NUR 204 EXAM 2 2024-2025 WITH ACTUAL
CORRECT QUESTIONS AND VERIFIED
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QUESTIONS AND SOLUTIONS |ALREADY
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1.Which clinical patient scenario is associated with the most critical need for the nurse to obtain vital
signs?
a. Complaining of feeling "chilled" after a shower
b. Complaining of pressure in the chest
c. Completing ambulation of 100 feet after a stroke
d. Complaining of hunger while NPO (nothing by mouth)
Answer: b
Chest pressure is a classic sign of a heart attack—vital signs should be checked immediately. Vital
signs may be monitored before, during, or after activity, but this is not the most critical need. Unless
the vital signs have changed drastically, not having baseline values before ambulation makes it hard
to interpret vital signs after activity. Hunger is not a critical indicator for the need for obtaining vital
signs.
2.The nurse understands that which statement is correct regarding respiratory rates?
a. Infants have a lower respiratory rate than adults.
b. Healthy adults breathe between 12 and 20 times a minute.
c. A compensatory response to a fever is to breathe at a slower rate.
d. An increase in intracranial pressure results in an increased respiratory rate.
Answer: b
The normal respiratory rate for a healthy adult is 12 to 20 BPM. Infants have a higher respiratory rate
than adults. A fever increases the metabolic rate and results in a higher rate. Intracranial pressure
decreases the respiratory rate.
3.The nurse is caring for a patient who has a blood pressure of 184/110. An hour after administering an
antihypertensive medication, the nurse returns to recheck the blood pressure, only to find the patient in
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,the chair pale, sweaty, and feeling faint. Which is the expected explanation for the nurse's observations?
a. The blood pressure is 184/110; the medication has not had an effect.
b. The blood pressure is 118/76; the sudden drop has caused the signs.
c. The blood pressure is 174/96; the medication has made the patient sick.
d. The blood pressure is 130/82; the symptoms are from another cause.
Answer: b
The symptoms are indicative of a sudden drop in the blood pressure; an alteration in dose or
medication may be needed.
4.It is 6 a.m. and the unlicensed assistive personnel reports to the nurse that the patient has a
temperature of 96.7° F (35.9° C) tympanic. Which factor explains this reading?
a. The patient's room is cold.
b. The patient was drinking cold water.
c. The patient is exhibiting a normal circadian rhythm.
d. The patient just completed a warm shower.
Answer: c
Normal circadian rhythms cause a lower temperature in the early morning and higher temperature in
the late afternoon. A cool room would initially cause compensatory mechanisms, such as shivering
and a feeling of being cold. Cold water could affect temperature if an oral thermometer was used. A
warm shower would not cause a decrease in temperature unless there was a delay in drying the skin
and dressing.
5.The nurse assesses a patient with chronic obstructive pulmonary disease (COPD). Which significant
finding does the nurse anticipate when inspecting the chest?
a. A ratio of 1 : 2 when comparing the side and front views of the chest
b. A barrel chest
c. A concave shape to the sternum
d. A severe lateral curvature of the spine
Answer: b
Chronic air trapping in COPD can cause a barrel-shaped chest. The intercostal spaces pull the chest
out, and the accessory muscles of breathing may compensate to enlarge the chest cavity, causing the
anteroposterior diameter of the chest to increase. The chest diameter ratio of 1:2 is the normal
finding for a person who does not have hyperinflation of the lungs. A concave sternum is not an
expected finding with COPD. A lateral curvature of the spine is consistent with scoliosis, which is not
an expected finding for most patients with COPD.
6.What is the desired outcome related to the nursing diagnosis of Impaired Airway Clearance?
a. Patient’s respiratory secretions will become thicker so they are not moved when coughing.
b. Patient’s respiratory secretions will have a thinner consistency after being given a mucolytic agent.
c. Patient will have improved range of motion while in bed.
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,d. Patient’s respiratory rate will increase from 16 to 28 breaths/min during hospitalization.
Answer: b
The use of mucolytic agents may thin the secretions and allow easier removal. Thickened secretions in
the airways can make it more difficult to cough effectively. The goal is to decrease the thickness of
secretions. Improved range of motion is related to musculoskeletal problems. The normal respiratory
rate is 12 to 20 breaths/min, and 28 breaths/min is considered tachypnea and is not desired.
7.The nurse is caring for a patient with severe chronic obstructive pulmonary disease (COPD). The
patient has albuterol treatments scheduled every 6 hours and PRN and is on oxygen 2L/min via nasal
cannula. Respiratory therapy (RT) administered the last breathing treatment 1 hour ago. When entering
the patient’s room to administer medications, the nurse notes that the patient is in acute respiratory
distress. Which priority interventions would the nurse take to safely manage the care of this patient?
(Select all that apply.)
a. Place patient in upright position.
b. Call respiratory therapy.
c. Increase oxygen to 7 L/min per nasal cannula.
d. Assess vital signs
e. Listen to lung sounds.
f. Administer metoprolol.
Answer: a, b, d, e
When a person is having difficulty breathing, placing the individual in an upright position (Fowler or
semi-Fowler) helps to increase the effectiveness of breathing by placing less pressure on the chest
from the bed. The nurse would put the patient in an upright position to improve breathing.
Respiratory therapy should come to assess the patient, to administer a second breathing treatment,
and evaluate oxygen requirements depending on the facility. It is important to assess vital signs and
lung sounds to determine what has changed with the patient since the last assessment. Do not
administer oxygen through a simple nasal cannula at greater than 6 L/min. Medications are given only
per order from the primary care provider.
8.When administering oxygen to a patient, the nurse recognizes that using which oxygen delivery
system places a patient in danger of receiving inadequate oxygen?
a. Nasal cannula at a flow rate of 2 L/min
b. Nasal cannula at a flow rate of 5 L/min
c. Simple mask at a flow rate of 6 L/min
d. Nonrebreather mask at a flow rate of 5 L/min
Answer: d
A nonrebreather mask with a flow rate of 5 L/min does not give the patient adequate levels of oxygen
in the reservoir bag and may result in the person developing hypoxemia. The accepted range of
oxygen delivery with a nonrebreather mask is 10 to 15 L/min. The amount that can be delivered by
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, nasal cannula is 1 to 6 L/min, and oxygen delivered at 2 or 5 L/min by nasal cannula is within the safe
range. Oxygen delivered at 5 L/min by a simple face mask delivers adequate oxygen because the
range for a face mask is 5 to 10 L/min.
9.The nurse knows that which of the following nursing actions are indicated when suctioning a patient
with a tracheostomy? (Select all that apply.)
a. Decrease the patient’s oxygen flow rate before beginning the deep suctioning.
b. Assess heart rate, respiratory rate, oxygen saturation, and lung sounds prior to suctioning.
c. Suction intermittently for no more than 10 to 15 seconds.
d. Flush the artificial airway with 5 mL of normal saline to loosen secretions
e. Reassess heart rate, respiratory rate, oxygen saturation, and lung sounds after suctioning.
f. Document time, amount, and characteristics of secretions.
Answer: b, c, e, f
Assess heart rate, respiratory rate, oxygen saturation, and lung sounds before suctioning to provide a
baseline for detecting changes in the patient’s condition. Reassess after suctioning to determine
whether suctioning was beneficial to the patient. Oxygen is removed during the suctioning procedure,
and the amount of time spent suctioning needs to be limited to 10 to 15 seconds. In some cases, the
nurse provides extra oxygen before and during suctioning procedures, and decreasing the oxygen is
contraindicated, therefore it would not be appropriate to decrease the flow rate. Documentation
ensures that changes are noticed and that other members of the interprofessional team are aware of
the patient’s condition. Evidence-based practice shows that flushing with sterile NSS has no benefit
because saline does not mix with secretions and the procedure may have negative effects for the
patient.
10.A patient admitted with a history of chronic obstructive pulmonary disease (COPD) admits to
smoking 1 pack of cigarettes per day for the last 40 years. When developing a plan of care for the
patient, the nurse includes smoking cessation as a priority education goal. Which interventions would
the nurse include in the patient education? (Select all that apply.)
a. Alternative therapies
b. Nicotine replacements
c. Support groups
d. Switching to e-cigarettes
e. Counseling
f. Decreasing the number of cigarettes smoked by half
g. Educating about the risks of smoking
Answer: a, b, c, e, g
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