A nurse reads in a patient's chart that the patient experiences epistaxis
frequently. The nurse knows to avoid which procedure. - ANSWER
Nasogastric tube placement
How many attempts can the nurse make to perform tracheal suctioning
at one time? - ANSWER No more than three
A patient visits the clinic because of chronic fatigue. The patient is an
obese man with hay fever that causes predominantly nasal symptoms.
He reports going to bed early, sleeps for 8 hours, and still does not feel
rested on awakening. The nurse anticipates the patient will undergo
tests for which conditions? - ANSWER Obstructive sleep apnea (OSA)
The nurse observes that the airway of an infant patient is obstructed with
fluid. Which action should the nurse perform to free the airway? -
ANSWER Perform suctioning.
Dyspnea indicates a problem with which body system? - ANSWER
Respiratory
If a light is shined in the eyes of a patient during the physical
assessment and the pupils are noted to be equal, round, and reactive to
light and accommodation, which system is being tested? - ANSWER
Neurologic
A nurse who is performing the admission assessment of a patient
entering the long-term care facility learns that the patient must be in a
recliner to be able to sleep comfortably. The nurse documents this as
which condition? - ANSWER Orthopnea
(Rationale: Orthopnea is a condition in which the patient does not
breathe well when lying flat.)
, A nurse is working on the cardiac unit caring for a patient on a heart
monitor. The nurse determines the patient's heart rate to be 130
beats/min. Which term does the nurse use to describe this heart rate? -
ANSWER Tachycardia
A registered nurse (RN) needs to determine whether a patient has a
pulse deficit. The licensed practical/vocational nurse (LPN/LVN) has
been asked to assist. The RN signals and begins counting the apical
pulse. Which pulse rate would the LPN/LVN count to assist the RN in
determining whether a pulse deficit is present? - ANSWER Radial
A patient sits up to breathe and reports, "I can't catch my breath." Which
condition does the nurse suspect in the patient? - ANSWER Hypoxia
The nurse is preparing to use pulse oximetry to monitor the oxygen
saturation level in a patient. Which precautions should the nurse take
before applying the fingertip sensors? - ANSWER Remove the patient's
nail polish before applying the sensors.
Which size suction catheter would the nurse select to perform suctioning
in an adult? - ANSWER 12-Fr
(Rationale: The correct size for an adult nasotracheal suctioning catheter
is 12-Fr or 14-Fr. 6-Fr or 8-Fr to suction an infant. 10-Fr or 12-Fr
suctioning a child))
An elderly patient comes to the clinic wearing layers of clothing. The
patient's temperature on assessment is 99.8 F. Which action would the
nurse take next? - ANSWER Have the patient remove some of the
layers and reassess.
An emergency tracheostomy was performed on a patient. Which primary
intervention would the nurse carry out in the immediate postoperative
period? - ANSWER Placing a communication board at the bedside
(Rationale: The primary nursing responsibilities for maintaining a
tracheostomy tube are to keep the airway clear, keep the inner cannula
clean, prevent impairment of surrounding tissues, and provide the
patient with a means of communication.)
frequently. The nurse knows to avoid which procedure. - ANSWER
Nasogastric tube placement
How many attempts can the nurse make to perform tracheal suctioning
at one time? - ANSWER No more than three
A patient visits the clinic because of chronic fatigue. The patient is an
obese man with hay fever that causes predominantly nasal symptoms.
He reports going to bed early, sleeps for 8 hours, and still does not feel
rested on awakening. The nurse anticipates the patient will undergo
tests for which conditions? - ANSWER Obstructive sleep apnea (OSA)
The nurse observes that the airway of an infant patient is obstructed with
fluid. Which action should the nurse perform to free the airway? -
ANSWER Perform suctioning.
Dyspnea indicates a problem with which body system? - ANSWER
Respiratory
If a light is shined in the eyes of a patient during the physical
assessment and the pupils are noted to be equal, round, and reactive to
light and accommodation, which system is being tested? - ANSWER
Neurologic
A nurse who is performing the admission assessment of a patient
entering the long-term care facility learns that the patient must be in a
recliner to be able to sleep comfortably. The nurse documents this as
which condition? - ANSWER Orthopnea
(Rationale: Orthopnea is a condition in which the patient does not
breathe well when lying flat.)
, A nurse is working on the cardiac unit caring for a patient on a heart
monitor. The nurse determines the patient's heart rate to be 130
beats/min. Which term does the nurse use to describe this heart rate? -
ANSWER Tachycardia
A registered nurse (RN) needs to determine whether a patient has a
pulse deficit. The licensed practical/vocational nurse (LPN/LVN) has
been asked to assist. The RN signals and begins counting the apical
pulse. Which pulse rate would the LPN/LVN count to assist the RN in
determining whether a pulse deficit is present? - ANSWER Radial
A patient sits up to breathe and reports, "I can't catch my breath." Which
condition does the nurse suspect in the patient? - ANSWER Hypoxia
The nurse is preparing to use pulse oximetry to monitor the oxygen
saturation level in a patient. Which precautions should the nurse take
before applying the fingertip sensors? - ANSWER Remove the patient's
nail polish before applying the sensors.
Which size suction catheter would the nurse select to perform suctioning
in an adult? - ANSWER 12-Fr
(Rationale: The correct size for an adult nasotracheal suctioning catheter
is 12-Fr or 14-Fr. 6-Fr or 8-Fr to suction an infant. 10-Fr or 12-Fr
suctioning a child))
An elderly patient comes to the clinic wearing layers of clothing. The
patient's temperature on assessment is 99.8 F. Which action would the
nurse take next? - ANSWER Have the patient remove some of the
layers and reassess.
An emergency tracheostomy was performed on a patient. Which primary
intervention would the nurse carry out in the immediate postoperative
period? - ANSWER Placing a communication board at the bedside
(Rationale: The primary nursing responsibilities for maintaining a
tracheostomy tube are to keep the airway clear, keep the inner cannula
clean, prevent impairment of surrounding tissues, and provide the
patient with a means of communication.)
