Nursing Board Exam Reviewer Part 2 of 5
121. Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration?
a) Non-rebreather mask
The non-rebreather mask provides high oxygen concentration but is usually poor fitting.
b) Venturi mask
The Venturi mask provides low levels of supplemental oxygen.
The catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention.
d) Face tent
A face tent provides a fairly accurate fraction of inspired oxygen, but is bulky and uncomfortable. It would not be the device of choice to provide high oxygen concentration.
122. Which of the following ranges identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration?
a) 20-25 mm Hg water pressure.
Usually the pressure is maintained at less than 25 cm water pressure to prevent injury and at more than 20 cm water pressure to prevent aspiration.
b) 10-15 mm Hg water pressure.
A measure of 10–15 mm Hg water pressure would indicate that the cuff is underinflated.
c) 30-35 mm Hg water pressure.
A measure of 30–35 mm Hg water pressure would indicate that the cuff is overinflated.
d) 0-5 mm Hg water pressure
A measure of 0-5 mm Hg water pressure would indicate that the cuff is underinflated.
123. When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?
a) 10-15 seconds
In general, the nurse should apply suction no longer than 10-15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest.
b) 30-35 seconds
Applying suction for 30-35 seconds is hazardous and may result in the patient’s developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest.
c) 20-25 seconds
Applying suction for 20-25 seconds is hazardous and may result in the patient’s developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest.
d) 0-5 seconds
Applying suction for 0-5 seconds would provide too little time for effective suctioning of secretions.
124. In general, chest drainage tubes are not used for the patient undergoing
Usually, no drains are used for the pneumonectomy patient because the accumulation of fluid in the empty hemithorax prevents mediastinal shift.
With lobectomy, two chest tubes are usually inserted for drainage, the upper for air and the lower for fluid
c) Wedge resection
With wedge resection, the pleural cavity usually is drained because of the possibility of an air or blood leak
With segmentectomy, drains are usually used because of the possibility of an air or blood leak.
125. Which term is used to describe the ability of the heart to initiate an electrical impulse?
Automaticity is the ability of specialized electrical cells of the cardiac conduction system to initiate an electrical impulse.
Contractility refers to the ability of the specialized electrical cells of the cardiac conduction system to contract in response to an electrical impulse.
Conductivity refers to the ability of the specialized electrical cells of the cardiac conduction system to transmit an electrical impulse from one cell to another.
Excitability refers to the ability of the specialized electrical cells of the cardiac conduction system to respond to an electrical impulse.
126. The nurse auscultates the apex beat at which of the following anatomical locations?
a) Fifth intercostal space, midclavicular line
The left ventricle is responsible for the apex beat or the point of maximum impulse, which is normally palpable in the left midclavicular line of the chest wall at the fifth intercostal space.
The right ventricle lies anteriorly, just beneath the sternum.
c) 2” to the left of the lower end of the sternum
Use of inches to identify the location of the apex beat is inappropriate based upon variations in human anatomy.
d) 1” to the left of the xiphoid process
Auscultation below and to the left of the xiphoid process will detect gastrointestinal sounds, but not the apex beat of the heart.
127. Which of the following terms describes the amount of blood ejected per heartbeat?
a) Stroke volume
Stroke volume is determined by preload, afterload, and contractility.
b) Cardiac output
Cardiac output is the amount of blood pumped by each ventricle during a given period and is computed by multiplying the stroke volume of the heart by the heart rate.
c) Ejection fraction
Ejection Fraction is the percentage of the end-diastolic volume that is ejected with each stroke, measured at 42–50% in the normal heart.
Afterload is defined as the pressure that the ventricular myocardium must overcome to eject blood during systole and is one of the determinants of stroke volume.
128. When measuring the blood pressure in each of the patient’s arms, the nurse recognizes that in the normal adult, the pressures
a) differ no more than 5 mm Hg between arm pressures.
Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures.
b) must be equal in both arms.
The pressures in each arm do not have to be equal in order to be considered normal.
c) may vary 10 mm Hg or more between arms.
Pressures that vary more than 10 mm Hg between arms indicate an abnormal finding.
d) may vary, with the higher pressure found in the left arm.
The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.
129. Central venous pressure is measured in which of the following heart chambers?
a) Right atrium
The pressure in the right atrium is used to assess right ventricular function and venous blood return to the heart.
b) Left atrium
The left atrium receives oxygenated blood from the pulmonary circulation.
c) Left ventricle
The left ventricle receives oxygenated blood from the left atrium.
d) Right ventricle
The right ventricle is not the central collecting chamber of venous circulation.
130. Which of the following ECG characteristics is usually seen when a patient’s serum potassium level is low?
a) U wave
The U wave is an ECG waveform characteristic that may reflect Purkinje fiber repolarization. It is usually seen when a patient’s serum potassium level is low.
b) T wave
The T wave is an ECG characteristic reflecting repolarization of the ventricles. It may become tall or “peaked” if a patient’s serum potassium level is high.
c) P wave
The P wave is an ECG characteristic reflecting conduction of an electrical impulse through the atria.
d) QT interval
The QT interval is an ECG characteristic reflecting the time from ventricular depolarization to repolarization.