NUR 242 Exam 3 study questions Unit 7 & 8. Questions and Correct Answers, With Rationale.
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NUR 242
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NUR 242
NUR 242 Exam 3 study questions Unit 7 & 8. Questions and Correct Answers, With Rationale.
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:...
NUR 242 Exam 3 study questions Unit 7
& 8. Questions and Correct Answers, With
Rationale.
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.
Which order is most important for the nurse to implement immediately?
A. Transfer to ICU
B. Increase O2 to 3 L per nasal cannula
C. ABGs 30 minutes after oxygen is increased
D. Methylprednisolone sodium succinate (Solu-Medrol) 40 mg IVP
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