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NSG 3130 EXAM 4 (GALEN) NEWEST 2026 ACTUAL
EXAM| NSG3130 FUNDAMENTAL CONCEPTS &
SKILLS FOR NURSING PRACTICE II EXAM 4 REVIEW
WITH COMPLETE REAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERES (VERIFIED
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The nurse identifies which patient who would benefit from postural drainage? a. A patient with a heart murmur and jugular venous distention. b. A patient with asthma and audible wheezing. c. A patient with right-sided heart failure and pitting edema. d. A patient with chronic bronchitis and congested cough. - Correct Answer - d. A patient with chronic bronchitis and congested cough. Patients who benefit from postural drainage therapy include those who are unable or reluctant to change body positions and patients with unilateral lung diseases that are related to poor oxygenation due to position. Patients who have diseases such as cystic fibrosis or bronchiectasis, COPD, abscesses, or difficulty removing secretions may benefit from postural drainage therapy. A patient with chronic bronchitis and a congested, productive cough would benefit from postural drainage because it would help clear the airway. The nurse is caring for a patient who has a history of congestive heart failure with generalized pitting edema. Which laboratory results will the nurse expect to find in the patient's chart? a. Glycosylated hemoglobin 12% b. Platelet count 450,000/mm
c. Hematocrit 32% d. Prothrombin time 8.8 seconds - Correct Answer - c. Hematocrit 32% Hemodilution may be found when patients are in fluid overload caused by congestive heart failure. A normal hematocrit result is 42% to 52% for a male and 37% to 47% for a female, so the patient's 32% hematocrit level is markedly low. The other laboratory results are not expected due to congestive heart failure or fluid overload. The nurse is caring for a patient with high cholesterol who has been prescribed atorvastatin (Lipitor). Which laboratory result indicates that the patient has been taking the medication as ordered and following the physician's dietary recommendations? a. Serum triglyceride level 325 mg/dL b. High-density lipoproteins (HDL) 56 mg/dL c. Low-density lipoproteins (LDL) 155 mg/dL d. Total cholesterol level 185 mg/Dl - Correct Answer - d. Total cholesterol level 185 mg/dL A total cholesterol level higher than 200 mg/dL is considered a risk factor for atherosclerosis, so a cholesterol level of 185 mg/dL indicates that the patient has been compliant with the prescribed therapy. The other laboratory results are abnormal and would not indicate compliance. The nurse is caring for a patient who has presented to the ER with chest pain. Which diagnostic test will best indicate if there is significant blockage of important blood vessels that provide oxygen to the heart muscle? a. Cardiac catheterization b. Chest x-ray
The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented, what is the priority action of the nurse? a. obtain an arterial blood gas to check for carbon dioxide retention b. increase the patient’s oxygen until the pulse oximetry is greater than 98%. c. lower the head of the patient’s bed and insert a nasal airway. d. administer a mild sedative and reorient the patient as needed. - Correct Answer – a. obtain an arterial blood gas to check for carbon dioxide retention. A patient requires a precise concentration of 40% oxygen, which of the following devices would best allow for this? a. a simple face mask b. a nonrebreather mask c. a partial rebreathing mask d. a Venturi mask - Correct Answer – d. a Venturi mask The nurse hears a loud murmur when listening to the patient's heart... which diagnostic test will best display the condition of the valves and structures within the patient's heart that could be causing the murmur? A. chest x-ray B. cardiac catheterization C. echocardiogram D. electrocardiogram - Correct Answer – c. echocardiogram
The nurse is caring for a patient with advanced COPD who reports feeling short of breath. The nurse notes that the patient's lung sounds are diminished bilaterally and the patient's pulse oximetry is 91% on 2 L/min oxygen via nasal cannula. What actions will the nurse take to make the patient more comfortable? (Select all that apply.) a. Increase the patient's oxygen to 4 L/min via nasal cannula. b. Suction the patient's airway using sterile technique. c. Maintain eye contact and provide calm reassurance. d. Turn the patient onto the side for postural drainage. e. Administer the ordered nebulized bronchodilator. f. Elevate the head of the patient's bed to fully upright. - Correct Answer
- c. Maintain eye contact and provide calm reassurance. e. Administer the ordered nebulized bronchodilator. f. Elevate the head of the patient's bed to fully upright. Patients who are acutely short of breath due to advanced COPD will benefit from nebulized bronchodilator medication to open the airways. Elevating the head of the bed will prevent pressure on the diaphragm from the abdominal contents. A caring demeanor with eye contact will help the patient remain calm until the medication begins to work and the shortness of breath is eased. Patients with COPD should be kept on low- flow oxygen to maintain pulse oximetry of more than 88%. The nurse is performing a respiratory assessment on a patient. Which assessment findings indicate to the nurse that the patient has a history of long-standing chronic respiratory disease? (Select all that apply.) a. All the patient's fingernails are noticeably clubbed.
b. The patient's sputum has turned from yellow to greenish-brown. c. The patient has dyspnea and wheezes heard in all lung fields. e. The patient has become confused and mildly disoriented. A patient who is unable to speak without gasping is indicative of poor airflow through the airways, which must be addressed promptly. Greenish-brown sputum may indicate pneumonia requiring antibiotic treatment. Dyspnea and wheezes are indicative of an acute asthma attack. Confusion and disorientation in a patient with COPD may indicate retention of carbon dioxide. Increased forced vital capacity is a positive sign. The nurse is working with a nursing assistant to care for a patient with a new tracheostomy. Which tasks may the nurse delegate to the assistant? (Select all that apply.) a. Obtaining masks, gloves, and suction supplies from the utility room b. Helping to reassure the patient before, during, and after suctioning c. Changing the Velcro or twill ties used to secure the tracheostomy d. Transporting sputum specimens to the lab for culture and sensitivity testing e. Assessing need for suctioning of the oropharynx or tracheostomy f. Teaching the patient how to remove and clean the inner cannula a. Obtaining masks, gloves, and suction supplies from the utility room b. Helping to reassure the patient before, during, and after suctioning d. Transporting sputum specimens to the lab for culture and sensitivity testing
Care of a new tracheostomy may not be delegated to a nursing assistant. Obtaining supplies needed for care, helping to reassure the patient, and bringing specimens to the lab are tasks that may be assigned to the assistant. The preceptor is working with a new nurse to provide care for a patient with a new tracheostomy. Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.) a. The outer cannula is cleaned with the brush and half-strength H2O2. b. The new tracheostomy holder is secured before the old soiled one is removed. c. A Yankauer suction catheter is used to remove secretions from the patient's mouth. d. Sterile gloves are applied before the soiled dressing is removed from the tracheostomy. e. Half-strength H2O2 is used to remove crusted secretions around the tracheostomy site. f. Pain medication is administered to the patient prior to suctioning. a. The outer cannula is cleaned with the brush and half-strength H2O2. d. Sterile gloves are applied before the soiled dressing is removed from the tracheostomy.
The head of the patient's bed should be elevated prior to suctioning to facilitate coughing out secretions. Suction is always applied intermittently as the catheter is withdrawn. Water-soluble lubricant is used when suctioning the naris but not a tracheostomy because the secretions negate the need for additional lubrication. what does pulmonary edema look like outwardly? accessory muscles used, discoloration or clubbing of fingernails, cyanosis, are they propped up in bed, not taking full breath in and out, etc. (they would not get swelling of the feet – that is with heart failure) what happens to cardiovascular system as we age? arteries harden, could get blockages, more prevalence as we age (other factors can increase risk too, but age is unavoidable and increases risk in general) pneumonia diagnostic tool chest x-ray to see fluid build up and inflammation (how much air vs fluid) the nurse is caring for a patient who will be returning to the nursing unit following a cardiac catheterization via the right femoral artery... which assessment is the highest priority for the nurse to perform when the patient arrives on the unit?
A. checking the patient’s right pedal pulse and warmth of the right leg - correct B. checking pulse oximetry and listening to the patient’s lung sounds C. checking bilateral radial pulses to check for a pulse deficit D. estimating the patient’s jugular venous pressure the nurse is caring for a patient who is hospitalized for pneumonia... which nursing diagnosis has the highest priority? A. activity intolerance r/t generalized weakness and hypoxemia B. impaired nutritional intake r/t poor appetite and increased metabolic needs C. impaired airway clearance r/t thick secretions in trachea and bronchi - correct D. lack of knowledge r/t use of nebulizer and inhaled bronchodilators the nurse is caring for a patient who has been prescribed warfarin (coumadin) therapy after being diagnosed with atrial fibrillation... the patient asks the nurse what could happen if the prescription doesn't get filled... what is the nurse's best response?
possible causes for hypoxia aspirated vomit, pulmonary fibrosis, high altitude, etc. when a patient with a tracheostomy tube is taken care of at home by family, tracheostomy care instructions from the nurse include: (select all that apply.) A. avoid going to crowded theaters and malls - correct B. change catheters every 8 hours - correct C. keep the home environment free of dust - correct D. use bleach to clean suction equipment - correct when assessing the lungs of a patient, the nurse assesses a wheezing sound on inspiration... this finding is documented as: stridor the nurse clarifies that the cough mechanism is stimulated when... foreign substances are propelled by the cilia toward the respiratory tract the nurse takes into consideration that a pulse oximeter may not give an accurate reading if the patient is... jaundiced
the nurse performing tracheotomy care will... suction tracheotomy before beginning care the nurse recognizes that, immediately before a tracheotomy cuff deflation, the patient should... have the pharynx suctioned a nurse performing oral suctioning on an adult patient should set the wall suction machine so that the suction pressure is between... 80 and 120mmHg a patient has a history of chronic obstructive pulmonary disease (COPD)... the patient's oxygen flow rate should be set to no more than... 2 to 3 L/min the nurse instructing the patient to perform forceful exhalation coughing would instruct the patient to take in... two deep breaths, then inhale deeply again and force out the air quickly the nurse uses a diagram to show that when the diaphragm moves... down, the negative pressure in the thoracic space pulls air into the lungs when air collects in the pleural space pneomothorax hyperoxygenation can be done...
- "homocysteine levels may be decreased by taking a multivitamin with B6 and B12" OXYGENNNNNN stuff oxygen delivery by high-flow nasal cannula
- air is heated and humidified
- delivered by high-flow system
- delivery rate 15-40 L/min
- oxygen delivered from 60-90% oxygen delivery devices fall into two categories low-flow systems and high-flow systems low-flow systems simple nasal cannula, simple face mask, partial-rebreather mask and non-rebreather mask high-flow systems air-entertainment or Venturi mask and high-flow nasal cannula oxygen delivery by simple nasal cannula
- encourage patient to breathe through the nose
- flow rates are as follows: 1 L/min - 24% 2 L/min - 28%
3 L/min - 32% 4 L/min - 36% 5 L/min - 40% 6 L/min - 44%
- do not administer oxygen through a simple nasal cannula greater than 6 L/min
- consider humidification at all levels, but especially flow rates of 4 L/min and higher oxygen delivery by simple nasal cannula FLOW RATES 1 L/min - 24% 2 L/min - 28% 3 L/min - 32% 4 L/min - 36% 5 L/min - 40% 6 L/min - 44%
- do not administer oxygen through a simple nasal cannula greater than 6 L/min
- consider humidification at all levels, but especially flow rates of 4 L/min and higher oxygen delivery by mask
- always humidify oxygen delivered by mask
- if there is a bad reservoir, ensure it is filled before placing mask on patient
- different kinds of masks
- special valves on the mark prevent room air from entering but allow exhaled air to leave the mask Venturi mask flowrates are 4 to 12 L/min and 24% to 60% respectively
- used to ensure accuracy of the oxygen concentration delivered; considered for use with carbon dioxide retaining patients
- color-coded dials; each color adaptor has a corresponding liter-per- minutes setting listed on it for the allowed perfect oxygen
- to change the perfect of oxygen being delivered, the adaptor must be changed inside of the tubing tracheostomy mask and collar
- require special adaptation for oxygen administration
- oxygen is always humidified for tracheostomies
- flow rates and percent oxygenation values are similar to those for simple face mask 5 L/min - 40% 6 L/min - 45% 7 L/min - 50% 8 L/min - 55% >8 L/min - 60%
hyperventilation - type of breathing? Kussmaul's? rapid, deep, and labored patient has paralysis, what is priority?
- aspiration risk ** trouble swallowing, worried about swallowing and aspiration - AIRWAY
- yes, you assess O2, inspirations and expirations.. yea, but what is priority ?? - AIRWAY (aspiration) postural drainage with what types of patients asthma, COPD, bronchitis, and pneumonia... it is for inflammation, congestion, sinus congestion (you don't want the mucus built-up) what is postural drainage the drainage by gravity of secretions from various lung segments what is suctioning suctioning is aspirating secretions through a catheter connected to a suction machine or wall suction outlet hyperinflation involves giving the clients breaths that are 1 to 1.5 times the tidal volume set on the ventilator through the ventilator circuit or via a manual resuscitation bag.
