SNLE Adult Health Nursing 2 — Questions and Answers
Question 1: A patient with COPD is receiving oxygen therapy. What is the safest initial oxygen flow rate?
- 1–2 L/min via nasal cannula (Correct answer)
- 10–15 L/min via non-rebreather mask
- 5 L/min via simple face mask
- High-flow oxygen without limit
Correct answer: 1–2 L/min via nasal cannula
Patients with COPD may rely on hypoxic drive to breathe. High-flow oxygen can suppress this drive and cause respiratory depression. Low-flow oxygen (1–2 L/min) targeting SpO2 of 88–92% is the safe starting point.
Question 2: Which nursing assessment is most important for a patient receiving heparin therapy?
- Monitor for signs of bleeding and check aPTT values (Correct answer)
- Monitor blood glucose levels
- Assess skin turgor
- Check urine specific gravity
Correct answer: Monitor for signs of bleeding and check aPTT values
Heparin is an anticoagulant that increases bleeding risk. Monitoring aPTT (target 1.5–2.5 times control), observing for hematuria, melena, petechiae, and excessive bruising are essential safety assessments.
Question 3: A post-operative patient reports sudden onset of chest pain and dyspnea on day 3. What should the nurse suspect first?
- Pulmonary embolism (Correct answer)
- Pneumonia
- Pleural effusion
- Atelectasis
Correct answer: Pulmonary embolism
Sudden pleuritic chest pain and dyspnea in a post-operative patient on day 2–5 is a classic presentation of pulmonary embolism from deep vein thrombosis. Immobility, surgery, and hypercoagulable state (Virchow's triad) are risk factors.
Question 4: What is the primary goal of nasogastric tube decompression after abdominal surgery?
- Remove gas and fluids to prevent abdominal distension and vomiting (Correct answer)
- Provide enteral nutrition
- Administer oral medications
- Monitor gastric pH
Correct answer: Remove gas and fluids to prevent abdominal distension and vomiting
Postoperative ileus causes accumulation of gas and secretions in the stomach and intestines. NG decompression removes these contents, reducing distension, nausea, vomiting, and risk of aspiration.
Question 5: A patient's wound culture reveals MRSA. What precautions are required?
- Contact precautions: gloves and gown for all patient contact (Correct answer)
- Airborne precautions with N95 mask
- Droplet precautions with surgical mask
- Standard precautions only
Correct answer: Contact precautions: gloves and gown for all patient contact
MRSA (methicillin-resistant Staphylococcus aureus) is transmitted via direct contact with the patient or contaminated surfaces. Contact precautions (gloves and gown) are required to prevent spread to other patients.
Question 6: Which assessment is most important when a patient is receiving a blood transfusion?
- Vital signs every 15 minutes for the first hour (Correct answer)
- Blood glucose monitoring
- Urine output only
- Pain assessment at each hour
Correct answer: Vital signs every 15 minutes for the first hour
Transfusion reactions can occur within the first 15 minutes. Vital signs (temperature, BP, pulse, respiratory rate) are monitored every 15 minutes during the first hour to detect early signs of hemolytic or febrile reactions.
SNLE Adult Health Nursing 2
A patient with COPD is receiving oxygen therapy.
What is the safest initial oxygen flow rate?