Nur201 Exam 3 Questions With Correct
Detailed Answers.
The nurse observes that a patient with respiratory disease experiences a decrease in
SpO2 from 93% to 88% while the patient is ambulating. What is the priority action of the
nurse?
a. Notify the health care provider.
b. Administer PRN supplemental O2.
c. Document the response to exercise.
d. Encourage the patient to pace activity. - ANSWER- b
A patient with acute shortness of breath is admitted to the hospital. Which action should
the nurse take during the initial assessment of the patient?
a. Ask the patient to lie down to complete a full physical assessment.
b. Briefly ask specific questions about this episode of respiratory distress.
c. Complete the admission database to check for allergies before treatment.
d. Delay the physical assessment to first complete pulmonary function tests. -
ANSWER- b
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How
should the nurse position the patient?
a. High-Fowler's position with the left arm extended
b. Supine with the head of the bed elevated 30 degrees
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table - ANSWER- d
A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg;
PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding?
a. Intercostal retractions c. Low oxygen saturation (SpO2)
b. Kussmaul respirations d. Decreased venous O2 pressure - ANSWER- b
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds
during inhalation in the lower third of both lungs. How should the nurse document this
finding?
a. Inspiratory crackles at the bases
b. Expiratory wheezes in both lungs
c. Abnormal lung sounds in the apices of both lungs
d. Pleural friction rub in the right and left lower lobes - ANSWER- a
The nurse teaches a patient about pulmonary spirometry testing. Which statement, if
made by the patient, indicates teaching was effective?
a. "I should use my inhaler right before the test."
b. "I won't eat or drink anything 8 hours before the test."
,c. "I will inhale deeply and blow out hard during the test."
d. "My blood pressure and pulse will be checked every 15 minutes." - ANSWER- c
The nurse observes a student who is listening to a patient's lungs. Which action by the
student indicates a need to review respiratory assessment skills?
a. The student compares breath sounds from side to side at each level.
b. The student listens during the inspiratory phase, then moves the stethoscope.
c. The student starts at the apices of the lungs, moving down toward the lung bases.
d. The student instructs the patient to breathe slowly and deeply through the mouth. -
ANSWER- b
A patient who has a history of chronic obstructive pulmonary disease (COPD) was
hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of
89% to 90%). In planning for discharge, which action by the nurse will be most effective
in improving compliance with discharge teaching?
a. Have the patient repeat the instructions immediately after teaching.
b. Accomplish the patient teaching just before the scheduled discharge.
c. Arrange for the patient's caregiver to be present during the teaching.
d. Start giving the patient discharge teaching during the admission process. - ANSWER-
c
A patient admitted to the emergency department complaining of sudden onset
shortness of breath is diagnosed with a possible pulmonary embolus. How should the
nurse prepare the patient for diagnostic testing to confirm the diagnosis?
a. Ensure that the patient has been NPO.
b. Start an IV so contrast media may be given.
c. Inform radiology that radioactive glucose preparation is needed.
d. Instruct the patient to expect to inspire deeply and exhale forcefully. - ANSWER- b
The nurse palpates the posterior chest while the patient says "99" and notes absent
fremitus. Which action should the nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally. - ANSWER- d
A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which
intervention will the nurse implement directly after the procedure?
a. Encourage the patient to drink clear liquids.
b. Place the patient on bed rest for at least 4 hours.
c. Keep the patient NPO until the gag reflex returns.
d. Maintain the head of the bed elevated 90 degrees. - ANSWER- c
The nurse completes a shift assessment on a patient admitted in the early phase of
heart failure. When auscultating the patient's lungs, which finding would the nurse most
likely hear?
, a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
b. Continuous high-pitched musical sounds on inspiration and expiration
c. Discontinuous, high-pitched sounds of short duration during inspiration
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration -
ANSWER- c
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who
has been admitted with increasing dyspnea over the past 3 days. Which finding is
important for the nurse to report to the health care provider?
a. Respirations are 36 breaths/min.
b. Anterior-posterior chest ratio is 1:1.
c. Lung expansion is decreased bilaterally.
d. Hyperresonance to percussion is present. - ANSWER- a
The laboratory has just called with the arterial blood gas (ABG) results on four patients.
Which result is most important for the nurse to report immediately to the health care
provider?
a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
b. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95%
c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%
d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96% - ANSWER- d
After the nurse has received change-of-shift report, which patient should the nurse
assess first?
a. A patient with pneumonia who has crackles in the right lung base
b. A patient with chronic bronchitis who has a low forced vital capacity
c. A patient with possible lung cancer who has just returned after bronchoscopy
d. A patient with hemoptysis and a 16-mm induration after tuberculin skin testing -
ANSWER- c
Using the illustrated technique, the nurse is assessing for which finding in a patient with
chronic obstructive pulmonary disease (COPD)?
a. Hyperresonance c. Reduced excursion
b. Tripod positioning d. Accessory muscle use - ANSWER- c
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel
(UAP)?
a. Listen to a patient's lung sounds for wheezes or crackles.
b. Label specimens obtained during percutaneous lung biopsy.
c. Instruct a patient about how to use home spirometry testing.
d. Measure induration at the site of a patient's intradermal skin test. - ANSWER- b
A patient is scheduled for a computed tomography (CT) scan of the chest with contrast
media. Which assessment findings should the nurse report to the health care provider
before the patient goes for the CT (select all that apply)?
Detailed Answers.
The nurse observes that a patient with respiratory disease experiences a decrease in
SpO2 from 93% to 88% while the patient is ambulating. What is the priority action of the
nurse?
a. Notify the health care provider.
b. Administer PRN supplemental O2.
c. Document the response to exercise.
d. Encourage the patient to pace activity. - ANSWER- b
A patient with acute shortness of breath is admitted to the hospital. Which action should
the nurse take during the initial assessment of the patient?
a. Ask the patient to lie down to complete a full physical assessment.
b. Briefly ask specific questions about this episode of respiratory distress.
c. Complete the admission database to check for allergies before treatment.
d. Delay the physical assessment to first complete pulmonary function tests. -
ANSWER- b
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How
should the nurse position the patient?
a. High-Fowler's position with the left arm extended
b. Supine with the head of the bed elevated 30 degrees
c. On the right side with the left arm extended above the head
d. Sitting upright with the arms supported on an over bed table - ANSWER- d
A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg;
PaO2 85 mm Hg; HCO3- 18 mEq/L. The nurse would expect which finding?
a. Intercostal retractions c. Low oxygen saturation (SpO2)
b. Kussmaul respirations d. Decreased venous O2 pressure - ANSWER- b
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds
during inhalation in the lower third of both lungs. How should the nurse document this
finding?
a. Inspiratory crackles at the bases
b. Expiratory wheezes in both lungs
c. Abnormal lung sounds in the apices of both lungs
d. Pleural friction rub in the right and left lower lobes - ANSWER- a
The nurse teaches a patient about pulmonary spirometry testing. Which statement, if
made by the patient, indicates teaching was effective?
a. "I should use my inhaler right before the test."
b. "I won't eat or drink anything 8 hours before the test."
,c. "I will inhale deeply and blow out hard during the test."
d. "My blood pressure and pulse will be checked every 15 minutes." - ANSWER- c
The nurse observes a student who is listening to a patient's lungs. Which action by the
student indicates a need to review respiratory assessment skills?
a. The student compares breath sounds from side to side at each level.
b. The student listens during the inspiratory phase, then moves the stethoscope.
c. The student starts at the apices of the lungs, moving down toward the lung bases.
d. The student instructs the patient to breathe slowly and deeply through the mouth. -
ANSWER- b
A patient who has a history of chronic obstructive pulmonary disease (COPD) was
hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of
89% to 90%). In planning for discharge, which action by the nurse will be most effective
in improving compliance with discharge teaching?
a. Have the patient repeat the instructions immediately after teaching.
b. Accomplish the patient teaching just before the scheduled discharge.
c. Arrange for the patient's caregiver to be present during the teaching.
d. Start giving the patient discharge teaching during the admission process. - ANSWER-
c
A patient admitted to the emergency department complaining of sudden onset
shortness of breath is diagnosed with a possible pulmonary embolus. How should the
nurse prepare the patient for diagnostic testing to confirm the diagnosis?
a. Ensure that the patient has been NPO.
b. Start an IV so contrast media may be given.
c. Inform radiology that radioactive glucose preparation is needed.
d. Instruct the patient to expect to inspire deeply and exhale forcefully. - ANSWER- b
The nurse palpates the posterior chest while the patient says "99" and notes absent
fremitus. Which action should the nurse take next?
a. Palpate the anterior chest and observe for barrel chest.
b. Encourage the patient to turn, cough, and deep breathe.
c. Review the chest x-ray report for evidence of pneumonia.
d. Auscultate anterior and posterior breath sounds bilaterally. - ANSWER- d
A patient with a chronic cough is scheduled to have a bronchoscopy with biopsy. Which
intervention will the nurse implement directly after the procedure?
a. Encourage the patient to drink clear liquids.
b. Place the patient on bed rest for at least 4 hours.
c. Keep the patient NPO until the gag reflex returns.
d. Maintain the head of the bed elevated 90 degrees. - ANSWER- c
The nurse completes a shift assessment on a patient admitted in the early phase of
heart failure. When auscultating the patient's lungs, which finding would the nurse most
likely hear?
, a. Continuous rumbling, snoring, or rattling sounds mainly on expiration
b. Continuous high-pitched musical sounds on inspiration and expiration
c. Discontinuous, high-pitched sounds of short duration during inspiration
d. A series of long-duration, discontinuous, low-pitched sounds during inspiration -
ANSWER- c
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who
has been admitted with increasing dyspnea over the past 3 days. Which finding is
important for the nurse to report to the health care provider?
a. Respirations are 36 breaths/min.
b. Anterior-posterior chest ratio is 1:1.
c. Lung expansion is decreased bilaterally.
d. Hyperresonance to percussion is present. - ANSWER- a
The laboratory has just called with the arterial blood gas (ABG) results on four patients.
Which result is most important for the nurse to report immediately to the health care
provider?
a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
b. pH 7.35, PaO2 85 mm Hg, PaCO2 50 mm Hg, and O2 sat 95%
c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%
d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96% - ANSWER- d
After the nurse has received change-of-shift report, which patient should the nurse
assess first?
a. A patient with pneumonia who has crackles in the right lung base
b. A patient with chronic bronchitis who has a low forced vital capacity
c. A patient with possible lung cancer who has just returned after bronchoscopy
d. A patient with hemoptysis and a 16-mm induration after tuberculin skin testing -
ANSWER- c
Using the illustrated technique, the nurse is assessing for which finding in a patient with
chronic obstructive pulmonary disease (COPD)?
a. Hyperresonance c. Reduced excursion
b. Tripod positioning d. Accessory muscle use - ANSWER- c
Which action is appropriate for the nurse to delegate to unlicensed assistive personnel
(UAP)?
a. Listen to a patient's lung sounds for wheezes or crackles.
b. Label specimens obtained during percutaneous lung biopsy.
c. Instruct a patient about how to use home spirometry testing.
d. Measure induration at the site of a patient's intradermal skin test. - ANSWER- b
A patient is scheduled for a computed tomography (CT) scan of the chest with contrast
media. Which assessment findings should the nurse report to the health care provider
before the patient goes for the CT (select all that apply)?
