NUR 235 Exam 1 (Oxygenation, Mobility, Cognition) - :
Questions With Step-by-Step Solutions
A patient with lung cancer develops respiratory distress. What action should
the nurse take first? Right Ans - Check SpO2
A patient with emphysema develops respiratory distress. Which common
symptoms would you look for? Right Ans - restlessness, tachycardia,
dyspnea
Which of the following are subjective signs of need for O2? Right Ans - light
headedness, headache, fatigue
Which of the following are objective signs of need for O2? Right Ans -
decreased SpO2, cyanosis, decreased LOC
The nurse is caring for a patient with a tracheostomy. Which assessment
finding would require immediate intervention by the nurse? Right Ans -
airway obstruction
When air or fluid enters into the pleural space, especially if resulting from
trauma, gas exchange is disrupted, and pressure ______________________________,
creating a pneumo/hemothorax. Right Ans - equalizes
A pneumothorax or hemothorax results from the loss of _______________
pressure in the pleural space. Right Ans - negative
As a prudent nurse you know that trach tubes with cuffs should be inflated
with _________________ of H20. Right Ans - 20-25 cm
The nurse is preparing to provide care for a patient with a tracheostomy.
While reviewing the plan of care for this patient which interventions can the
nurse safely implement? Right Ans - using humidified air
The nurse is preparing to provide care for a patient scheduled to receive a
bedside tracheostomy. While reviewing the plan of care for this patient which
interventions should the nurse question? Right Ans - positioning the
patient in High Fowlers position
,As a prudent nurse you know that in order to perform a bedside
tracheostomy, you should request the presence of which member of the
medical term during the procedure? Right Ans - respiratory therapist
The patient you are currently caring for has questioned the doctor's order to
have a tracheostomy placed rather than an endotracheal tube. As a student
nurse who has just taken Med Surg 2, you know that the correct answer is?
Right Ans - The tracheostomy allows for better oral hygiene and, therefore,
prevention of pneumonia.
The nurse prepares to administer oxygen to a patient diagnosed in respiratory
distress. When administering this medication to the patient which action by
the nurse would be considered negligent? Right Ans - Administering 6L of
oxygen
Which of the following is not an appropriate means of confirming placement
of tracheostomy placement? Right Ans - palpating the stoma site
The nurse is caring for a patient diagnosed with a tracheostomy. Which
assessment finding would require immediate intervention by the nurse?
Right Ans - lack of assessment of stoma and patency in 48 hrs
Your patient has rolled in their sleep and dislodged their new trach resulting
in decannulation. What is the first step you should take? Right Ans - call for
help
You are educating a patient and their spouse about trach care in preparation
for discharge. Which of the following statements made by the patient would
indicate that further teaching is necessary? Right Ans - Once my stoma is
healed I do not need to observe for signs or symptom of infection.
Which factor ultimately decides if a patient should have an inflated cuff on
their trach? Right Ans - risk for aspiration
T/F: Once a patient has a tracheostomy, it is irreversible and the patient will
no longer be able to speak. Right Ans - False
, When educating a patient prior to decannulation, which statement by the
patient indicates that the teaching has been understood? Right Ans - My
stoma will heal and close within 4-5 days and splinting will be necessary.
Which of the following food choices would be inappropriate for the patient
with a cuffed tracheostomy tube? Right Ans - celery
Which of the following etiologies is responsible for 85% of head and neck
cancers? Right Ans - smoking
T/F: Head and neck cancer predominately affects men over the age of 50.
Right Ans - true
You are currently counseling a patient with a person history of smoking and
exposure to industrial carcinogens about the prevention of head and neck
cancer. As a prudent nurse, what do you tell your patient is the best
preventative method for survival? Right Ans - early detection
Which of the following are symptoms of head and neck cancer? (SATA)
A. chronic sore throat
B. a painless indurated ulcer on the lip
C. a palpable mass that causes no pain
D. chronic laryngitis
E. a white buildup on the tongue Right Ans - all of the above
You are currently caring for a 65 year old male who has a personal history of
smoking and has been complaining of chronic hoarseness and sore throats for
the last 3 months. The strep A test is negative and when you assess his oral
cavity you notice a white patch on the patient's tongue. Which of the following
symptoms would indicate that this patient is starting to decline? Right Ans
- tooth and ear pain
What does TNM stand for? Right Ans - tumor size, number and location of
involved lymph nodes, and extent of metastasis
After your patient is notified of their neck biopsy results confirming squamous
cell carcinoma, which treatment do you suspect the doctor will suggest due to
its efficacy? Right Ans - surgical removal
Questions With Step-by-Step Solutions
A patient with lung cancer develops respiratory distress. What action should
the nurse take first? Right Ans - Check SpO2
A patient with emphysema develops respiratory distress. Which common
symptoms would you look for? Right Ans - restlessness, tachycardia,
dyspnea
Which of the following are subjective signs of need for O2? Right Ans - light
headedness, headache, fatigue
Which of the following are objective signs of need for O2? Right Ans -
decreased SpO2, cyanosis, decreased LOC
The nurse is caring for a patient with a tracheostomy. Which assessment
finding would require immediate intervention by the nurse? Right Ans -
airway obstruction
When air or fluid enters into the pleural space, especially if resulting from
trauma, gas exchange is disrupted, and pressure ______________________________,
creating a pneumo/hemothorax. Right Ans - equalizes
A pneumothorax or hemothorax results from the loss of _______________
pressure in the pleural space. Right Ans - negative
As a prudent nurse you know that trach tubes with cuffs should be inflated
with _________________ of H20. Right Ans - 20-25 cm
The nurse is preparing to provide care for a patient with a tracheostomy.
While reviewing the plan of care for this patient which interventions can the
nurse safely implement? Right Ans - using humidified air
The nurse is preparing to provide care for a patient scheduled to receive a
bedside tracheostomy. While reviewing the plan of care for this patient which
interventions should the nurse question? Right Ans - positioning the
patient in High Fowlers position
,As a prudent nurse you know that in order to perform a bedside
tracheostomy, you should request the presence of which member of the
medical term during the procedure? Right Ans - respiratory therapist
The patient you are currently caring for has questioned the doctor's order to
have a tracheostomy placed rather than an endotracheal tube. As a student
nurse who has just taken Med Surg 2, you know that the correct answer is?
Right Ans - The tracheostomy allows for better oral hygiene and, therefore,
prevention of pneumonia.
The nurse prepares to administer oxygen to a patient diagnosed in respiratory
distress. When administering this medication to the patient which action by
the nurse would be considered negligent? Right Ans - Administering 6L of
oxygen
Which of the following is not an appropriate means of confirming placement
of tracheostomy placement? Right Ans - palpating the stoma site
The nurse is caring for a patient diagnosed with a tracheostomy. Which
assessment finding would require immediate intervention by the nurse?
Right Ans - lack of assessment of stoma and patency in 48 hrs
Your patient has rolled in their sleep and dislodged their new trach resulting
in decannulation. What is the first step you should take? Right Ans - call for
help
You are educating a patient and their spouse about trach care in preparation
for discharge. Which of the following statements made by the patient would
indicate that further teaching is necessary? Right Ans - Once my stoma is
healed I do not need to observe for signs or symptom of infection.
Which factor ultimately decides if a patient should have an inflated cuff on
their trach? Right Ans - risk for aspiration
T/F: Once a patient has a tracheostomy, it is irreversible and the patient will
no longer be able to speak. Right Ans - False
, When educating a patient prior to decannulation, which statement by the
patient indicates that the teaching has been understood? Right Ans - My
stoma will heal and close within 4-5 days and splinting will be necessary.
Which of the following food choices would be inappropriate for the patient
with a cuffed tracheostomy tube? Right Ans - celery
Which of the following etiologies is responsible for 85% of head and neck
cancers? Right Ans - smoking
T/F: Head and neck cancer predominately affects men over the age of 50.
Right Ans - true
You are currently counseling a patient with a person history of smoking and
exposure to industrial carcinogens about the prevention of head and neck
cancer. As a prudent nurse, what do you tell your patient is the best
preventative method for survival? Right Ans - early detection
Which of the following are symptoms of head and neck cancer? (SATA)
A. chronic sore throat
B. a painless indurated ulcer on the lip
C. a palpable mass that causes no pain
D. chronic laryngitis
E. a white buildup on the tongue Right Ans - all of the above
You are currently caring for a 65 year old male who has a personal history of
smoking and has been complaining of chronic hoarseness and sore throats for
the last 3 months. The strep A test is negative and when you assess his oral
cavity you notice a white patch on the patient's tongue. Which of the following
symptoms would indicate that this patient is starting to decline? Right Ans
- tooth and ear pain
What does TNM stand for? Right Ans - tumor size, number and location of
involved lymph nodes, and extent of metastasis
After your patient is notified of their neck biopsy results confirming squamous
cell carcinoma, which treatment do you suspect the doctor will suggest due to
its efficacy? Right Ans - surgical removal
