ACTUAL EXAM 500 QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS)
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The nurse in the community health center identifies which of the following types
of food is MOST likely to present problems for a client with respiratory
difficulties?
1. Fruits
2. Grains
3. Diary
4. Fish
Answer: Dairy
Diary products such as milk and cheese are mucus-producing; this would cause
problems for persons with respiratory difficulties since it could cause secretions
and/or thicken secretions that are already there; the person has difficulty
expelling these, making breathing difficult and also providing a medium for
bacterial growth; cystic fibrosis, pneumonia, and cerebrovascular accident
(CVA) are examples of conditions where secretions are a serious problem.
,A patient diagnosed with chronic obstructive pulmonary disease (COPD) is
drowsy and unable to expectorate secretions. The nurse should take which of the
following actions.
1. Force fluids
2. Administer high-flow oxygen via mask
3. Perform nasotracheal suction
4. Perform postural drainage.
Answer Perform nasotracheal suction
If patient is unable to expectorate sections, suctioning is appropriate; auscultate
breath sounds to determine if suctioning is required.
Which of the following actions is essential for the nurse to take after arterial
blood gases are drawn?
1. Apply pressure to puncture site
2. Check and record vital signs
3. Give 100% oxygen
4. Assess for presences of ulnar pulse
Answer: Apply pressure to puncture site
Blood gases measure acid/base balance; following arterial puncture, pressure
should be applied to the site for a full five minutes by the clock to prevent
bleeding or hematoma formation.
,The nurse teaches pursed-lip breathing to a patient diagnosed with COPD. The
nurse understands which of the following BEST describes the underlying purpose
of this type of breathing?
1. Prevent air trapping
2. Strengthen oral musculature
3. Promote deep relaxation
4. Enhance inspiration capacity
Answer: Prevent air trapping
As air is pushed against the small opening between the lips, the resistance
created goes backwards and through the airways and pushes them open
throughout
expiration; pursing lips also prolongs exhalation; all this results in a delay of
airway compression or collapse, allowing more air to escape and preventing air
trapping;
in pursed lip breathing, the patient breathes in deeply through the nose, hold it
for a moment, and then exhales slowly through lips that are almost closed or
pursed as if the patient were going to whistle; exhalation should be at least
twice as long as
inhalation.
, The nurse cares for patients on the medical/surgical unit. The nurse expects postural
drainage to e ordered for which of the following patients?
1. A patient diagnosed with cystic fibrosis.
2. A patient diagnosed with ascities due to cirrhosis.
3. A patient diagnosed with lymphedema
4. A patient diagnosed with a subdural hematoma.
Answer: A patient diagnosed with cystic fibrosis.
Postural drainage is a treatment of choice for cystic fibrosis because of serious
respiratory dysfunction; postural drainage involves using gravity, along with
percussion and vibration to facilitate drainage of secretions form bronchi and
lungs into the trachea where coughing and suctioning can expel them; involves
patient
assuming a range of positions, most of them with the head down.
The clinic nurse instructs a client in the used of a metered dose inhaler (MDI). Which
statement by the client indicates the need for further teaching?
1. I will breathe in deeply and slowly as I press down on the canister.
2. I will hold the mouth piece 2 inches in front of my mouth
3. I will count to 10 on my fingers after I breathe in
4. I will be careful not to shake the canister before I use it
Answer: I will be careful not to shake the canister before I use it.
Incorrect understanding; before using the canister it should be shaken vigorously to
disperse and mix the aerosol propellant with the medication in order to ensure
correct dosage is administered; MDI is a hand held device which enables a
person to intermittently give themselves an exact amount of medication in a
readily