Final Exam 2.0

Question 1

A health care provider prescribes 3000 mL of D5W to be administered over a 24-hour period. The nurse determines that how many milliliters per hour will be administered to the client?

Answer 1

125 mL

Question 2

After change of shift, you are assigned to care for the following patients. Which patient should you assess first?

a) 60-year old patient on a ventilator for whom a sterile sputum specimen must be sent to the lab
b) 55-year old with COPD and a pulse oximetry reading from the previous shift of 90% saturation
c) 70-year old with pneumonia who needs to be started on intravenous (IV) antibiotics
d) 50-year old with asthma who complains of shortness of breath after using a bronchodilator

Answer 2

d) 50-year old with asthma who complains of shortness of breath after using a bronchodilator

Question 3

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for the patient’s care, you would anticipate a physician order for which action?

A. Perform endotracheal intubation and initiate mechanical ventilation
B. Immediately begin continuous positive airway pressure (CPAP) via the patient’s nose and mouth
C. Administer furosemide (Lasix) 100 mg IV Push immediately (STAT)
D. Call a code for respiratory arrest

Answer 3

A. Perform endotracheal intubation and initiate mechanical ventilation

Question 4

You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced nursing assistant?

A. Assessing the patient’s respiratory status every 4 hours

B. Taking vital signs and pulse oximetry readings every 4 hours

C. Checking the ventilator settings to make sure they are as prescribed

D. Observing whether the patient’s tube needs suctioning every 2 hours

Answer 4

B. Taking vital signs and pulse oximetry readings every 4 hours

The nursing assistant’s educational preparation includes measurement of vital signs, and an experienced nursing assistant would know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN

Question 5

After the respiratory therapist performs suctioning on a patient who is intubated, the nursing assistant measures vital signs for the patient. Which vital sign value should the nursing assistant report to the RN immediately?

A. Heart rate of 98 beats/min

B. Respiratory rate of 24 breaths/min

C. Blood pressure of 168/90 mm Hg

D. Tympanic temperature of 101.4 F (38.6 C)

Answer 5

D. Tympanic temperature of 101.4 F (38.6 C)

Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body’s normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system.

Question 6

The high-pressure alarm on a patient’s ventilator goes off. When the nurse enters the room to assess the patient, who has acute respiratory distress syndrome (ARDS), the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first?

A.) Reassure the patient that the ventilator will do the work of breathing for him.

B.) Manually ventilate the patient while assessing possible reasons for the high-pressure alarm.

C.) Increase the fraction of inspired oxygen (Fio2) on the ventilator to 100% in preparation for endotracheal suctioning.

D.) Insert an oral airway to prevent the patient from biting on the endotracheal tube.

Answer 6

B.) Manually ventilate the patient while assessing possible reasons for the high-pressure alarm.

Rationale:
Manual ventilation of the patient will allow the nurse to deliver an Fio2 of 100% to the patient while attempting to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, or insertion of an oral airway, but the first step should be assessing the reason for the high-pressure alarm and resolving the hypoxemia.

Question 7

When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate?

A.) Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes.

B.) Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs.

C.) Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation.

D.)Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (FIO2) and call physician for further orders.

Answer 7

D.)Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (FIO2) and call physician for further orders.

Rationale:
The patient’s history and symptoms suggest the development of acute respiratory distress syndrome (ARDS), which will require intubation and mechanical ventilation to maintain oxygenation and gas exchange. The HCP must be notified so that appropriate interventions can be taken. Application of a nonrebreather mask can improve oxygenation up to 95 to 100%. The maximum oxygen delivery with a nasal cannula is an Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.

Question 8

You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care?

A. Administer ordered antibiotics as scheduled

B. Hyperoxygenate the patient before suctioning

C. Maintain the head of the bed at a 30 - to 45-degree angle

D. Suction the airway when coarse crackles are audible

Answer 8

C. Maintain the head of the bed at a 30 - to 45-degree angle

Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP

Question 9

The nurse correlates the P wave on the ECG tracing to which cardiac action?

a. ) Repolarization of the purkinje fibers
b. ) Repolarization of the ventricles
c. ) Depolarization of the atria
d. ) Depolarization of the ventricles

Answer 9

c.) Depolarization of the atria

Question 10

A patient is being evaluated for a blockage in the cardiac ventricles. The nurse assesses which part of the ECG as evidence of this blockage?

a. ) T wave
b. ) U wave
c. ) PR interval
d. ) QRS interval

Answer 10

d.) QRS interval

Question 11

The nurse monitors for which clinical manifestation in the patient with atrial fibrillation at a heart rate of 90 beats per minute. Which manifestation should the nurse expect to assess in this patient?

a. ) Headache
b. ) Chest pain
c. ) Palpitations
d. ) Hypotension

Answer 11

c.) Palpitations

Question 12

Once ventricular fibrillation has been confirmed in a patient, which action is the priority?

a. ) Assessing vital signs
b. ) Opening the airway
c. ) Beginning rescue breathing
d. ) Starting chest compressions

Answer 12

d.) Starting chest compressions

Question 13

A patient is in normal sinus rhythm with prolonged PR intervals which prescribed treatment does the nurse plan for this client?

A. Continue to monitor
B. Prepare for defibrillation
C. Prepare for cardioversion
D. Prepare for pacemaker insertion

Answer 13

A. Continue to monitor

Question 14

The nurse is monitoring the electrocardiogram (ECG) of patient who has an internal ventricular pacemaker. Which pacer spike indicates the pacemaker is functioning properly?

A. The pacer spike occurs before the P wave
B. The pacer spike occurs before the QRS
C. Two pacer spikes occur before the QRS
D. Two pacer spikes occur before the T wave

Answer 14

B. The pacer spike occurs before the QRS

Question 15

A patient becomes unresponsive without a palpable pulse despite showing bradycardia on the rhythm strip. What action should the nurse take immediately? Select all that apply.

1) Auscultate heart sounds
2) Begin cardiac compressions
3) Adjust cardiac monitor leads
4) Obtaining blood samples for electrolytes
5) Retrieve STAT epinephrine and place at the bedside

Answer 15

2) Begin cardiac compressions
5) Retrieve STAT epinephrine and place at the bedside

Question 16

The nurse prepares to administer which prescribed medication to the patient with shortness of breath and a heart rhythm of 46 beats per minute?

a. ) Atropine
b. ) Atenolol
c. ) Diltiazem
d. ) Adenosine

Answer 16

a.) Atropine

Question 17

In preparing a patient with atrial fibrillation for cardioversion, the nurse prepares the patient for which diagnostic test prior?

a. ) Chest x-ray
b. ) CT scan of the chest
c. ) 12-lead ECG
d. ) Transesophageal echocardiogram (TEE)

Answer 17

d.) Transesophageal echocardiogram (TEE)

Question 18

The nurse provides care to a patient who is undergoing cardioversion. Which is the priority nursing action before initiating the shock?

A. Documenting the vital signs
B. Telling the patient what to expect
C. Holding the patient’s hand
D. Stating, “I am clear, you are clear, we are all clear.”

Answer 18

D. Stating, “I am clear, you are clear, we are all clear.”

Question 19

The nurse working on the telemetry unit correlates which data to normal ECG parameters? Select all the apply

A. SA node is located in right upper wall of R atrium
B. Inherent rate of SA node is 60-100 BPM
C. Inherent rate of AV node is 20-40 BPM
D. Impulses from the AV node travel through ventricular pathways
E. inherent rate of purkinjie fibers is 40 BPM or less

Answer 19

A. SA node is located in right upper wall of R atrium
B. Inherent rate of SA node is 60-100 BPM
D. Impulses from the AV node travel through ventricular pathways

Question 20

In the patient with acute respiratory failure the nurse interprets which set of arterial blood gases as respiratory acidosis with hypoxemia?

A. pH 7.30, PaCo2 55 mm Hg, HCO3- 22 mEq/L, PaO2 66 mm Hg

B. pH 7.32, PaCo2 48 mm Hg, HCO3- 22 mEq/L, PaO2 88 mm Hg

C. pH 7.37, PaCo2 42 mm Hg, HCO3- 24 mEq/L, PaO2 82 mm Hg

Answer 20

A. pH 7.30, PaCo2 55 mm Hg, HCO3- 22 mEq/L, PaO2 66 mm Hg

Question 21

Which arterial blood gas results does the nurse recognize as most indicative of impending respiratory failure?

A. PaCO2 33 mm Hg, PaO2 66 mm Hg
B. PaCO2 30 mm Hg, PaO2 80 mm Hg
C. PaCO2 45 mm Hg, PaO2 70 mm Hg
D. PaCO2 48 mm Hg, PaO2 60 mm Hg

Answer 21

D. PaCO2 48 mm Hg, PaO2 60 mm Hg

Question 22

The nurse monitors for which clinical manifestations in the patient experiencing intermediate respiratory failure?

A. Frequent Urination
B. Lethargy
C. GI Upset
D. Anxiety

Answer 22

B. Lethargy

Question 23

In triaging patients in the emergency department the nurse prioritizes the patient with which clinical manifestations?

A. Dyspnea
B. Cyanosis and decreased level of consciousness
C. Confusion and pink skin color
D. Restlessness and tachycardia

Answer 23

B. Cyanosis and decreased level of consciousness

Question 24

In the patient admitted with acute respiratory distress syndrome (ARDS) the nurse identifies the nursing diagnosis impaired gas exchange to which physiologic change?

A. Increased lung compliance
B. Increased capillary permeability
C. Increased left ventricular pressure
D. Increased airway resistance

Answer 24

B. Increased capillary permeability

Question 25

A patient admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS). The nurse prepares to implement which healthcare provider prescription?

A. Intubation and mechanical ventilation
B. Oxygen via a nasal cannula
C. Face mask oxygen administration
D. CPAP via face mask

Answer 25

A. Intubation and mechanical ventilation

Question 26

The nurse is providing care for a patient requiring mechanical ventilation. When the nurse enters the room at the beginning of the shift, the patient’s monitor displays a heart rate of 64 and oxygen saturation of 88%. Which nursing action is the priority?

A. Increasing the oxygen concentration
B. Removing the patient from the ventilator and hyperoxygenating the patient
C. Assessing the patient for airway obstruction
D. Checking ventilator settings

Answer 26

C. Assessing the patient for airway obstruction

Question 27

Which assessment alerts the nurse to the possibility that the intrathoracic pressure in a mechanically ventilated client is too high?

a. Hypotension
b. Pulse oximetry value of 96%
c. Increased diaphragmatic excursion
d. Low-pressure alarm sounds on the ventilator

Answer 27

a. Hypotension

Increased intrathoracic pressure can inhibit blood return to the heart and cause decreased cardiac output. A pulse oximetry reading of 96% is normal. Increased diaphragmatic excursion is associated with taking keep breaths, not mechanical ventilation. The low-pressure alarm sounds when there is decreased resistance to airflow from the ventilator, as when the tubing becomes disconnected from the ventilator or endotracheal or tracheostomy tube.

Question 28

A patient’s blood pressure drops from 120/76 to 90/60 as soon as positive end-expiratory pressure is initiated for the treatment of hypoxemia. What is the most likely cause of this decrease in blood pressure?

A. Decrease in cardiac output
B. Neurogenic shock
C. Increase in venous return
D. Hypovolemic shock

Answer 28

A. Decrease in cardiac output

Question 29

The nurse correlates which mechanical ventilator setting as placing the patient at risk for barotrauma?

A. CPAP 3 cm H2O
B. FIO2 0.30
C. PEEP 7 cm H2O
D. Low tidal volumes

Answer 29

C. PEEP 7 cm H2O

Question 30

The nurse caring for a patient admitted with septic shock is aware of the need to assess for the development of acute respiratory distress syndrome (ARDS). Which early clinical manifestation would indicate the development of ARDS?

A) Intercostal retractions
B) Cyanosis
C) Tachypnea
D) Respiratory rate of 14

Answer 30

C) Tachypnea

Dyspnea and tachypnea are early clinical manifestations of ARDS

Question 31

the nurse correlates which disorders as placing a patient at increase risk of acute respiratory failure secondary to mechanical lung modifications? Select all that apply!

A. Anemia
B. High spinal cord injury
C. Myasthenia Gravis
D. Pulmonary edema
E. Opioid overdose

Answer 31

B. High spinal cord injury
C. Myasthenia Gravis
D. Pulmonary edema
E. Opioid overdose

Question 32

The nurse correlates which assessment data to the patient experiencing early respiratory distress? Select all the apply

A. Dyspnea
B. Restlessness
C. Tachycardia
D. Vomiting
E. Cyanosis

Answer 32

A. Dyspnea
B. Restlessness
C. Tachycardia

Question 33

The nurse educator prepares to speak to a group of nursing students about insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS). The nurse includes which as causes related to direct injury to the lungs? Select all that apply.

A. Aspiration
B. Chest trauma
C. Drug overdose
D. Pulmonary embolus
E. Septic shock

Answer 33

A. Aspiration
B. Chest trauma
D. Pulmonary embolus

Question 34

The nurse monitors for which clinical manifestations in the exudative phase of acute respiratory distress syndrome(ARDS)? Select all that apply.

A. Frequent urination
B. Blood pressure 88/40
C. Hypoxemia
D. Respiratory alkalosis
E. Respiratory rate 26

Answer 34

C. Hypoxemia
D. Respiratory alkalosis
E. Respiratory rate 26

Question 35

Choose the correct arrhythmia interpretation for the rhythm strip

A. Atrial flutter
B. Atrial fibrillation
C. Sinus tachycardia
D. 3rd degree heart block

Answer 35

A. Atrial flutter

Question 36

Choose the correct arrhythmia interpretation for the rhythm strip

A. Supraventricular Tachycardia (SVT)
B. Ventricular Tachycardia (VT)
C. Ventricular Fibrillation
D. Atrial fibrillation

Answer 36

B. Ventricular Tachycardia (VT)

Question 37

Interpret the rhythm associated with the strip

A. Asystole
B. Normal Sinus Rhythm
C. Atrial fibrillation
D. Atrial flutter

Answer 37

B. Normal Sinus Rhythm

Question 38

Interpret the rhythm associated with the strip:

A. Sinus bradycardia
B. Atrial fibrillation
C. Normal Sinus Rhythm
D. Ventricular Fibrillation

Answer 38

D. Ventricular Fibrillation

Question 39

A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with

a. obtaining a ventilation-perfusion scan.
b. drawing blood for arterial blood gases.
c. insertion of a pulmonary artery catheter.
d. positioning the patient for a chest x-ray.

Answer 39

c. insertion of a pulmonary artery catheter.

Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema.

Question 40

A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced?

a. The patient’s PaO2 is 50 mm Hg and the SaO2 is 88%.
b. The patient has subcutaneous emphysema on the upper thorax.
c. The patient has bronchial breath sounds in both the lung fields.
d. The patient has a first-degree atrioventricular heart block with a rate of 58.

Answer 40

b. The patient has subcutaneous emphysema on the upper thorax.

The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not specific indications that PEEP should be reduced.

Question 41

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is accurate?

a. “PEEP will push more air into the lungs during inhalation.”
b. “PEEP prevents the lung air sacs from collapsing during exhalation.”
c. “PEEP will prevent lung damage while the patient is on the ventilator.”
d. “PEEP allows the breathing machine to deliver 100% oxygen to the lungs.”

Answer 41

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

By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage (e.g., fibrotic changes that occur with ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.

Question 42

A patient with acute respiratory distress syndrome (ARDS) is placed in the prone position. When prone positioning is used, which information obtained by the nurse indicates that the positioning is effective?

a. The patient’s PaO2 is 89 mm Hg, and the SaO2 is 91%.
b. Endotracheal suctioning results in clear mucous return.
c. Sputum and blood cultures show no growth after 48 hours.
d. The skin on the patient’s back is intact and without redness

Answer 42

a. The patient’s PaO2 is 89 mm Hg, and the SaO2 is 91%.

The purpose of prone positioning is to improve the patient’s oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective.

Question 43

The nurse documents the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next?

a. Give the scheduled IV antibiotic.
b. Give the PRN acetaminophen (Tylenol).
c. Obtain oxygen saturation using pulse oximetry.
d. Notify the health care provider of the patient’s vital signs.

Answer 43

c. Obtain oxygen saturation using pulse oximetry.

The patient’s increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Giving the scheduled antibiotic and the PRN acetaminophen will also be done, but they are not the highest priority for a patient who may be developing ARDS.

Question 44

A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?

a. Elevate head of bed to 30 to 45 degrees.
b. Suction the endotracheal tube every 2 to 4 hours.
c. Limit the use of positive end-expiratory pressure.
d. Give enteral feedings at no more than 10 mL/hr

Answer 44

a. Elevate head of bed to 30 to 45 degrees.

Elevation of the head decreases the risk for aspiration. Positive end-expiratory pressure is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient’s high energy needs.

Question 45

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which action will the nurse anticipate taking next?

a. Increase the tidal volume and respiratory rate.
b. Increase the fraction of inspired oxygen (FIO2).
c. Perform endotracheal suctioning more frequently.
d. Lower the positive end-expiratory pressure (PEEP).

Answer 45

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

Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for pneumothorax.

Question 46

After receiving change-of-shift report on a medical unit, which patient should the nurse assess first?

a. A patient with cystic fibrosis who has thick, green-colored sputum
b. A patient with pneumonia who has crackles bilaterally in the lung bases
c. A patient with emphysema who has an oxygen saturation of 90% to 92%
d. A patient with septicemia who has intercostal and suprasternal retractions

Answer 46

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

This patient’s history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation. The other patients should also be assessed as quickly as possible, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.

Question 47

A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding by the nurse is most important to report to the health care provider?

a. The patient has bibasilar lung crackles.
b. The patient is sitting in the tripod position.
c. The patient’s respirations have decreased from 30 to 10 breaths/minute.
d. The patient’s pulse oximetry indicates an O2 saturation of 91%.

Answer 47

c. The patient’s respirations have decreased from 30 to 10 breaths/minute.

A decrease in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore immediate action such as positive pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An oxygen saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.

Question 48

When assessing a acute respiratory syndrome (ARDS), the nurse finds a new onset of agitation and confusion. Which action should the nurse take first?

a. Notify the health care provider.
b. Check pupils for reaction to light.
c. Attempt to calm and reorient the patient.
d. Assess oxygenation using pulse oximetry.

Answer 48

d. Assess oxygenation using pulse oximetry.

Because agitation and confusion are frequently the initial indicators of hypoxemia, the nurse’s initial action should be to assess oxygen saturation. The other actions are also appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider.

Question 49

The nurse is caring for a 33-year-old patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action?

a. The patient’s PaO2 is 45 mm Hg.
b. The patient’s PaCO2 is 33 mm Hg.
c. The patient’s respirations are shallow.
d. The patient’s respiratory rate is 32 breaths/minute.

Answer 49

a. The patient’s PaO2 is 45 mm Hg.

The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient’s poor oxygenation.

Question 50

The nurse is caring for a 78-year-old patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider?

a. Scattered crackles bilaterally in the posterior lung bases.
b. Persistent cough that is productive of blood-tinged sputum.
c. Temperature of 101.5° F (38.6° C) after 2 days of IV antibiotic therapy.
d. Decreased oxygen saturation to 90% with 100% O2 by non-rebreather mask.

Answer 50

d. Decreased oxygen saturation to 90% with 100% O2 by non-rebreather mask.

The patient’s low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patient’s blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.

Question 51

Which actions should the nurse initiate to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)?

a. Obtain arterial blood gases daily.
b. Provide a sedation holiday daily.
c. Elevate the head of the bed to at least 30.
d. Give prescribed pantoprazole (Protonix).
e. Provide oral care with chlorhexidine (0.12%) solution daily

Answer 51

b. Provide a sedation holiday daily.
c. Elevate the head of the bed to at least 30.
d. Give prescribed pantoprazole (Protonix).
e. Provide oral care with chlorhexidine (0.12%) solution daily

Question 52

A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse take next?

a. Administer bicarbonate.
b. Complete a head-to-toe assessment.
c. Place the patient on high-flow oxygen.
d. Obtain repeat arterial blood gases (ABGs).

Answer 52

c. Place the patient on high-flow oxygen.

Question 53

The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider?

a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
b. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%
c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%
d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

Answer 53

d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal

Question 54

The nurse assesses a patient with acute respiratory distress syndrome (ARDS) who has been admitted with increasing dyspnea over the past 3 hours. Which finding is most important for the nurse to report to the health care provider?

a. Respirations are 36 breaths/minute.
b. Anterior-posterior chest ratio is 1:1.
c. Lung expansion is decreased bilaterally.
d. Slight crackles are audible to the lower lung bases

Answer 54

a. Respirations are 36 breaths/minute.

The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications.

Question 55

A patient admitted with acute respiratory failure has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action is a priority for the nurse to include in the plan of care?

a. Encourage use of the incentive spirometer.
b. Offer the patient fluids at frequent intervals.
c. Teach the patient the importance of ambulation.
d. Titrate oxygen level to keep O2 saturation >93%.

Answer 55

b. Offer the patient fluids at frequent intervals.

Because the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. Patients should be instructed to use the incentive spirometer on a regular basis (e.g., every hour) in order to facilitate the clearance of the secretions. The other actions may also be helpful in improving the patient’s gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.

Question 56

During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first?

a. Give the prescribed PRN sedative drug.
b. Offer reassurance and reorient the patient.
c. Use pulse oximetry to check the oxygen saturation.
d. Notify the health care provider about the patient’s status.

Answer 56

c. Use pulse oximetry to check the oxygen saturation.

Agitation may be an early indicator of hypoxemia. The other actions may also be appropriate, depending on the findings about oxygen saturation.

Question 57

Which action will the nurse in the hypertension clinic take to obtain an accurate baseline blood pressure (BP) for a new patient?

a. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second.
b. Have the patient sit in a chair with the feet flat on the floor.
c. Assist the patient to the supine position for BP measurements.
d. Obtain two BP readings in the dominant arm and average the results.

Answer 57

b. Have the patient sit in a chair with the feet flat on the floor.

The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, and the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.

Question 58

Which priority action should the nurse take when giving the first dose of oral medication in a patient with hypertension?

A. Encourage the use of hard candy to prevent dry mouth
B. Teach the patient that headaches often occur with that drug
C. Instruct the patient to call for help if heart palpitations occur
D. Ask the patient to request assistance before getting out of bed

Answer 58

D. Ask the patient to request assistance before getting out of bed

Question 59

After the nurse teaches the patient with pre-hypertension about diet modifications that should be implemented, which diet choice indicates that the teaching has been effective?

a. The patient avoids eating nuts or nut butters.
b. The patient restricts intake of dietary protein.
c. The patient has only one cup of coffee in the morning.
d. The patient drinks low-fat milk with meals

Answer 59

d. The patient drinks low-fat milk with meals

Question 60

A patient has just been diagnosed with hypertension and has a new prescription for captopril (Capoten). Which information is important to include when teaching the patient?

a. Check BP daily before taking the medication.
b. Increase fluid intake if dryness of the mouth is a problem.
c. Include high-potassium foods such as bananas in the diet.
d. Change position slowly to help prevent dizziness and falls.

Answer 60

d. Change position slowly to help prevent dizziness and falls.

The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the medication, and the patient is taught to use gum or hard candy to relieve dry mouth. The BP does not need to be checked at home by the patient before taking the medication. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.

Question 61

Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this drug when the patient reveals a history of:

A. Asthma
B. Daily alcohol use
C. Peptic ulcer disease
D. Myocardial Infarction

Answer 61

A. Asthma

Question 62

The nurse has just finished teaching a hypertensive patient about the newly prescribed drug, Enalapril(Vasotec). Which patient statement indicates that more teaching is needed?

A. I will take my time when standing up
B. I can expect some swelling and edema
C. I should call my doctor if I experience dizziness frequently
D. I will call the doctor if I notice I have a frequent cough

Answer 62

B. I can expect some swelling and edema

Question 63

During change-of-shift report, the nurse obtains the following information about a hypertensive patient who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention?

A. The patient’s blood pressure (BP) reading is now 158/91 mm Hg.

B. The patient complains that the fingers and toes feel quite cold.

C. The patient has developed wheezes throughout the lung fields.

D. The patient’s pulse has dropped from 68 to 57 beats/min.

Answer 63

C. The patient has developed wheezes throughout the lung fields.

Question 64

An older patient has been diagnosed with possible white coat hypertension. Which planned action by the nurse best addresses the suspected cause of the hypertension?

A. Schedule the patient for regular blood pressure (BP) checks in the clinic.

B. Inform the patient and caregiver that major dietary changes will be needed.

C. Instruct the patient about the need to decrease stress levels.

D. Teach the patient how to self-monitor and record BPs at home.

Answer 64

D. Teach the patient how to self-monitor and record BPs at home.

Question 65

Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 48-yr-old patient with newly diagnosed hypertension?

A. 142/78 mm Hg

B. 124/70 mm Hg

C. 128/92 mm Hg

D. 98/56 mm Hg

Answer 65

B. 124/70 mm Hg

Question 66

Which information is most important for the nurse to include when teaching a patient with newly diagnosed hypertension?

A. Increasing physical activity alone controls blood pressure (BP) for most people.

B. Hypertension is usually asymptomatic until target organ damage occurs.

C. Most people are able to control BP through dietary changes.

D. Annual BP checks are needed to monitor treatment effectiveness

Answer 66

B. Hypertension is usually asymptomatic until target organ damage occurs.

Question 67

Which assessment finding for a patient who is receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider?

A. Blood glucose level of 175 mg/dL

B. Orthostatic systolic BP decrease of 12 mm Hg

C. Most recent blood pressure (BP) reading of 168/94 mm Hg

D. Serum potassium level of 3.0 mEq/L

Answer 67

D. Serum potassium level of 3.0 mEq/L

Question 68

A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department complaining of a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings?

A. Have you recently taken any antihistamines?
B. Have you suddenly stopped taking your medications?
C. Did you take any acetaminophen this week?
D. Have there been recent stressful events in your life?

Answer 68

B. Have you suddenly topped taking your medications?

Question 69

The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider?

a. Urine output over 8 hours is 50 mL less than the fluid intake.
b. The patient cannot move the left arm and leg when asked to do so and has developed slurred speech
c. Tremors are noted in the fingers when the patient extends the arms.
d. The patient complains of a headache with pain at level 7 of 10 (0 to 10 scale).

Answer 69

b. The patient cannot move the left arm and leg when asked to do so and has developed slurred speech

The patient’s inability to move the left arm and leg indicates that a stroke may be occurring and will require immediate action to prevent further neurologic damage. The other clinical manifestations are also likely caused by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes.

Question 70

The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be fastest to use?

A. Count the number of large squares in the RR interval and divide by 300
B. Print a 1-minute electrocardiogram strip and count the number of QRS complexes
C. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

Answer 70

C. Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

Question 71

After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective?

A. Increase in patient’s heart rate
B. Increase in strength of peripheral pulses
C. Decreased in premature atrial contractions
D. Decrease in premature ventricular contractions

Answer 71

A. Increase in patient’s heart rate

Question 72

A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about:

A. Anticoagulant therapy
B. Permanent pacemakers
C. Emergency cardioversion
D. IV adenosine (Adenocard)

Answer 72

A. Anticoagulant therapy

Question 73

Which information will the nurse include when teaching a patient who is scheduled for a catheter ablation?

A. The procedure stimulates the growth of new pathways
B. The procedure uses cold therapy to stop formulation of flutter waves
C. The procedure will use electrical energy to destroy areas of the conduction system.

Answer 73

C. The procedure will use electrical energy to destroy areas of the conduction system.