NUR 2115 / NUR 211 Exam 2 Fundamentals of Nursing

NUR 2115 / NUR 211 Exam 2 Fundamentals of Nursing 1. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath would be… A. Maintain the patient on strict bed rest at all times B. Maintain the patient in an orthopneic position as needed C. Administer oxygen by Venturi mask at 24%, as needed D. Allow a 1 hour rest period between activities B. When a patient develops dyspnea and shortness of breath, the orthopneic position encourages maximum chest expansion and keeps the abdominal organs from pressing against the diaphragm, thus improving ventilation. Bed rest and oxygen by Venturi mask at 24% would improve oxygenation of the tissues and cells but must be ordered by a physician. Allowing for rest periods decreases the possibility of hypoxia. 2. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse documents this breathing as: A. Tachypnea B. Eupnca C. Orthopnea D. Hyperventilation C. Orthopnea is difficulty of breathing except in the upright position. Tachypnea is rapid respiration characterized by quick, shallow breaths. Eupnea is normal respiration – quiet, rhythmic, and without effort. 3. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for: A. Instructing the patient about this diagnostic test B. Writing the order for this test C. Giving the patient breakfast D. All of the above C. A platelet count evaluates the number of platelets in the circulating blood volume. The nurse is responsible for giving the patient breakfast at the scheduled time. The physician is responsible for instructing the patient about the test and for writing the order for the test. 4. Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include: A. A ham and Swiss cheese sandwich on whole wheat bread B. Mashed potatoes and broiled chicken C. A tossed salad with oil and vinegar and olives D. Chicken bouillon B. Mashed potatoes and broiled chicken are low in natural sodium chloride. Ham,