Gearing up for exam #2

1. Which of the following is the primary purpose of surfactant?
a. to propel sheets of mucus toward the upper airway
b. to warm inspired air
c. to produce watery mucus
d. to reduce surface tension of the fluid lining the alveoli

2. a pt who has difficulty breathing, increased respiratory and HR and pale skin with regions of cyanosis may be suffering from...
a. hyperventilation
b. hypoxia
c. perfusion
d. atelectasis

3. when inspecting a pt's chest to assess respiratory status, the nurse should be aware of which of the following normal findings?
a. the contour of the intercostal spaces should be rounded
b. the skin at the thorax should be cool and moist
c. the anteroposterior diameter should be greater than the transverse diameter
d. the chest should be slightly convex with no sternal depression

4. which of the following normal breath sounds should be heard over the rtrachea?
a. vesicular
b. bronchovesicluar
c. bronchial
d. tympanic

5. mr. paks has COPD. his nurse has taught him pursed-lip breathing, which helps him in which of the following ways?
a. increase CO2, which stimulates breathing
b. teaches him to porlong inspiration and shorten expiration
c. helps liquefy his scretions
d. decreases the amount of air trapping and resistance

6. when caring for a pt with a tracheotomy, the nurse should be aware of which of the following?
a. the wound around the tube and inner cannula should be cleaned at least every 24 hrs
b. the pt has no impairment of speaking function
c. a newly inserted tracheostomy tube requires no immediate attention
d. suctioning of the tracheostomy tube must be done using sterile technique

7. which of the following statements regarding nursing diagnoses is accurate?
a. nursing diagnoses remain the same for as long as the disease is present
b. nursing diagnoses are written to identify disease
c. nursing diagnoses are written to describe pt problems that nurses can treat
d. nursing diagnoses focus on identifying healthy responses to health and illness

8. which of the following would be an appropriate nursing diagnosis for a toddler who has been treated on 2 different occasions for lacerations and contusions due to the parents' negligence in providing a safe environment?
a. high risk for injury related to abusive parents
b. high risk for injury related to impaired home managment
c. child abuse related to unsafe home environment
d. high risk for injury related to unsafe home environment
e. high risk for parents to be hung by their toenails by the nurse (just seeing if you are paying attention)

9. which of the following actions would be performed during the planning step of the nursing process?
a. interpreting and analyzing pt data
b. establishing the database
c. identifying factors contributing to pt's success or failure
d. selecting nursing measures

10. which of the following is a correctly written goal for a pt who is scheduled to amb following hip surgery?
a. over the next 24 hr period, the pt will walk the length of the hallway assisted by the nurse
b. the nurse will help the pt amb the length of the hallway once a day
c. offer to help the pt walk the length of the hallway each day
d. pt will become mobile within a 24 hr period

11. mr. conner is a 48-yr-old pt with a new colostomy. which of the following pt goals is written correctly?
a. explain to mr. conner the proper care of the stoma by 3/29/08
b. mr conner will know how to care for his stoma by 3/29/08
c. mr conner will demonstrate proper care of stoma by 3/29/08
d. mr conner will be able to care for stoma and cope with psychological loss by 3/29/08

12. which nursing action is considered an independent (nurse initiated) action?
a. executing physician orders for a catheter
b. meeting with other healthcare professionals to discuss a pt
c. helping to allay a pt's fears about surgery
d. administering meds to a pt

13. your pt, who is presented with high bp, is put on a low salt diet and instructed to quit smoking. you find him in the cafeteria eating a cheeseburger and french fries. he tells you there is not way he can quit smoking what is your first objective when implementing care for this pt?
a. explain to the pt the effects of a high salt diet and smoking on bp
b. identify why the pt is not following the therapy
c. collaborate with other healthcare professionals about the pt's treatment
d. change the nursing care plan

14. which is the most important act of evaluation performed by the nurse?
a. evaluating the pt's goal/outcome achievement
b. " the plan of care
c. " the competence of nurse practitioners
d. " the types of healthcare services available to the pt

15. which should the nurse do when pt data indicate that the stated goals have not been achieved?
a. collect more data for the database
b. review each preceding step of the nursing process
c. implement a standardized plan of care
d. change the nursing orders