Linda Waterfall VSim feedback 2023 Mental
Health 100% CORRECT
Expected assessment findings of a patient with pneumonia may include which of the
following? (Select all that apply.)
a. Enuresis
b. Malaise
c. Use of accessory muscles
d. Tachypnea
e. Fever - ANSWER: b. Malaise
c. Use of accessory muscles
d. Tachypnea
e. Fever
A patient in semi-fowlers is having difficulty breathing. What is the priority action of
the nurse?
a. Auscultate the lungs
b. Call respiratory therapy
c. Conduct a pain assessment
d. Raise the head of the bed - ANSWER: d. Raise the head of the bed
A patient demonstrates correct usage of the incentive spirometer when the patient
places the mouthpiece in the mouth and does which of the following?
a. Inhales quickly and forcefully
b. Inhales slowly and deeply
c. Exhales slowly and deeply
d. Exhales quickly and forcefully - ANSWER: b. Inhales slowly and deeply
A patient with newly diagnosed pneumonia has an oxygen saturation of 94% on
room air, an increased respiratory rate, and an increased pulse rate. The patient is
pale and anxious. The nurse questions the oxygen saturation results and looks up
which of the following test results?
a. WBC count
b. Gram stain
c. Chest X-ray
d. Hemoglobin - ANSWER: d. Hemoglobin
A patient states he does not want to use the incentive spirometer because it makes
the patient cough up too much sputum, and it is difficult to breathe. What is the
correct information to teach the patient about the incentive spirometer?
,a. You have to use your incentive spirometer because your provider has ordered it
for you.
b. The incentive spirometer will cause you to cough less because you are moving
more air through your lungs.
c. The incentive spirometer helps you to maximize lung function and minimize the
risk for atelectasis.
d. You should wait to use your incentive spirometer until you are not coughing up so
much sputum. - ANSWER: c. The incentive spirometer helps you to maximize lung
function and minimize the risk for atelectasis.
The nurse titrates the patients oxygen to 3L per nasal cannula in order to maintain
an oxygen saturation of at least 94%, per the provider's orders. What is the rationale
for this order? (Select all that apply.)
a. Allows the body to meet metabolic demands
b. Promotes a decrease in myocardial workload
c. Prevents atelectasis in a patient with pneumonia
d. Promotes a decrease in respiratory effort
e. Allows the patient to receive 100% oxygen - ANSWER: a. Allows the body to meet
metabolic demands
b. Promotes a decrease in myocardial workload
d. Promotes a decrease in respiratory effort
While completing discharge instructions with a patient, the nurse notices the patient
is short of breath. What is the priority nursing action at this time?
a. Ask if the patient has support at home
b. Determine if the patient has any questions
c. Reassure the patient
d. Listen to the patients lungs - ANSWER: d. Listen to the patients lungs
During her hospitalization for pneumonia, the provider orders arterial blood gases
for Mona Hernandez. What is the best explanation for why this is ordered?
a. Patient has a productive cough with rust colored sputum
b. Patient has shallow, ineffective breathing
c. Patient has fever and malaise
d. Patient has a history of smoking 1/2 a pack of cigarettes per day - ANSWER: b.
Patient has shallow ineffective breathing
Mona Hernandez's lab work indicates an elevated WBC count with a left shift in the
differential. The nurse interprets this to mean which of the following?
a. There is a high number of WBC, but not immature WBC, present in the circulation.
b. There is a high number of WBC to fight the infection, and the RBC are
compensation.
c. A left shift in the differential means that there is no infection present.
, d. There is a high number of WBC and immature WBC present to fight infection. -
ANSWER: d. There is a high number of WBC and immature WBC present to fight
infection.
Mona Hernandez's blood gas results indicate respiratory acidosis. Her oxygen
saturation is 95% per the pulse oximeter. Which interventions should the nurse
provide? (Select all that apply.)
a. Assist the patient with adequate ventilation
b. Promote voluntary coughing activities to clear secretions
c. None; the patient has a 95% oxygenation
d. Provide supplemental oxygen as ordered
e. Ensure the patient is well hydrated - ANSWER: a. Assist the patient with adequate
ventilation
b. Promote voluntary coughing activities to clear secretions
d. Provide supplemental oxygen as ordered
e. Ensure the patient is well hydrated
Identify the following potential problems or actual problems that the nurse should
include when planning care for the patient diagnosed with pneumonia? (Select all
that apply. )
a. Metabolic acidosis
b. Difficulty breathing
c. Ineffective respiratory gas exchange
d. Not able to tolerate activity
e. Acute pain - ANSWER: b. Difficulty breathing
c. Ineffective respiratory gas exchange
d. Not able to tolerate activity
e. Acute pain
Mona Hernandez asks the nurse why it is necessary to use the incentive spirometer
when she is already having difficulty breathing. What is the BEST response by the
nurse?
a. It helps prevent atelectasis or collapsing o the alveoli in the lungs
b. It increases the oxygen taken in by the lungs when you inhale
c. It was ordered by your provider
d. It decreases cardiac workload during inspiration - ANSWER: a. It helps prevent
atelectasis or collapsing o the alveoli in the lungs
A nurse rounding on a patient with pneumonia notices the patient is more confused
than at the beginning of the shift. What is the best response by the nurse?
a. Notify the provider
b. Ensure a sitter is available to watch the patient
c. Check oxygen saturation level
Health 100% CORRECT
Expected assessment findings of a patient with pneumonia may include which of the
following? (Select all that apply.)
a. Enuresis
b. Malaise
c. Use of accessory muscles
d. Tachypnea
e. Fever - ANSWER: b. Malaise
c. Use of accessory muscles
d. Tachypnea
e. Fever
A patient in semi-fowlers is having difficulty breathing. What is the priority action of
the nurse?
a. Auscultate the lungs
b. Call respiratory therapy
c. Conduct a pain assessment
d. Raise the head of the bed - ANSWER: d. Raise the head of the bed
A patient demonstrates correct usage of the incentive spirometer when the patient
places the mouthpiece in the mouth and does which of the following?
a. Inhales quickly and forcefully
b. Inhales slowly and deeply
c. Exhales slowly and deeply
d. Exhales quickly and forcefully - ANSWER: b. Inhales slowly and deeply
A patient with newly diagnosed pneumonia has an oxygen saturation of 94% on
room air, an increased respiratory rate, and an increased pulse rate. The patient is
pale and anxious. The nurse questions the oxygen saturation results and looks up
which of the following test results?
a. WBC count
b. Gram stain
c. Chest X-ray
d. Hemoglobin - ANSWER: d. Hemoglobin
A patient states he does not want to use the incentive spirometer because it makes
the patient cough up too much sputum, and it is difficult to breathe. What is the
correct information to teach the patient about the incentive spirometer?
,a. You have to use your incentive spirometer because your provider has ordered it
for you.
b. The incentive spirometer will cause you to cough less because you are moving
more air through your lungs.
c. The incentive spirometer helps you to maximize lung function and minimize the
risk for atelectasis.
d. You should wait to use your incentive spirometer until you are not coughing up so
much sputum. - ANSWER: c. The incentive spirometer helps you to maximize lung
function and minimize the risk for atelectasis.
The nurse titrates the patients oxygen to 3L per nasal cannula in order to maintain
an oxygen saturation of at least 94%, per the provider's orders. What is the rationale
for this order? (Select all that apply.)
a. Allows the body to meet metabolic demands
b. Promotes a decrease in myocardial workload
c. Prevents atelectasis in a patient with pneumonia
d. Promotes a decrease in respiratory effort
e. Allows the patient to receive 100% oxygen - ANSWER: a. Allows the body to meet
metabolic demands
b. Promotes a decrease in myocardial workload
d. Promotes a decrease in respiratory effort
While completing discharge instructions with a patient, the nurse notices the patient
is short of breath. What is the priority nursing action at this time?
a. Ask if the patient has support at home
b. Determine if the patient has any questions
c. Reassure the patient
d. Listen to the patients lungs - ANSWER: d. Listen to the patients lungs
During her hospitalization for pneumonia, the provider orders arterial blood gases
for Mona Hernandez. What is the best explanation for why this is ordered?
a. Patient has a productive cough with rust colored sputum
b. Patient has shallow, ineffective breathing
c. Patient has fever and malaise
d. Patient has a history of smoking 1/2 a pack of cigarettes per day - ANSWER: b.
Patient has shallow ineffective breathing
Mona Hernandez's lab work indicates an elevated WBC count with a left shift in the
differential. The nurse interprets this to mean which of the following?
a. There is a high number of WBC, but not immature WBC, present in the circulation.
b. There is a high number of WBC to fight the infection, and the RBC are
compensation.
c. A left shift in the differential means that there is no infection present.
, d. There is a high number of WBC and immature WBC present to fight infection. -
ANSWER: d. There is a high number of WBC and immature WBC present to fight
infection.
Mona Hernandez's blood gas results indicate respiratory acidosis. Her oxygen
saturation is 95% per the pulse oximeter. Which interventions should the nurse
provide? (Select all that apply.)
a. Assist the patient with adequate ventilation
b. Promote voluntary coughing activities to clear secretions
c. None; the patient has a 95% oxygenation
d. Provide supplemental oxygen as ordered
e. Ensure the patient is well hydrated - ANSWER: a. Assist the patient with adequate
ventilation
b. Promote voluntary coughing activities to clear secretions
d. Provide supplemental oxygen as ordered
e. Ensure the patient is well hydrated
Identify the following potential problems or actual problems that the nurse should
include when planning care for the patient diagnosed with pneumonia? (Select all
that apply. )
a. Metabolic acidosis
b. Difficulty breathing
c. Ineffective respiratory gas exchange
d. Not able to tolerate activity
e. Acute pain - ANSWER: b. Difficulty breathing
c. Ineffective respiratory gas exchange
d. Not able to tolerate activity
e. Acute pain
Mona Hernandez asks the nurse why it is necessary to use the incentive spirometer
when she is already having difficulty breathing. What is the BEST response by the
nurse?
a. It helps prevent atelectasis or collapsing o the alveoli in the lungs
b. It increases the oxygen taken in by the lungs when you inhale
c. It was ordered by your provider
d. It decreases cardiac workload during inspiration - ANSWER: a. It helps prevent
atelectasis or collapsing o the alveoli in the lungs
A nurse rounding on a patient with pneumonia notices the patient is more confused
than at the beginning of the shift. What is the best response by the nurse?
a. Notify the provider
b. Ensure a sitter is available to watch the patient
c. Check oxygen saturation level
