NURS 441 Concepts: Exam 1
Questions and Answers
ANS: D
Effects of nicotine on blood vessels and lung tissue have been proven to increase
pathological changes, leading to heart disease and lung cancer. - answer- A patient
who started smoking in adolescence and continues to smoke 40 years later comes
to the clinic. The nurse understands that this patient has an increased risk for being
diagnosed with which disorder:
a. Alcoholism and hypertension
b. Obesity and diabetes
c. Stress-related illnesses
d. Cardiopulmonary disease and lung cancer
ANS: D
Hypoxia occurs because of decreased circulating blood volume, which leads to
decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a
feeling of shortness of breath. - answer- A patient has been diagnosed with severe
iron deficiency anemia. During physical assessment for which of the following
symptoms would the nurse assess to determine the patient's oxygen status?
a. Increased breathlessness but increased activity tolerance
b. Decreased breathlessness and decreased activity tolerance
c. Increased activity tolerance and decreased breathlessness
d. Decreased activity tolerance and increased breathlessness
ANS: B
Carbon monoxide strongly binds to hemoglobin, making it unavailable for oxygen
binding and transport. - answer- A patient is admitted to the emergency department
with suspected carbon monoxide poisoning. Even though the patient's color is ruddy,
not cyanotic, the nurse understands that the patient is at a risk for decreased
oxygen-carrying capacity of blood because carbon monoxide does which of the
following:
a. Stimulates hyperventilation, causing respiratory alkalosis
b. Forms a strong bond with hemoglobin, creating a functional anemia.
c. Stimulates hypoventilation, causing respiratory acidosis
d. Causes alveoli to overinflate, leading to atelectasis
ANS: A
When the body cannot meet the increased oxygenation need, the increased
metabolic rate causes breakdown of protein and wasting of respiratory muscles,
increasing the work of breathing. - answer- A 6-year-old boy is admitted to the
pediatric unit with chills and a fever of 104°F (40°C). What physiological process
explains why the child is at risk for developing dyspnea?
a. Fever increases metabolic demands, requiring increased oxygen need.
b. Blood glucose stores are depleted, and the cells do not have energy to use
oxygen.
c. Carbon dioxide production increases as result of hyperventilation.
,d. Carbon dioxide production decreases as a result of hypoventilation.
ANS: D
Decreased effective contraction of left side of heart leads to back up of fluid in the
lungs, increasing hydrostatic pressure and causing pulmonary edema, resulting in
crackles in lung bases. - answer- A patient is admitted with the diagnosis of severe
left-sided heart failure. The nurse expects to auscultate which adventitious lung
sounds?
a. Sonorous wheezes in the left lower lung
b. Rhonchi midsternum
c. Crackles only in apex of lungs
d. Inspiratory crackles in lung bases
ANS: B
Movement not only mobilizes secretions but helps strengthen respiratory muscles by
impacting the effectiveness of gas exchange processes. - answer- The nurse is
caring for a patient who has decreased mobility. Which intervention is a simple and
cost-effective method for reducing the risks of stasis of pulmonary secretions and
decreased chest wall expansion?
a. Antibiotics
b. Frequent change of position
c. Oxygen humidification
d. Chest physiotherapy
ANS: C
Impaired ability to cough up mucus caused by weakness or very thick secretions
indicates a need for suctioning when you know the patient has pneumonia. - answer-
A patient is admitted with severe lobar pneumonia. Which of the following
assessment findings would indicate that the patient needs airway suctioning?
a. Coughing up thick sputum only occasionally
b. Coughing up thin, watery sputum easily after nebulization
c. Decreased independent ability to cough
d. Lung sounds clear only after coughing
ANS: A
When the lung collapses, the thoracic space fills with air on each inspiration, and the
atmospheric air irritates the parietal pleura, causing pain. - answer- A patient was
admitted after a motor vehicle accident with multiple fractured ribs. Respiratory
assessment includes signs/symptoms of secondary pneumothorax, which includes
which of the following?
a. Sharp pleuritic pain that worsens on inspiration
b. Crackles over lung bases of affected lung
c. Tracheal deviation toward the affected lung
d. Increased diaphragmatic excursion on side of rib fractures
ANS: D
Hypoxia is the drive to breathe in a patient with chronic obstructive pulmonary
disease who has become used to acidic pH and elevated CO2 levels. Turning up to
6 L/min increases the oxygen level, which turns off the drive to breathe. - answer- A
,patient has been newly diagnosed with emphysema. In discussing his condition with
the nurse, which of his statements would indicate a need for further education?
a. "I'll make sure that I rest between activities so I don't get so short of breath."
b. "I'll rest for 30 minutes before I eat my meal."
c. "If I have trouble breathing at night, I'll use two to three pillows to prop up."
d. "If I get short of breath, I'll turn up my oxygen level to 6 L/min."
ANS: A
Raising the head of the bed brings the diaphragm down and allows for better chest
expansion, thus improving ventilation. - answer- The nurse goes to assess a new
patient and finds him lying supine in bed. The patient tells the nurse that he feels
short of breath. Which nursing action should the nurse perform first?
a. Raise the head of the bed to 45 degrees.
b. Take his oxygen saturation with a pulse oximeter.
c. Take his blood pressure and respiratory rate.
d. Notify the health care provider of his shortness of breath.
ANS: D
Saline has been found to cause more side effects when suctioning and does not
increase the amount of secretions removed. - answer- Which of the following
statements made by a student nurse indicates the need for further teaching about
suctioning a patient with an endotracheal tube?
a. "Suctioning the patient requires sterile technique."
b. "I'll apply suction while rotating and withdrawing the suction catheter."
c. "I'll suction the mouth after I suction the endotracheal tube."
d. "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."
ANS: C
An incentive spirometer is used to encourage deep breathing to inflate alveoli and
open pores of Kohn. The rest are used to treat atelectasis and increased mucus
production. - answer- Which nursing intervention is appropriate for preventing
atelectasis in the postoperative patient?
a. Postural drainage
b. Chest percussion
c. Incentive spirometer
d. Suctioning
ANS: B
This client's physiologic parameters did not exceed normal during and after activity,
so it is safe for the client to continue using the bathroom. There is no indication that
the client needs oxygen, a commode, or a bedpan. - answer- A client is in the
hospital after suffering a myocardial infarction and has bathroom privileges. The
nurse assists the client to the bathroom and notes the client's O2 saturation to be
95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed.
What action by the nurse is best?
a. Administer oxygen at 2 L/min
b. Allow continued bathroom privileges
c. Obtain a bedside commode
d. Suggest the client use a bedpan
, ANS: A, B, D
The nurse can delegate assisting the client to get up in the chair or ambulate to the
bathroom, applying TEDs or sequential compression devices, and taking/recording
vital signs. The spirometer should be used every hour the day after surgery.
Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client
reports pain, the UAP should inform the nurse so a more detailed assessment is
done. - answer- A nurse is caring for a client who had coronary artery bypass
grafting yesterday. What actions does the nurse delegate to the unlicensed assistive
personnel (UAP)? (Select all that apply.)
a. Take and record a full set of vitals per hospital protocol.
b. Assist the client to the chair for meals and to the bathroom
c. Have the client rate pain on a 0-10 scale and report to the nurse
d. Ensure the client wears TED hose or sequential compression devices
ANS: A, B, D
Hypertension, obesity, and excessive stress are all modifiable risk factors for
coronary artery disease. Age is a nonmodifiable risk factor. - answer- A nursing
student learns about modifiable risk factors for coronary artery disease. Which
factors does this include? (Select all that apply.)
a. Hypertension
b. Stress
c. Age
d. Obesity
ANS: B
Clients are often in denial after a coronary event. The client who seems to be in
denial but is compliant with treatment may be using a healthy form of coping that
allows time to process the event and start to use problem-focused coping. The
student should not discourage this type of denial and coping, but rather continue
providing education in a positive manner. Emphasizing complications may make the
client defensive and more anxious. Telling the client that denial is normal is placing
too much attention on the process. Forcing the client to verbalize understanding of
the illness is also potentially threatening to the client. - answer- A nursing student is
caring for a client who had a myocardial infarction. The student is confused because
the client states nothing is wrong and yet listens attentively while the student
provides education on lifestyle changes and healthy menu choices. What response
by the experienced nurse is best?
a. "You need to make sure the client understands this illness."
b. "Continue to educate the client on possible healthy changes."
c. "Emphasize complications that can occur with noncompliance."
d. "Tell the client that denial is normal and will soon go away."
ANS: D
Airway always is the priority. The other actions are important in this situation as well,
but the nurse should stay with the client and ensure the airway remains patent
(especially if vomiting occurs) while another person calls the provider (or Rapid
Response Team) and facilitates getting an ECG done. Aspirin will probably be
administered, depending on the provider's prescription and the client's current
medications. - answer- A client in the cardiac stepdown unit reports severe, crushing
Questions and Answers
ANS: D
Effects of nicotine on blood vessels and lung tissue have been proven to increase
pathological changes, leading to heart disease and lung cancer. - answer- A patient
who started smoking in adolescence and continues to smoke 40 years later comes
to the clinic. The nurse understands that this patient has an increased risk for being
diagnosed with which disorder:
a. Alcoholism and hypertension
b. Obesity and diabetes
c. Stress-related illnesses
d. Cardiopulmonary disease and lung cancer
ANS: D
Hypoxia occurs because of decreased circulating blood volume, which leads to
decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a
feeling of shortness of breath. - answer- A patient has been diagnosed with severe
iron deficiency anemia. During physical assessment for which of the following
symptoms would the nurse assess to determine the patient's oxygen status?
a. Increased breathlessness but increased activity tolerance
b. Decreased breathlessness and decreased activity tolerance
c. Increased activity tolerance and decreased breathlessness
d. Decreased activity tolerance and increased breathlessness
ANS: B
Carbon monoxide strongly binds to hemoglobin, making it unavailable for oxygen
binding and transport. - answer- A patient is admitted to the emergency department
with suspected carbon monoxide poisoning. Even though the patient's color is ruddy,
not cyanotic, the nurse understands that the patient is at a risk for decreased
oxygen-carrying capacity of blood because carbon monoxide does which of the
following:
a. Stimulates hyperventilation, causing respiratory alkalosis
b. Forms a strong bond with hemoglobin, creating a functional anemia.
c. Stimulates hypoventilation, causing respiratory acidosis
d. Causes alveoli to overinflate, leading to atelectasis
ANS: A
When the body cannot meet the increased oxygenation need, the increased
metabolic rate causes breakdown of protein and wasting of respiratory muscles,
increasing the work of breathing. - answer- A 6-year-old boy is admitted to the
pediatric unit with chills and a fever of 104°F (40°C). What physiological process
explains why the child is at risk for developing dyspnea?
a. Fever increases metabolic demands, requiring increased oxygen need.
b. Blood glucose stores are depleted, and the cells do not have energy to use
oxygen.
c. Carbon dioxide production increases as result of hyperventilation.
,d. Carbon dioxide production decreases as a result of hypoventilation.
ANS: D
Decreased effective contraction of left side of heart leads to back up of fluid in the
lungs, increasing hydrostatic pressure and causing pulmonary edema, resulting in
crackles in lung bases. - answer- A patient is admitted with the diagnosis of severe
left-sided heart failure. The nurse expects to auscultate which adventitious lung
sounds?
a. Sonorous wheezes in the left lower lung
b. Rhonchi midsternum
c. Crackles only in apex of lungs
d. Inspiratory crackles in lung bases
ANS: B
Movement not only mobilizes secretions but helps strengthen respiratory muscles by
impacting the effectiveness of gas exchange processes. - answer- The nurse is
caring for a patient who has decreased mobility. Which intervention is a simple and
cost-effective method for reducing the risks of stasis of pulmonary secretions and
decreased chest wall expansion?
a. Antibiotics
b. Frequent change of position
c. Oxygen humidification
d. Chest physiotherapy
ANS: C
Impaired ability to cough up mucus caused by weakness or very thick secretions
indicates a need for suctioning when you know the patient has pneumonia. - answer-
A patient is admitted with severe lobar pneumonia. Which of the following
assessment findings would indicate that the patient needs airway suctioning?
a. Coughing up thick sputum only occasionally
b. Coughing up thin, watery sputum easily after nebulization
c. Decreased independent ability to cough
d. Lung sounds clear only after coughing
ANS: A
When the lung collapses, the thoracic space fills with air on each inspiration, and the
atmospheric air irritates the parietal pleura, causing pain. - answer- A patient was
admitted after a motor vehicle accident with multiple fractured ribs. Respiratory
assessment includes signs/symptoms of secondary pneumothorax, which includes
which of the following?
a. Sharp pleuritic pain that worsens on inspiration
b. Crackles over lung bases of affected lung
c. Tracheal deviation toward the affected lung
d. Increased diaphragmatic excursion on side of rib fractures
ANS: D
Hypoxia is the drive to breathe in a patient with chronic obstructive pulmonary
disease who has become used to acidic pH and elevated CO2 levels. Turning up to
6 L/min increases the oxygen level, which turns off the drive to breathe. - answer- A
,patient has been newly diagnosed with emphysema. In discussing his condition with
the nurse, which of his statements would indicate a need for further education?
a. "I'll make sure that I rest between activities so I don't get so short of breath."
b. "I'll rest for 30 minutes before I eat my meal."
c. "If I have trouble breathing at night, I'll use two to three pillows to prop up."
d. "If I get short of breath, I'll turn up my oxygen level to 6 L/min."
ANS: A
Raising the head of the bed brings the diaphragm down and allows for better chest
expansion, thus improving ventilation. - answer- The nurse goes to assess a new
patient and finds him lying supine in bed. The patient tells the nurse that he feels
short of breath. Which nursing action should the nurse perform first?
a. Raise the head of the bed to 45 degrees.
b. Take his oxygen saturation with a pulse oximeter.
c. Take his blood pressure and respiratory rate.
d. Notify the health care provider of his shortness of breath.
ANS: D
Saline has been found to cause more side effects when suctioning and does not
increase the amount of secretions removed. - answer- Which of the following
statements made by a student nurse indicates the need for further teaching about
suctioning a patient with an endotracheal tube?
a. "Suctioning the patient requires sterile technique."
b. "I'll apply suction while rotating and withdrawing the suction catheter."
c. "I'll suction the mouth after I suction the endotracheal tube."
d. "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."
ANS: C
An incentive spirometer is used to encourage deep breathing to inflate alveoli and
open pores of Kohn. The rest are used to treat atelectasis and increased mucus
production. - answer- Which nursing intervention is appropriate for preventing
atelectasis in the postoperative patient?
a. Postural drainage
b. Chest percussion
c. Incentive spirometer
d. Suctioning
ANS: B
This client's physiologic parameters did not exceed normal during and after activity,
so it is safe for the client to continue using the bathroom. There is no indication that
the client needs oxygen, a commode, or a bedpan. - answer- A client is in the
hospital after suffering a myocardial infarction and has bathroom privileges. The
nurse assists the client to the bathroom and notes the client's O2 saturation to be
95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed.
What action by the nurse is best?
a. Administer oxygen at 2 L/min
b. Allow continued bathroom privileges
c. Obtain a bedside commode
d. Suggest the client use a bedpan
, ANS: A, B, D
The nurse can delegate assisting the client to get up in the chair or ambulate to the
bathroom, applying TEDs or sequential compression devices, and taking/recording
vital signs. The spirometer should be used every hour the day after surgery.
Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client
reports pain, the UAP should inform the nurse so a more detailed assessment is
done. - answer- A nurse is caring for a client who had coronary artery bypass
grafting yesterday. What actions does the nurse delegate to the unlicensed assistive
personnel (UAP)? (Select all that apply.)
a. Take and record a full set of vitals per hospital protocol.
b. Assist the client to the chair for meals and to the bathroom
c. Have the client rate pain on a 0-10 scale and report to the nurse
d. Ensure the client wears TED hose or sequential compression devices
ANS: A, B, D
Hypertension, obesity, and excessive stress are all modifiable risk factors for
coronary artery disease. Age is a nonmodifiable risk factor. - answer- A nursing
student learns about modifiable risk factors for coronary artery disease. Which
factors does this include? (Select all that apply.)
a. Hypertension
b. Stress
c. Age
d. Obesity
ANS: B
Clients are often in denial after a coronary event. The client who seems to be in
denial but is compliant with treatment may be using a healthy form of coping that
allows time to process the event and start to use problem-focused coping. The
student should not discourage this type of denial and coping, but rather continue
providing education in a positive manner. Emphasizing complications may make the
client defensive and more anxious. Telling the client that denial is normal is placing
too much attention on the process. Forcing the client to verbalize understanding of
the illness is also potentially threatening to the client. - answer- A nursing student is
caring for a client who had a myocardial infarction. The student is confused because
the client states nothing is wrong and yet listens attentively while the student
provides education on lifestyle changes and healthy menu choices. What response
by the experienced nurse is best?
a. "You need to make sure the client understands this illness."
b. "Continue to educate the client on possible healthy changes."
c. "Emphasize complications that can occur with noncompliance."
d. "Tell the client that denial is normal and will soon go away."
ANS: D
Airway always is the priority. The other actions are important in this situation as well,
but the nurse should stay with the client and ensure the airway remains patent
(especially if vomiting occurs) while another person calls the provider (or Rapid
Response Team) and facilitates getting an ECG done. Aspirin will probably be
administered, depending on the provider's prescription and the client's current
medications. - answer- A client in the cardiac stepdown unit reports severe, crushing
