Chapter 30 to Chapter 42: Vital Signs Potter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE

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Chapter 30 to Chapter 42: Vital Signs Potter et al.: Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE Chapter 30: Vital Signs 1. A patient has a head injury and damages the hypothalamus. Whi... ch vital sign will the nurse monitor most closely? a. Pulse 
 b. Respirations 
 c. Temperature d. Blood pressure 
 ANS: C Disease or trauma to the hypothalamus or the spinal cord, which carries hypothalamic messages, causes serious alterations in temperature control. The hypothalamus does not control pulse, respirations, or blood pressure. DIF:Understand (comprehension)REF:488 OBJ:Explain the principles and mechanism of thermoregulation. TOP: Assessment MSC: Physiological Adaptatin 2. A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss? a. Radiation 
 b. Conduction 
 c. Convection 
 d. Evaporation 
 ANS: C Convection is the transfer of heat away from the body by air movement. Conduction is the transfer of heat from one object to another with direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. 3. The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient’s temperature? a. Radiation 
 b. Conduction c. Convection 
 d. Evaporation 
 ANS: B Applying an ice pack or bathing a patient with a cool cloth increases conductive heat loss because of the direct contact. Radiation is the transfer of heat from the surface of one object to the surface of another without direct contact between the two. Evaporation is the transfer of heat energy when a liquid is changed to a gas. Convection is the transfer of heat away from the body by air movement. DIF:Understand (comprehension)REF:489 OBJ:Explain the principles and mechanism of thermoregulation. TOP: Implementation MSC: Basic Care and Comfort 4. A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take? a. Apply just a diaper. 
 b. Double the clothing. 
 c. Place a cap on their heads. d. Increase room temperature to 90 degrees. ANS: C A newborn loses up to 30% of body heat through the head and therefore needs to wear a cap to prevent heat loss. Temperature control mechanisms in newborns are immature and respond drastically to changes in the environment; do not increase the room temperature to 90 degrees. Take extra care to protect newborns from environmental temperatures. Provide adequate clothing; do not double the clothing or apply just a diaper. DIF:Apply (application)REF:489
OBJ: Describe nursing measures that promote heat loss and heat conservation. TOP: Implementation MSC: Health Promotion and Maintenance 5. The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient’s temperature is 96.8° F (36° C), whereas at 4:00 PM the preceding day, it was 98.6° F (37° C). What should the nurse do? a. Call the health care provider immediately to report a possible infection. 
 b. Administer medication to lower the temperature further. 
 c. Provide another blanket to conserve body temperature. 
 d. Realize that this is a normal temperature variation. ANS: D Body temperature normally changes 0.5° to 1° C (0.9° to 1.8° F) during a 24-hour period and is usually lowest between 1:00 and 4:00 AM, with a maximum temperature at 4:00 PM, making this variation normal for the time of day. Unless the patient reports being cold, there is no physiological need for providing an extra blanket or medication to lower the body temperature further. There is also no need to call a health care provider to report a normal temperature variation. 6. The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient’s last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take? b. Wait 30 minutes and recheck the patient’s temperature. 
 c. Assume that the patient has an infection and order blood cultures. 
 d. Encourage the patient to move around to increase muscular activity. 
 e. Be aware that temperatures this high are harmful and affect patient safety. 
 ANS: A Waiting 30 minutes and rechecking the patient’s temperature would be the most appropriate action in this case. A fever is usually not harmful if it stays below 102.2° F (39° C), and a single temperature reading does not always indicate a fever. In addition to physical signs and symptoms of infection, a fever determination is based on several temperature readings at different times of the day compared with the usual value for that person at that time. Nurses should base actions on knowledge, not on assumptions. Encouraging the patient to increase muscular activity will cause heat production to increase up to 50 times normal. The temperature has decreased and a symptom of infection would be an increase in temperature. DIF:Analyze (analysis)REF:490 OBJ: Describe nursing measures that promote heat loss and heat conservation. TOP: Implementation MSC: Reduction of Risk Potential 7. A patient is pyrexic. Which piece of equipment will the nurse obtain to monitor this condition? a. Stethoscope a. Thermometer 
 b. Blood pressure cuff c. Sphygmomanometer 
 ANS: B Pyrexia, or fever, occurs because heat loss mechanisms are unable to keep pace with excess heat production, resulting in an abnormal rise in body temperature; therefore, a thermometer is needed. A stethoscope is not used to take a temperature but can be used for apical pulse and blood pressure. A pulse oximeter is used to determine oxygen content in the blood. A sphygmomanometer and blood pressure cuff is used to determine blood pressure and will be used for blood pressure problems. DIF:Apply (application)REF:490 OBJ: Discuss physiological changes associated with fever. TOP: Assessment MSC:Health Promotion and Maintenance 8. The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient? a. Hyperthermia and fever are the same thing. 
 b. Hyperthermia is an upward shift in the set point. 
c. Hyperthermia occurs when the body cannot reduce heat production. d. Hyperthermia results from a reduction in thermoregulatory mechanisms. 
 ANS: C An elevated body temperature related to the inability of the body to promote heat loss or reduce heat production is hyperthermia. Whereas fever is an upward shift in the set point, hyperthermia results from an overload of the thermoregulatory mechanisms of the body. DIF:Understand (comprehension)REF:491 OBJ: Discuss physiological changes associated with fever. TOP: Planning MSC: Physiological Adaptation 9. The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take? a. Place the patient on oxygen. b. Encourage the patient to cough. 
 c. Restrict the patient’s fluid intake. 
 d. Increase the patient’s metabolic rate. 
 ANS: A Interventions during a fever include oxygen therapy. During a fever, cellular metabolism increases and oxygen consumption rises. Myocardial hypoxia produces angina. Cerebral hypoxia produces confusion. Dehydration is a serious problem through increased respiration and diaphoresis. The patient is at risk for fluid volume deficit. Fluids should not be restricted, even though the patient has heart failure; the patient needs fluids at this time due to the fever. Increasing the metabolic rate further would not be advisable. Coughing will increase muscular activity, which will increase fever. DIF:Apply (application)REF:491 OBJ: Discuss physiological changes associated with fever. TOP: Implementation MSC: Reduction of Risk Potential 10. The patient requires temperatures to be taken every 2 hours. Which task will the nurse assign to an RN? a. Using appropriate route and device 
b. Assessing changes in body temperature c. Being aware of the usual values for the patient d. Obtaining temperature measurement at ordered frequency ANS: B The nurse is responsible for assessing changes in body temperature. The nursing assistive personnel can use the appropriate route and device to measure temperature, obtain temperature measurement at ordered frequency, and be aware of the usual values for the patient. 11. The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse use to obtain the patient’s temperature? a. Oral 
 b. Rectal 
 c. Axillary 
 d. Tympanic ANS: D The tympanic route is easily accessible, requires minimal patient repositioning, and often can be used without disturbing the patient. It also has a very rapid measurement time. Oral temperatures require patient cooperation and are not recommended for patients with a history of seizures. Rectal temperatures require positioning and may increase patient agitation. Axillary temperatures need long measurement times and continuous positioning. The patient’s agitation state may not allow for long periods of attention. DIF:Apply (application)REF:493 12. The patient is being admitted to the emergency department following a motor vehicle accident. The patient’s jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading? a. Oral 
 b. Axillary 
 c. Tympanicd. Temporal 
 ANS: C The tympanic route is the best choice in this situation. Oral temperatures are not used for patients who have had oral surgery, trauma, history of epilepsy, or shaking chills. Axillary temperature is affected by exposure to the environment, including time to place the thermometer. It also requires a long measurement time. Temporal artery temperature is affected by skin moisture such as diaphoresis or sweating. DIF:Apply (application)REF:493 13. The nurse is caring for an infant and is obtaining the patient’s vital signs. Which artery will the nurse use to bestobtain the infant’s pulse? a. Radial b. Brachial c. Femoral d. Popliteal ANS: B The brachial or apical pulse is the best site for assessing an infant’s or a young child’s pulse because other peripheral pulses such as the radial, femoral, and popliteal arteries are deep and difficult to palpate accurately. DIF:Understand (comprehension)REF:497 OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Implementation MSC: Health Promotion and Maintenance 14. The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use? a. Radial 
 b. Apical 
 c. Carotid d. Brachial 
ANS: C The heart continues to deliver blood through the carotid artery to the brain as long as possible. The carotid pulse is easily accessible during physiological shock or cardiac arrest. The radial pulse is used to assess peripheral circulation or to assess the status of circulation to the hand. The brachial site is used to assess the status of circulation to the lower arm. The apical pulse is used to auscultate the apical area. DIF:Apply (application)REF:497-498
OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Implementation MSC: Physiological Adaptation 15. The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement? b. Place the tips of the first two fingers over the groove along the thumb side of the patient’s wrist. 
 c. Place the tips of the first two fingers over the groove along the little finger side of the patient’s wrist. 
 d. Place the thumb over the groove along the little finger side of the patient’s wrist. 
 e. Place the thumb over the groove along the thumb side of the patient’s wrist. 
 ANS: A Place the tips of the first two or middle three fingers of the hand over the groove along the radial or thumb side of the patient’s inner wrist. Fingertips are the most sensitive parts of the hand to palpate arterial pulsation. The thumb has a pulsation that interferes with accuracy. The groove along the little finger is the ulnar pulse. DIF:Apply (application)REF:498 | 518
OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Implementation MSC: Health Promotion and Maintenance
16. The nurse is assessing the patient’s respirations. Which action by the nurse is most appropriate? a. Inform the patient that she is counting respirations. 
 b. Do not touch the patient until completed. 
 c. Obtain without the patient knowing. 
 d. Estimate respirations. 
ANS: C Do not let a patient know that you are assessing respirations. A patient aware of the assessment can alter the rate and depth of breathing. Assess respirations immediately after measuring pulse rate, with your hand still on the patient’s wrist as it rests over the chest or abdomen. Respirations are the easiest of all vital signs to assess, but they are often the most haphazardly measured. Do not estimate respirations. DIF:Apply (application)REF:501
OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Implementation MSC: Health Promotion and Maintenance
17. The patient’s blood pressure is 140/60. Which value will the nurse record for the pulse pressure? a. 60 
 b. 80 
 c. 140 
 d. 200 
 ANS: B The difference between the systolic pressure and the diastolic pressure is the pulse pressure. For a blood pressure of 140/60, the pulse pressure is 80 (140 − 60 = 80). 140 is the systolic pressure. 60 is the diastolic pressure. 200 is the systolic (140) added to the diastolic (60), but this has no clinical significance. DIF:Apply (application)REF:503 OBJ:Explain the physiology of normal regulation of blood pressure, pulse, oxygen saturation, and respirations.TOP:Implementation MSC:Health Promotion and Maintenance 18. The nurse reviews the laboratory results for a patient and determines the viscosity of the blood is thick. Which laboratory result did the nurse check? a. Arteral blood gas a. Blood culture 
 b. Hematocrit 
c. Potassium 
 ANS: C The hematocrit, or the percentage of red blood cells in the blood, determines blood viscosity. Blood cultures determine the causative agent of an infection. Abnormal potassium levels can cause dysrhythmias. Arterial blood gases determine acid-base balance or the pH levels of the blood. DIF:Apply (application)REF:503 OBJ: Explain the physiology of normal regulation of blood pressure, pulse, oxygen saturation, and respirations. TOP: Assessment MSC: Physiological Adaptation 19. The patient is being admitted to the emergency department with reports of shortness of breath. The patient has had chronic lung disease for many years but still smokes. What will the nurse do? a. Allow the patient to breathe into a paper bag. 
 b. Use oxygen cautiously in this patient. 
 c. Administer high levels of oxygen. 
 Give CO2 via mask. Oxygen must be used cautiously in these types of patients. Hypoxemia helps to control ventilation in patients with chronic lung disease. Because low levels of arterial O2 provide the stimulus that allows a patient to breathe, administration of high oxygen levels may be fatal for patients with chronic lung disease. Patients with chronic lung disease have ongoing hypercarbia (elevated CO2 levels) and do not need to have CO2 administered or ―rebreathed‖ with a paper bag. DIF:Apply (application)REF:500 OBJ: Explain the physiology of normal regulation of blood pressure, pulse, oxygen saturation, and respirations. TOP: Implementation MSC: Physiological Adaptation 20. A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up? a. 35 mm Hg 
 b. 40 mm Hg 
 c. 45 mm Hg 
d. 50 mm Hg 
 ANS: D 50 mm Hg is abnormal so the nurse will follow up. Normal capnography results are 35 to 45 mm Hg. DIF:Understand (comprehension)REF:487 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Assessment MSC:Management of Care 21. The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient’s low heart rate? b. The patient has a fever. 
 c. The patient has possible hemorrhage or bleeding. 
 d. The patient has chronic obstructive pulmonary disease (COPD). 
 e. The patient has calcium channel blockers or digitalis medication prescriptions. 
 ANS: D Negative chronotropic drugs such as digitalis, beta-adrenergic agents, and calcium channel blockers can slow down pulse rate. Fever, bleeding, hemorrhage, and COPD all increase the body’s need for oxygen, leading to an increased heart rate. DIF:Apply (application)REF:499 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Assessment MSC: Physiological Adaptation 22. The patient was found unresponsive in an apartment and is being brought to the emergency department. The patient has arm, hand, and leg edema, temperature is 95.6° F, and hands are cold secondary to a history of peripheral vascular disease. It is reported that the patient has a latex allergy. What should the nurse do to quickly measure the patient’s oxygen saturation? a. Attach a finger probe to the patient’s index finger. 
b. Place a nonadhesive sensor on the patient’s earlobe. 
 c. Attach a disposable adhesive sensor to the bridge of the patient’s nose. 
 d. Place the sensor on the same arm that the electronic blood pressure cuff is on. 
 ANS: B A nonadhesive sensor is best for latex allergy, and the earlobe site is the best choice for this patient with peripheral vascular disease and edema. Select forehead, ear or bridge of nose if an adult patient has a history of peripheral vascular disease. Do not attach probe to finger, ear, forehead, or bridge of nose if area is edematous or skin integrity is compromised. Do not use disposable adhesive probes if the patient has latex allergy. Do not attach probe to fingers that are hypothermic. Do not place the sensor on the same extremity as the electronic blood pressure cuff because blood flow to the finger will be temporarily interrupted when the cuff inflates. DIF:Apply (application)REF:524 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Implementation MSC: Physiological Adaptation 23. The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient’s symptoms? a. Red blood cell count of 5.0 million/mm3 a. Hemoglobin level of 8.0 g/100 mL 
 b. Hematocrit level of 45% 
 c. Pulse oximetry of 95% 
 ANS: B The concentration of hemoglobin reflects the patient’s capacity to carry oxygen, which if low can lead to shortness of breath and chest discomfort. Normal hemoglobin levels range from 14 to 18 g/100 mL in males and from 12 to 16 g/100 mL in females. Hemoglobin of 8.0 is low and indicates a decreased ability to deliver oxygen to meet bodily needs. All other values in the selection are considered normal. DIF:Analyze (analysis)REF:501 | 522 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Assessment MSC: Reduction of Risk Potential 24. A nurse reviews blood pressures of several patients. Which finding will the nurse report as prehypertension? a. 98/50 in a 7-year-old child 
 b. 115/70 in an infant 
 c. 120/80 in a middle-aged adult 
 d. 146/90 in an older adult ANS: C An adult’s blood pressure tends to rise with advancing age. The optimal blood pressure for a healthy, middle-aged adult is less than 120/80. Values of 120 to 139/80 to 89 mm Hg are considered prehypertension. Blood pressure greater than 140/90 is defined as hypertension. Blood pressure of 98/50 is normal for a child, whereas 115/70 can be normal for an infant. DIF:Analyze (analysis)REF:504-505 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Assessment MSC:Health Promotion and Maintenance
25. The nurse is providing a blood pressure clinic for the community. Which group will the nurse most likely address? a. Non-Hispanic Caucasians 
 b. European Americans 
 c. African-Americans 
 d. Asian Americans 
ANS: C The incidence of hypertension is greater in diabetic patients, older adults, and AfricanAmericans. The incidence of hypertension (high BP) is higher in African-Americans than in European Americans. DIF:Understand (comprehension)REF:504-505
OBJ: Describe cultural and ethnic variations with blood pressure assessment. TOP lanningMSC:Health Promotion and Maintenance 26. A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient’s blood pressure (BP)? a. Smoking increases BP for up to 3 hours. 
 b. Caffeine increases BP for up to 15 minutes. 
 c. Smoking result in vasoconstriction, falsely elevating BP. 
 d. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement. 
 ANS: C Smoking results in vasoconstriction, a narrowing of blood vessels. BP rises when a person smokes and returns to baseline about 15-20 minutes after stopping smoking. Caffeine increases BP for up to 3 hours. Be sure that patient has not ingested caffeine or smoked 20 to 30 minutes before BP measurement. DIF:Apply (application)REF:504 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Assessment MSC:Health Promotion and Maintenance 27. When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding? a. This is normal for an infant. 
 b. This is too fast for an infant. 
 c. This is too slow for an infant. 
 d. This is not a rate for an infant but for a toddler. 
ANS: A The normal rate for an infant is 120 to 160 beats/min. The rate obtained (145 beats/min) is within the normal range for an infant. The normal rate for a toddler is between 90 and 140 beats/min; 145 is too high for a toddler. DIF:Understand (comprehension)REF:499 OBJ: Identify ranges of acceptable vital sign values for an infant, a child, and an adult. TOP:AssessmentMSC:Health Promotion and Maintenance 28. The nurse is caring for an older-adult patient and notes that the temperature is 96.8° F (36° C). How will the nurse interpret this finding? a. The patient has hyperthermia. 
 b. The patient has a normal temperature. 
 c. The patient is suffering from hypothermia. 
 d. The patient is demonstrating increased metabolism. 
 ANS: B The average body temperature of older adults is approximately 35° to 36.1° C (95° to 97° F). This is not hypothermia or hyperthermia. Older adults have poor vasomotor control, reduced amounts of subcutaneous tissue, reduced sweat gland activity, and reduced metabolism. The end result is lowered body temperature. DIF:Understand (comprehension)REF:489 OBJ: Identify ranges of acceptable vital sign values for an infant, a child, and an adult. TOP:AssessmentMSC:Health Promotion and Maintenance 29. When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse’s action? a. It is not affected by skin moisture. a. It has no risk of injury to patient or nurse. 
 b. It reflects rapid changes in radiant temperature. 
c. It is accurate even when the forehead is covered with hair. 
 ANS: B The temporal artery thermometer is especially beneficial when used in premature infants, newborns, and children because there is no risk of injury to the patient or nurse. Temporal artery temperature is a reliable noninvasive measure of core temperature. However, it is inaccurate with head covering or hair on the forehead and is affected by skin moisture such as diaphoresis, or sweating. It provides very rapid measurement and reflects rapid changes in core temperature, not radiant temperature. DIF:Understand (comprehension)REF:493 OBJ: Explain variations in technique used to assess an infant’s, a child’s, and an adult’s vital signs. TOP:AssessmentMSC:Health Promotion and Maintenance 30. The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP? b. Ulnar site 
 c. Radial site 
 d. Brachial site 
 e. Femoral site 
 ANS: C The nurse will praise the NAP when obtaining the pulse from the brachial site. The brachial or apical pulse is the best site for assessing an infant’s or a young child’s pulse because other peripheral pulses are deep and difficult to palpate accurately. DIF:Apply (application)REF:497
OBJ: Explain variations in technique used to assess an infant’s, a child’s, and an adult’s vital signs. TOP:AssessmentMSC:Management of Care 31. The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn? a. 30 to 60 
 b. 22 to 28 
c. 16 to 20 
 d. 10 to 15 
 ANS: A The acceptable respiratory rate range for a newborn is 30 to 60 breaths/min. An infant (6 months) is expected to have a rate between 30 and 50 breaths/min. A toddler’s respiratory range is 25 to 32 breaths/min. A child should breathe 20 to 30 times a minute. An adolescent should breathe 16 to 20 times a minute. An adult should breathe 12 to 20 times a minute. DIF:Apply (application)REF:501 OBJ: Explain variations in technique used to assess an infant’s, a child’s, and an adult’s vital signs. TOP lanningMSC:Health Promotion and Maintenance 32. The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take? a. Secure the sensor to the toddler’s earlobe. 
 b. Determine whether the toddler has a latex allergy. 
 c. Place the sensor on the bridge of the toddler’s nose. d. Overlook variations between an oximeter pulse rate and the toddler’s pulse rate. ANS: B The nurse should determine whether the patient has latex allergy because disposable adhesive probes should not be used on patients with latex allergies. Earlobe and bridge of the nose sensors should not be used on infants and toddlers because of skin fragility. Oximeter pulse rate and the patient’s apical pulse rate should be the same. Any difference requires re-evaluation of oximeter sensor probe placement and reassessment of pulse rates. DIF:Apply (application)REF:524 OBJ: Explain variations in technique used to assess an infant’s, a child’s, and an adult’s vital signs. TOP: Implementation MSC: Health Promotion and Maintenance 33. The nurse is preparing to assess the blood pressure of a 3-year-old. How should the nurse proceed? a. Use the diaphragm portion of the stethoscope to detect Korotkoff sounds. 
 b. Obtain the reading before the child has a chance to ―settle down.‖ 
 c. Choose the cuff that says ―Child‖ instead of ―Infant.‖ 
 d. Explain the procedure to the child. 
 ANS: D The child’s cooperation is increased when you or the parent have prepared the child for the unusual sensation of the BP cuff. Most children understand the analogy of a ―tight hug on your arm.‖ Different arm sizes require careful and appropriate cuff size selection. Do not choose a cuff based on the name of the cuff. An ―Infant‖ cuff is too small for some infants. Readings are difficult to obtain in restless or anxious infants and children. Allow at least 15 minutes for children to recover from recent activities and become less apprehensive. Korotkoff sounds are difficult to hear in children because of low frequency and amplitude. A pediatric stethoscope bell is often helpful. DIF:Apply (application)REF:507
OBJ: Explain variations in technique used to assess an infant’s, a child’s, and an adult’s vital signs. TOP: Implementation MSC: Health Promotion and Maintenance
34. A nurse is caring for a group of patients. Which patient will the nurse see first? a. A crying infant with P-165 and R-54 
 b. A sleeping toddler with P-88 and R-23 
 c. A calm adolescent with P-95 and R-26 
 d. An exercising adult with P-108 and R-24 
 ANS: C A calm adolescent should have the following findings: P—60-90 and R—16-20. Since both findings are elevated, the nurse should see this patient first. An infant should have the following findings: P— 120-160 and R—30-50; however, since the infant is crying these values will be elevated and this is normal. A toddler should have the following findings: P—90-140 and R—25-32; however, since the toddler is sleeping these values can be slightly decreased and this is normal. An adult should have the following findings: P—60-100 and R—12-20; however, since the adult is exercising these values will be elevated and this is normal. DIF:Analyze (analysis)REF:499 | 501
OBJ: Identify ranges of acceptable vital sign values for an infant, a child, and an adult. TOP:AssessmentMSC:Management of Care 35. The nurse is caring for a patient who is being discharged from the hospital after being treated for hypertension. The patient is instructed to take blood pressure 3 times a day and to keep a record of the readings. The nurse recommends that the patient purchase a portable electronic blood pressure device. Which other information will the nurse share with the patient? a. You can apply the cuff in any manner. 
 b. You will need to recalibrate the machine. 
 c. You can move your arm during the reading. 
 d. You will need to use a stethoscope properly. 
 ANS: B Electronic devices are easier to manipulate but require frequent recalibration—more than once a year. Because of their sensitivity, improper cuff placement or movement of the arm causes electronic devices to give incorrect readings. The portable home devices include the aneroid sphygmomanometer and electronic digital readout devices that do not require the use of a stethoscope. The cuff will need to be applied correctly, and the patient’s arm needs to be still during the reading. DIF:Apply (application)REF:510
OBJ: Describe the benefits and precautions involving self-measurement of blood pressure. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 36. The nurse is caring for a patient who reports feeling light-headed and ―woozy.‖ The nurse checks the patient’s pulse and finds that it is irregular. The patient’s blood pressure is 100/72. It was 113/80 an hour earlier. What should the nurse do? a. Apply more pressure to the radial artery to feel pulse. 
 b. Perform an apical/radial pulse assessment. 
 c. Call the health care provider immediately. 
 d. Obtain arterial blood gases. 
 ANS: B If the pulse is irregular, do an apical/radial pulse assessment to detect a pulse deficit. If pulse count differs by more than 2, a pulse deficit exists, which sometimes indicates alterations in cardiac output. The nurse needs to gather as much information as possible before calling the health care provider. The radial pulse is more accurately assessed with moderate pressure. Too much pressure occludes the pulse and impairs blood flow. Arterial blood gases is a laboratory test that measures blood pH and oxygenation status. Arterial blood gases would be appropriate if respirations were abnormal or if pulse oximetry results were severely low. DIF:Analyze (analysis)REF:519 OBJ: Identify when to measure vital signs. TOP: Implementation MSC: Reduction of Risk Potential 37. A nurse is caring for a group of patients. Which patient will the nurse see first? a. A 17-year-old male who has just returned from outside ―for a smoke‖ who needs a temperature taken 
 b. A 20-year-old male postoperative patient whose blood pressure went from 128/70 to 100/60 
c. A 27-year-old male patient reporting pain whose blood pressure went from 124/70 to 130/74 
 d. An 87-year-old male suspected of hypothermia whose temperature is below normal 
 ANS: B When a blood pressure drops in a postoperative patient, bleeding may be occurring and lead to shock. The nurse should assess this patient first. Pain will cause the blood pressure to elevate so this is an expected finding, and while it does need to be assessed, it is not the first one to assess. A teenager who has returned from smoking will have to wait at least 20 minutes before a temperature can be taken, so this is not the first one to see. A patient with hypothermia is expected to have a temperature below normal, so this is not the first one to see. DIF:Analyze (analysis)REF:503-505
OBJ: Identify when to measure vital signs. TOP: Assessment MSC:Management of Care 38. The health care provider prescription reads ―Metoprolol (Lopressor) 50 mg PO daily. Do not give if blood pressure is less than 100 mm Hg systolic.‖ The patient’s blood pressure is 92/66. The nurse does not give the medication. Which action should the nurse take? a. Documents that the medication was not given because of low blood pressure 
 b. Does not inform the health care provider that the medication was held 
 c. Does not tell the patient what the blood pressure is 
 d. Documents only what the blood pressure was. 
 ANS: A The nurse must document any interventions initiated as a result of vital sign measurement such as holding an antihypertensive drug. The nurse should inform the patient of the blood pressure value and the need for periodic reassessment of the blood pressure. Documenting the blood pressure only is not sufficient. Any intervention must be documented as well. Abnormal findings must be reported to the nurse in charge or to the health care provider. DIF:Apply (application)REF:510 OBJ:Accurately record and report vital sign measurements. TOP: Communication and Documentation MSC: Management of Care 39. After taking the patient’s temperature, the nurse documents the value and the route used to obtain the reading. What is the reason for the nurse’s action? a. Temperatures vary depending on the route used. 
 b. Temperatures are readings of core measurements. 
 c. Rectal temperatures are cooler than when taken orally. 
 d. Axillary temperatures are higher than oral temperatures. 
 ANS: A Temperatures obtained vary depending on the site used. Rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures, and axillary temperatures are usually 0.5° C (0.9° F) lower than oral temperatures. There are core temperature readings and body surface readings. DIF:Understand (comprehension)REF:492
OBJ: Accurately record and report vital sign measurements. TOP: Implementation MSC:Health Promotion and Maintenance 40. When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding? b. 68 
c. 76 
 d. 138/62 
 e. 138/70 
 ANS: C 138/62 is the correct reading. The fifth sound marks the disappearance of sound. In adolescents and adults the fifth sound corresponds with the diastolic pressure. The fourth sound becomes muffled and low pitched as the cuff is further deflated. At this point the cuff pressure has fallen below the pressure within the vessel walls; this sound is the diastolic pressure in infants and children. 68 is the pulse pressure of 138/70; 76 is the pulse pressure for 138/62. DIF:Apply (application)REF:507 | 528
OBJ:Accurately record and report vital sign measurements. TOP:Communication and Documentation
MSC:Health Promotion and Maintenance 41. The nursing assistive personnel (NAP) is taking vital signs and reports that a patient’s blood pressure is abnormally low. What should the nurse do next? a. Ask the NAP retake the blood pressure. 
 b. Instruct the NAP to assess the patient’s other vital signs. 
 c. Disregard the report and have it rechecked at the next scheduled time. 
 d. Retake the blood pressure personally and assess the patient’s condition. 
 ANS: D The nursing assistive personnel should report abnormalities to the nurse, who should further assess the patient. The nursing assistive personnel should not retake the blood pressure or other vital signs because the nurse needs to assess the patient. The report cannot be disregarded. Assessment must be done by the nurse. DIF:Apply (application)REF:492 | 525
OBJ: Appropriately delegate measurement of vital signs to nursing assistive personnel. TOP:ImplementationMSC:Management of Care MULTIPLE RESPONSE 1. A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature? (Select all that apply.) a. Rectal 
 b. Tympanic 
 c. Esophagus 
 d. Temporal artery 
 e. Pulmonary artery 
 ANS: B, C, E Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. Because the tympanic membrane shares the same arterial blood supply as the hypothalamus, the tympanic temperature is a core temperature. Temporal artery measurements detect the temperature of cutaneous blood flow. Oral, rectal, axillary, and skin temperature sites rely on effective blood circulation at the measurement site. DIF:Understand (comprehension)REF:492
OBJ: Accurately assess body temperature, pulse, respirations, oxygen saturation, and blood pressure. TOP: Assessment MSC: Physiological Adaptation 2. The patient has new-onset restlessness and confusion. Pulse rate is elevated, as is respiratory rate. Oxygen saturation is 94%. The nurse ignores the pulse oximeter reading and calls the health care provider for orders because the pulse oximetry reading is inaccurate. Which factors can cause inaccurate pulse oximetry readings? (Select all that apply.) a. O2 saturations (SaO2) > 70% b. Carbon monoxide inhalation 
 c. Hypothermic fingers 
 d. Intravascular dyes 
 e. Nail polish 
 f. Jaundice 
 ANS: B, C, D, E, F Inaccurate pulse oximetry readings can be caused by outside light sources, carbon monoxide (caused by smoke inhalation or poisoning), patient motion, jaundice, intravascular dyes (methylene blue), nail polish, artificial nails, metal studs, or dark skin. SpO2 is a reliable estimate of SaO2 when the SaO2 is over 70%. DIF:Understand (comprehension)REF:503 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Assessment MSC: Reduction of Risk Potential 3. The nurse is assessing the patient and family for probable familial causes of the patient’s hypertension. The nurse begins by analyzing the patient’s personal history, as well as family history and current lifestyle situation. Which findings will the nurse consider to be risk factors? (Select all that apply.) a. Obesity 
 b. Cigarette smoking 
 c. Recent weight loss 
 d. Heavy alcohol intake 
 e. Regular exercise sessions 
 ANS: A, B, D Obesity, cigarette smoking, and heavy alcohol consumption are risk factors linked to hypertension. Weight loss and regular exercise can decrease the risk for hypertension. DIF:Apply (application)REF:505 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Assessment MSC:Health Promotion and Maintenance 4. The patient is being encouraged to purchase a portable automatic blood pressure device to monitor blood pressure at home. Which information will the nurse present as benefits for this type of treatment? (Select all that apply.) a. Patients can actively participate in their treatment. 
 b. Self-monitoring helps with compliance and treatment. 
c. The risk of obtaining an inaccurate reading is decreased. 
 d. Blood pressures can be obtained if pulse rates become irregular. 
 e. Patients can provide information about patterns to health care providers. 
 ANS: A, B, E Self-measurement of blood pressure has several benefits. Sometimes elevated blood pressure is detected in persons previously unaware of a problem. Persons with prehypertension provide information about the pattern of blood pressure values to their health care provider. Patients with hypertension benefit from participating actively in their treatment through self-monitoring, which promotes compliance with treatment. Disadvantages of self-measurement include the risk of inaccurate readings. Electronic devices are not recommended if the patient has an irregular heart rate. DIF:Understand (comprehension)REF:509-510 OBJ: Describe the benefits and precautions involving self-measurement of blood pressure. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 5. A nurse is teaching the staff about alterations in breathing patterns. Which information will the nurse include in the teaching session? (Select all that apply.) a. Apnea—no respirations 
 b. Tachypnea—regular, rapid respirations 
 c. Kussmaul’s—abnormally deep, regular, fast respirations 
 d. Hyperventilation—labored, increased in depth and rate respirations 
a. Cheyne-Stokes—abnormally slow and depressed ventilation respirations 
 b. Biot’s—irregular with alternating periods of apnea and hyperventilation respirations 
 ANS: A, B, C Apnea—Respirations cease for several seconds. Persistent cessation results in respiratory arrest. Tachypnea—Rate of breathing is regular but abnormally rapid (greater than 20 breaths/min). Kussmaul’s—Respirations are abnormally deep, regular, and increased in rate. Hyperventilation— Rate and depth of respirations increase; breaths are not labored. Hypocarbia sometimes occurs. Cheyne-Stokes—Respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Biot’s—Respirations are abnormally shallow for 2 to 3 breaths followed by irregular period of apnea. DIF:Understand (comprehension)REF:502 OBJ: Describe factors that cause variations in body temperature, pulse, oxygen saturation, respirations, capnography, and blood pressure. TOP: Teaching/Learning MSC:Management of Care MATCHING A nurse is assessing results of vital signs for a group of patients. Match the condition to the assessment findings the nurse is reviewing. a. Patient’s temperature is 113° F (45° C) with hot, dry skin. 
 b. Patient’s blood pressure sitting is 130/60 and 110/40 standing. 
 c. Patient’s pulse is 110 beats/min. 
 d. Patient’s temperature is 93.2° F (34° C). 
 e. Patient’s blood pressure went from 126/76 to 90/50. 
 a. Hypothermia 
 b. Shock/Hypotension 
3. Heatstroke
4. Orthostatic hypotension 5. Tachycardia 1.ANS DIF:Understand (comprehension)REF:491 | 499 | 505
OBJ: Accurately assess body temper Chapter 40: Hygiene
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. A nurse is preparing to provide hygiene care. Which principle should the nurse consider when planning hygiene care? a. Hygiene care is always routine and expected. 
 b. No two individuals perform hygiene in the same manner. 
 c. It is important to standardize a patient’s hygienic practices. 
 d. During hygiene care do not take the time to learn about patient needs. 
 ANS: B No two individuals perform hygiene in the same manner; it is important to individualize the patient’s care based on knowing about the patient’s unique hygiene practices and preferences. Hygiene care is never routine; this care requires intimate contact with the patient and communication skills to promote the therapeutic relationship. In addition, during hygiene, the nurse should take time to learn about the patient’s health promotion practices and needs, emotional needs, and health care education needs. DIF:Understand (comprehension)REF:823 OBJ escribe factors that influence personal hygiene practices. TOP: Planning MSC: Basic Care and Comfort 2. A patient’s hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care? a. Adolescent 
 b. Preschooler 
 c. Older adult 
 d. Adult 
 ANS: B Family customs play a major role during childhood in determining hygiene practices such as the frequency of bathing, the time of day bathing is performed, and even whether certain hygiene practices such as brushing of the teeth or flossing are performed. As children enter adolescence, peer groups and media often influence hygiene practices. During the adult years involvement with friends and work groups shape the expectations that people have about personal appearance. Some older adults’ hygiene practices change because of changes in living conditions and available resources. DIF:Apply (application)REF:823
OBJ escribe factors that influence personal hygiene practices. TOP: Implementation MSC: Health Promotion and Maintenance 3. The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind? a. Patients who appear unkempt place little importance on hygiene practices. a. Personal preferences determine hygiene practices and are unchangeable. 
 b. The patient’s illness may require teaching of new hygiene practices. 
 c. All cultures value cleanliness with the same degree of importance. 
 ANS: C The nurse must assist the patient in developing new hygiene practices when indicated by an illness or condition. For example, the nurse will need to teach a patient with diabetes proper foot hygiene. Patients who appear unkempt often need further assessment regarding their ability to participate in daily hygiene. Patients with certain types of physical limitations or disabilities often lack the physical energy and dexterity to perform hygienic care. Culturally, maintaining cleanliness does not hold the same importance for some ethnic groups as it does for others. DIF:Understand (comprehension)REF:823 OBJ escribe factors that influence personal hygiene practices. TOP: Planning MSC: Basic Care and Comfort 4. The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says ―I always bathe in the evening.‖ Which action by the nurse is best? a. Defer the bath until evening and pass on the information to the next shift. 
 b. Tell the patient that daily morning baths are the ―normal‖ routine. 
 c. Explain the importance of maintaining morning hygiene practices. 
 d. Cancel hygiene for the day and attempt again in the morning. 
 ANS: A Allow the patient to follow normal hygiene practices; change the bath to evening. Patients have individual preferences about when to perform hygiene and grooming care. Knowing the patient’s personal preferences promotes individualized care for the patient. Hygiene care is never routine. Maintaining individual personal preferences is important unless new hygiene practices are indicated by an illness or condition. Cancelling hygiene and trying again is not an option since the nurse already knows the reason for refusal. Adapting practices to meet individual needs is required. DIF:Apply (application)REF:823
OBJ escribe factors that influence personal hygiene practices.
TOP: Implementation MSC: Basic Care and Comfort
5. A nurse is completing an assessment of the patient. Which principle is a priority? a. Foot care will always be important. 
 b. Daily bathing will always be important. 
 c. Hygiene needs will always be important. 
 d. Critical thinking will always be important. 
 ANS: D A patient’s condition is always changing, requiring ongoing critical thinking and changing of nursing diagnoses. Apply the elements of critical thinking as you use the nursing process to meet patients’ hygiene needs. Critical thinking will help you determine when foot care, daily bathing, and hygiene needs are important and when they are not. DIF:Understand (comprehension)REF:825 OBJ iscuss the role that critical thinking plays in providing hygiene. TOP lanningMSC:Management of Care 6. When providing hygiene for an older-adult patient, the nurse closely assesses the skin. What is the rationale for the nurse’s action? a. Outer skin layer becomes more resilient. 
 b. Less frequent bathing may be required. 
c. Skin becomes less subject to bruising. d. Sweat glands become more active. ANS: B In older adults, daily bathing as well as bathing with water that is too hot or soap that is harsh causes the skin to become excessively dry. As the patient ages, the skin thins and loses its resiliency and moisture, and lubricating skin glands become less active, making the skin fragile and prone to bruising and breaking. DIF:Understand (comprehension)REF:824 OBJ: Conduct a comprehensive assessment of a patient’s total hygiene needs. TOP: Planning MSC: Basic Care and Comfort 7. The nurse is bathing a patient and notices movement in the patient’s hair. Which action will the nurse take? a. Use gloves to inspect the hair. 
 b. Apply a lindane-based shampoo immediately. 
 c. Shave the hair off of the patient’s head. 
 d. Ignore the movement and continue. 
 ANS: A In community health and home care settings, it is particularly important to inspect the hair for lice so appropriate hygienic treatment can be provided. If pediculosis capitis (head lice) is suspected, the nurse must protect self against self-infestations by handwashing and by using gloves or tongue blades to inspect the patient’s hair. Suspicions cannot be ignored. Shaving hair off affected areas is the treatment for pediculosis pubis (crab lice) and is rarely used for head lice. Caution against use of products containing lindane because the ingredient is toxic and known to cause adverse reactions. DIF:Apply (application)REF:828
OBJ: Conduct a comprehensive assessment of a patient’s total hygiene needs. TOP: Implementation MSC: Basic Care and Comfort 8. The patient has been brought to the emergency department following a motor vehicle accident. The patient is unresponsive. The driver’s license states that glasses are needed to operate a motor vehicle, but no glasses were brought in with the patient. Which action should the nurse take next? a. Stand to the side of the patient’s eye and observe the cornea. 
 b. Conclude that the glasses were lost during the accident. 
 c. Notify the ambulance personnel for missing glasses. 
 d. Ask the patient where the glasses are. 
 ANS: A An important aspect of an eye examination is to determine if the patient wears contact lenses, especially in patients who are unresponsive. To determine whether a contact lens is present, stand to the side of the patient’s eye and observe the cornea for the presence of a soft or rigid lens. It is also important to observe the sclera to detect the presence of a lens that has shifted off the cornea. An undetected lens causes severe corneal injury when left in place too long. Never assume that glasses were lost or were not worn. Contacting ambulance personnel takes time and cannot assume the glasses are missing. Asking the patient where the glasses are is inappropriate since the patient is unresponsive. DIF:Apply (application)REF:830
OBJ: Conduct a comprehensive assessment of a patient’s total hygiene needs. TOP:ImplementationMSC:Management of Care
9. A nurse is assessing a patient’s skin. Which patient is most at risk for impaired skin integrity? a. A patient who is afebrile a. A patient who is diaphoretic 
 b. A patient with strong pedal pulses 
 c. A patient with adequate skin turgor 
 ANS: B Excessive moisture (diaphoretic) on the surface of the skin serves as a medium for bacterial growth and causes irritation, softens epidermal cells, and leads to skin maceration. A patient who is afebrile is not a high risk; however, a patient who is febrile (fever) is prone to skin breakdown. A patient with strong pedal pulses is not a high risk; however, a patient with vascular insufficiency is. A patient with adequate skin turgor is not a high risk; however, a patient with poor skin turgor is. DIF:Apply (application)REF:829 OBJ: Discuss conditions that place patients at risk for impaired skin integrity. TOP: Assessment MSC: Basic Care and Comfort 10. The nurse is caring for a patient who is immobile. The nurse frequently checks the patient for impaired skin integrity. What is the rationale for the nurse’s action? a. Inadequate blood flow leads to decreased tissue ischemia. 
 b. Patients with limited caloric intake develop thicker skin. 
 c. Pressure reduces circulation to affected tissue. 
 d. Verbalization of skin care needs is decreased. 
ANS: C Body parts exposed to pressure have reduced circulation to affected tissue. Patients with limited caloric and protein intake develop thinner, less elastic skin with loss of subcutaneous tissue. Inadequate blood flow causes ischemia and breakdown. Verbalization is affected when altered cognition occurs from dementia, psychological disorders, or temporary delirium, not from immobility. DIF:Apply (application)REF:829 OBJ: Discuss conditions that place patients at risk for impaired skin integrity. TOP: Planning MSC: Basic Care and Comfort 11. The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with peripheral neuropathy and urinary incontinence. On which areas does the nurse focus care? a. Decreased pain sensation and increased risk of skin impairment 
 b. Decreased caloric intake and accelerated wound healing 
 c. High risk for skin infection and low saliva pH level 
 d. High risk for impaired venous return and dementia 
 ANS: A Patients with paralysis, circulatory insufficiency, or peripheral neuropathy (nerve damage) are unable to sense an injury to the skin (decreased pain sensation). The presence of urinary incontinence, circulatory insufficiency, and neuropathy can combine to result in breakdown, so the patient has an increased risk of skin impairment. While the patient may have decreased caloric intake, the patient will not have accelerated wound healing with circulatory insufficiency, neuropathy, and incontinence. While the patient is at high risk for skin infection, the low salivary pH level is not an issue. While the patient may have a high risk for impaired venous return from the circulatory insufficiency, there is no indication the patient has dementia. DIF:Analyze (analysis)REF:827 | 829 | 838 | 863
OBJ: Discuss conditions that place patients at risk for impaired skin integrity. TOP lanningMSC:Management of Care 12. The nurse is caring for a patient who has undergone surgery for a broken leg and has a cast in place. What should the nurse do to prevent skin impairment? a. Assess surfaces exposed to the edges of the cast for pressure areas. 
 b. Keep the patient’s blood pressure low to prevent overperfusion of tissue. 
 c. Do not allow turning in bed because that may lead to redislocation of the leg. 
 d. Restrict the patient’s dietary intake to reduce the number of times on the bedpan. 
 ANS: A Assess surfaces exposed to casts, cloth restraints, bandages and dressings, tubing, or orthopedic devices. An external device applied to or around the skin exerts pressure or friction on the skin, leading to skin impairment. When restricted from moving, dependent body parts are exposed to pressure that reduces circulation to affected tissues, promoting pressure ulcers. Patients with limited caloric and protein intake develop impaired or delayed wound healing. Keeping the blood pressure artificially low may decrease arterial blood supply, leading to ischemia and breakdown. DIF:Apply (application)REF:829 OBJ: Discuss conditions that place patients at risk for impaired skin integrity. TOP: Implementation MSC: Basic Care and Comfort 13. Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage? a. Insert an indwelling urinary catheter. 
 b. Limit caloric and protein intake. 
 c. Turn the patient every 2 hours. 
 d. Assess for pain during a bath. 
 ANS: D During a bath, assess the status of sensory nerve function by checking for touch, pain, heat, cold, and pressure. When restricted from moving freely, dependent body parts are exposed to pressure that reduces circulation. However, this patient is mobile and therefore is able to change positions. Limiting caloric and protein intake may result in impaired or delayed wound healing. A mobile patient can use bathroom facilities or a urinal and does not need a urinary catheter. DIF:Analyze (analysis)REF:829 OBJ: Discuss conditions that place patients at risk for impaired skin integrity. TOP: Implementation MSC: Basic Care and Comfort 14. After performing foot care, the nurse checks the medical record and discovers that the patient has a foot disorder caused by a virus. Which condition did the nurse most likely observe? a. Corns 
 b. A callus 
 c. Plantar warts 
d. Athlete’s foot 
 ANS: C Plantar warts appear on the sole of the foot and are caused by the papillomavirus. Corns are caused by friction and pressure from ill-fitting or loose shoes. Athlete’s foot (tinea pedis) is a fungal infection and can spread to other body parts. A callus is caused by local friction or pressure. DIF:Apply (application)REF:830
OBJ iscuss factors that influence the condition of the nails and feet. TOP: Assessment MSC: Basic Care and Comfort 15. The nurse is caring for a patient who is reporting severe foot pain due to corns. The patient has been using oval corn pads to self-treat the corns, but they seem to be getting worse. Which information will the nurse share with the patient? a. Corn pads are an adequate treatment and should be continued. 
 b. The patient should avoid soaking the feet before using a pumice stone. 
 c. Depending on severity, surgery may be needed to remove the corns. 
 d. Tighter shoes would help to compress the corns and make them smaller. 
 ANS: C Surgical removal is necessary, depending on severity of pain and the size of the corn. Oval corn pads should be avoided because they increase pressure on the toes and reduce circulation. Warm water soaks soften corns before gentle rubbing with a callus file or pumice stone. Wider and softer shoes, especially shoes with a wider toe box, are helpful. DIF:Apply (application)REF:830
OBJ iscuss factors that influence the condition of the nails and feet. TOP: Teaching/Learning MSC: Reduction of Risk Potential 16. The patient is diagnosed with athlete’s foot (tinea pedis). The patient says that he is relieved because it is only athlete’s foot, and it can be treated easily. Which information should the nurse consider when formulating a response to the patient? a. Contagious with frequent recurrences 
 b. Helpful to air-dry feet after bathing 
 c. Treated with salicylic acid 
 d. Caused by lice 
 ANS: A Athlete’s foot spreads to other body parts, especially the hands. It is contagious and frequently recurs. Drying feet well after bathing and applying powder help prevent infection. It is caused by a fungus, not lice, and is treated with applications of griseofulvin, miconazole, or tolnaftate. Plantar wars are treated with salicylic acid or electrodesiccation. DIF:Apply (application)REF:830 OBJ iscuss factors that influence the condition of the nails and feet. TOP: Planning MSC: Basic Care and Comfort 17. When assessing a patient’s feet, the nurse notices that the toenails are thick and separated from the nail bed. What does the nurse most likely suspect is the cause of this condition? a. Fungi 
 b. Friction 
c. Nail polish 
 d. Nail polish remover 
 ANS: A Inflammatory lesions and fungus of the nail bed cause thickened, horny nails that separate from the nail bed. Ask women whether they frequently polish their nails and use polish remover because chemicals in these products cause excessive nail dryness. Friction and pressure from ill-fitting or loose shoes causes keratosis (corns). It is seen mainly on or between toes, over bony prominences. DIF:Understand (comprehension)REF:827 OBJ iscuss factors that influence the condition of the nails and feet. TOP: Assessment MSC: Basic Care and Comfort 18. The nurse is providing education about the importance of proper foot care to a patient who has diabetes mellitus. Which primary goal is the nurse trying to achieve? a. Prevention of plantar warts 
 b. Prevention of foot fungus 
 c. Prevention of neuropathy d. Prevention of amputation ANS: D Foot ulceration is the most common single precursor to lower extremity amputations among persons with diabetes. Prevention of plantar warts and foot fungus are important but not the primary goal. Neuropathy is a degeneration of the peripheral nerves usually due to poor control of blood glucose levels; it is not a direct result of foot care. DIF:Apply (application)REF:827 OBJ:Explain the importance of foot care for the patient with diabetes. TOP lanningMSC:Management of Care 19. The nurse is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. Which term will the nurse use when reporting to the oncoming shift? a. Cheilitis 
 b. Halitosis 
 c. Glossitis 
 d. Dental caries 
 ANS: B
Halitosis is the term for ―bad breath.‖ Cheilitis is the term for cracked lips. Dental caries are cavities in the teeth and could be a cause of the halitosis. Glossitis is the term for inflamed tongue. DIF:Understand (comprehension)REF:828 | 840
OBJ: Discuss conditions that place patients at risk for impaired oral mucous membranes. TOP:ImplementationMSC:Management of Care 20. The nurse is caring for a patient with diabetes. Which task will the nurse assign to the nursing assistive personnel? a. Providing nail care 
 b. Teaching foot care 
c. Making an occupied bed 
 d. Determining aspiration risk 
 ANS: C The skill of making an occupied bed can be delegated to nursing assistive personnel. Nail care, teaching foot care, and assessing aspiration risk of a patient with diabetes must be performed by the RN; these skills cannot be delegated. DIF:Apply (application)REF:849 OBJ iscuss different approaches used in maintaining a patient’s comfort and safety during hygiene care.TOP lanningMSC:Management of Care 21. The patient is being treated for cancer with weekly radiation therapy to the head and chemotherapy treatments. Which assessment is the priority? a. Feet 
 b. Nail beds 
 c. Perineum 
 d. Oral cavity 
 ANS: D The oral cavity is the priority. Radiation to the head reduces salivary flow and lowers pH of saliva, leading to stomatitis and tooth decay, while chemotherapy drugs kill the normal cells lining the oral cavity, leading to ulcers and inflammation. While the feet, nail beds, and perineum are important, they are not as affected as the oral cavity with head or neck radiation and chemotherapy. DIF:Apply (application)REF:827 | 829 | 841
OBJ: Discuss conditions that place patients at risk for impaired oral mucous membranes. TOP:AssessmentMSC:Management of Care
22. The nurse is providing oral care to an unconscious patient. Which action should the nurse take? a. Moisten the mouth using lemon-glycerin sponges. 
 b. Hold the patient’s mouth open with gloved fingers. 
 c. Use foam swabs to help remove plaque. 
 d. Suction the oral cavity. 
 ANS: D When providing oral hygiene to an unconscious patient, the nurse needs to protect him or her from choking and aspiration. Have two nurses provide care; one nurse does the actual cleaning, and the other caregiver removes secretions with suction equipment. The nurse can delegate nursing assistive personnel to participate. Some agencies use equipment that combines a mouth swab with the suction device. This device can be used safely by one nurse to provide oral care. Commercially made foam swabs are ineffective in removing plaque. Do not use lemon-glycerin sponges because they dry mucous membranes and erode tooth enamel. While cleansing the oral cavity, use a small oral airway or a padded tongue blade to hold the mouth open. Never use your fingers to hold the patient’s mouth open. A human bite contains multiple pathogenic microorganisms. DIF:Apply (application)REF:841
OBJ: Discuss conditions that place patients at risk for impaired oral mucous membranes. TOP: Implementation MSC: Basic Care and Comfort 23. The nurse is teaching the patient about flossing and oral hygiene. Which instruction will the nurse include in the teaching session? a. Using waxed floss prevents bleeding. 
 b. Flossing removes plaque and tartar from the teeth. 
 c. Performing flossing at least 3 times a day is beneficial. 
 d. Applying toothpaste to the teeth before flossing is harmful. 
 ANS: B Dental flossing removes plaque and tartar between teeth. To prevent bleeding, the patient should use unwaxed floss. Flossing once a day is sufficient. If toothpaste is applied to the teeth before flossing, fluoride will come in direct contact with tooth surfaces, aiding in cavity prevention. DIF:Apply (application)REF:839 OBJ: Discuss conditions that place patients at risk for impaired oral mucous membranes. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 24. The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session? a. Treatment is use of regular shampoo. 
 b. Products containing lindane are most effective. 
 c. Head lice may spread to furniture and other people. 
 d. Manual removal is not a realistic option as treatment. 
 ANS: C Head lice are difficult to remove and spread to furniture and other people if not treated. Caution against use of products containing lindane because the ingredient is toxic and is known to cause adverse reactions. Treatments use medicated shampoo for eliminating lice. Manual removal is the best option when treatment has failed. DIF:Apply (application)REF:831 OBJ: List common hair and scalp problems and their related interventions. TOP: Teaching/Learning MSC: Safety and Infection Control 25. A patient has scaling of the scalp. Which term will the nurse use to report this finding to the oncoming staff? a. b. c. d. ANS: A Dandruff Alopecia Pediculosis Xerostomia Dandruff is scaling of the scalp that is
on scalp attached to hair strands; eggs loss or balding. Xerostomia is dry mouth. accompanied by itching. Pediculosis (lice infestation) resides look like oval particles, similar to dandruff. Alopecia is hair DIF:Understand (comprehension)REF:831 OBJ: List common hair and scalp problems and their related interventions. TOP:ImplementationMSC:Management of Care 26. A nurse is providing a bath. In which order will the nurse clean the body, beginning with the first area? 1. Face
2. Eyes
3. Perineum
4. Arm and chest 5. Hands and nails 6. Back and buttocks 7. Abdomen and legs a. 1, 2, 5, 4, 7, 6, 3 
 b. 2, 1, 4, 5, 7, 3, 6 
 c. 2, 1, 5, 4, 6, 7, 3 
 d. 1, 2, 4, 5, 3, 7, 6 
 ANS: B The sequence for giving a bath is as follows: eyes, face, both arms, chest, hands/nails, abdomen, both legs, perineal hygiene, back, and buttocks/anus. DIF:Understand (comprehension)REF:856-859 OBJ:Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose.TOP:Implementation MSC: Basic Care and Comfort 27. The nurse is caring for a patient who has multiple ticks on lower legs and body. What should the nurse do to rid the patient of ticks? a. Use blunt tweezers and pull upward with steady pressure. 
 b. Burn the ticks with a match or small lighter. 
 c. Allow the ticks to drop off by themselves. 
 d. Apply miconazole and cover with plastic. 
 ANS: A Using blunt tweezers, grasp the tick as close to the head as possible and pull upward with even, steady pressure. Hold until the tick pulls out, usually for about 3 to 4 minutes. Save the tick in a plastic bag, and put it in the freezer if necessary to identify the type of tick. Because ticks transmit several diseases to people, they must be removed. Allowing them to drop off by themselves is not an option. Do not burn ticks off with a match or lighter. Miconazole is used to treat athlete’s foot; it is a fungal medication. Covering ticks with plastic does not remove ticks. DIF:Apply (application)REF:831 | 842 OBJ: List common hair and scalp problems and their related interventions. TOP: Implementation MSC: Reduction of Risk Potential 28. The nurse is providing oral care to a patient. In which order will the nurse clean the oral cavity, starting with the first area? 1. Roof of mouth, gums, and inside cheek 2. Chewing and inner tooth surfaces
3. Outer tooth surfaces
4. Tongue a. 4, 1, 3, 2 
 b. 3, 2, 4, 1 
 c. 2, 3, 1, 4 
 d. 1, 4, 2, 3 
 ANS: C Oral care is provided in the following sequence: Clean chewing and inner tooth surfaces first. Clean outer tooth surfaces. Moisten brush with chlorhexidine rinse to rinse. Use toothette to clean roof of mouth, gums, and inside cheeks. Gently brush tongue but avoid stimulating gag reflex. Rinse. DIF:Understand (comprehension)REF:866 OBJ:Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose.TOP:Implementation MSC: Basic Care and Comfort 29. The nurse is caring for an older-adult patient with Alzheimer’s disease who is ambulatory but requires total assistance with activities of daily living (ADLs). The nurse notices that the patient is edentulous. Which area should the nurse assess? a. Assess oral cavity. 
 b. Assess room for drafts. 
 c. Assess ankles for edema. 
 d. Assess for reduced sensations. 
 ANS: A Edentulous means without teeth; therefore, the nurse needs to assess the oral cavity. While older adults may want the room warmer and drafts should be avoided, this does not help with being edentulous. Edentulous does not mean the patient has edema. While older-adult patients can have reduced sensations, this is not the meaning of edentulous. DIF:Apply (application)REF:828 | 839 OBJ: Describe how hygiene care for the older adult differs from that for the younger patient. TOP: Assessment MSC: Basic Care and Comfort 30. A self-sufficient bedridden patient is unable to reach all body parts. Which type of bath will the nurse assign to the nursing assistive personnel? b. Bag bath 
 c. Sponge bath 
 d. Partial bed bath 
d. Complete bed bath ANS: C A partial bath consists of washing body parts that the patient cannot reach, including the back, and providing a backrub. Dependent patients in need of partial hygiene or selfsufficient bedridden patients who are unable to reach all body parts receive a partial bed bath. Complete bed baths are administered to totally dependent patients in bed. The bag bath contains several soft, nonwoven cotton cloths that are premoistened in a solution of no-rinse surfactant cleanser and emollient. The sponge bath involves bathing from a bath basin or a sink with the patient sitting in a chair. DIF:Understand (comprehension)REF:836 OBJ iscuss different approaches used in maintaining a patient’s comfort and safety during hygiene care.TOP lanningMSC:Management of Care 31. The nurse is preparing to provide a complete bed bath to an unconscious patient. The nurse decides to use a bag bath. In which order will the nurse clean the body, starting with the first area? 1. Neck, shoulders, and chest
2. Abdomen and groin/perineum
3. Legs, feet, and web spaces
4. Back of neck, back, and then buttocks
5. Both arms, both hands, web spaces, and axilla a. 5, 1, 2, 3, 4 
 b. 1, 5, 2, 3, 4 
 c. 1, 5, 2, 4, 3 
 d. 5, 1, 2, 4, 3 
 ANS: B Use all six chlorhexidene gluconate (CHG) cloths in the following order: 1. Cloth 1: Neck, shoulders, and chest
2. Cloth 2: Both arms, both hands, web spaces, and axilla
3. Cloth 3: Abdomen and then groin/perineum 4. Cloth 4: Right leg, right foot, and web spaces 5. Cloth 5: Left leg, left foot, and web spaces
6. Cloth 6: Back of neck, back, and then buttocks DIF:Understand (comprehension)REF:860 OBJ: Discuss different approaches used in maintaining a patient’s comfort and safety during hygiene care. TOP: Implementation MSC: Basic Care and Comfort 32. The female nurse is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient? a. Should be postponed because it may cause embarrassment 
 b. Should be unnecessary because the patient is uncircumcised 
 c. Should be done by the patient 
 d. Should be done by the nurse 
 ANS: C If a patient is able to perform perineal self-care, encourage this independence. Patients most in need of perineal care are those at greatest risk for acquiring an infection such as uncircumcised males; perineal care is necessary. Embarrassment should not cause the nurse to overlook the patient’s hygiene needs. The nurse should provide this care only if the patient is unable to do so. DIF:Apply (application)REF:838 OBJ: Discuss different approaches used in maintaining a patient’s comfort and safety during hygiene care. TOP: Implementation MSC: Basic Care and Comfort 33. A nursing assistive personnel (NAP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene? b. Not offering a backrub to a patient with fractured ribs 
 c. Not offering to wash the hair of a patient with neck trauma 
 d. Turning off the television while giving a backrub to the patient 
 e. Turning patient’s head with neck injury to side when giving oral care 
 ANS: D The nurse must intervene if the NAP turns the patient’s head with a neck injury; this is contraindicated and must be stopped to prevent further injury. All the other actions are appropriate and do not need follow-up. Consult the medical record for any contraindications to a massage (e.g., fractured ribs, burns, and heart surgery). Before washing a patient’s hair, determine that there are no contraindications to procedure (e.g., neck injury). When providing a backrub, enhance relaxation by reducing noise (turning off the television) and ensuring that the patient is comfortable. DIF:Apply (application)REF:866 OBJ iscuss different approaches used in maintaining a patient’s comfort and safety during hygiene care.TOP:ImplementationMSC:Management of Care 34. A nurse is providing AM care to patients. Which action will the nurse take? a. Soaks feet of patient with peripheral vascular disease 
 b. Applies CHG solution to wash perineum of patient with a stroke 
 c. Cleanses eye from outer canthus to inner canthus of patient with diabetes 
 d. Uses long, firm stroke to wash legs of patient with blood-clotting disorder 
ANS: B CHG is safe to use on the perineum and external mucosa. If patient has diabetes or peripheral vascular disease with impaired circulation and/or sensation, do not soak feet. Maceration of skin may predispose to infection. Do not use long, firm strokes to wash the lower extremities of patients with history of deep vein thrombosis or blood-clotting disorders. Use short, light strokes instead. Eye should be cleansed from the inner to outer canthus on all patients. DIF:Apply (application)REF:838 | 858 OBJ: Discuss different approaches used in maintaining a patient’s comfort and safety during hygiene care. TOP: Implementation MSC: Basic Care and Comfort 35. The nurse is providing a complete bed bath to a patient using a commercial bath cleansing pack (bag bath). What should the nurse do? a. Rinse thoroughly. 
 b. Allow the skin to air-dry. 
 c. Do not use a bath towel. 
 d. Dry the skin with a towel. 
 ANS: B The nurse should allow the skin to air-dry for 30 seconds. Drying the skin with a towel removes the emollient that is left behind after the water/cleanser solution evaporates. It is permissible to lightly cover the patient with a bath blanket or towel to prevent chilling. Do not rinse when using a bag bath. DIF:Apply (application)REF:860 OBJ:Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose.TOP:Implementation MSC: Basic Care and Comfort 36. A nurse is providing perineal care to a female patient. Which washing technique will the nurse use? a. Back to front 
 b. In a circular motion 
 c. From pubic area to rectum 
 d. Upward from rectum to pubic area 
 ANS: C Cleansing from pubic area to rectum (front to back) reduces the transfer of microorganisms to the urinary meatus and decreases the risk of urinary tract infection. Cleansing from rectum to pubic area or back to front increases the risk of urinary tract infection. Circular motions are used in male perineal care. DIF:Apply (application)REF:858 OBJ:Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose.TOP:Implementation MSC: Basic Care and Comfort 37. The nurse is providing perineal care to an uncircumcised male patient. Which action will the nurse take? a. Leave the foreskin alone because there is little chance of infection. 
 b. Retract the foreskin for cleansing and allow it to return on its own. 
 c. Retract the foreskin and return it to its natural position when done. 
d. Leave the foreskin retracted. 
 ANS: C Return the foreskin to its natural position. Keeping the foreskin retracted leads to tightening of the foreskin around the shaft of the penis, causing local edema and discomfort. The foreskin may not return to its natural position on its own. Patients at greatest risk for infection are uncircumcised males. DIF:Apply (application)REF:859 OBJ:Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose.TOP:Implementation MSC: Basic Care and Comfort 38. Which instruction will the nurse provide to the nursing assistive personnel when providing foot care for a patient with diabetes? a. Do not place slippers on the patient’s feet. 
 b. Trim the patient’s toenails daily. 
 c. Report sores on the patient’s toes. 
 d. Check the brachial artery. 
 ANS: C Report any changes that may indicate inflammation or injury to tissue. Do not allow the diabetic patient to go barefoot; injury can lead to amputations. Clipping toenails is not allowed. Patients with peripheral vascular disease or diabetes mellitus often require nail care from a specialist to reduce the risk of infection. When assessing the patient’s feet, the nurse palpates the dorsalis pedis of the foot, not the brachial artery. DIF:Apply (application)REF:862 OBJ:Explain the importance of foot care for the patient with diabetes. TOP:ImplementationMSC:Management of Care 39. The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse takenext? a. Insert an oral airway. a. Place the patient in a flat, supine position. 
 b. Use undiluted hydrogen peroxide as a cleaner. 
 c. Quickly proceed while not talking to the patient. 
 ANS: A If the patient is uncooperative, or is having difficulty keeping the mouth open, insert an oral airway. Insert it upside down, and then turn the airway sideways and over the tongue to keep the teeth apart. Do not use force. Position the patient on his or her side or turn the head to allow for drainage. Placing the patient in a flat, supine position could lead to aspiration. Hydrogen peroxide is irritating to mucosa. Even though the patient is debilitated, explain the steps of mouth care and the sensations that he or she will feel. Also tell the patient when the procedure is completed. DIF:Apply (application)REF:866 OBJ:Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose.TOP:Implementation MSC: Basic Care and Comfort
40. A nurse is providing oral care to a patient with stomatitis. Which technique will the nurse use? a. Avoid commercial mouthwashes. 
 b. Avoid normal saline rinses. 
 c. Brush with a hard toothbrush. 
 d. Brush with an alcohol-based toothpaste. 
 ANS: A Stomatitis causes burning, pain, and change in food and fluid tolerance. Advise patients to avoid alcohol and commercial mouthwash and stop smoking. When caring for patients with stomatitis, brush with a soft toothbrush and floss gently to prevent bleeding of the gums. In some cases, flossing needs to be temporarily omitted from oral care. Normal saline rinses (approximately 30 mL) on awaking in the morning, after each meal, and at bedtime help clean the oral cavity. DIF:Apply (application)REF:841 OBJ:Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose.TOP:Implementation MSC: Basic Care and Comfort 41. The nurse is teaching a patient about contact lens care. Which instructions will the nurse include in the teaching session? a. Use tap water to clean soft lenses. 
 b. Wash and rinse lens storage case daily. 
c. Reuse storage solution for up to a week. 
 d. Keep the lenses is a cool dry place when not being used. 
 ANS: B Thoroughly wash and rinse lens storage case on a daily basis. Clean periodically with soap or liquid detergent, rinse thoroughly with warm water, and air-dry. Do not use tap water to clean soft lenses. Lenses should be kept moist or wet when not worn. Use fresh solution daily when storing and disinfecting lenses. DIF:Apply (application)REF:845 OBJ:Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose.TOP:Teaching/Learning MSC: Basic Care and Comfort 42. The patient reports to the nurse about a perceived decrease in hearing. When the nurse examines the patient’s ear, a large amount of cerumen buildup at the entrance to the ear canal is observed. Which action will the nurse take next? b. Teach the patient how to use cotton-tipped applicators. 
 c. Tell the patient to use a bobby pin to extract earwax. 
 d. Apply gentle, downward retraction of the ear canal. 
 e. Instill hot water into the ear canal to melt the wax. 
 ANS: C When cerumen is visible, gentle, downward retraction at the entrance to the ear canal causes the wax to loosen and slip out. Instruct the patient never to use sharp objects such as bobby pins or paper clips to remove earwax. Use of such objects can traumatize the ear canal and ruptures the tympanic membrane. Avoid the use of cotton-tipped applicators as well because they cause earwax to become impacted within the canal. Instilling cold or hot water causes nausea or vomiting. DIF:Apply (application)REF:845 OBJ:Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose.TOP:Implementation MSC: Basic Care and Comfort 43. The patient is being fitted with a hearing aid. In teaching the patient how to care for the hearing aid, which instructions will the nurse provide? a. Change the battery every day or as needed. 
 b. Adjust the volume for a talking distance of 1 yard. 
 c. Wear the hearing aid 24 hours per day except when sleeping. 
 d. Avoid the use of hairspray, but aerosol perfumes are allowed. 
 ANS: B Adjust volume to a comfortable level for talking at a distance of 1 yard. Initially, wear a hearing aid for 15 to 20 minutes; then gradually increase wear time to 10 to 12 hours per day. Batteries last 1 week with daily wearing of 10 to 12 hours. Avoid the use of hairspray and perfume while wearing hearing aids. Residue from the spray can cause the aid to become oily and greasy. DIF:Apply (application)REF:846 OBJ:Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose.TOP:Teaching/Learning MSC: Basic Care and Comfort
44. The patient is reporting an inability to clear nasal passages. Which action will the nurse take? a. Use gentle suction to prevent tissue damage. 
 b. Instruct patient to blow nose forcefully to clear the passage. 
 c. Place a dry washcloth under the nose to absorb secretions. 
 d. Insert a cotton-tipped applicator to the back of the nose. 
 ANS: A Excessive nasal secretions can be removed using gentle suctioning. However, patients usually remove secretions from the nose by gentle blowing into a soft tissue. Caution the patient against harsh blowing that creates pressure capable of injuring the eardrum, the nasal mucosa, and even sensitive eye structures. If the patient is unable to remove nasal secretions, assist by using a wet washcloth or a cotton-tipped applicator moistened in water or saline. Never insert the applicator beyond the length of the cotton tip. DIF:Apply (application)REF:846 OBJ:Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose.TOP:Teaching/Learning MSC: Basic Care and Comfort
45. A patient uses an in-the-canal hearing aid. Which assessment is a priority? b. Eyeglass usage 
 c. Cerumen buildup 
 d. Type of physical exercise 
 e. Excessive moisture problems 
ANS: B With this type of model (in-the-canal), cerumen tends to plug this model more than others. There are three popular types of hearing aids. An in-the-canal (ITC) aid is the newest, smallest, and least visible and fits entirely in the ear canal. It has cosmetic appeal, is easy to manipulate and place in the ear, and does not interfere with wearing eyeglasses or using the telephone, and the patient can wear it during most physical exercise. An inthe-ear aid (ITE, or intra-aural) is more noticeable than the ITC aid and is not for people with moisture or skin problems in the ear canal. The larger size of this type of aid (behind-the-ear, BTE, or post-aural) can make use of eyeglasses and phones difficult; it is more difficult to keep in place during physical exercise. DIF:Apply (application)REF:846 OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Assessment MSC: Management of Care MULTIPLE RESPONSE 1. The nurse is caring for a patient with cognitive impairments. Which actions will the nurse take during AM care? (Select all that apply.) a. Administer ordered analgesic 1 hour before bath time. 
 b. Increase the frequency of skin assessment. 
 c. Reduce triggers in the environment. 
 d. Keep the room temperature cool. 
 e. Be as quick as possible. ANS: B, C If a patient is physically dependent or cognitively impaired, increase the frequency of skin assessment. Adapt your bathing procedures and the environment to reduce the triggers. For example, administer any ordered analgesic 30 minutes before a bath and be gentle in your approach. Keep the patient’s body as warm as possible with warm towels and be sure the room temperature is comfortable. DIF:Understand (comprehension)REF:836 OBJ:Adapt hygiene care for a patient who is cognitively impaired. TOP: Implementation MSC: Basic Care and Comfort 2. The nurse is caring for a patient who has peripheral neuropathy. Which clinical manifestations does the nurse expect to find upon assessment? (Select all that apply.) a. Abnormal gait 
 b. Foot deformities 
 c. Absent or decreased pedal pulses 
 d. Muscle wasting of lower extremities 
 e. Decreased hair growth on legs and feet 
 ANS: A, B, D A patient with peripheral neuropathy has muscle wasting of lower extremities, foot deformities, and abnormal gait. A patient with vascular insufficiency will have decreased hair growth on legs and feet, absent or decreased pulses, and thickened nails. DIF:Understand (comprehension)REF:838
OBJ: Discuss conditions that place patients at risk for impaired skin integrity. TOP: Assessment MSC: Physiological Adaptation
3. A nurse is providing hygiene care to a bariatric patient using chlorhexidine gluconate (CHG) wipes. Which actions will the nurse take? (Select all that apply.) a. Do not rinse. 
 b. Clean under breasts. 
 c. Inform that the skin will feel sticky. 
 d. Dry thoroughly between skin folds. 
 e. Use two wipes for each area of the body. 
 ANS: A, B, C CHG wipes are easy to use and accessible for older patients and bariatric patients, offering a no-rinse or -drying procedure. For a bariatric patient or a patient who is diaphoretic, provide special attention to body areas such as beneath the woman’s breasts, in the groin, skin folds, and perineal area, where moisture collects and irritates skin surfaces. Use wipes as directed on package—one wipe per each area of the body. CHG can leave the skin feeling sticky. If patients complain about its use, you need to explain their vulnerability to infection and how CHG helps reduce occurrence of health care– associated infection. DIF:Apply (application)REF:829 | 831
OBJ: Adapt hygiene care for the bariatric patient. TOP: Implementation
MSC: Basic Care and Comfort
4. Which patients will the nurse determine are in need of perineal care? (Select all that apply.) e. A patient with rectal and genital surgical dressings 
 f. A patient with urinary and fecal incontinence 
c. A circumcised male who is ambulatory e. A patient who has an indwelling catheter 
 f. A bariatric patient 
 ANS: A, B, D, E Patients most in need of perineal care include those at greatest risk for acquiring an infection (e.g., uncircumcised males, patients who have indwelling urinary catheters, or those who are recovering from rectal or genital surgery or childbirth). A patient with urinary and bowel incontinence needs perineal cleaning with each episode of soiling. Bariatric patients need special attention to body areas such as skin folds and the perineal area. In addition, women who are having a menstrual period require perineal care. Circumcised males are not at high risk for acquiring infection, and ambulatory patients can usually provide perineal self-care. DIF:Analyze (analysis)REF:838 OBJ: Successfully perform hygiene procedures for the care of the skin, perineum, feet and nails, mouth, eyes, ears, and nose. TOP: Assessment MSC: Management of Care 5. The patient must stay in bed for a bed change. Which actions will the nurse implement? (Select all that apply.) e. Apply sterile gloves. 
 f. Keep soiled linen close to uniform. 
 g. Advise patient will feel a lump when rolling over. 
 h. Turn clean pillowcase inside out over the hand holding it. 
 i. Make a modified mitered corner with sheet, blanket, and spread. 
 ANS: C, D, E When making an occupied bed, advise patients they will feel a lump when turning, turn clean pillowcase inside out, and make a modified mitered corner. Clean gloves are used. Keep soiled linen away from uniform. DIF:Apply (application)REF:849-851 OBJ: Discuss different approaches used in maintaining a patient’s comfort and safety during hygiene care. TOP: Implementation MSC: Basic Care and Comfort Chapter 41: Oxygenation Chapter 41: Oxygenation
Potter et al.: Fundamentals of Nursing, 9th Edition
MULTIPLE CHOICE
1. A nurse is teaching staff about the conduction of the heart. In which order will the nurse present the conduction cycle, starting with the first structure? 1. Bundle of His
2. Purkinje network
3. Intraatrial pathways
4. Sinoatrial (SA) node
5. Atrioventricular (AV) node c. 5, 4, 3, 2, 1 
 d. 4, 3, 5, 1, 2 
 e. 4, 5, 3, 1, 2 
 f. 5, 3, 4, 2, 1 
 ANS: B The conduction system originates with the SA node, the ―pacemaker‖ of the heart. The electrical impulses are transmitted through the atria along intraatrial pathways to the AV node. It assists atrial emptying by delaying the impulse before transmitting it through the Bundle of His and the ventricular Purkinje network. DIF:Understand (comprehension)REF:875 OBJ: Describe the structure and function of the cardiopulmonary system. TOP: Teaching/Learning MSC: Physiological Adaptation 2. A nurse is teaching the patient with mitral valve problems about the valves in the heart. Starting on the right side of the heart, describe the sequence of the blood flow through these valves. 1. Mitral
2. Aortic
3. Tricuspid 4. Pulmonic e. 1, 3, 2, 4 
 f. 4, 3, 2, 1 
 g. 3, 4, 1, 2 
 h. 2, 4, 1, 3 
 ANS: C
The blood flows through the valves in the following direction: tricuspid, pulmonic, mitral, and aortic. DIF:Understand (comprehension)REF:874
OBJ: Describe the structure and function of the cardiopulmonary system.
TOP: Teaching/Learning MSC: Physiological Adaptation 3. A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli’s function will the nurse share with the patient? f. Carries out gas exchange 
 g. Regulates tidal volume 
h. Produces hemoglobin 
 i. Stores oxygen 
 ANS: A The alveolus is a capillary membrane that allows gas exchange of oxygen and carbon dioxide during respiration. The alveoli do not store oxygen, regulate tidal volume, or produce hemoglobin. DIF:Understand (comprehension)REF:872-873 OBJ: Describe the physiological processes of ventilation, perfusion, and exchange of respiratory gases. TOP: Teaching/Learning MSC: Physiological Adaptation 4. A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close? d. Aortic and mitral 
 e. Mitral and tricuspid 
 f. Aortic and pulmonic 
 g. Mitral and pulmonic 
 ANS: C As the ventricles empty, the ventricular pressures decrease, allowing closure of the aortic and pulmonic valves, producing the second heart sound, S2. The mitral and tricuspid produce the first heart sound, S1. The aortic and mitral do not close at the same time. The mitral and pulmonic do not close at the same time. DIF:Apply (application)REF:874 OBJ: Describe the structure and function of the cardiopulmonary system. TOP:AssessmentMSC:Health Promotion and Maintenance 5. The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process? a. Ventilation e. Surfactant 
 f. Perfusion 
 g. Diffusion 
 ANS: D Diffusion is the process of gases exchanging across the alveoli and capillaries of body
tissues. Ventilation is the process of moving gases into and out of the lungs. Surfactant is a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing. Perfusion is the ability of the cardiovascular system to carry oxygenated blood to tissues and return deoxygenated blood to the heart. DIF:Understand (comprehension)REF:873 OBJ: Describe the physiological processes of ventilation, perfusion, and exchange of respiratory gases. TOP: Teaching/Learning MSC: Physiological Adaptation 6. A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority? e. Pulse 
 f. Respirations 
 g. Temperature 
d. Blood pressure ANS: B Respirations and oxygen saturation are the priorities. Cervical trauma at C3 to C5 usually results in paralysis of the phrenic nerve. When the phrenic nerve is damaged, the diaphragm does not descend properly, thus reducing inspiratory lung volumes and causing hypoxemia. While pulse and blood pressure are important, respirations are the priority. Temperature is not a high priority in this situation. DIF:Analyze (analysis)REF:877 OBJ:Assess for the risk factors affecting a patient’s oxygenation. TOP:AssessmentMSC:Management of Care 7. The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires? c. Stimulation of chemical receptors in the aorta 
 d. Reduction of arterial oxygen saturation levels 
 e. Requirement of elastic recoil lung properties 
 f. Enhancement of accessory muscle usage 
 ANS: A Inspiration is an active process, stimulated by chemical receptors in the aorta. Reduced arterial oxygen saturation levels indicate hypoxemia, an abnormal finding. Expiration is a passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work. Prolonged use of the accessory muscles does not promote effective ventilation and causes fatigue. DIF:Understand (comprehension)REF:872
OBJ: State the process of the neural and chemical regulation of respiration. TOP: Assessment MSC: Physiological Adaptation 8. The home health nurse recommends that a patient with respiratory problems install a carbon monoxide detector in the home. What is the rationale for the nurse’s action? e. Carbon monoxide detectors are required by law in the home. 
 f. Carbon monoxide tightly binds to hemoglobin, causing hypoxia. 
 g. Carbon monoxide signals the cerebral cortex to cease ventilations. 
 h. Carbon monoxide combines with oxygen in the body and produces a deadly toxin. 
 ANS: B Carbon monoxide binds tightly to hemoglobin; therefore, oxygen is not able to bind to hemoglobin and be transported to tissues, causing hypoxia. A carbon monoxide detector is not required by law, does not signal the cerebral cortex to cease ventilations, and does not combine with oxygen but with hemoglobin to produce a toxin. DIF:Apply (application)REF:876 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Planning MSC:Health Promotion and Maintenance 9. While performing an assessment, the nurse hears crackles in the patient’s lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient’s medical record? e. Atrial fibrillation 
 f. Myocardial ischemia 
 g. Left-sided heart failure 
d. Right-sided heart failure ANS: C Left-sided heart failure results in pulmonary congestion, the signs and symptoms of which include shortness of breath, cough, crackles, and paroxysmal nocturnal dyspnea (difficulty breathing when lying flat). Right-sided heart failure is systemic and results in peripheral edema, weight gain, and distended neck veins. Atrial fibrillation is often described as an irregularly irregular rhythm; rhythm is irregular because of the multiple pacemaker sites. Myocardial ischemia results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet myocardial oxygen demands, producing angina or myocardial infarction. DIF:Apply (application)REF:878 OBJ: Assess for the physical manifestations that occur with alterations in oxygenation. TOP: Assessment MSC: Physiological Adaptation 10. A patient has a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia? d. Superior vena cava 
 e. Pulmonary artery 
 f. Coronary artery 
 g. Carotid artery 
 ANS: C A myocardial infarction is the lack of blood flow due to obstruction to the coronary artery, which supplies the heart with blood. The superior vena cava returns blood back to the heart. The pulmonary artery supplies deoxygenated blood to the lungs. The carotid artery supplies blood to the brain. DIF:Understand (comprehension)REF:878 OBJ: Differentiate among the physiological processes of cardiac output, myocardial blood flow, and coronary artery circulation. TOP: Planning MSC: Physiological Adaptation 11. A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium? e. Right ventricle, left ventricle, left atrium 
 f. Left atrium, right ventricle, left ventricle 
 g. Right ventricle, left atrium, left ventricle 
 h. Left atrium, left ventricle, right ventricle 
 ANS: C Unoxygenated blood flows through the venae cavae into the right atrium, where it is pumped down to the right ventricle; the blood is then pumped out the pulmonary artery and is returned oxygenated via the pulmonary vein to the left atrium, where it flows to the left ventricle and is pumped out to the rest of the body via the aorta. DIF:Understand (comprehension)REF:874 OBJ: Describe the structure and function of the cardiopulmonary system. TOP: Teaching/Learning MSC: Health Promotion and Maintenance 12. The nurse suspects the patient has increased afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition? f. Pulse oximeter 
g. Oxygen cannula 
 h. Blood pressure cuff 
 d. Yankauer suction tip catheter ANS: C A blood pressure cuff is needed. The diastolic aortic pressure is a good clinical measure of afterload. Afterload is the resistance to left ventricular ejection. In hypertension the afterload increases, making cardiac workload also increase. A pulse oximeter is used to monitor the level of arterial oxygen saturation; it will not help determine increased afterload. While an oxygen cannula may be needed to help decrease the effects of increased afterload, it will not help determine the presence of afterload. A Yankauer suction tip catheter is used to suction the oral cavity. DIF:Analyze (analysis)REF:875 OBJ: Describe the relationship of cardiac output, preload, afterload, contractility, and heart rate to the process of oxygenation. TOP: Planning MSC: Physiological Adaptation 13. A patient has heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output? a. Myocardial contractility × Myocardial blood flow b. Ventricular filling time/Diastolic filling time c. Stroke volume × Heart rate d. Preload/Afterload ANS: C Cardiac output can be calculated by multiplying the stroke volume and the heart rate. The other options are not measures of cardiac output. DIF:Understand (comprehension)REF:875 OBJ: Differentiate among the physiological processes of cardiac output, myocardial blood flow, and coronary artery circulation. TOP: Assessment MSC: Physiological Adaptation 14. A patient’s heart rate increased from 94 to 164 beats/min. What will the nurse expect? e. Increase in diastolic filling time 
 f. Decrease in hemoglobin level 
 g. Decrease in cardiac output 
 h. Increase in stroke volume 
 ANS: C With a sustained heart rate greater than 160 beats/min, diastolic filling time decreases, decreasing stroke volume and cardiac output. The hemoglobin level would not be affected. DIF:Understand (comprehension)REF:875 OBJ: Describe the relationship of cardiac output, preload, afterload, contractility, and heart rate to the process of oxygenation. TOP: Planning MSC: Physiological Adaptation 15. The nurse is careful to monitor a patient’s cardiac output. Which goal is the nurse trying to achieve? e. To determine peripheral extremity circulation 
 f. To determine oxygenation requirements 
 g. To determine cardiac dysrhythmias 
 h. To determine ventilation status 
 ANS: A Cardiac output indicates how much blood is being circulated systemically throughout the body to the periphery. The amount of blood ejected from the left ventricle each minute is the cardiac output. Oxygen status would be determined by pulse oximetry and the presence of cyanosis. Cardiac dysrhythmias are an electrical impulse monitored through ECG results. Ventilation status is measured by respiratory rate, pulse oximetry, and capnography. Capnography provides instant information about the patient’s ventilation. Ventilation status does not depend solely on cardiac output. DIF:Apply (application)REF:875 | 903 OBJ: Describe the relationship of cardiac output, preload, afterload, contractility, and heart rate to the process of oxygenation. TOP: Planning MSC: Physiological Adaptation 16. A nurse is caring for a group of patients. Which patient should the nurse see first? d. A patient with hypercapnia wearing an oxygen mask 
 e. A patient with a chest tube ambulating with the chest tube unclamped 
f. A patient with thick secretions being tracheal suctioned first and then orally 
 g. A patient with a new tracheostomy and tracheostomy obturator at bedside 
 ANS: A The mask is contraindicated for patients with carbon dioxide retention (hypercapnia) because retention can be worsened; the nurse must see this patient first to correct the problem. All the rest are using correct procedures and do not need to be seen first. A chest tube should not be clamped when ambulating. Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a tension pneumothorax. Use nasotracheal suctioning before pharyngeal suctioning whenever possible. The mouth and pharynx contain more bacteria than the trachea. Keep tracheostomy obturator at bedside with a fresh (new) tracheostomy to facilitate reinsertion of the outer cannula if dislodged. DIF:Analyze (analysis)REF:902
OBJ:Assess for the risk factors affecting a patient’s oxygenation. TOP:AssessmentMSC:Management of Care 17. A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer? d. Diuretics 
 e. Vasodilators 
 f. Chest physiotherapy 
 g. Intravenous (IV) fluids 
 ANS: D Preload is affected by the circulating volume; if the patient has decreased fluid volume, it will need to be replaced with fluid or blood therapy. Preload is the amount of blood in the left ventricle at the end of diastole, often referred to as end-diastolic volume. Giving diuretics and vasodilators will make the situation worse. Diuretics causes fluid loss; the patient is already low on fluids or the preload would not be decreased. Vasodilators reduced blood return to the heart, making the situation worse; the patient does not have enough blood and fluid to the heart or the preload would not be decreased. Chest physiotherapy is a group of therapies for mobilizing pulmonary secretions. Chest physiotherapy will not help this cardiovascular problem. DIF:Apply (application)REF:875 OBJ: Describe the relationship of cardiac output, preload, afterload, contractility, and heart rate to the process of oxygenation. TOP: Planning MSC: Management of Care 18. A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning? e. Pulse 75 
 f. Pulse 80 
 g. Oxygen saturation 91% 
 h. Oxygen saturation 88% 
 ANS: D Stop when oxygen saturation is 88%. Monitor patient’s vital signs and oxygen saturation during procedure; note whether there is a change of 20 beats/min (either increase or decrease) or if pulse oximetry falls below 90% or 5% from baseline. If this occurs, stop suctioning. A pulse rate of 75 is only 10 beats different from the start of the procedure. A pulse rate of 80 is 15 beats different from the start of suctioning. Oxygen saturation of 91% is not 5% from baseline or below 90%. DIF:Apply (application)REF:911 OBJ: Identify the clinical outcomes occurring as a result of hyperventilation, hypoventilation, and hypoxemia. TOP: Assessment MSC: Reduction of Risk Potential 19. The patient has right-sided heart failure. Which finding will the nurse expect when performing an assessment? f. Peripheral edema 
 g. Basilar crackles 
 h. Chest pain 
 i. Cyanosis 
 ANS: A Right-sided heart failure results from inability of the right side of the heart to pump effectively, leading to a systemic backup. Peripheral edema, distended neck veins, and weight gain are signs of right-sided failure. Basilar crackles can indicate pulmonary congestion from left-sided heart failure. Cyanosis and chest pain result from inadequate tissue perfusion. DIF:Apply (application)REF:878
OBJ: Assess for the physical manifestations that occur with alterations in oxygenation. TOP: Assessment MSC: Physiological Adaptation 20. A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave? e. SA node 
 f. AV node 
 g. Bundle of His 
 h. Purkinje fibers 
ANS: A The P wave represents the electrical conduction through both atria; the SA node initiates electrical conduction through the atria. The AV node conducts down through the bundle of His and the Purkinje fibers to cause ventricular contraction. DIF:Apply (application)REF:875-876 OBJ: Describe the relationship of cardiac output, preload, afterload, contractility, and heart rate to the process of oxygenation. TOP: Evaluation MSC: Physiological Adaptation 21. A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis? d. ―Atelectasis affects only those with chronic conditions such as emphysema.‖ 
 e. ―It is important to do breathing exercises every hour to prevent atelectasis.‖ 
 f. ―If I develop atelectasis, I will need a chest tube to drain excess fluid.‖ 
 g. ―Hyperventilation will open up my alveoli, preventing atelectasis.‖ 
 ANS: B Atelectasis develops when alveoli do not expand. Breathing exercises, especially deep breathing and incentive spirometry, increase lung volume and open the airways, preventing atelectasis. Deep breathing also opens the pores of Kohn between alveoli to allow sharing of oxygen between alveoli. Atelectasis can affect anyone who does not deep breathe. A chest tube is for pneumothorax or hemothorax. It is deep breathing, not hyperventilation, that prevents atelectasis. DIF:Apply (application)REF:872 | 892 | 896 OBJ: Identify the clinical outcomes occurring as a result of hyperventilation, hypoventilation, and hypoxemia. TOP: Evaluation MSC: Physiological Adaptation 22. The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia? d. Elevated blood pressure 
 e. Increased pulse rate 
 f. Restlessness 
 g. Cyanosis 
 ANS: D Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. Elevated blood pressure, increased pulse rate, and restlessness are early signs of hypoxia. DIF:Understand (comprehension)REF:877
OBJ: Assess for the physical manifestations that occur with alterations in oxygenation. TOP: Assessment MSC: Physiological Adaptation 23. A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation? e. Anxiety over illness 
 f. Decreased drive to breathe 
c. Increased metabolic demands d. Infection destroying lung tissues ANS: C Increased body temperature (fever) increases the metabolic rate, thereby increasing carbon dioxide production. The increased carbon dioxide level stimulates an increase in the patient’s rate and depth of respiration, causing hyperventilation. Anxiety can cause hyperventilation, but this is not the direct cause from a fever. Sleep causes a decreased respiratory drive; hyperventilation speeds up breathing. The cause of the fever in this question is unknown. DIF:Understand (comprehension)REF:877 OBJ: Discuss the effects of a patient’s level of health, age, lifestyle, and environment on oxygenation. TOP: Planning MSC: Physiological Adaptation 24. A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step? 1. Insert catheter.
2. Apply suction and remove.
3. Have patient deep breathe.
4. Encourage patient to cough.
5. Attach catheter to suction system.
6. Rinse catheter and connecting tubing. e. 1, 2, 3, 4, 5, 6 
 f. 4, 5, 1, 2, 3, 6 
 g. 5, 3, 1, 2, 4, 6 
 d. 3, 1, 2, 5, 4, 6 ANS: C The steps for nasotracheal suctioning are as follows: Verify that catheter is attached to suction; have patient deep breathe; insert catheter; apply intermittent suction for no more than 10 seconds and remove; encourage patient to cough; and rinse catheter and connecting tubing with normal saline. DIF:Understand (comprehension)REF:907-911 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Implementation MSC: Basic Care and Comfort
25. A patient has carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient? e. Low-carbohydrate 
 f. Low-caffeine 
 g. High-caffeine 
 h. High-carbohydrate 
 ANS: A A low-carbohydrate diet is best. Diets high in carbohydrates play a role in increasing the carbon dioxide load for patients with carbon dioxide retention. As carbohydrates are metabolized, an increased load of carbon dioxide is created and excreted via the lungs. A low- or high-caffeine diet is not as important as the carbohydrate load. DIF:Understand (comprehension)REF:879 OBJ: Discuss the effects of a patient’s level of health, age, lifestyle, and environment on oxygenation. TOP: Implementation MSC: Basic Care and Comfort 26. A nurse is caring for a patient who is taking warfarin (Coumadin) and discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient? e. Increased cholesterol level 
 f. Distended jugular vein 
 g. Bleeding 
 h. Angina 
 ANS: C Patients taking warfarin (Coumadin) for anticoagulation prolong the prothrombin time (PT)/international normalized ratio (INR) results if they are taking gingko biloba, garlic, or ginseng with the anticoagulant. The drug interaction can precipitate a life-threatening bleed. Increased cholesterol levels are associated with saturated fat dietary intake. A distended jugular vein and peripheral edema are associated with damage to the right side of the heart. Angina is temporary ischemia of the heart muscle. DIF:Apply (application)REF:883 OBJ: Discuss the effects of a patient’s level of health, age, lifestyle, and environment on oxygenation. TOP: Assessment MSC: Pharmacological and Parenteral Therapies 27. A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest? d. A cup of nonfat yogurt with granola and a handful of dried apricots 
 e. Whole wheat toast with butter and a side of bacon 
 f. A bowl of cereal with whole milk and a banana 
 g. Omelet with sausage, cheese, and onions 
 ANS: A A 2000-calorie diet of fruits, vegetables, and low-fat dairy foods that are high in fiber, potassium, calcium, and magnesium and low in saturated and total fat helps prevent and reduce the effects of hypertension. Nonfat yogurt with granola is a good source of calcium, fiber, and potassium; dried apricots add a second source of potassium. Although cereal and a banana provide fiber and potassium, skim milk should be substituted for whole milk to decrease fat. An omelet with sausage and cheese is high in fat. Butter and bacon are high in fat. DIF:Analyze (analysis)REF:879-880 OBJ: Develop a plan of care for a patient with altered need for oxygenation. TOP lanningMSC:Health Promotion and Maintenance 28. Upon auscultation of the patient’s chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse? f. The beginning of the systolic phase 
 g. Regurgitation of the mitral valve 
 h. The opening of the aortic valve 
 i. Presence of orthopnea 
 ANS: B When regurgitation occurs, there is a backflow of blood into an adjacent chamber. For example, in mitral regurgitation the mitral leaflets do not close completely. When the ventricles contract, blood escapes back into the atria, causing a murmur, or ―whooshing‖ sound. The systolic phase begins with ventricular filling and closing of the aortic valve, which is heard as the first heart sound, S1. Orthopnea is an abnormal condition in which a patient uses multiple pillows when reclining to breathe easier or sits leaning forward with arms elevated. DIF:Understand (comprehension)REF:878 OBJ: Identify the clinical outcomes occurring as a result of disturbances in conduction, altered cardiac output, impaired valvular function, myocardial ischemia, and impaired tissue perfusion. TOP: Assessment MSC: Physiological Adaptation 29. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen? e. Nasal cannula 
 f. Simple face mask 
 g. Non-rebreather mask 
 h. Partial non-rebreather mask 
 ANS: A Nasal cannulas deliver oxygen from 1 to 6 L/min. All other devices (simple face mask, non- rebreather mask, and partial non-rebreather mask) are intended for flow rates greater than 6 L/min. DIF:Apply (application)REF:903 OBJ: Develop a plan of care for a patient with altered need for oxygenation. TOP: Planning MSC: Reduction of Risk Potential 30. The nurse needs to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change? c. Thinner heart valves cause lipid accumulation and fibrosis. 
 d. Diminished respiratory muscle strength may cause poor chest expansion. 
 e. Alterations in mental status prevent patients’ awareness of ineffective breathing. 
 f. An increased number of pacemaker cells make proper anesthesia induction more difficult. 
 ANS: B Age-related changes in the thorax that occur from ossification of costal cartilage, decreased space between vertebrae, and diminished respiratory muscle strength lead to problems with chest expansion and oxygenation,whereby the patient will have difficulty excreting anesthesia gas. The nurse needs to monitor the patient’s oxygen status carefully to make sure the patient does not retain too much of the drug. Older adults experience alterations in cardiac function as a result of calcification of the conduction pathways, thicker and stiffer heart valves caused by lipid accumulation and fibrosis, and a decrease in the number of pacemaker cells in the SA node. Altered mental status is not a normal age- related change; it indicates possible cardiac and/or respiratory problems. DIF:Understand (comprehension)REF:879 OBJ: Discuss the effects of a patient’s level of health, age, lifestyle, and environment on oxygenation. TOP: Assessment MSC: Health Promotion and Maintenance 31. The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient? e. Inform the patient of the importance of finishing the entire dose of antibiotics. 
 f. Encourage the patient to stay up-to-date on all vaccinations. 
 g. Schedule patient to get annual tuberculosis skin testing. 
 h. Create an exercise routine to run 45 minutes every day. 
 ANS: B A nursing care plan for preventative health measures should be reasonable and feasible. Keeping up- to-date on vaccinations is important because vaccine reduces the severity of illnesses and serious complications. Determine if and when the patient has had a pneumococcal or influenza (flu) vaccine. This is especially important when assessing older adults because of their increased risk for respiratory disease. Although it is important to finish the full course of antibiotics, it is not a preventative health measure. Scheduling annual tuberculosis skin tests does not address prevention and is an unreliable indictor of tuberculosis in older patients. The exercise routine should be reasonable to increase compliance; exercise is recommended only 3 to 4 times a week for 30 to 60 minutes, and walking, rather than running, is an efficient method. DIF:Apply (application)REF:879 | 890-891 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Planning MSC:Health Promotion and Maintenance
32. The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most likely expect? e. Increased preload 
 f. Increased heart rate 
 g. Decreased afterload 
 h. Decreased tissue perfusion 
 ANS: A Preload refers to the amount of blood in the left ventricle at the end of diastole; an increase in circulating volume would increase the preload of the heart. Afterload refers to resistance; increased pressure would lead to increased resistance, and afterload would increase. A decrease in tissue perfusion would be seen with hypovolemia. A decrease in fluid volume would cause an increase in heart rate as the body is attempting to increase cardiac output. DIF:Apply (application)REF:875 OBJ: Describe the relationship of cardiac output, preload, afterload, contractility, and heart rate to the process of oxygenation. TOP: Planning MSC: Physiological Adaptation 33. A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately? e. Ventricular tachycardia 
 f. Atrial fibrillation 
 c. Sinus rhythm d. Paroxysmal supraventricular tachycardia ANS: A Ventricular tachycardia and ventricular fibrillation are life-threatening rhythms that require immediate intervention. Ventricular tachycardia is a life-threatening dysrhythmia because of the decreased cardiac output and the potential to deteriorate into ventricular fibrillation or sudden cardiac death. Atrial fibrillation is a common dysrhythmia in older adults and is not as serious as ventricular tachycardia. Sinus rhythm is normal. Paroxysmal supraventricular tachycardia is a sudden, rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously. DIF:Apply (application)REF:878 OBJ: Identify the clinical outcomes occurring as a result of disturbances in conduction, altered cardiac output, impaired valvular function, myocardial ischemia, and impaired tissue perfusion. TOP:ImplementationMSC:Management of Care 34. The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination? e. Experiences chest pain after eating a heavy meal 
f. Experiences adequate oxygen saturation during exercise 
 g. Experiences crushing chest pain for more than 20 minutes 
 h. Experiences tingling in the left arm that lasts throughout the morning 
 ANS: A Angina pectoris is chest pain that results from limited oxygen supply. Often pain is precipitated by activities such as exercise, stress, and eating a heavy meal and lasts 3 to 5 minutes. Symptoms of angina pectoris are relieved by rest and/or nitroglycerin. Adequate oxygen saturation occurs with rest; inadequate oxygen saturation occurs during exercise. Pain lasting longer than 20 minutes or arm tingling that persists could be a sign of myocardial infarction. DIF:Apply (application)REF:878 OBJ: Assess for the physical manifestations that occur with alterations in oxygenation. TOP: Assessment MSC: Physiological Adaptation 35. A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the nurse describe as modifiable? e. Stress 
 f. Allergies 
 g. Family history 
 h. Gender 
 ANS: A Young and middle-age adults are exposed to multiple cardiopulmonary risk factors: an unhealthy diet, lack of exercise, stress, over-the-counter and prescription drugs not used as intended, illegal substances, and smoking. Reducing these modifiable factors decreases a patient’s risk for cardiac or pulmonary diseases. A nonmodifiable risk factor is family history; determine familial risk factors such as a family history of lung cancer or cardiovascular disease. Other nonmodifiable risk factors include allergies and gender. DIF:Understand (comprehension)REF:879 OBJ:Assess for the risk factors affecting a patient’s oxygenation. TOP:AssessmentMSC:Health Promotion and Maintenance 36. The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal the patient could achieve? a. Sleeping on two to three pillows at night e. Limiting the diet to 1500 calories a day 
 f. Running 30 minutes every morning 
 g. Stopping smoking immediately 
 ANS: A To achieve a short-term goal, the nurse should plan a lifestyle change that the patient can make immediately that will have a quick effect. Sleeping on several pillows at night will immediately relieve orthopnea and open the patient’s airway, thereby reducing fatigue. Running 30 minutes a day will improve cardiopulmonary health, but a patient needs to build up exercise tolerance. Smoking cessation is another process that many people have difficulty doing immediately. A more realistic short-term goal would be to gradually reduce the number of cigarettes smoked. Limiting caloric intake can help a patient lose weight, but this is a gradual process and is not reasonable for a short- term goal. DIF:Apply (application)REF:882
OBJ: Develop a plan of care for a patient with altered need for oxygenation. TOP: Planning MSC: Basic Care and Comfort 37. A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is apriority? a. b. c. d. ANS: B Risk for skin breakdown Impaired gas exchange Activity intolerance Risk for infection The most important nursing intervention is to maintain airway and circulation for this patient; therefore, Impaired gas exchange is the first nursing priority. Activity intolerance is a concern but is not the priority in this case. Risk for skin breakdown and Risk for infection are also important but do not address an immediate impairment with physiologic integrity. DIF:Analyze (analysis)REF:886 | 888 OBJ: Develop a plan of care for a patient with altered need for oxygenation. TOP iagnosisMSC:Management of Care 38. Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient? e. Discontinue the humidification delivery device to keep excess fluid from lungs. 
 f. Monitor oxygen saturation, and frequently auscultate lung bases. 
g. Assist the patient to cough, turn, and deep breathe every 2 hours. 
 h. Decrease fluid intake to 300 mL a shift. 
 ANS: C The goal of the nursing action should be the prevention of pneumonia; the action that best addresses this is to cough, turn, and deep breathe to keep secretions from pooling at the base of the lungs. Humidification thins respiratory secretions, making them easier to expel and should be used. Monitoring oxygen status is important but is not a method of prevention. Hydration assists in preventing hospital-acquired pneumonia. The best way to maintain thin secretions is to provide a fluid intake of 1500 to 2500 mL/day unless contraindicated by cardiac or renal status. Restricting fluids is contraindicated in this situation since there is no data indicating cardiac or renal disease. DIF:Apply (application)REF:892 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Implementation MSC: Reduction of Risk Potential 39. The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider? f. Increased anterior-posterior diameter of the chest 
 g. Accessory muscle used for breathing 
 h. Clubbing of the fingers 
 i. Hemoptysis 
 ANS: D Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies are needed to determine the cause of blood in the sputum. Clubbing of the fingers, barrel chest (increased anterior- posterior chest diameter), and accessory muscle use are all normal findings in a patient with emphysema. DIF:Apply (application)REF:882 OBJ: Assess for the physical manifestations that occur with alterations in oxygenation. TOP:AssessmentMSC:Management of Care 40. A patient with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic? e. ―Your disease doesn’t send enough oxygen to your fingers.‖ 
 f. ―Your disease affects both your lungs and your heart, and not enough blood is being pumped.‖ 
 g. ―Your disease will be helped if you pursed-lip breathe.‖ 
 h. ―Your disease often makes patients lose mental status.‖ 
 ANS: A Clubbing of the nail bed can occur with COPD and other diseases that cause prolonged oxygen deficiency or chronic hypoxemia. Pursed-lipped breathing helps the alveoli stay open but is not the cause of clubbing. Loss of mental status is not a normal finding with COPD and will not result in clubbing. Low oxygen and not low circulating blood volume is the problem in COPD that results in clubbing. DIF:Apply (application)REF:884 OBJ: Identify the clinical outcomes occurring as a result of hyperventilation, hypoventilation, and hypoxemia. TOP: Teaching/Learning MSC: Physiological Adaptation 41. A patient with a pneumothorax has a chest tube inserted and is placed on low constant suction. Which finding requires immediate action by the nurse? f. The patient reports pain at the chest tube insertion site that increases with movement. 
 g. Fifty milliliters of blood gushes into the drainage device after the patient coughs. 
 h. No bubbling is present in the suction control chamber of the drainage device. 
 i. Yellow purulent discharge is seen leaking out from around the dressing site. 
 ANS: C No bubbling in the suction control chamber indicates an obstruction of the drainage system. An obstruction causes increased pressure, which can cause a tension pneumothorax, which can be life threatening. The nurse needs to determine whether the leak is inside the thorax or in the tubing and act from there. Occasional blood gushes from the lung owing to lung expansion, as during a cough; this is reserve drainage. Drainage over 100 mL/hr after 3 hours of chest tube placement is cause for concern. Yellow purulent drainage indicates an infection that should be reported to the health care provider but is not as immediately life threatening as the lack of bubbling in the suction control chamber. DIF:Apply (application)REF:899 | 925 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Implementation MSC:Management of Care
42. The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance? g. Suctioning respiratory secretions several times every hour 
 h. Administering humidified oxygen through a tracheostomy collar 
i. Instilling normal saline into the tracheostomy to thin secretions before suctioning 
 j. Deflating the tracheostomy cuff before allowing the patient to cough up secretions 
 ANS: B Humidification from air humidifiers or humidified oxygen tracheostomy collars can help prevent drying of secretions that cause occlusion. Suctioning should be done only as needed; too frequent suctioning can damage the mucosal lining, resulting in thicker secretions. Normal saline should not be instilled into a tracheostomy; research showed no benefit with this technique. The purpose of the tracheostomy cuff is to keep secretions from entering the lungs; the nurse should not deflate the tracheostomy cuff unless instructed to do so by the health care provider. DIF:Apply (application)REF:896 OBJ: Develop a plan of care for a patient with altered need for oxygenation. TOP: Implementation MSC: Physiological Adaptation 43. The nurse is educating a student nurse on caring for a patient with a chest tube. Which statement from the student nurse indicates successful learning? f. ―I should clamp the chest tube when giving the patient a bed bath.‖ 
 g. ―I should report if I see continuous bubbling in the water-seal chamber.‖ 
 h. ―I should strip the drains on the chest tube every hour to promote drainage.‖ 
 d. ―I should notify the health care provider first, if the chest tube becomes dislodged.‖ ANS: B Correct care of a chest tube involves knowing normal and abnormal functioning of the tube. A constant or intermittent bubbling in the water-seal chamber indicates a leak in the drainage system, and the health care provider must be notified immediately. Stripping the tube is not routinely performed as it increases pressure. If the tubing disconnects from the drainage unit, instruct the patient to exhale as much as possible and to cough. This maneuver rids the pleural space of as much air as possible. Temporarily reestablish a water seal by immersing the open end of the chest tube into a container of sterile water. The chest tube should not be clamped unless necessary; if so, the length of time clamped would be minimal to reduce the risk of pneumothorax. DIF:Apply (application)REF:899 | 922 | 926 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Evaluation MSC:Management of Care
44. Which coughing technique will the nurse use to help a patient clear central airways? f. Huff 
 g. Quad 
 h. Cascade 
 i. Incentive spirometry 
 ANS: A The huff cough stimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the word huff. The quad cough technique is for patients without abdominal muscle control such as those with spinal cord injuries. While the patient breathes out with a maximal expiratory effort, the patient or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough. With the cascade cough the patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then he or she opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in patients with large volumes of sputum. Incentive spirometry encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It promotes deep breathing and prevents or treats atelectasis in the postoperative patient. DIF:Understand (comprehension)REF:892 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Implementation MSC: Physiological Adaptation
45. The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take? e. Set suction regulator at 150 to 200 mm Hg. 
 f. Limit the length of suctioning to 10 seconds. 
 g. Apply suction while gently rotating and inserting the catheter. 
 h. Liberally lubricate the end of the suction catheter with a water-soluble solution. 
 ANS: B Suctioning passes should be limited to 10 seconds to avoid hypoxemia. Suction for a tracheostomy should be set at 100 to 150 mm Hg. Excessive lubrication can clog the catheter or occlude the airway; lubricant is not necessary for oropharyngeal or artificial airway (tracheostomy) suctioning. Suction should never be applied on insertion. DIF:Apply (application)REF:912 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Implementation MSC: Reduction of Risk Potential 46. The nurse is caring for a patient who needs oxygen via a nasal cannula. Which task can the nurse delegate to the nursing assistive personnel? c. Applying the nasal cannula 
 d. Adjusting the oxygen flow 
 e. Assessing lung sounds 
 f. Setting up the oxygen 
 ANS: A The skill of applying (not adjusting oxygen flow) a nasal cannula or oxygen mask can be delegated to nursing assistive personnel (NAP). The nurse is responsible for assessing the patient’s respiratory system, response to oxygen therapy, and setup of oxygen therapy, including adjustment of oxygen flow rate. DIF:Apply (application)REF:900 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Planning MSC:Management of Care 47. The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method? f. A 5-year-old with excessive drooling from epiglottitis 
 g. A 5-year-old with an asthma attack following severe allergies 
 h. A 24-year-old with a right pneumothorax following a motor vehicle accident 
 i. A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation 
 ANS: D Closed suctioning is most often used on patients who require invasive mechanical ventilation to support their respiratory efforts because it permits continuous delivery of oxygen while suction is performed and reduces the risk of oxygen desaturation. In this case, the acute respiratory distress syndrome requires mechanical ventilation. In the presence of epiglottitis, croup, laryngospasm, or irritable airway, the entrance of a suction catheter via the nasal route causes intractable coughing, hypoxemia, and severe bronchospasm, necessitating emergency intubation or tracheostomy. The 5- year-old child with asthma would benefit from an inhaler. A chest tube is needed for the pneumothorax. DIF:Analyze (analysis)REF:895 OBJ: Discuss the effects of a patient’s level of health, age, lifestyle, and environment on oxygenation. TOP: Implementation MSC: Physiological Adaptation 48. While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first? c. Press the emergency response button. 
 d. Insert a spare tracheostomy with the obturator. 
 e. Manually occlude the tracheostomy with sterile gauze. 
 f. Place a face mask delivering 100% oxygen over the nose and mouth. 
 ANS: B The nurse’s first priority is to establish a stable airway by inserting a spare trach into the patient’s airway; ideally an obturator should be used. The nurse could activate the emergency response team if the patient is still unstable after the tracheostomy is placed. A patient with a tracheostomy breathes through the tube, not the nose or mouth; a face mask would not be an effective method of getting air into the lungs. Manually occluding pressure over the tracheostomy site is not appropriate and would block the patient’s only airway. DIF:Apply (application)REF:921-922
OBJ: Develop a plan of care for a patient with altered need for oxygenation. TOP:ImplementationMSC:Management of Care MULTIPLE RESPONSE 1. A nurse is following the Ventilator Bundle standards to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.) a. Head of bed elevation to 90 degrees at all times 
 b. Daily oral care with chlorhexidine 
 c. Cuff monitoring for adequate seal 
 d. Clean technique when suctioning 
 e. Daily ―sedation vacations‖ 
 f. Heart failure prophylaxis 
 ANS: B, C, E
The key components of the Institute for Healthcare Improvement (IHI) Ventilator Bundle are: Elevation of the head of the bed (HOB)—elevation is 30 to 45 degrees
Daily ―sedation vacations‖ and assessment of readiness to extubate
Peptic ulcer disease prophylaxis
Deep venous thrombosis prophylaxis
Daily oral care with chlorhexidine Monitor cuff pressure frequently to ensure that there is an adequate seal to prevent aspiration of secretions is also included. Sterile technique is used for suctioning when on ventilators. Heart failure prophylaxis is not a component. DIF:Apply (application)REF:898 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Implementation MSC: Reduction of Risk Potential
2. A nurse is teaching a community health promotion class and discusses the flu vaccine. Which information will the nurse include in the teaching session? (Select all that apply.) a. It is given yearly. 
 b. It is given in a series of four doses. 
 c. It is safe for children allergic to eggs. 
 d. It is safe for adults with acute febrile illnesses. 
 e. The nasal spray is given to people over 50. 
 f. The inactivated flu vaccine is given to people over 50. 
 ANS: A, F Annual (yearly) flu vaccines are recommended for all people 6 months and older. The inactivated flu vaccine should be given to these individuals with chronic health problems and those 50 and older. People with a known hypersensitivity to eggs or other components of the vaccine should consult their health care provider before being vaccinated. There is a flu vaccine made without egg proteins that is approved for adults 18 years of age and older. Adults with an acute febrile illness should schedule the vaccination after they have recovered. The live, attenuated nasal spray vaccine is given to people from 2 through 49 years of age if they are not pregnant or do not have certain long-term health problems such as asthma; heart, lung, or kidney disease; diabetes; or anemia. DIF:Apply (application)REF:890-891 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Teaching/Learning MSC:Health Promotion and Maintenance 3. A nurse is caring for a patient with sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.) a. Assist-control (AC) 
 b. Pressure support ventilation (PSV) 
 c. Bilevel positive airway pressure (BiPAP) 
 d. Continuous positive airway pressure (CPAP) 
 e. Synchronized intermittent mandatory ventilation (SIMV) 
 ANS: C, D Ventilatory support is achieved using a variety of modes, including continuous positive airway pressure (CPAP) and bilevel pos [Show More]

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