NUR242 / NUR 242 Exam 3
Medical-Surgical Nursing Concepts
100% Guarantee passing score of 90% or higher
Consist of 50 Questions with Answers
1. The nurse recognizes that a patient with sleep apnea may benefit from which
intervention(s)? (Select all that apply.)
A. Weight loss
B. Nasal mask to deliver BiPAP
C. A change in sleeping position
D. Medication to increase daytime sleepiness
E. Position-fixing device that prevents tongue subluxation:
: ANSWER A, B, C, E
All interventions listed are viable interventions that can be of benefit to patients who
have sleep apnea. Patients should work with their providers of care to determine
the severity of their sleep apnea and which specific interventions would be of most
importance to them. Encouraging daytime sleepiness is the opposite of the effect
needed for this patient.
,2. Based on the patient's diagnosis, which clinical manifestations would the
nurse expect to see when assessing this patient? (Select all that apply.)
A. Bradycardia
B. Shortness of breath
C. Use of accessory muscles
D. Sitting in a forward posture
E. Barrel chest appearance:
: ANSWER B, C, D, E
The patient with COPD often has a barrel chest appearance, is short of breath,
and may use accessory muscles when breathing. These patients tend to move
slowly and are slightly stooped. Usually they sit with a forward-bending posture. With
severe dyspnea, they exhibit activity intolerance and activities such as bathing and
grooming are avoided.
3. When the patient arrives to the unit, she is assessed and is in acute respira-
tory distress. Her respirations are labored and her respiratory rate is 34. She
states that she had a peak flow meter measurement of "Red Zone" on the way
and is severely short of air. Her oxygen saturation is 82% on O2 at 2 L via nasal
cannula.
Based on these findings, what should the nurse do next?:
: ANSWER The Rapid Response Team should be notified immediately. All of these
,assessment findings indicate acute respiratory distress. The peak flow meter is in
the RED Zone. The oxygen saturation should be at least 90% on 2 L per NC.
4. While the Rapid Response Team is at the bedside, the patient's healthcare
provider arrives. The provider writes several orders.
Which order is most important for the nurse to implement immediately?
A. Transfer to ICU
B. Increase O2 to 3 L per nasal cannula
C. ABGs 30 minutes after oxygen is increased
D. Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP:
: ANSWER B
All of the provider's orders are very important, but based on the patient's severe
shortness of breath, the first thing that should be done is to increase her oxygen.
Once her oxygen is increased, the nurse should note the time and remember to
call for stat ABGs in 30 minutes. The patient should then be transferred to the ICU
as soon as possible. Once the patient arrives in the ICU, they can administer the
one-time dose of Solu-Medrol.
5. The nurse immediately checks on the patient and finds that she appears
anxious and her vital signs are as follows:
ØBlood pressure: 128/84 mm Hg
ØHeart rate: 114 (sinus tachycardia)
ØRespiratory rate: 24, labored and restless
, ØTemperature: 99.4° F (axillary)
ØO2 saturation: 91% on 40% O2 via trach collar
Which of these findings are cause for concern?:
: ANSWER **The BP is within normal range and only slightly elevated. **The
temperature is only slightly elevated. **Her heart rate is elevated; the nurse should
check the patient's medications to see if she is on a bronchodilator or other
medication that could cause her heart rate to increase. The priority concern is the
RESTLESSNESS with increased respiratory rate and the decreased oxygen
saturation despite the 40% oxygen setting.
6. A patient with a history of chronic obstructive pulmonary disease is admit-
ted with shortness of breath. Which nursing intervention is most appropriate?
A. Do not administer oxygen.
B. Administer oxygen via Venturi mask.
C. Use nasal cannula to administer high flow oxygen.
D. Administer oxygen at 6L per simple face mask.:
: ANSWER B
Oxygen therapy is prescribed at the lowest liter flow needed to manage hypoxemia.
A system that delivers more precise oxygen levels (e.g., a Venturi mask) is preferred.
Monitor the patient's response to therapy closely to ensure adequate gas exchange
and correction of hypoxemia.
7. While suctioning a patient, vagal stimulation occurs. What is the appropriate
Medical-Surgical Nursing Concepts
100% Guarantee passing score of 90% or higher
Consist of 50 Questions with Answers
1. The nurse recognizes that a patient with sleep apnea may benefit from which
intervention(s)? (Select all that apply.)
A. Weight loss
B. Nasal mask to deliver BiPAP
C. A change in sleeping position
D. Medication to increase daytime sleepiness
E. Position-fixing device that prevents tongue subluxation:
: ANSWER A, B, C, E
All interventions listed are viable interventions that can be of benefit to patients who
have sleep apnea. Patients should work with their providers of care to determine
the severity of their sleep apnea and which specific interventions would be of most
importance to them. Encouraging daytime sleepiness is the opposite of the effect
needed for this patient.
,2. Based on the patient's diagnosis, which clinical manifestations would the
nurse expect to see when assessing this patient? (Select all that apply.)
A. Bradycardia
B. Shortness of breath
C. Use of accessory muscles
D. Sitting in a forward posture
E. Barrel chest appearance:
: ANSWER B, C, D, E
The patient with COPD often has a barrel chest appearance, is short of breath,
and may use accessory muscles when breathing. These patients tend to move
slowly and are slightly stooped. Usually they sit with a forward-bending posture. With
severe dyspnea, they exhibit activity intolerance and activities such as bathing and
grooming are avoided.
3. When the patient arrives to the unit, she is assessed and is in acute respira-
tory distress. Her respirations are labored and her respiratory rate is 34. She
states that she had a peak flow meter measurement of "Red Zone" on the way
and is severely short of air. Her oxygen saturation is 82% on O2 at 2 L via nasal
cannula.
Based on these findings, what should the nurse do next?:
: ANSWER The Rapid Response Team should be notified immediately. All of these
,assessment findings indicate acute respiratory distress. The peak flow meter is in
the RED Zone. The oxygen saturation should be at least 90% on 2 L per NC.
4. While the Rapid Response Team is at the bedside, the patient's healthcare
provider arrives. The provider writes several orders.
Which order is most important for the nurse to implement immediately?
A. Transfer to ICU
B. Increase O2 to 3 L per nasal cannula
C. ABGs 30 minutes after oxygen is increased
D. Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP:
: ANSWER B
All of the provider's orders are very important, but based on the patient's severe
shortness of breath, the first thing that should be done is to increase her oxygen.
Once her oxygen is increased, the nurse should note the time and remember to
call for stat ABGs in 30 minutes. The patient should then be transferred to the ICU
as soon as possible. Once the patient arrives in the ICU, they can administer the
one-time dose of Solu-Medrol.
5. The nurse immediately checks on the patient and finds that she appears
anxious and her vital signs are as follows:
ØBlood pressure: 128/84 mm Hg
ØHeart rate: 114 (sinus tachycardia)
ØRespiratory rate: 24, labored and restless
, ØTemperature: 99.4° F (axillary)
ØO2 saturation: 91% on 40% O2 via trach collar
Which of these findings are cause for concern?:
: ANSWER **The BP is within normal range and only slightly elevated. **The
temperature is only slightly elevated. **Her heart rate is elevated; the nurse should
check the patient's medications to see if she is on a bronchodilator or other
medication that could cause her heart rate to increase. The priority concern is the
RESTLESSNESS with increased respiratory rate and the decreased oxygen
saturation despite the 40% oxygen setting.
6. A patient with a history of chronic obstructive pulmonary disease is admit-
ted with shortness of breath. Which nursing intervention is most appropriate?
A. Do not administer oxygen.
B. Administer oxygen via Venturi mask.
C. Use nasal cannula to administer high flow oxygen.
D. Administer oxygen at 6L per simple face mask.:
: ANSWER B
Oxygen therapy is prescribed at the lowest liter flow needed to manage hypoxemia.
A system that delivers more precise oxygen levels (e.g., a Venturi mask) is preferred.
Monitor the patient's response to therapy closely to ensure adequate gas exchange
and correction of hypoxemia.
7. While suctioning a patient, vagal stimulation occurs. What is the appropriate
