Fundamentals Exam 1 (Potter & Perry Chapter Practice Questions) Updated 2023 Graded A+ ___ are accepted as truths and are based on values and beliefs. - AnswerAssumptions
___ are the words or phrases that identify, define, and establish structure and boundaries for ideas generated about a particular phenomena. - AnswerConcepts
___ have different purposes and are sometimes classified by levels of abstraction or the goals. - AnswerTheories
___ is considered to be the mother of psychiatric nursing. - AnswerHildegard Peplau
___ is the end product of a system. - Answeroutput
___ nursing practice helps nurses to design and implement nursing interventions that address individual and family responses to health problems. - AnswerTheory-based
___ offer well-grounded rationales for how and why nurses perform specific interventions and for predicting patient behaviors and outcomes. - AnswerTheories
___ research determines how accurately a theory describes a nursing phenomenon. - AnswerTheory-testing
___ research uses logic to explore relationships between phenomena. - AnswerTheory- generating
___ serves as the foundation for the art and science of nursing. - AnswerTheory
___ theories are more limited in scope and less abstract. - AnswerMiddle-range
___ theories continue to advance nursing knowledge through nursing research. - AnswerMiddle- range
___ theories help shape and define your practice. - AnswerGrand
___ theories help you provide specific care for individuals and groups of diverse populations and situations. - AnswerPractice
(**) A nurse is caring for a patient with respiratory problems. which assessment finding indicates a late sign of hypoxia?
- elevated blood pressure
- increased pulse rate
- restlessness
d. cyanosis - AnswerANS: D 1 / 4
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
(**) A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis?
- "Atelectasis affects only those with chronic conditions such as emphysema."
- "It is important to do breathing exercises every hour to prevent atelectasis."
- "If I develop atelectasis, I will need a chest tube to drain excess fluid."
- "Hyperventilation will open up my alveoli, preventing atelectasis." - AnswerANS: 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
(**) The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider?
- Increased anterior-posterior diameter of the chest
- Accessory muscle used for breathing
- Clubbing of the fingers
d. Hemoptysis - AnswerANS: 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
(**) The nurse suspects the patient has increased after load. Which piece of equipment should the nurse obtain to determine the presence of this condition?
- pulse oximeter
- oxygen cannula
- blood pressure cuff
d. yankauer suction tip catheter - AnswerANS: 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 2 / 4
(**)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?
- pulse
- respirations
- temperature
d. blood pressure - AnswerANS: 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
(**)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 a priority?
- Risk for skin breakdown
- Impaired gas exchange
- Activity intolerance
d. Risk for infection - AnswerANS: B
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
(**)A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the nurse describe as modifiable?
- Stress
- Allergies
- Family history
d. Gender - AnswerANS: 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
(**)A patient has a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia?
- superior vena cava 3 / 4
- pulmonary artery
- coronary artery
d. carotid artery - AnswerANS: 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
(**)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?
- Applying the nasal cannula
- Assessing lung sounds
b.Adjusting the oxygen flow
d. Setting up the oxygen - AnswerANS: 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
(**)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?
- Sleeping on two to three pillows at night
- Limiting the diet to 1500 calories a day
- Running 30 minutes every morning
d. Stopping smoking immediately - AnswerANS: 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
(**)The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method?
- A 5-year-old with excessive drooling from epiglottitis
- A 5-year-old with an asthma attack following severe allergies
- A 24-year-old with a right pneumothorax following a motor vehicle accident
- A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation -
AnswerANS: D
- / 4