chapter 70

Question 1

To evaluate the effectiveness of prescribed therapies for a client with ventilatory failure, which of the following diagnostic tests will be most useful to the nurse?
a. Chest x-rays
b. Pulse oximetry
c. Arterial blood gas (ABG) analysis
d. Pulmonary artery pressure monitoring

Answer 1

c. Arterial blood gas (ABG) analysis

Question 2

The nurse is caring for a client who has been admitted with a pulmonary embolism and notes a change in the client’s oxygen saturation (SpO2) from 94% to 88%. Which of the following actions should the nurse implement?
a. Increase the oxygen flow rate.
b. Suction the client’s oropharynx.
c. Assist the client to cough and deep breathe.
d. Help the client to sit in a more upright position.

Answer 2

a. Increase the oxygen flow rate.

Question 3

The nurse is caring for a client with respiratory failure who has a respiratory rate of 8/min and a SpO2 of 89%. The client is increasingly lethargic. Which of the following actions should the nurse anticipate?
a. Administration of 100% oxygen by non-rebreather mask
b. Endotracheal intubation and positive pressure ventilation
c. Insertion of a mini-tracheostomy with frequent suctioning
d. Initiation of bilevel positive pressure ventilation (BiPAP)

Answer 3

b. Endotracheal intubation and positive pressure ventilation

Question 4

The pulse oximetry for a client with right lower lobe pneumonia indicates an oxygen saturation of 90%. The client has rhonchi, a weak cough effort, and complains of fatigue. Which of the following actions is best for the nurse to take?
a. Position the client on the right side.
b. Place a humidifier in the client’s room.
c. Assist the client with staged coughing.
d. Schedule a 2-hour rest period for the client.

Answer 4

c. Assist the client with staged coughing.

Question 5

The nurse is caring for an obese client with left lower lobe pneumonia. Which of the following positions should the nurse place the client in for optimal gas exchange?
a. Left lateral
b. Right lateral
c. Tripod position.
d. High Fowler’s position

Answer 5

b. Right lateral

Question 6

The nurse is admitting a client who is in possible respiratory failure with a high PaCO2. Which of the following assessment information will be of most concern to the nurse?
a. The client is somnolent.
b. The client’s SpO2 is 90%.
c. The client complains of weakness.
d. The client’s blood pressure is 162/94 mmHg.

Answer 6

a. The client is somnolent.

Question 7

Chest physiotherapy is indicated for which of the following clients?
a. Takes a bronchodilator
b. Produces 40 mL of sputum per 24 hours
c. Has an increased PCO2 level
d. Is taking vancomycin

Answer 7

b. Produces 40 mL of sputum per 24 hours

Question 8

The nurse is caring for a client who develops increasing dyspnea and hypoxemia 2 days after having cardiac surgery. To determine whether the client has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the
nurse will anticipate assisting with which of the following actions?
a. Inserting a pulmonary artery catheter
b. Obtaining a ventilation–perfusion scan
c. Drawing blood for arterial blood gases
d. Positioning the client for a chest radiograph

Answer 8

a. Inserting a pulmonary artery catheter

Question 9

Which of the following assessment findings by the nurse when caring for a client with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates that the PEEP may need to be decreased?
a. The client has subcutaneous emphysema.
b. The client has a sinus bradycardia with a rate of 52.
c. The client’s PaO2 is 50 mm Hg and the SaO2 is 88%.
d. The client has bronchial breath sounds in both the lung fields.

Answer 9

a. The client has subcutaneous emphysema.

Question 10

Which of the following statements by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a client with ARDS is correct?
a. “PEEP will prevent fibrosis of the lung from occurring.”
b. “PEEP will push more air into the lungs during inhalation.”
c. “PEEP allows the ventilator to deliver 100% oxygen to the lungs.”
d. “PEEP prevents the lung air sacs from collapsing during exhalation.”

Answer 10

d. “PEEP prevents the lung air sacs from collapsing during exhalation.”

Question 11

When prone positioning is used in the care of a client with acute respiratory distress syndrome (ARDS), which of the following information obtained by the nurse indicates that the positioning is effective?
a. The client’s PaO2 is 90 mm Hg, and the SaO2 is 92%.
b. Endotracheal suctioning results in minimal mucous return.
c. Sputum and blood cultures show no growth after 24 hours.
d. The skin on the client’s back is intact and without redness.

Answer 11

a. The client’s PaO2 is 90 mm Hg, and the SaO2 is 92%.

Question 12

The nurse obtains the vital signs for a client admitted 2 days ago with gram-negative sepsis: temperature 38.4°C (101.1°F), blood pressure 90/56 mm Hg, pulse 92 beats/minute, respirations 34/minute. Which of the following actions should the nurse take next?
a. Administer the scheduled IV antibiotic.
b. Give the PRN acetaminophen 650 mg.
c. Obtain oxygen saturation using pulse oximetry.
d. Notify the health care provider of the client’s vital signs.

Answer 12

c. Obtain oxygen saturation using pulse oximetry.

Question 13

To decrease the risk for ventilator-associated pneumonia, which of the following actions should the nurse include in the plan of care for a client who requires intubation and mechanical ventilation?
a. Avoid use of positive end-expiratory pressure (PEEP).
b. Suction every 2 hours.
c. Elevate head of bed to 45 degrees.
d. Give enteral feedings at no more than 10 mL/hour.

Answer 13

c. Elevate head of bed to 45 degrees.

Question 14

The nurse is caring for a client who has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which of the following actions should the nurse include in the plan of care?
a. Encourage use of the incentive spirometer.
b. Offer the client fluids at frequent intervals.
c. Teach the client the importance of coughing.
d. Increase oxygen level to keep O2 saturation >95%.

Answer 14

b. Offer the client fluids at frequent intervals.

Question 15

The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is intubated, receiving mechanical ventilation and has developed a pneumothorax. Which of the following actions will the nurse anticipate taking?
a. Lower the positive end-expiratory pressure (PEEP).
b. Increase the fraction of inspired oxygen (FIO2).
c. Suction more frequently.
d. Increase the tidal volume.

Answer 15

a. Lower the positive end-expiratory pressure (PEEP).

Question 16

After receiving change-of-shift report, which of the following clients should the nurse assess first?
a. A client with cystic fibrosis who has thick, green-coloured sputum
b. A client with pneumonia who has coarse crackles in both lung bases
c. A client with emphysema who has an oxygen saturation of 91% to 92%
d. A client with septicemia who has intercostal and suprasternal retractions

Answer 16

d. A client with septicemia who has intercostal and suprasternal retractions

Question 17

The nurse is admitting a client with chronic obstructive pulmonary disease (COPD) who has shortness of breath and dyspnea. Which of the following assessment findings is most important to report to the health care provider?
a. The client has bibasilar lung crackles.
b. The client is sitting in the tripod position.
c. The client’s respiratory rate has decreased from 30 to 10 breaths/minute.
d. The client’s pulse oximetry indicates an O2 saturation of 91%.

Answer 17

c. The client’s respiratory rate has decreased from 30 to 10 breaths/minute.

Question 18

The nurse is assessing a client with chronic lung disease and finds a sudden onset of agitation and confusion. Which of the following actions should the nurse take first?
a. Check pupil reaction to light.
b. Notify the health care provider.
c. Attempt to calm and reassure the client.
d. Assess oxygenation using pulse oximetry.

Answer 18

d. Assess oxygenation using pulse oximetry.

Question 19

The nurse is caring for a client who came to the emergency department with acute respiratory distress. Which of the following information requires the most rapid action by the nurse?
a. Respiratory rate is 32 breaths/minute.
b. Pattern of breathing is shallow.
c. The client’s PaO2 is 45 mm Hg.
d. The client’s PaCO2 is 34 mm Hg.

Answer 19

c. The client’s PaO2 is 45 mm Hg.

Question 20

The nurse is caring for a client who was hospitalized 2 days earlier with aspiration pneumonia. Which of the following assessment information is most important to
communicate to the health care provider?
a. Cough that is productive of blood-tinged sputum
b. Scattered crackles throughout the posterior lung bases
c. Temperature of 38.6°C (101.5°C) after 2 days of IV antibiotic therapy
d. Oxygen saturation (SpO2) has dropped to 90% with administration of 100% O2 by non-rebreather mask

Answer 20

d. Oxygen saturation (SpO2) has dropped to 90% with administration of 100% O2 by non-rebreather mask

Question 21

The nurse is caring for a client with hypoxemia and a PaO2/FiO2 ratio of 170 while being administered oxygen 8 L/minute via mask. Which of the following information is accurate in relation to the client’s situation?
a. Is at risk for ARDS
b. Also has an increased PaCO2 level
c. Should be prepared for mechanical ventilation
d. Requires packed red cells as soon as possible

Answer 21

a. Is at risk for ARDS

Question 22

A client with ARDS who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV) has settings of fraction of inspired oxygen (FIO2) 80%, tidal volume 500, rate 18, and positive end-expiratory pressure (PEEP) 5 cm. Which of the following assessment findings is most important for the nurse to report to the health care provider?
a. Oxygen saturation 99%
b. Client respiratory rate 22 breaths/minute
c. Crackles audible at lung bases
d. Apical pulse rate 104 beats/minute

Answer 22

a. Oxygen saturation 99%

Question 23

The nurse is caring for a client with chronic hypercapnia and is to receive supplemental oxygen. Which of the following prescribed actions should the nurse implement?
a. Venturi mask at 48%
b. Nasal cannula at 1–2 L/minute
c. Noninvasive ventilation
d. Face mask at 4–5 L/minute

Answer 23

b. Nasal cannula at 1–2 L/minute