Nokea
The nurse is caring for a patient who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the patient is hypoxemic?
- A. Assess the patients level of consciousness (LOC)
- B. Assess the patients extremities for signs of cyanosis
- C. Assess the patients oxygen saturation level
- D. Review the patients hemoglobin, hematocrit, and red blood cell levels
Correct Answer: C
Rationale: The effectiveness of the patients oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The patients LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.
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The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke. What response related to risk for lung cancer in smokers is most accurate?
- A. The younger you are when you start smoking, the higher your risk of lung cancer
- B. The risk for lung cancer never decreases once you have smoked, which is why smokers need annual chest x-rays
- C. The risk for lung cancer is determined mostly by what type of cigarettes you smoke
- D. The risk for lung cancer depends primarily on the other risk factors for cancer that you have
Correct Answer: A
Rationale: Risk is determined by the pack-year history (number of packs of cigarettes used each day, multiplied by the number of years smoked), the age of initiation of smoking, the depth of inhalation, and the tar and nicotine levels in the cigarettes smoked. The younger a person is when he or she starts smoking, the greater the risk of developing lung cancer. Risk declines after smoking cessation. The type of cigarettes is a significant variable, but this is not the most important factor.
The nurse is reviewing the electronic health record of a patient with an empyema. What health problem in the patients history is most likely to have caused the empyema?
- A. Smoking
- B. Asbestosis
- C. Pneumonia
- D. Lung cancer
Correct Answer: C
Rationale: Most empyemas occur as complications of bacterial pneumonia or lung abscess. Cancer, smoking, and asbestosis are not noted to be common causes.
A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What intervention should the nurse first anticipate?
- A. Preparing to assist with intubating the patient
- B. Setting up oxygen at 5 L/minute by nasal cannula
- C. Performing deep suctioning
- D. Setting up a nebulizer to administer corticosteroids
Correct Answer: A
Rationale: A patient who has ARDS usually requires intubation and mechanical ventilation. Oxygen by nasal cannula would likely be insufficient. Deep suctioning and nebulizers may be indicated, but the priority is to secure the airway.
A new employee asks the occupational health nurse about measures to prevent inhalation exposure of the substances. Which statement by the nurse will decrease the patients exposure risk to toxic substances?
- A. Position a fan blowing on the toxic substances to prevent the substance from becoming stagnant in the air
- B. Wear protective attire and devices when working with a toxic substance
- C. Make sure that you keep your immunizations up to date to prevent respiratory diseases resulting from toxins
- D. Always wear a disposable paper face mask when you are working with inhalable toxins
Correct Answer: B
Rationale: When working with toxic substances, the employee must wear or use protective devices such as face masks, hoods, or industrial respirators. Immunizations do not confer protection from toxins and a paper mask is normally insufficient protection. Never position a fan directly blowing on the toxic substance as it will disperse the fumes throughout the area.
A critical-care nurse is caring for a patient diagnosed with pneumonia as a surgical complication. The nurses assessment reveals that the patient has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do?
- A. Increase oral fluids unless contraindicated
- B. Call the nurse for oral suctioning, as needed
- C. Lie in a low Fowlers or supine position
- D. Increase activity
Correct Answer: A
Rationale: The nurse should encourage hydration because adequate hydration thins and loosens pulmonary secretions. Oral suctioning is not sufficiently deep to remove tracheobronchial secretions. The patient should have the head of the bed raised, and rest should be promoted to avoid exacerbation of symptoms.