Question

study guide for fundamentals of nursing 9780803669079

224 UNIT 4 Clinical skills and Care ha diagnosis the time of day 35. As you assess your patient with a dark skin tone, you notice that the color of her skin is ashen. What will you do next? a. Increase the temperature of the room because the patient is most likely too cold. b. Assess the patient's mucous membranes, palms, and soles of the feet for evidence of cyanosis. c. Ask the patient's family if this color is normal for her. d. Take a set of vital signs, paying special attention to the blood pressure. 40 A 54-year-old hospitalized patient with a di congestive heart heart failure is normally quite alert easygoing. Now he seems unsure of the time When you tell him it is early evening, he bec imitated with you. What concem would you he The patient could be developing early Alzhe disease with a rapid onset. h. The patient may have an undetected brain causing personality changes. The patient may be developing hypoxia and assessment is indicated. The patient may be having a CVA (stroke should be sent to the operating room as soon as possible. detected brain injury 41 36. How can you assess a patient for exertional dyspnea? a. Ask the patient if he feels short of breath during meals. b. Count the patient's respirations at rest and note the number of breaths higher than 22 per minute. c. Compare the patient's respiratory rate at rest with the respiratory rate when the patient ambulates for even a short distance d. Assess oxygen saturation during sleeping and during talking and compare the difference. natient from Africa has a positive reading after skin test. What is the significance of this? a. The patient has active tuberculosis and should quarantined. h. The patient may have a false-positive result as a of a malaria vaccine but needs follow-up testine c. The patient may have a resistant form of pneumonia and should have more testing d. The patient may have asthma or another type of restrictive lung disease and should have pulmonary function tests. 37. When making an assessment on a young child, you note retractions around the ribs and the sternum. Which action will you take first? a. Notify the physician immediately. b. Obtain a sputum specimen via suction. c. Auscultate the child's lungs when he or she is not crying d. Obtain a tympanic or temporal temperature. 42. Which respiratory diagnostic test measures the amount of air that can be exhaled with force? a. Pulmonary function tests b. Peak flow Chest x-ray d. TB skin test 38. Which of the following assessments about a patient's cough should be documented? a. Whether it is productive or nonproductive b. Color of sputum c. Time that each cough occurred d. Respiratory rate prior to the patient coughing e. Approximate amount of sputum f. Sputum specimen obtained after each cough g. Consistency of sputum 43. Why is a patient at risk for pneumonia if he or she is unable to get out of bed? a. Many bacteria and viruses are present in the hospital that could lead to pneumonia. b. Mucus pools in the lungs, providing a favorable environment for bacterial growth c. When on bedrest, the patient is more prone to develop asthma, which can lead to pneumonia. d. The need for supplemental oxygen increases with bedrest, which then increases the risk of developing pneumonia 39. A patient's face and neck are swollen. When you palpate the area, you feel crackling beneath your fingers. What could this be an indication of? a. The patient has fluid beneath the skin of her face and neck. b. The patient has developed a tension pneumothorax c. The patient has air from the lungs in the subcutaneous tissue. d. The patient has fluid in the chest cavity resulting in a pleural effusion. 44. Which is true of administerine nebulizer treatments a. Medications must be mixed with saline carefully to avoid overdosing. b. A health care provider's order is required before nebulizer treatment can be given. c. The medication is given as an inhaled spray mo with oxygen d. The medication can only be delivered using am making it difficult for patients with claustrophe use nebulizers. patients with claustrophobia 10

Answer 1

35.B.assess patient skin colour because this can be due to lack oxygen in the patients body.if cyanosis find then we can administer oxygen.

36.C.while comparing the respiratory rate on rest as well as on exercise helps to understand the exe.rtionel dyspnoea.patient will have difficulty to take breath while walking if it presents.

37.A.first we should inform to the doctor.

38. B.colour of sputum inorder to find out the disease condition.

39.A

40A.

41.A.

42.B.