NURS 110 EXAM 4 PostQuestions With Complete Solutions.
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Course
NURS 110
Institution
NURS 110
The nurse is caring for a patient with a pneumothorax.
Which factor should the nurse suspect caused this alteration?
Trauma
Obesity
Asthma
Pneumonia - Answer Trauma
(While a pneumothorax may occur spontaneously, most occur as the result of trauma. Obesity can cause apnea. Asthma and pn...
NURS 110 EXAM 4 PostQuestions With
Complete Solutions.
The nurse is caring for a patient with a pneumothorax.
Which factor should the nurse suspect caused this alteration?
Trauma
Obesity
Asthma
Pneumonia - Answer Trauma
(While a pneumothorax may occur spontaneously, most occur as the result of trauma. Obesity can cause
apnea. Asthma and pneumonia can cause orthopnea.)
Alteration in oxygenation - Answer Hypoxemia (Decreased level of oxygen)
Dyspnea (Labored breathing or shortness of breath)
Apnea (Absence of breathing)
Tachypnea (A respiratory rate greater than 20 breaths per minute for children and adults, 60 breaths per
minute for an infant)
Orthopnea (Difficulty breathing when lying down)
Pneumothorax (Lung collapse caused by the collection of free air within the pleural space)
A patient asks, "Why do I need to have my position changed every 2 hours?"
Which response should the nurse provide?
"You need to be moved to prevent muscle atrophy from occurring."
"A change of position helps you clear the airway."
"Low oxygen in the tissues increases the risk of skin breakdown."
,"Changing positions frequently helps increase oxygen in your lungs." - Answer "Low oxygen in the
tissues increases the risk of skin breakdown."
(Tissue hypoxia (low oxygen levels) increases the risk of skin breakdown, which in turn increases the risk
of infection and sepsis in the patient. Changing positions does not prevent muscle atrophy in a patient.
Changing position does not always help clear the airway or increase oxygenation.)
A patient is being evaluated for the source of a productive cough and shortness of breath.
Which diagnostic test should the nurse expect to be ordered first?
Sputum specimen
Bronchoscopy
Thoracentesis
Pulmonary function test (PFT) - Answer Sputum specimen
(A sputum specimen is expectorant matter that may contain mucus, cellular debris, blood,
microorganisms, or purulent matter from the respiratory tract that can help identify infection and
inflammation. This test is ordered first. Bronchoscopy is an invasive procedure and would not be used
first for diagnosis of a productive cough. Thoracentesis is used to remove fluid from the pleural space. It
is invasive and not directly linked to productive cough. PFT is used to measure changes in lung function,
but it is not used to diagnose a productive cough.)
Sputum specimen diagnostic test - Answer May be taken to identify the presence of microbes,
metabolites of inflammation, and immunoglobulins.
Bronchoscopy diagnostic test - Answer Is a procedure that allows direct visualization of the lungs and is
usually performed by a pulmonologist. It may also be performed by a primary care or emergency care
provider.
Thoracentesis diagnostic test - Answer -Is both an intervention and a diagnostic test. It is performed to
drain excessive pleural fluid from between the pleural linings.
-The fluid drained is often analyzed for blood, fiber, and microbe content.
,Pulmonary function tests (PFTs) diagnostic test - Answer Demonstrate changes in pulmonary health
related to ventilation airflow, lung volume and capacity, and the diffusion of gas.
The nurse is assessing a group of patients.
Which patient should the nurse consider to be at the greatestrisk for an alteration in oxygenation?
A 22-year-old patient
A 62-year-old patient
A 2-year-old child
A 67-year-old patient - Answer A 67-year-old patient
(Although the inability to oxygenate properly can occur at any point during the lifespan, very young
children (less than 1 year of age) and older adults (over the age of 65) are at increased risk for alterations
in oxygenation. Very young children are more susceptible to respiratory disorders that affect
oxygenation. Older adults carry an increased risk of developing a variety of health impairments, such as
respiratory or cardiac diseases that can affect oxygenation. The 2-year-old, 22-year-old, and 62-year-old
patients are not in the age groups at increased risk.)
A patient with respiratory distress is showing signs of decreasing cardiac output and hypoxemia.
Which action should the nurse take first?
Administer oxygen via face mask.
Assess pulmonary function.
Assess the nail beds for cyanosis.
Assess the patient's arterial blood gases. - Answer Administer oxygen via face mask.
(With signs of hypoxemia, oxygen via face mask should be administered first. Pulmonary function can be
assessed after oxygenation is restored. Assessment of the nail beds for cyanosis and arterial blood gases
are not the first actions due to signs of hypoxemia being seen already.)
A patient with diffuse emphysema asks about options for improving lung health.
Which statement by the nurse is correct?
, There are no options to treat diffuse emphysema other than medications.
Diffuse emphysema is a terminal disease.
Surgical options can be considered to improve lung health with diffuse emphysema.
Exercise can be used to improve lung health and endurance. - Answer Surgical options can be
considered to improve lung health with diffuse emphysema.
(Lung reduction surgery is an experimental surgical intervention for advanced diffuse emphysema.
Diffuse emphysema can be terminal due to significant lung impairment, but surgery is an option. Exercise
will not improve diffuse emphysema.)
A patient is experiencing decreased tissue perfusion, hypovolemia, and hypoxemia.
(The patient has decreased tissue perfusion due to hypovolemia, so fluids will increase blood volume
and improve perfusion to the tissues. The prone position is not indicated for hypoxemia, because it limits
lung function and expansion. Changing from a face mask to a nasal cannula will deliver less oxygen to the
patient. High Fowler position can help when fluid in the lungs or decreased lung expansion is the
problem.)
Independent nursing actions for oxygenation issues include: - Answer -Teaching deep breathing
exercises.
-Positioning.
-Monitoring activity tolerance.
-Promoting secretion clearance.
-Suctioning.
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