Exam 3: NSG3280 / NSG 3280 (Latest 2026/2027 Update) Pathophysiology for Nurses I | Complete Review | Questions & Verified Answers | 100% Correct | Grade A – Galen

Exam 3: NSG3280 / NSG 3280 (Latest 2026/2027 Update) Pathophysiology for Nurses I | Complete Review | Questions & Verified Answers | 100% Correct | Grade A – Galen The physiologic change most likely to lead to an increase in intracranial pressure is a. cerebral vasodilation. b. hypernatremia. c. respiratory hyperventilation. d. REM sleep. a. cerebral vasodilation Manifestations of acute brain ischemia (Cushing reflex) are due primarily to a. parasympathetic nervous system activation. b. sympathetic nervous system activation. c. autoregulation of body systems. d. loss of brainstem reflexes. b. sympathetic nervous system activation. Which group of clinical findings indicates the poorest neurologic functioning? a. Spontaneous eye opening, movement to command, oriented to self only. b. Eyes open to light touch on shoulder, pupils briskly reactive to light bilaterally. c. Assumes decorticate posture with light touch, no verbal response. d. No eye opening, responds to painful stimulus by withdrawing. c. Assumes decorticate posture with light touch, no verbal response. Acceleration-deceleration movements of the head often result in polar injuries in which: a. injury is localized to the site of initial impact. b. widespread neuronal damage is incurred. c. bleeding from venules fills the subdural space. d. focal injuries occur in two places at opposite poles. d. focal injuries occur in two places at opposite poles. Secondary injury after head trauma refers to: a. brain injury resulting from the initial trauma. b. focal areas of bleeding. c. brain injury resulting from the body's response to tissue damage. d. injury as a result of medical therapy. c. brain injury resulting from the body's response to tissue damage. An example of inappropriate treatment for head trauma would be: a. head elevation. b. free water restriction. c. hypoventilation. d. bed rest. C. Hypoventilation Risk factors for hemorrhagic stroke include: a. atherosclerosis. b. dysrhythmias. c. acute hypertension. d. sedentary lifestyle. c. acute hypertension. The stroke etiology with the highest morbidity and mortality is: a. intracranial hemorrhage. b. intracranial thrombosis. c. intracranial embolization. d. cardiac arrest. a. intracranial hemorrhage Clinical manifestations of a stroke within the right cerebral hemisphere include: a. cortical blindness. b. right visual field blindness. c. expressive and receptive aphasia. d. left-sided muscle weakness and neglect. d. left-sided muscle weakness and neglect. The most important preventive measure for hemorrhagic stroke is: a. anticoagulation. b. blood pressure control. c. thrombolytics. d. management of dysrhythmias. B. blood pressure control. In the acute phase of stroke, treatment is focused on: a. stabilization of respiratory and cardiovascular function. b. risk factor modification. c. prevention of and contractures spasticity. d. neurologic rehabilitation. a. stabilization of respiratory and cardiovascular function. Cerebral aneurysm is most frequently the result of: a. embolic stroke. b. subarachnoid hemorrhage. c. subdural hemorrhage. d. meningitis. B. Subarachnoid hemorrhage Leakage of CS from the nose or ears is commonly associated with: a. epidural hematoma. b. temporal skull fracture. c. basilar skull fracture. d. cerebral aneurysm. c. basilar skull fracture. Rupture of a cerebral aneurysm should be suspected if the patient reports: a. ringing in the ears. b. transient episodes of numbness. c. transient episodes of vertigo. d. sudden, severe headache. D. sudden, severe headache Subarachnoid hemorrhage is usually managed with volume expansion and blood pressure support to enhance cerebral perfusion. This is necessary because subarachnoid hemorrhage predisposes to: a. cerebral vasospasm. b. hypotension. c. excessive volume loss. d. decreased intracranial pressure. a. cerebral vasospasm. A college student living in a dormitory reports a stiff neck and headache and is found to have a fever of 102°F. This information is most consistent with: a. encephalitis. b. meningitis. c. skull fracture. d. cerebral ischemia. b. meningitis It is true that encephalitis is usually: a. because of a bacterial infection in the CNS. b. fatal. c. because of a viral infection in brain cells. d. asymptomatic. c. because of a viral infection in brain cells. It is true that epidural bleeding is: a. associated with widespread vascular disruption. b. located between the arachnoid and the dura mater. c. usually because of venous leakage. d. characterized by a lucid interval immediately after injury. d. characterized by a lucid interval immediately after injury. The most important determinant for prescribing therapy for acute stroke is: a. location of ischemia. b. thrombotic versus embolic cause. c. ischemic versus hemorrhagic cause. d. age of the patient. C. ischemic versus hemorrhagic cause. Intracranial pressure normally ranges from - mm Hg a. O to 15 b. 10 to 20 c. 15 to 25 d. 20 to 30 a. O to 15 - edema occurs when ischemic tissue swells because of cellular energy failure. a. Interstitial b. Osmotic c. Vasogenic d. Cytotoxic d. Cytotoxic A severe complication of elevated intracranial pressure is: a. Cushing reflex. b. brain herniation. c. burr hole. d. hydrocephalus. b. brain herniation. A tool used to assess levels of consciousness is: a. magnetic resonance imaging (MRI). b. intracranial pressure (ICP) monitoring. c. Glasgow Coma Scale (GCS). d. central perfusion pressure (CPP). c. Glasgow Coma Scale (GCS) The first indication of brain compression from increasing intracranial pressure (ICP) may be: a. decorticate posturing. b. absence of verbalization. c. sluggish pupil response to light. d. Glasgow Coma Scale score of 13. c. sluggish pupil response to light. A level of - on the Glasgow Coma Scale indicates likely fatal damage a. 3 b. 8 c. 12 d. 15 a. 3 - occurs when a brainstem impaired patient exhibits a persistent rhythmic or jerky movement in one or both eyes. a. Nystagmus b. Dysconjugate movement c. Ocular palsy d. Doll's eyes a. Nystagmus Which brain disorders are a cause of acute brain injury? (Select all that apply.) a. Seizure disorders b. Brain trauma c. Dementias d. Brain hemorrhage e. Central nervous system infections B. Brain trauma D. Brain hemorrhage E. Central nervous system infections Seizures that involve both hemispheres at the outset are termed: a. partial. b. complex. c. focal. d. generalized. d. generalized The primary reason that prolonged seizure activity predisposes to ischemic brain damage is that: a. neurons are unable to transport glucose. b. cardiovascular regulation is impaired. c. the brainstem is depressed. d. the lack of airway maintenance can lead to hypoxia. d. the lack of airway maintenance can lead to hypoxia. The dementia of Alzheimer disease is associated with structural changes in the brain, including: a. deposition of amyloid plaques in the brain. b. degeneration of basal ganglia. c. hypertrophy of frontal lobe neurons. d. significant aluminum deposits in the brain. a. deposition of amyloid plaques in the brain. Before making a diagnosis of Alzheimer disease: a. a brain biopsy demonstrating organic changes is necessary. b. biochemical tests for aluminum toxicity must be positive. c. other potential causes of dementia must be ruled out. d. increased protein is found in a lumbar puncture. c. other potential causes of dementia must be ruled out. Parkinson disease is associated with: a. demyelination of CNS neurons. b. a pyramidal nerve tract lesion. c. insufficient production of acetylcholine in the basal ganglia. d. a deficiency of dopamine in the substantia nigra. d. a deficiency of dopamine in the substantia nigra. Dopamine precursors and anticholinergics are all used in the management of Parkinson disease because they: a. increase dopamine activity in the basal ganglia. b. induce regeneration of neurons in the basal ganglia. c. prevent progression of the disease. d. produce excitation of basal ganglia structures. a. increase dopamine activity in the basal ganglia. The classic manifestations of Parkinson disease include: a. intention tremor and akinesia. b. rest tremor and skeletal muscle rigidity. c. ataxia and intention tremor. d. skeletal muscle rigidity and intention tremor. b. rest tremor and skeletal muscle rigidity. What effect do demyelinating disorders such as multiple sclerosis have on neurotransmission? a. Slower rate of action potential conduction b. Increased rate of action potential conduction c. Facilitation of action potential initiation d. Faster rate of repolarization a. Slower rate of action potential conduction Steroids may be used in the management of acute exacerbation of symptoms in patients with multiple sclerosis because a. viral damage can be inhibited. b. demyelination is mediated by immune mechanisms. c. steroids reverse the progression of the disease. d. steroids inhibit synaptic degradation of neurotransmitters. b. demyelination is mediated by immune mechanisms. Upper extremity weakness in association with degeneration of CNS neurons is characteristic: a. multiple sclerosis. b. Guillain-Barré syndrome. c. myasthenia gravis. d. amyotrophic lateral sclerosis. d. Amyotrophic lateral sclerosis Ascending paralysis with no loss of sensation is characteristic of: a. multiple sclerosis. b. Guillain-Barré syndrome. c. myasthenia gravis. d. amyotrophic lateral sclerosis. b. Guillain-Barré syndrome. The stage of spinal shock that follows spinal cord injury is characterized by: a. reflex urination and defecation. b. autonomic dysreflexia. c. absent spinal reflexes below the level of injury. d. motor spasticity and hyperreflexia below the level of injury. C. absent spinal reflexes below the level of injury. Autonomic dysreflexia is characterized by: a. hypertension and bradycardia. b. hypotension and shock. c. pallor and vasoconstriction above the level of injury. d. extreme pain below the level of injury. a. hypertension and bradycardia It is true that Bell palsy is a: a. permanent facial paralysis after stroke. b. severe neuropathic pain affecting the trigeminal nerve. c. paralysis of the muscles innervated by the facial nerve. d. herpetic outbreak in a facial dermatome. c. paralysis of the muscles innervated by the facial nerve. A patient who experiences early symptoms of muscle twitching, cramping, and stiffness of the hands may be demonstrating signs of: a. Guillain-Barré syndrome. b. amyotrophic lateral sclerosis. c. Parkinson disease. d. hydrocephalus. b. Amyotrophic lateral sclerosis What type of seizure usually occurs in children and is characterized by brief staring spells? a. Epileptic b. Idiopathic c. Partial d. Absence d. Absence The initial treatment of an individual experiencing a seizure is concentrated on a. maintaining an airway. b. administering anticonvulsant medication. c. documenting the seizure pattern. d. obtaining an EEG. a. maintaining an airway - is a form of spina bifida in which a saclike cyst filled with CSF protrudes through the spinal defect but does not involve the spinal cord. a. Spina bifida occulta b. Meningocele c. Myelomeningocele d. Meningomyelocele b. Meningocele It is recommended that women of childbearing age take folic acid daily for prevention of: a. neural tube defects. b. seizure disorders. c. cerebral palsy. d. hydrocephalus. a. neural tube defects Which neurologic disorder is commonly referred to as Lou Gehrig disease? a. Multiple sclerosis b. Parkinson disease c. Alzheimer disease d. Amyotrophic lateral sclerosis d. Amyotrophic lateral sclerosis Which statement is true about the incidence of multiple sclerosis? a. The age of onset ranges from 20 to 40 years. b. MS is more common in men than women. c. There is a higher incidence of MS in military veterans. d. There is a higher rate of MS in African-Americans. a. The age of onset ranges from 20 to 40 years. Orthostatic hypotension may be a manifestation of: a. Alzheimer disease. b. multiple sclerosis. c. Parkinson disease. d. amyotrophic lateral sclerosis. c. Parkinson disease Which conditions are risk factors for the development of cerebral palsy? (Select all that apply.) a. Birth trauma b. Seizure disorder c. Kernicterus d. Prenatal maternal infection e. Scoliosis A. Birth trauma C. Kernicterus D. Prenatal maternal infection Which are common causes of acquired parkinsonism? (Select all that apply.) a. Degeneration of dopaminergic neurons b. History of infection c. History of intoxication d. History of trauma e. Seizure disorder B. history of infection C. history of intoxication D. history of trauma Pain is thought of as: a. a subjective experience that is difficult to measure objectively. b. associated with changes in vital signs reflecting its intensity. c. experienced in the same way by all individuals. d. always the result of tissue damage that activates nociceptors. a. A subjective experience that is difficult to measure objectively The gate control theory of pain transmission predicts that activity in touch receptors will: a. enhance perception of pain. b. decrease pain signal transmission in the spinal cord. c. activate opioid receptors in the CNS. d. increase secretion of substance P in the spinal cord. b. decrease pain signal transmission in the spinal cord. Referred pain may be perceived at some distance from the area of tissue injury, but generally felt: a. on the same side of the body. b. with slightly less intensity. c. within the same dermatome. d. within 10 to 15 cm area. c. within the same dermatome. Slow pain sensation is transmitted primarily by: a. group la afferents. b. motor neurons. c. unmyelinated C fibers. d. A fibers c. unmyelinated C fibers. Which treatment is helpful in neuropathic pain but not used for acute pain? a. Narcotic analgesics b. Nonsteroidal anti-inflammatory drugs and aspirin c. Anticonvulsants d. Nonnarcotic analgesics c. Anticonvulsants The physiologic mechanisms involved in the pain phenomenon are termed: a. nociception. b. sensitization. c. neurotransmission. d. proprioception. a. nociception It is useful to conceptualize pain physiology according to the four stages because each stage provides an opportunity for: a. education. b. stimulation. c. intervention. d. documentation. c. Intervention Most sensory afferent pain fibers enter the spinal cord by way of the _ nerve roots a. anterior b. posterior c. C fiber d. anterolateral b. posterior The - is the level of painful stimulation required to be perceived. a. perception b. tolerance c. expression d. threshold d. threshold Modulation of pain signals is thought to be mediated by the release of: a. histamine. b. endorphins. c. cholecystokinin. d. glutamine. b. endorphins. One of the most common causes of acute pain is: a. headache. b. fibromyalgia. c. malignancy. d. trigeminal neuralgia. a. headache A patient presenting with a severe, pounding headache accompanied by nausea and photophobia is likely experiencing a - headache. a. tension b. migraine c. sinus d. chronic b. migraine It is true that a conductive hearing loss: a. cannot be corrected. b. is as a result of damage to hair cells in the inner ear. c. usually results from chronic exposure to loud noise. d. is because of dysfunction of outer and middle ear structures. d. is because of dysfunction of outer and middle ear structures. Ménière disease is characterized by: a. bilateral hearing impairment. b. vertigo in association with hearing loss. c. middle ear infection. d. ossification of bones in the middle ear. b. vertigo in association with hearing loss. Myopia is as a result of an error of light refraction in which: a. light rays are scattered as they pass through the cornea. b. the focal point of an image is behind the retina. c. far vision is impaired. d. accommodation is impaired. c. far vision is impaired. Opacification of the lens is commonly referred to as: a. hyperopia. b. glaucoma. c. presbyopia. d. cataract. D. Cataract A sudden onset of eye pain and impaired vision associated with pupil dilation is characteristic of: a. narrow-angle glaucoma. b. open-angle glaucoma. c. cataract. d. retinal detachment. a. narrow angle glaucoma Hearing loss associated with aminoglycosides is known as: a. sensorineural. b. conductive. c. presbycusis. d. otosclerosis. a. sensorineural Expected management of acute otitis media includes: a. surgical removal of debris in the middle ear. b. placement of ventilation tubes in the tympanic membrane. c. antibiotic therapy. d. adenoidectomy. c. antibiotic therapy When dealing with an elderly patient with hearing loss, the nurse should: a. speak loudly so that the patient can hear better. b. stand to the side of the patient, speaking into the dominant ear. c. speak at a normal rate, rhythm, and volume. d. use long sentences and draw pictures. c. speak at a normal rate, rhythm, and volume. A condition of ocular misalignment that causes a cross-eyed appearance is referred to as: a. strabismus. b. amblyopia. c. cataract. d. retinopathy. a. strabismus - is one of the most common complications of diabetes. a. Cataract b. Diabetic retinopathy c. Macular degeneration d. Glaucoma b. Diabetic retinopathy The nurse caring for an individual with vision impairment should be prepared to: a. keep the patient on bed rest to avoid injury. b. speak to the patient with a clear, loud voice. c. announcing himself or herself at all interactions. d. provide as much bright light as possible. c. announcing himself or herself at all interactions. Nerve fibers of the - system have their cell bodies in the mucous membrane of the upper and posterior parts of the nasal cavity. a. visual b. auditory c. gustatory d. olfactory d. olfactory A vestibular disorder that is manifested by the sensation of motion without actual motion is referred to as: a. equilibrium. b. nystagmus. c. vertigo. d. effusion. C. Vertigo Which structures make up the middle ear? (Select all that apply.) a. Cerumen b. Malleus c. Incus d. Scala media e. Stapes b. Malleus c. Incus e. Stapes Complete healing of a bone fracture occurs when: a. no movement of the break is detectable. b. the callus has been completely replaced with mature bone. c. the fracture site and surrounding soft tissue are pain free. d. a cast is no longer required to stabilize the break. b. the callus has been completely replaced with mature bone. Rickets is characterized by soft, weak bones resulting from a deficiency of a. Calcium b. estrogen c. Phosphate d. Vitamin D Vitamin D In older women, osteoporosis is thought to be primarily because of: a. dietary inadequacies. b. estrogen deficiency. c. malabsorption syndrome. d. inactivity. b. estrogen deficiency. Pain with passive stretching of a muscle is indicative of: a. noncontractile tissue injury. b. contractile tissue injury. c. vascular insufficiency. d. skeletal muscle damage. a. noncontractile tissue injury Muscular dystrophy includes a number of muscle disorders that are: a. genetically transmitted. b. easily prevented and managed. c. autoimmune in nature. d. demyelinating focused a. genetically transmitted Myasthenia gravis is an autoimmune disease in which: a. neuronal demyelination disrupts nerve transmission. b. muscles become increasingly bulky but weakened. c. acetylcholine receptors are destroyed or dysfunctional. d. acetylcholine release from motor neurons is disrupted. c. acetylcholine receptors are destroyed or dysfunctional. Anticholinesterase inhibitors may be used to manage: a. muscular dystrophy. b. myasthenia gravis. c. fibromyalgia. d. rheumatoid arthritis. b. Myasthenia gravis A Type I open fracture is best described as a bone that is: a. broken in two or more pieces. b. cracked but not completely separated. c. broken along the long axis d. broken and protruding through the skin d. broken and protruding through the skin The complication which is not likely to result from an open, transverse fracture of the tibia and fibula is: a. bone infection. b. fat emboli. c. air embolus. d. compartment syndrome. c. air embolus Assessment of an extremity six hours after surgical alignment and casting demonstrates pulselessness and pallor. The priority action to take is to: a. increase the administration of his pain medication. b. initiate action to have the cast split or removed. c. note the increase in pain in the chart, and recheck the extremity in 30 minutes. d. elevate the extremity to relieve swelling. b. initiate action to have the cast split or removed. Following a bone fracture, the earliest likely event to occur is: a. development of a blood clot beneath the periosteum. b. leukocyte infiltration into bone tissue. c. blood vessel growth at the fracture site. d. migration of osteoblasts to the fracture site. a. development of a blood clot beneath the periosteum. Bone healing may be impaired by A. excessive vitamin C. B. nicotine use. C. a high-protein diet. D. immobilization. B. nicotine use. A unique characteristic feature of fibromyalgia is the presence of: a. tender point pain. b. head pain. c. contractures. d. muscle atrophy. a. tender point pain A fracture in which bone breaks into two or more fragments is referred to as: a. Comminuted b. Open c. Greenstick d. Stress a. comminuted What type of fracture generally occurs in children? a. Greenstick b. Stress c. Oblique d. Colles a. Greenstick Most muscle strains are caused by A. a tear in an adjoining tendon. B. abnormal muscle contraction. C. muscle asymmetry. D. bleeding into the muscle. B. abnormal muscle contraction. People who have osteoporosis are at risk for: a. rhabdomyolysis. b. osteomyelitis. c. osteomalacia. d. bone fractures. d. bone fractures. risk factor for osteoporosis is: a. endometriosis. b. early menopause. c. Late menopause d. Ovarien cysts b. early menopause. Which disorder usually causes skeletal pain and involves significant bone demineralization from vitamin D deficiency? a. Osteomalacia b. Osteopenia c. Osteomyelitis d. Osteoporosis a. osteomalacia Healing of a fractured bone with a poor alignment is called: a. malunion. b. nonunion. c. disunion d. delayed union a. malunion The displacement of two bones in which the articular surfaces partially lose contact with each other is called: a. subluxation. b. subjugation. C. sublimation. d. dislocation. a. subluxation The pathophysiology of ostomalacia involves: a. Increased osteoclasts activity b. collagen breakdown in the bone matrix. c. Crowding of cells in the osteoid d. Inadequate mineralization osteoid d. Inadequate mineralization osteoid The disease that is similar to osteomalacia and occurs in growing children is: a. rickets. b. osteosarcoma. c. Paget disease. d. osteopenia. a. Rickets Pain in fibromyalgia involves: a. Muscle inflammation b. autoimmune destruction of muscle tissue c. Nerve inflammation d. Changes in pain transmission in the spinal cord d. changes in pain transmission in the spinal cord. A malignant bone-forming tumor is referred to as a(n) a. rhabdosarcoma. b. liposarcoma. c. osteosarcoma. d. Chondrosarcoma c. osteosarcoma Inflammation of the sacs that overlie bony prominences is called: a. epicondylitis. b. arthritis. c. tendinitis. d. bursitis. d. bursitis. The disorder characterized by softening and then enlargement of bones is referred to as: a. osteomyelitis. b. osteoporosis. c. Paget disease. d. rickets c. Paget disease. The person at highest risk of a greenstick fracture from falling off a tall ladder is age: a. 68. b. 44. с. 8. d. 23. c. 8 A bone disorder that results from insufficient vitamin D is referred to as a rickets. b. osteoporosis. c. osteomalacia. d. subluxation. c. osteomalacia The most common source of osteomyelitis is: a. An infection that migrates via the bloodstream. b. direct invasion from a fracture. c. surgical contamination. d. a joint prosthesis. an infection that migrates via the bloodstream A patient diagnosed with diabetes smokes a pack of cigarettes daily and eats very few green leafy vegetables. After experiencing a fractured toe, this patient is at risk for: a. delayed healing. b. malunion. c. nonunion d. dysunion a. delayed healing Paget disease is characterized by: a. overactivity of osteoblasts leading to multiple bone tumors b. excessive bone resorption followed by excessive formation of fragile bone. c. inflammatory disorder resulting in fusion of spine joints. d. failure of resorption by osteoclasts resulting in hard bones. b. excessive bone resorption followed by excessive formation of fragile bone. The most common site affected in Paget disease is the: a. lower spine. b. skull. c. pelvis. d. joints. a. Lower spine The most common type of osteomyelitis is a. hematogenous. b. contiguous focus. c. Brodie abscess. d. direct invasion. a. hematogenous Compartment syndrome occurs secondary to: a. bone infarction. b. soft-tissue damage. c. muscle necrosis. d. breakdown of RBCs. b. soft-tissue damage. The most common symptom of multiple myeloma is: a pathologic fracture. b. fever. c. bone pain. d. osteomyelitis. c. bone pain. Manifestations of fibromyalgia often include which of the following? (Select all that apply.) a. Generalized pain b. Sensitivity to heat c. Headaches d. Fatigue e. Sleep disturbance a. Generalized pain b. Sensitivity to heat c. Headaches d. Fatigue Characteristics of scoliosis include which of the following? (Select all that apply.) a. Involvement of lateral curvature of the spine b. Increase during periods of rapid growth c. More common in boys d. Identifiable by uneven shoulders or scapular prominence e. Possibility of leading to respiratory complications a. Involvement of lateral curvature of the spine b. Increase during periods of rapid growth d. Identifiable by uneven shoulders or scapular prominence e. Possibility of leading to respiratory complications Gouty arthritis is a complication of: a. group A streptococcal infection. b. autoimmune destruction of joint collagen. C. excessive production of urea. d. inadequate renal excretion of uric acid. d. inadequate renal excretion of uric acid. A clinical finding consistent with a diagnosis of rheumatoid arthritis would be a. systemic manifestations of inflammation. b. localized pain in weight-bearing joints. c. reduced excretion of uric acid by the kidney. d. firm, crystallized nodules or -tophill at the affected joints. a. systemic manifestations of inflammation. Rheumatoid arthritis is commonly associated with the presence of rheumatoid factor autoantibodies in the bloodstream. This indicates that rheumatoid arthritis is likely to be: a. caused by bacterial infection. b. an autoimmune process. c. An infective process d. Because of an enzymatic defect b. an autoimmune process. In contrast to osteoarthritis, rheumatoid arthritis may be associated with: a. debilitating joint pain and stiffness. b. improvement in symptoms with aspirin therapy. c. changes in activities of daily living. d. systemic aching in the musculoskeletal system. D. systemic aching in the musculoskeletal system. Systemic lupus erythematosus (SLE) is: a. rheumatic disease attributed to wear and tear on weight-bearing joints. b. septic joint inflammation and necrosis. c. unknown etiologic factors. d. autoimmune mechanisms. d. autoimmune mechanisms. Individuals diagnosed with systemic lupus erythematosus (SLE) are at risk for developing numerous complications of various organs because of: a. excessive production of connective tissue. b. formation of osteophytes in tissues. c. immune injury to basement membranes. d. impaired tissue oxygen transport. c. immune injury to basement membranes. A laboratory test result that helps confirm the diagnosis of systemic lupus erythematosus (SLE) is: a. elevated serum calcium level. b. elevated monoclonal antibody titer. c. positive antinuclear antibodies. d. positive microsomal antibodies. c. positive antinuclear antibodies. To avoid the progression of cutaneous lesions, a patient diagnosed with systemic lupus erythematosus (SLE) should: a. avoid sun exposure. b. avoid excessive use of moisturizers. c. refrain from washing the affected areas. d. Apply warm, compresses daily. a. avoid sun exposure Although skin manifestations may occur in numerous locations, the classic presentation of systemic lupus erythematosus (SLE) includes: a. lesions affecting the palms of hands and the soles of feet. b. dry, scaly patches in the antecubital area and behind the knees. c. cracked, scaly areas in the webs of fingers. d. a butterfly pattern rash on the face across the bridge of the nose. D. a butterfly pattern rash on the face across the bridge of the nose. Ankylosing spondylitis is characterized by: a. inflammation, stiffness, and fusion of spinal joints. b. loss of articular cartilage in weight-bearing joints. c. excessive bone remodeling leading to soft bone. d. immune mechanisms leading to widespread joint inflammation. a. inflammation, stiffness, and fusion of spinal joints Prosthetic joint infection is most often because of: a. defective replacement material. b. injury to the joint. c. hematogenous transfer. d. arthritis. C. hematogenous transfer. It is true that scleroderma involves: a. inflammation and fibrosis of connective tissue. b. autoantibodies against acetylcholine receptors. c. infection by B-hemolytic streptococcus. d. inflammation caused by antigenic fragments of dead organisms. a. inflammation and fibrosis of connective tissue. The earliest manifestation of scleroderma is: a. thick, tight, shiny skin. b. skin hyper/hypopigmentation. c. renal impairment. d. Raynaud phenomenon. d. Raynaud phenomenon The most common presenting sign/symptom with rheumatic fever is: a. cardiac murmur. b. polyarthritis. c. rash. d. painless nodules. b. polyarthritis. Enteropathic arthritis is associated with: a. irritable bowel syndrome. b. inflammatory bowel disease. c. chronic constipation. d. chronic diarrhea. b. Inflammatory bowel disease The pain of nonarticular rheumatism (- growing pain) is worse: a. during activity. b. following strenuous exercise. c. upon awakening. d. during the night. d. during the night. Rheumatial arteritis involves joint inflammation caused by: a. bacterial infection b. trauma c. autoimmune injury d. congenital hypermobility c. autoimmune injury Tophi are: a. renal calculi composed of uric acid. b. deposits of urate crystals in tissues. c. painful edematous joints. d. spots that coalesce in a malar rash. b. deposits of urate crystals in tissues. The final stage of gout, characterized by crystalline deposits in cartilage, synovial membranes, and soft tissue, is called: a. tophaceous gout. b. gouty arthritis. c. complicated gout. d. asymptomatic hyperuricemia. a. tophaceous gout The pathophysiology of rheumatoid arthritis involves: a. Immune cells accumulating in pannus and destroying articular cartilage b. free radicals attaching to the synovial membrane and tunneling into articular cartilage c. excessive wear and tear and microtrauma that damage articular cartilage. d. cysts developing in subchondral bone and creating fissures in articular cartilage. a. immune cells accumulating in pannus and destroying articular cartilage. Tell me again the name of that chemical that makes crystals when my gout flares up, asks the client. The nurse's best response is: a. calcium phosphate. b. urea. c. uric acid. d. B-hydroxybutyric acid. c. Uric acid Ankylosing spondylitis causes: a. intervertebral joint fusion. b. instability of synovial joints. c. costal cartilage degeneration. d. temporomandibular joint degeneration. a. intervertebral joint fusion The chief pathologic features of osteoarthritis are a. stress fractures of the epiphysis, inflammation of the diaphysis, and accumulation of excessive synovial fluid. b. autoimmune damage to the synovium, destruction of articular cartilage by pannus, and thickening of synovial fluid. c. degeneration of articular cartilage, destruction of the bone under the cartilage, and thickening of the synovium. d. thinning of the joint capsule, resorption of bone, excessive formation of new bone, and formation of bone spurs. c. degeneration of articular cartilage, destruction of the bone under the cartilage, and thickening of the synovium. Characteristics of gout include which features? (Select all that apply.) a. Disturbed uric acid metabolism b. Crystalline deposits in bony and connective tissue c. Onset before menopause in women d. Cardiac involvement e. Renal involvement a. Disturbed uric acid metabolism b. Crystalline deposits in bony and connective tissue d. Cardiac involvement e. Renal involvement Which of the following are manifestation of osteoarhitis? (select all that apply) a. Nodules on joints of the hands b. Crepitus with joint movement c. Pain that is worse upon arising in the morning d. Stiffness that worsens with joint use e. Narrowing of joints spaces a. Nodules on joints of the hands b. Crepitus with joint movement e. Narrowing of joints spaces For which signs/symptoms of Lyme disease would the nurse assess? (Select all that apply.) a. Fever and chills b. Migratory rash c. Arthritic pain d.Headache e. Myalgia a. Fever and chills c. Arthritic pain d. Headsche e. Myalgia Which are signs and symptoms of Sjogren syndrome? (Select all that apply.) a. Xerophthalmia b. Xerostomia c. Candida vaginal infections d. Annular erythema e. Increased dental caries a. Xerophthalmia b. Xerostomia d. Annular erythema e. Increased dental caries Which drugs are considered Disease Modifying Antirheumatic Drugs (DMARDs)? (Select all that apply.) a. Methotrexate b. Leflunomide c. Hydroxychloroquine d. Prednisone e. Gold a. Methotrexate b. Leflunomide c. Hydroxychloroquine A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action? A. Shine available light on the equipment to facilitate accurate reading. B. Use a blood pressure cuff to increase circulation to the site. C. Warm the client's hands and try again. D. Place the probe on the client's earlobe. C. Warm the client's hands and try again. The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? A. face tent B. tracheostomy collar C. simple mask D. nasal cannula B. tracheostomy collar A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. All other devices are less appropriate for this client. A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate? A.The client's available hemoglobin is adequately saturated with oxygen. B. The client's respiratory rate is in the normal range. C. The client's red blood cell (RBC) count is in the normal range. D. The client's oxygen demands are being met. A.The client's available hemoglobin is adequately saturated with oxygen. Pulse oximetry is a noninvasive technique that measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial blood. This test measures only the percentage of oxygen carried by the available hemoglobin. Thus, even a client with a low hemoglobin level could appear to have a normal SpO2 because most of that hemoglobin is saturated. However, the client may not have enough oxygen to meet body needs. A normal pulse oximetry reading does not necessarily indicate a normal RBC count or heart rate. Which should the nurse teach the family about caring for a client with emphysema at home? Select all that apply. Maintain a smoke-free environment. Follow health care provider's prescription for oxygen administration. Watch for increased wheezing or signs of a flare-up. Take advantage of pulmonary rehabilitation programs. Create a long-term caregiving plan. Even if the person with emphysema is not smoking anymore, the person may be living in a home where family members still smoke. Family must understand why it is important to keep tobacco smoke out of the house. Caregivers need to be ready and know the signs of a flare-up. For instance, the client may wheeze more, get increasingly short of breath, cough more than usual, or have more or a change in color of mucus. If there is a flare-up, the sooner the client can get treatment, the less likely the client will require hospitalization. It is worthwhile for clients with emphysema to look into pulmonary rehabilitation programs. These programs combine exercise, support, and education that will improve one's breathing and health. People with emphysema can live a really long time. Therefore, the family will require a clear plan to address caregiving long term. Oxygen therapy in a client with emphysema is often necessary but too much oxygen may result in knocking out the hypoxic drive, causing further depression of the respiratory drive. (all the above) Maintain a smoke-free environment. Follow health care provider's prescription for oxygen administration. Watch for increased wheezing or signs of a flare-up. Take advantage of pulmonary rehabilitation programs. Create a long-term caregiving plan. Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? A. It determines whether the client is getting enough oxygen. B. It prescribes oxygen concentration. C. It regulates the amount of oxygen received. D. It decreases dry mucous membranes via delivering small water droplets. A. It determines whether the client is getting enough oxygen. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes. Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? Snack on high-carbohydrate foods frequently. Eat one large meal at noon. Eat smaller meals that are high in protein. Contact the physician for nutrition shake. Eat smaller meals that are high in protein The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting? A. Vesicular B. Crackles C. Bronchial D. Bronchovesicular A. Vesicular Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds. Bronchial breath sounds are loud, high pitched sounds heard over the trachea and larynx. The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document? A. Wheezing B. Crackles C. Absent breath sounds in lower lobes D. Stridor A. Wheezing The nurse expects to document wheezing in the lungs of a client with asthma, which would be more pronounced when the client has a respiratory infection. Wheezing is a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration. Wheezing is caused by air passing through constricted passages caused by swelling or secretions. Stridor and crackles are other abnormal breath sounds caused by fluid, infection, or inflammation in the lungs. Absent breath sounds are not normally found in asthmatic clients; they are characteristic of pneumonia. The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client? "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." "Breathing through your nose first will warm, filter, and humidify the air you are breathing." "If you breathe through the mouth first, you will swallow germs into your stomach." "Breathing through your nose first will warm, filter, and humidify the air you are breathing." Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring. A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? "An occasional cigarette will not hurt you." "I understand; I used to be a smoker also." "You should never smoke when oxygen is in use." "Oxygen is a flammable gas." "You should never smoke when oxygen is in use." The nurse will educate the client about the dangers of smoking when oxygen is in use. Oxygen is not flammable, but it oxidizes other materials. Other answers are inappropriate. A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is: A. "He is using his chest muscles to help him breathe." B. "His lung muscles are swollen so he is using abdominal muscles." C. "He will require additional testing to determine the cause." D. "His infection is causing him to breathe harder." A. "He is using his chest muscles to help him breathe." The client will use accessory muscles to ease dyspnea and improve breathing. A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen? A. Place the client in the dorsal recumbent position to collect the specimen. B. Discard the first sputum produced by the client. C. Instruct the client to inhale deeply and then cough. D. Have the client clear the nose and throat and gargle with salt water before beginning the procedure. C. Instruct the client to inhale deeply and then cough. The client should be instructed to inhale deeply and cough; if this results in sputum, it should be collected in the container. The client should be placed in a semi-Fowler's position and instructed to clear the nose and throat and rinse the throat with water. The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations? A. Hyperventilation B. Perfusion C. Atelectasis D. Hypoxia D. Hypoxia Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia. Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements. Perfusion refers to the process by which oxygenated capillary blood passes through body tissues. Atelectasis refers to collapsed alveoli. A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? A. Suction the client's mouth through the oropharyngeal airway to prevent aspiration. B. Leave the airway in place and promptly notify the health care provider for further instructions. C. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. D. Remove the airway, turn the client to the side, and provide mouth suction, if necessary. D. Remove the airway, turn the client to the side, and provide mouth suction, if necessary. If the client vomits as the oropharyngeal airway is inserted, quickly position the client onto his or her side to prevent aspiration, remove the oral airway, and suction the mouth, if needed. It would be inappropriate and unsafe to leave the airway in place. Rinsing the client's mouth with water is not a priority. The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response? A. Page the respiratory therapist STAT. B. Cover the tracheostomy stoma and apply oxygen by nasal cannula C. Maintain the client's oxygenation and alert the health care provider immediately. D. Assess the client's respiratory status and check vital signs every 1 minute for the next hour. C. Maintain the client's oxygenation and alert the health care provider immediately. If the tracheostomy becomes dislodged and is not easily replaced, the nurse should notify the primary care provider immediately, cover the tracheostomy stoma, and assess client's respiratory status. The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia? Clubbing Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many clients with chronic hypoxia due to respiratory or cardiac disease. Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD. Hemoptysis, edema, and diarrhea do not result from hypoxia. After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. True False True After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A nurse caring for a client with a chest tube should monitor the client's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system. A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client? pulse oximetry Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes. In which client should the nurse prioritize assessments for respiratory depression? A client taking opioids for cancer pain Many medications affect the function of the respiratory system and depress the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Beta-adrenergic blockers, antibiotics, and insulin do not appreciably affect the respiratory system. A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing: a bronchospasm When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm. A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first? Educate client on incentive spirometry Assist with intubation Apply oxygen as prescribed Raise the head of the bed Apply oxygen as prescribed The nurse should first apply oxygen, which will help to improve oxygen saturation and health status. The client may not require intubation, once oxygen is provided. Although the client may require education on incentive spirometry, the immediate priority intervention is to stabilize the client's oxygen saturation. Similarly, raising the head of the bed may help with the client's comfort but may not have sufficient effect on oxygen saturation. A nurse is reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would the nurse most likely identify as an effect of exposure to automobile pollutants? Croup Bronchitis Bronchiectasis Atelectasis Bronchitis The home health nurse arrives at a client's home and immediately notes the client is experiencing increased dyspnea. The client has a 7-year history of chronic obstructive pulmonary disease (COPD). Which assessment finding should the nurse prioritize? redness behind both ears nasal cannula placed upside down flow meter set at 5 liters of oxygen nasal mucosa appears crusty flow meter set at 5 liters of oxygen High percentages of oxygen are contraindicated for a client with COPD, because the client has adapted to excessive levels of retained carbon dioxide and low blood oxygen levels to stimulate the drive to breathe. If a client with COPD receives more than 2 to 3 liters of oxygen over a sustained period, the respiratory rate slows or even stops. Adjusting the flow meter and performing necessary emergent care would be the priority. The other findings are also concerns which can occur when receiving oxygen and would be addressed after dealing with the dyspnea. A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from: pulmonary embolism. myocardial infarction. congestive heart failure. lung cancer. congestive heart failure A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure. A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function? Pleural effusion Pneumonia Tachypnea Wheezes Pleural effusion Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis. Pneumonia would necessitate the procedure only if the infection resulted in pleural effusion. A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action? Encourage the client to do deep-breathing exercises. Review the medications that the client has taken in the past 90 minutes. Raise the head of the client's bed slightly, if tolerated. Document this expected assessment finding. Document this expected assessment finding. A range of 95% to 100% is considered normal oxygen saturation. As such, there is no need to change the client's position, encourage deep-breathing exercises and coughing, or to review the client's medication history. When reviewing data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom? strong, rapid pulse rapid respirations increased urine output weight loss rapid respirations Normal cardiac output averages from 3.5 to 8.0 liter/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing the respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display a thready pulse. The nurse is caring for a client who is wearing oxygen via nasal cannula. The client asks about the bubbling water attached to the oxygen. Which response by the nurse is appropriate? It prescribes oxygen concentration. It determines whether you are getting enough oxygen. It regulates the amount of oxygen received. It decreases dry mucous membranes by delivering small water droplets. It decreases dry mucous membranes by delivering small water droplets. The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather? face tent tracheostomy collar nasal cannula simple mask face tent A face tent is used without a mask; it is open and loose around the face and is often used for clients with facial trauma or burns. A simple mask or nasal cannula would irritate the facial skin. The client does not have a tracheostomy. Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? Bronchoscopy Skin tests Pulmonary function tests Chest x-ray Pulmonary function tests Pulmonary function testing is used to measure lung size and airway patency. Chest x rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies. An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's: age. hemoglobin level. blood pH. sodium and potassium levels. hemoglobin level Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry. A client, 90 years of age, has been in a motor vehicle collision and sustained four fractured ribs on the left side of the thorax. The nurse recognizes the client is experiencing respiratory complications when which sign(s) is observed? Select all that apply. The client demonstrates restlessness. The client has uneven movements of the chest with respirations. The client has a respiratory rate of 16 breaths/min. The client's capillary refill is assessed at 4 seconds. The client has flaring nostrils. The client demonstrates restlessness The client has uneven movements of the chest with respirations. The client's capillary refill is assessed at 4 seconds. The client has flaring nostrils. Careful assessment of older adults who demonstrate restlessness or confusion is imperative for accurately differentiating signs of inadequate oxygenation from signs of delirium or dementia. While the nurse may be observing signs of cognitive impairment, restlessness commonly accompanies respiratory distress. The nurse will not dismiss this sign and will consider it as part of the respiratory assessment. A prolonged capillary refill time (any time longer than 3 seconds) is indicative of poor perfusion secondary to poor oxygenation. This is a sign that the client may be experiencing respiratory complications. The nurse observes for paradoxical (uneven) chest movement that would indicate a possible flail chest. These complications may require insertion of a chest tube or other surgery, blood transfusion or artificial ventilation. Flaring nostrils indicate increased work of breathing related to poor gas exchange. A respiratory rate that ranges from 12 to 16 breaths/min is normal for adults and older adults. A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? A. Dyspnea B. Hypotension C. Decreased respiratory rate D. Decreased pulse rate A. Dyspnea If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis. A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? A. The patient vomits during suctioning. B. The secretions appear to be stomach contents. C. The catheter touches an unsterile surface. D. A nosebleed is noted with continued suctioning. D. A nosebleed is noted with continued suctioning. When nosebleed (epistaxis) is noted with continued suctioning, the nurse should notify the health care provider and anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning. A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? A. The nurse assures that the oxygen is flowing into the prongs. B. The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. C. The nurse encourages the patient to breathe through the nose with the mouth closed. D. The nurse adjusts the flow rate to 6 L/min or more. C. The nurse encourages the patient to breathe through the nose with the mouth closed. The nurse should encourage the patient to breathe through the nose with the mouth closed. The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should adjust the fit of the cannula so it is snug but not tight against the skin. The nurse should adjust the flow rate as ordered. A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? A. Notify the health care provider. B. Apply an occlusive dressing on the site. C. Assess the patient for signs of respiratory distress. D. Put on gloves and insert the chest tube in a bottle of sterile saline. D. Put on gloves and insert the chest tube in a bottle of sterile saline. When a chest tube becomes separated from the drainage device, the nurse should submerge the end in water, creating a water seal, but allowing air to escape, until a new drainage unit can be attached. This is done instead of clamping to prevent another pneumothorax. Then the nurse should assess vital signs and notify the health care provider. An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? A. Tilt the patient's head forward. B. Hold the mask tightly over the patient's nose and mouth. C. Pull the patient's jaw backward. D. Compress the bag twice the normal respiratory rate for the patient. B. Hold the mask tightly over the patient's nose and mouth. With the patient's head tilted back, jaw pulled forward, and airway cleared, the mask is held tightly over the patient's nose and mouth. The bag also fits easily over tracheostomy and endotracheal tubes. The operator's other hand compresses the bag at a rate that approximates normal respiratory rate (e.g., 16 to 20 breaths/min in adults). Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. A. Closely assess the patient before, during, and after the procedure. B. Hyperoxygenate the patient before and after suctioning. C. Limit the application of suction to 20 to 30 seconds. D. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. E. Use an appropriate suction pressure (80 to 150 mm Hg). F. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube. A. Closely assess the patient before, during, and after the procedure. B. Hyperoxygenate the patient before and after suctioning. D. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. E. Use an appropriate suction pressure (80 to 150 mm Hg). Close assessment of the patient before, during, and after the procedure is necessary to limit negative effects. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. The nurse should also take the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis related to the use of high negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis. nasal cannula (low flow) 1-6L/min, 24-44% FiO2 apply if SpO2 lower than 90%, increased resp rate patient is stable high flow nasal cannula up to 60 L/min, 100% FiO2 humidified air simple mask non-rebreather mask low flow 10-15L/min 80-95% FiO2 allows release of CO2, used in emergent situations The brain needs which of the two to survive? Oxygen & Glucose 3 multi