Select All That Apply Practice Exam Flashcards

The high-pressure alarm on a patient’s ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next?

Answer: Manually ventilate the patient while assessing possible reasons for the high-pressure alarm

When a patient with ARDS on a ventilator experiences a high-pressure alarm and desaturation, the immediate priority is to ensure adequate oxygenation and ventilation. Manually ventilating the patient with a bag-valve mask allows the nurse to immediately provide breaths, assess lung compliance, and troubleshoot the ventilator issue or patient problem (e.g., kinked tube, secretions) without delay. This is a critical safety intervention.

The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient’s comfort for this problem?

Answer: Suggest that the patient’s oxygen be humidified

Oxygen administered via nasal cannula, especially at higher flow rates, can dry out the nasal passages, leading to discomfort, irritation, and even nosebleeds. Humidifying the oxygen adds moisture to the gas, preventing dryness and improving patient comfort. This simple intervention significantly alleviates the common side effect of oxygen therapy.

The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision?

Answer: Observe how well the patient performs pursed-lip breathing

Observing a patient's technique for pursed-lip breathing is within the scope of practice for an experienced LPN, as it involves monitoring and reinforcing a learned skill. Planning nursing care regimens, assisting with complex ADLs requiring significant assessment, or consulting with other departments typically fall under the RN's scope. The LPN can effectively contribute to patient education reinforcement and assessment of learned behaviors.

The patient with COPD tells the nursing assistant that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the nursing assistant to report which of these?

Answer: Oral temperature of 101.2 F (38.4C)

A patient with COPD who has not received flu or pneumonia vaccinations is at high risk for respiratory infections, which can severely exacerbate their condition. An oral temperature of 101.2 F (38.4C) indicates a fever, a key sign of infection, and warrants immediate reporting to the nurse. The other vital signs, while notable, are less indicative of an acute, concerning infection in this high-risk patient.

To improve respiratory status, which medication should you be prepared to administer to the newborn infant with RDS?

Answer: Surfactant (Exosurf)

Respiratory Distress Syndrome (RDS) in newborns is caused by a deficiency of surfactant, a substance that reduces surface tension in the lungs and prevents alveolar collapse. Administering exogenous surfactant (e.g., Exosurf) directly into the infant's lungs helps improve lung compliance, reduce the work of breathing, and facilitate gas exchange. This is the primary treatment for RDS.

When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching?

Answer: “I will continue to take my isoniazid until I am feeling completely well.”

Tuberculosis treatment, particularly with isoniazid, requires a prolonged course (typically 6-9 months) to eradicate the bacteria completely and prevent drug resistance. Stopping the medication prematurely, even if feeling well, can lead to a relapse of the infection and the development of drug-resistant TB. Therefore, the statement indicates a need for further teaching about medication adherence.

When assessing a 22-year old patient who required emergency surgery and multiple transfusion 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate?

Answer: Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status

The patient is in acute respiratory distress with severe hypoxemia (SpO2 90% on 6L NC), indicating a critical need for higher oxygen delivery. A nonrebreather mask delivers the highest possible concentration of oxygen (up to 95-100%), which is crucial for immediate improvement of oxygen saturation in this situation. Simultaneously, notifying the physician is essential for further assessment, diagnosis, and management of the underlying cause of the respiratory compromise.

Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team?

Answer: Auscultating the lungs for crackles

Auscultating the lungs for crackles is a skill within the LPN's scope of practice, as it involves data collection and monitoring of a stable patient. LPNs are trained to perform focused assessments and gather objective data. However, evaluating the significance of these findings or performing initial comprehensive assessments remains the responsibility of the Registered Nurse.

Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before administration?

Answer: Warfarin (Coumadin) 1.0 mg by mouth (PO)

Warfarin (Coumadin) 1.0 mg is an unusually low dose for a patient with a new pulmonary embolism, where therapeutic anticoagulation is critical. Initial dosing typically starts higher and is titrated based on INR. This order warrants clarification with the physician to ensure appropriate and effective treatment for the PE.

The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?

Answer: Respiratory stridor

Respiratory stridor is a high-pitched, harsh sound indicating upper airway obstruction, which is a life-threatening emergency. In a post-tonsillectomy patient, this could be caused by swelling or bleeding in the surgical site, compromising the airway. Immediate reporting is crucial to prevent respiratory arrest.

The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort lessens when he:

Answer: Eats a meal

Duodenal ulcer pain is typically described as burning or gnawing, occurring 2-3 hours after a meal or waking the patient at night. The pain is characteristically relieved by eating food, which buffers stomach acid, or by taking antacids. This temporary relief distinguishes it from gastric ulcer pain, which often worsens with food.

Which of the following meal selections is appropriate for the client with celiac disease?

Answer: Rice Krispies bar and milk

Clients with celiac disease must adhere to a strict gluten-free diet, avoiding all products containing wheat, barley, and rye. Rice Krispies are made from rice, which is naturally gluten-free, making a Rice Krispies bar and milk an appropriate snack choice. Other options contain wheat, which would trigger symptoms in a client with celiac disease.

A client with hyperthyroidism is taking lithium carbonate to inhibit thyroid hormone release. Which complaint by the client should alert the nurse to a problem with the client’s medication?

Answer: The client complains of increased thirst and increased urination.

Increased thirst (polydipsia) and increased urination (polyuria) are common side effects of lithium carbonate, often indicating its effect on the kidneys, potentially leading to nephrogenic diabetes insipidus. These symptoms can also be early indicators of lithium toxicity, requiring immediate assessment of serum lithium levels and potential dose adjustment to prevent more severe complications.

A 2-month-old infant has just received her first Tetramune injection. The nurse should tell the mother that the immunization:

Answer: Is one of a series of injections that protects against dpt and Hib

Tetramune is a combination vaccine that provides protection against Diphtheria, Tetanus, Acellular Pertussis (DTaP), and Haemophilus influenzae type b (Hib). It is administered as part of a series of injections during infancy to build immunity against these serious childhood diseases.

The nurse is caring for a client hospitalized with bipolar disorder, manic phase. Which of the following snacks would be best for the client with mania?

Answer: Milkshake

Clients in a manic phase often have high energy levels, are restless, and may neglect their nutritional and fluid intake, leading to weight loss and dehydration. A milkshake is an ideal snack because it is high in calories, protein, and fluids, and can be consumed quickly and easily, even while the client is on the go.

A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?

Answer: “Currant jelly” stools

"Currant jelly" stools, which are a mixture of blood and mucus, are a classic and highly indicative sign of intussusception. This occurs due to the telescoping of the intestine, leading to venous obstruction, ischemia, and sloughing of the intestinal mucosa. Other common signs include sudden onset of severe, colicky abdominal pain and a sausage-shaped abdominal mass.