. 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 b. Bag-valve-mask unit 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 spontaneous respirations. The non-rebreather mask and nasal cannula require the patient to breathe on his or her own. CPAP is used for patients who are awake, oriented, and in respiratory failure. 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. a. Insert an oral airway. An oral (oropharyngeal) 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. 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. a. Administer the ordered intravenous diuretic. The patient's respiratory distress is due to pulmonary edema and fluid overload from left-sided congestive heart failure. A patient with heart failure may be on diuretics. 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. 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 recovery? a. Placement of a tracheostomy tube b. Diagnostic thoracentesis c. Pulmonary angiogram d. Lung transplantation surgery a. Placement of a tracheostomy tube 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 eating while minimizing damage to the oropharynx from the endotracheal tube. 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. a. Clamp the chest tube until the collection device is replaced. 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 the lung space until the new collection device is attached. 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 d. Lack of knowledge r/t use of nebulizer and inhaled bronchodilators c. Impaired airway clearance r/t thick secretions in trachea and bronchi. 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. 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 to 10 scale. d. The patient will ambulate 50 feet in hallway without shortness of breath. a. The patient will maintain pulse oximetry values of at least 95% on room air. 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. 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. a. Obtain an arterial blood gas to check for carbon dioxide retention. 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. COPD causes impaired gas exchange, leading to decreased oxygen levels and higher circulating levels of carbon dioxide (i.e., respiratory acidosis). 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. 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." b. "Your kidneys could fail." c. "You could develop heart failure." d. "You could go into respiratory failure." a. "You could have a stroke." A major complication of chronic atrial fibrillation is formation of blood clots within the atria due to sluggish blood flow. Anticoagulation therapy is common to prevent blood clot formation that could travel to the brain, causing a stroke. 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. b. The collection device is emptied at the end of the shift and output recorded in the chart. 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 is documented in the patient's chart. 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?" b. "Do you have any chest pain or shortness of breath?" 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. The nurse identifies which patient who 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. d. A patient with chronic bronchitis and congested cough. Patients who benefit from postural drainage therapy include those who are unable or reluctant to change body positions and patients with unilateral lung diseases that are related to poor oxygenation due to position. Patients who have diseases such as cystic fibrosis or bronchiectasis, COPD, abscesses, or difficulty removing secretions may 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. The nurse is caring for a patient who has a history of congestive heart failure with generalized pitting edema. Which laboratory results will the nurse expect to find in the patient's chart? a. Glycosylated hemoglobin 12% b. Platelet count 450,000/mm3 c. Hematocrit 32% d. Prothrombin time 8.8 seconds c. Hematocrit 32% Hemodilution may be found 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 due to congestive heart failure or fluid overload. 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 d. Total cholesterol level 185 mg/dL A total cholesterol level higher than 200 mg/dL is considered a risk factor for atherosclerosis, 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. 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 important blood vessels that provide oxygen to the heart muscle? a. Cardiac catheterization b. Chest x-ray c. Echocardiogram d. Electrocardiogram a. Cardiac catheterization 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. 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 c. Echocardiogram Echocardiograms allow for ultrasound visualization of the structures of the heart along with function of the heart valves and cardiac musculature. 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 a. Checking the patient's right pedal pulse and warmth of the right leg Cardiac catheterization includes the insertion of a large IV needle into the patient's right femoral or brachial artery to view the left side of the heart and inserted into the antecubital or femoral vein to view structures on the right side of the heart. In this case, 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. 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 more than 88%. 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. a. Reduce the oxygen flow rate until the patient's pulse oximetry value is more than 88%. COPD causes impaired gas exchange, leading to decreased oxygen levels and higher circulating levels of carbon dioxide. For COPD patients the PCP often orders oxygen to be titrated to keep the oxygen saturation above 88%. Oxygen saturation may decrease during exercise, sleep, or deterioration of the respiratory status. For the patient with COPD, use low-flow oxygen delivery only (2 L/min) unless a higher level of oxygen administration is indicated by low oxygen saturation levels. High-flow oxygen may lead to respiratory suppression caused by loss of the patient's drive to breathe. For COPD patients the PCP often orders oxygen to be titrated to keep the oxygen saturation above 88%. Therefore, the nurse should reduce the oxygen flow rate until the patient's pulse oximetry is more than 88% and educate the patient about oxygen therapy for COPD. 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. c. Maintain eye contact and provide calm reassurance. e. Administer the ordered nebulized bronchodilator. f. Elevate the head of the patient's bed to fully upright. 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 of more than 88%. The nurse is performing a respiratory assessment on a patient. Which assessment findings indicate to the nurse that the patient has a history of long-standing chronic respiratory disease? (Select all that apply.) a. All the patient's fingernails are noticeably clubbed. b. The patient needs to sleep on at least four to five pillows at night. c. The patient's chest has equal antero-posterior and transverse diameters. d. The patient's lower legs have large areas of brownish spotted discoloration. e. The patient reports puffiness of both feet when standing for long periods. f. The patient's forced vital capacity test result is 3.8 L of air. a. All the patient's fingernails are noticeably clubbed. b. The patient needs to sleep on at least four to five pillows at night. c. The patient's chest has equal antero-posterior and transverse diameters. Clubbing of fingernails, the need to sleep in an upright position, and a barrel chest are all indicative of long-standing chronic respiratory disease like COPD. Brownish spotted discoloration is indicative of venous insufficiency. Edema can be seen in renal and heart failure. Forced vital capacity of almost 4 L is found in patients with good respiratory function. The nurse notes the following findings when assessing a patient with COPD. Which require prompt nursing intervention? (Select all that apply.) a. The patient is unable to speak without gasping. b. The patient's sputum has turned from yellow to greenish-brown. c. The patient has dyspnea and wheezes heard in all lung fields. d. The patient's forced vital capacity has increased from 2.8 to 3.4 L. e. The patient has become confused and mildly disoriented. a. The patient is unable to speak without gasping. b. The patient's sputum has turned from yellow to greenish-brown. c. The patient has dyspnea and wheezes heard in all lung fields. e. The patient has become confused and mildly disoriented. A patient who is unable to speak without gasping is indicative of poor airflow through the airways, which must be addressed promptly. Greenish-brown sputum may indicate pneumonia requiring antibiotic treatment. Dyspnea and wheezes are indicative of an acute asthma attack. Confusion and disorientation in a patient with COPD may indicate retention of carbon dioxide. Increased forced vital capacity is a positive sign. The nurse is working with a nursing assistant to care for a patient with a new tracheostomy. Which tasks may the nurse delegate to the assistant? (Select all that apply.) a. Obtaining masks, gloves, and suction supplies from the utility room b. Helping to reassure the patient before, during, and after suctioning c. Changing the Velcro or twill ties used to secure the tracheostomy d. Transporting sputum specimens to the lab for culture and sensitivity testing e. Assessing need for suctioning of the oropharynx or tracheostomy f. Teaching the patient how to remove and clean the inner cannula a. Obtaining masks, gloves, and suction supplies from the utility room b. Helping to reassure the patient before, during, and after suctioning d. Transporting sputum specimens to the lab for culture and sensitivity testing Care of a new tracheostomy may not be delegated to a nursing assistant. Obtaining supplies needed for care, helping to reassure the patient, and bringing specimens to the lab are tasks that may be assigned to the assistant. The preceptor is working with a new nurse to provide care for a patient with a new tracheostomy. Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.) a. The outer cannula is cleaned with the brush and half-strength H2O2. b. The new tracheostomy holder is secured before the old soiled one is removed. c. A Yankauer suction catheter is used to remove secretions from the patient's mouth. d. Sterile gloves are applied before the soiled dressing is removed from the tracheostomy. e. Half-strength H2O2 is used to remove crusted secretions around the tracheostomy site. f. Pain medication is administered to the patient prior to suctioning. a. The outer cannula is cleaned with the brush and half-strength H2O2. d. Sterile gloves are applied before the soiled dressing is removed from the tracheostomy. e. Half-strength H2O2 is used to remove crusted secretions around the tracheostomy site. Only the inner cannula of the tracheostomy is removed for cleaning. The outer cannula stays in the trachea to maintain airway patency. Clean gloves are applied before the soiled dressing is removed. Normal sterile saline is used to remove secretions that have built up on the inner cannula and also is used to clean the patient's skin as needed. The preceptor is working with a new nurse to suction a patient through a new tracheostomy. Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.) a. The suction is not applied to the catheter until it is being withdrawn. b. The patient is placed in the supine position prior to suctioning. c. The suction catheter is twirled side to side as it is being withdrawn. d. Suction is applied continuously as the catheter is withdrawn. e. The patient's oxygen is reapplied between suction attempts. f. Water-soluble lubricant is applied to the suction catheter before insertion. b. The patient is placed in the supine position prior to suctioning. d. Suction is applied continuously as the catheter is withdrawn. f. Water-soluble lubricant is applied to the suction catheter before insertion. The head of the patient's bed should be elevated prior to suctioning to facilitate coughing out secretions. Suction is always applied intermittently as the catheter is withdrawn. Water-soluble lubricant is used when suctioning the naris but not a tracheostomy because the secretions negate the need for additional lubrication.