NR 341/ NR341 COMPLEX ADULT HEALTH EXAM 1 LATEST REAL EXAM QUESTIONS AND CORRECT ANSWERS|AGRADE

NUR 242 Exam 3 study questions Unit

7 & 8

The nurse immediately checks on the patient and finds that she appears anxious

and her vital signs are as follows:

ØBlood pressure: 128/84 mm Hg

ØHeart rate: 114 (sinus tachycardia)

ØRespiratory rate: 24, labored and restless

ØTemperature: 99.4° F (axillary)

ØO2 saturation: 91% on 40% O2 via trach collar

Which of these findings are cause for concern?

ANS: **The BP is within normal range and only slightly elevated. **The

temperature is only slightly elevated. **Her heart rate is elevated; the nurse

should check the patient’s medications to see if she is on a bronchodilator or

other medication that could cause her heart rate to increase. The priority concern

is the RESTLESSNESS with increased respiratory rate and the decreased oxygen

saturation despite the 40% oxygen setting.

A patient with a history of chronic obstructive pulmonary disease is admitted with

shortness of breath. Which nursing intervention is most appropriate?

A. Do not administer oxygen.

B. Administer oxygen via Venturi mask.

C. Use nasal cannula to administer high flow oxygen.

D. Administer oxygen at 6L per simple face mask.

ANS: B

Oxygen therapy is prescribed at the lowest liter flow needed to manage

hypoxemia. A system that delivers more precise oxygen levels (e.g., a Venturi

mask) is preferred. Monitor the patient’s response to therapy closely to ensure

adequate gas exchange and correction of hypoxemia.

While suctioning a patient, vagal stimulation occurs. What is the appropriate

nursing action?

A. Instruct the patient to cough.

B. Place the patient in a high Fowler's position.

C. Oxygenate the patient with 100% oxygen.

D. Instruct the patient to breathe slowly and deeply.

ANS: C

Vagal stimulation may occur during suctioning and result in severe bradycardia,

hypotension, heart block, ventricular tachycardia, asystole, or other dysrhythmias.

If vagal stimulation occurs, stop suctioning immediately and oxygenate the patient

manually with 100% oxygen. Repositioning the patient, slow deep breathing, and

coughing will not address the cardiovascular effects of vagal stimulation.

The nurse recognizes that a patient with sleep apnea may benefit from which

intervention(s)? (Select all that apply.)

A. Weight loss

B. Nasal mask to deliver BiPAP

C. A change in sleeping position

D. Medication to increase daytime sleepiness

E. Position-fixing device that prevents tongue subluxation

ANS: A, B, C, E

All interventions listed are viable interventions that can be of benefit to patients

who have sleep apnea. Patients should work with their providers of care to

determine the severity of their sleep apnea and which specific interventions

would be of most importance to them. Encouraging daytime sleepiness is the

opposite of the effect needed for this patient.

Based on the patient’s diagnosis, which clinical manifestations would the nurse

expect to see when assessing this patient? (Select all that apply.)

A. Bradycardia

B. Shortness of breath

C. Use of accessory muscles

D. Sitting in a forward posture

E. Barrel chest appearance

ANS: B, C, D, E

The patient with COPD often has a barrel chest appearance, is short of breath, and

may use accessory muscles when breathing. These patients tend to move slowly

and are slightly stooped. Usually they sit with a forward-bending posture. With

severe dyspnea, they exhibit activity intolerance and activities such as bathing and

grooming are avoided.

When the patient arrives to the unit, she is assessed and is in acute respiratory

distress. Her respirations are labored and her respiratory rate is 34. She states that

she had a peak flow meter measurement of "Red Zone" on the way and is severely

short of air. Her oxygen saturation is 82% on O2 at 2 L via nasal cannula.

Based on these findings, what should the nurse do next?

ANS: The Rapid Response Team should be notified immediately. All of these

assessment findings indicate acute respiratory distress. The peak flow meter is in

the RED Zone. The oxygen saturation should be at least 90% on 2 L per NC.

While the Rapid Response Team is at the bedside, the patient's healthcare

provider arrives. The provider writes several orders.

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