NUR 354 EXAM #3 REVIEW QUESTIONS
AND ANSWERS
Priority decision: A pulse oximetry monitor indicates that the patient has a drop in SpO2
from 95% to 85% over several hours. What is the FIRST action the nurse should take?
a. order stat ABGs to confirm the SpO2 with a SaO2
b. start oxygen administration by nasal cannula at 2L/min
c. check the position of the probe on the finger or earlobe
d. notify the health care provider of the change in baseline PaO2 - Answer-Check the
position of the probe on the finger or earlobe
Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient?
a. patient with a fever
b. patient who is anesthetized
c. patient in hypovolemic shock
d. patient recieving oxygen therapy - Answer-patient in hypovolemic shock
A 73 y/o patient who has an SpO2 of 70%. What other assessment should the nurse
consider before making a judgment about the adequacy of the patients oxygenation?
a. what the oxygenation status is with a stress test
b. trend and rate of development of the hyperkalemia
c. comparison of patients SpO2 values with the normal values
d. Comparison of patients current vital signs with normal vital signs - Answer-
Comparison of patients current vital signs with normal vital signs
Which values indicate a need for the use of continuous oxygen therapy?
a. SpO2 of 92%; PaO2 of 65 mmHg
b. SpO2 of 95%; PaO2 of 70 mmHg
c. SpO2 of 90%; PaO2 of 60 mmHg
d. SpO2 of 88%; PaO2 55 mmHg - Answer-SpO2 of 88%; PaO2 55 mmHg
Why does a patients RR increase when there is an excess of carbon dioxide in the
blood?
a. CO2 displaces O2 on hemoglobin, leading to a decreased PaO2
b. CO2 causes an increase in the amount of hydrogen ions available in the body
c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal
fluid.
d. CO2 directly stimulates chemoreceptors in the medulla to increase RR and volume -
Answer-CO2 combines with water to form carbonic acid, which lowers the pH of
cerebrospinal fluid.
Which respiratory defense mechanism is most impaired by smoking?
a. Cough reflex
b. Filtration of air
, c. Mucocillary clearance
d. reflex bronchospasm - Answer-Mucociliary clearance
Which age related changes in the respiratory system cause decreased secretion
clearance (select all that apply)?
a. Decrease force of cough
b. decreased functional cilia
c. decreased chest wall compliance
d. small airway closure eariler in expiration
e. decreased functional immunoglobulin A (IgA) - Answer-a, b
The abdominal assessment findings of dullness and hyper resonance are found with
which assessment technique?
a. Inspection
b. palpation
c. percussion
d. auscultation - Answer-percussion
Palpation is the assessment technique used to find which abnormal assessment
findings (select all that apply)?
a. stridor
b. finger clubbing
c. tracheal deviation
d. limited chest expansion
e. increased tactile fremitus
f. use of accessory muscles - Answer-c, d, e
How does the nurse assess the patients chest expansion?
a. put the palms of the hands against the chest walls
b. put the index fingers on either side of the trachea
c. place the thumbs at the midline of the lower chest
d. place one hand on the lower anterior chest and one hand on the upper abdomen -
Answer-place the thumbs at the midline of the lower chest
When does the nurse record the presence of an increased anteroposterior (AP)
diameter of the chest?
a. there is a prominent protrusion of the sternum
b. the width of the chest is equal to the depth of the chest
c. there is equal but diminished movement of the two sides of the chest
d. the patient cannot fully expand the lungs because of kyphosis of the spine - Answer-
the width of the chest is equal to the depth of the chest
The patient is admitted with pneumonia, and the nurse hears a grating sound when she
assesses the patient. How should the nurse document this sound?
a. stridor
b. bronchophony
AND ANSWERS
Priority decision: A pulse oximetry monitor indicates that the patient has a drop in SpO2
from 95% to 85% over several hours. What is the FIRST action the nurse should take?
a. order stat ABGs to confirm the SpO2 with a SaO2
b. start oxygen administration by nasal cannula at 2L/min
c. check the position of the probe on the finger or earlobe
d. notify the health care provider of the change in baseline PaO2 - Answer-Check the
position of the probe on the finger or earlobe
Pulse oximetry may not be a reliable indicator of oxygen saturation in which patient?
a. patient with a fever
b. patient who is anesthetized
c. patient in hypovolemic shock
d. patient recieving oxygen therapy - Answer-patient in hypovolemic shock
A 73 y/o patient who has an SpO2 of 70%. What other assessment should the nurse
consider before making a judgment about the adequacy of the patients oxygenation?
a. what the oxygenation status is with a stress test
b. trend and rate of development of the hyperkalemia
c. comparison of patients SpO2 values with the normal values
d. Comparison of patients current vital signs with normal vital signs - Answer-
Comparison of patients current vital signs with normal vital signs
Which values indicate a need for the use of continuous oxygen therapy?
a. SpO2 of 92%; PaO2 of 65 mmHg
b. SpO2 of 95%; PaO2 of 70 mmHg
c. SpO2 of 90%; PaO2 of 60 mmHg
d. SpO2 of 88%; PaO2 55 mmHg - Answer-SpO2 of 88%; PaO2 55 mmHg
Why does a patients RR increase when there is an excess of carbon dioxide in the
blood?
a. CO2 displaces O2 on hemoglobin, leading to a decreased PaO2
b. CO2 causes an increase in the amount of hydrogen ions available in the body
c. CO2 combines with water to form carbonic acid, which lowers the pH of cerebrospinal
fluid.
d. CO2 directly stimulates chemoreceptors in the medulla to increase RR and volume -
Answer-CO2 combines with water to form carbonic acid, which lowers the pH of
cerebrospinal fluid.
Which respiratory defense mechanism is most impaired by smoking?
a. Cough reflex
b. Filtration of air
, c. Mucocillary clearance
d. reflex bronchospasm - Answer-Mucociliary clearance
Which age related changes in the respiratory system cause decreased secretion
clearance (select all that apply)?
a. Decrease force of cough
b. decreased functional cilia
c. decreased chest wall compliance
d. small airway closure eariler in expiration
e. decreased functional immunoglobulin A (IgA) - Answer-a, b
The abdominal assessment findings of dullness and hyper resonance are found with
which assessment technique?
a. Inspection
b. palpation
c. percussion
d. auscultation - Answer-percussion
Palpation is the assessment technique used to find which abnormal assessment
findings (select all that apply)?
a. stridor
b. finger clubbing
c. tracheal deviation
d. limited chest expansion
e. increased tactile fremitus
f. use of accessory muscles - Answer-c, d, e
How does the nurse assess the patients chest expansion?
a. put the palms of the hands against the chest walls
b. put the index fingers on either side of the trachea
c. place the thumbs at the midline of the lower chest
d. place one hand on the lower anterior chest and one hand on the upper abdomen -
Answer-place the thumbs at the midline of the lower chest
When does the nurse record the presence of an increased anteroposterior (AP)
diameter of the chest?
a. there is a prominent protrusion of the sternum
b. the width of the chest is equal to the depth of the chest
c. there is equal but diminished movement of the two sides of the chest
d. the patient cannot fully expand the lungs because of kyphosis of the spine - Answer-
the width of the chest is equal to the depth of the chest
The patient is admitted with pneumonia, and the nurse hears a grating sound when she
assesses the patient. How should the nurse document this sound?
a. stridor
b. bronchophony
