LACHARITY 6 - Respiratory Problems

Question 1

The nurse is providing care for a patient diagnosed with laryngeal cancer who is receiving radiation therapy. The patient tells the nurse that he is experiencing hoarseness and difficulty with speaking. What is the nurse’s best response?

1. “Let’s elevate the head of your bed and see if that helps.”
2. “Your voice should improve in 6 to 8 weeks after completion of the radiation.”
3. “Sometimes patients also experience dry mouth and difficulty with swallowing.”
4. “I will call your health care provider and let him know about this.”

Answer 1

Hoarseness often gets worse during treatment with radiation therapy. The nurse should reassure the patient that this usually improves within 6 to 8 weeks after therapy is completed. Strategies that may help during radiation therapy include voice rest with use of alternative means of communication, as well as saline gargles or sucking on ice chips. Elevating the head of the bed may help with oxygenation but will not help with hoarseness. Responses 3 and 4 are important but do not speak directly to the patient’s concern.
Focus: Prioritization.

Question 2

The nurse is supervising a nursing student providing care for a patient with shortness of breath who has expressed interest in smoking cessation. Which
questions would the nurse suggest the student ask to determine nicotine dependence? Select all that apply.
1. How soon after you wake up in the morning do you smoke?
2. Do other members of your family smoke?
3. Do you smoke when you are ill?
4. Do you wake up in the middle of your sleep time to smoke?
5. Do you smoke indoors or outside?
6. Do you have a difficult time not smoking in places where it is not allowed?

Answer 2

Ans: 1, 3, 4, 6 When a patient expresses interest in smoking cessation, this is an important teaching moment for the nurse. However, it is essential to determine the patient’s level of nicotine dependence by asking questions such as questions 1, 3, 4, and 6, which will give clues to this important information. While it is important to know about other family smokers and whether the patient smokes inside or outside, this information does not necessarily help with determining nicotine dependence. Focus: Supervision, Prioritization.

Question 3

The RN clinical instructor is discussing a patient’s oxygen-hemoglobin dissociation curve with a student. The student states that the patient’s oral body temperature is elevated at 100.8°F (38.2°C). Which statement by the student indicates correct understanding of this patient’s curve shift?

1. “When a patient’s body temperature is elevated, there is no change in the oxygen-hemoglobin dissociation curve.”
2. “When a patient’s body temperature is elevated, there is a shift to the left because the oxygen tension level is lower.”
3. “When a patient’s body temperature is elevated, there is no shift in the curve because the patient is using less oxygen.”
4. “When the patient’s body temperature is elevated, there is a shift to the right so that hemoglobin will dissociate oxygen faster.”

Answer 3

Ans: 4 When the need for oxygen is greater in the tissues, there is a curve shift to the right. This means that oxygen is dissociated from hemoglobin faster.
Conditions that shift the curve to the right include increased body temperature, increased carbon dioxide concentration, and decreased pH or acidosis. This means that hemoglobin unloads oxygen to the tissues because they need it to support the higher metabolism, and this is a tissue protection that increases oxygen delivery to the tissues that need it the most. Focus:
Prioritization.

Question 4

An experienced LPN/LVN, under the supervision of the team leader RN, is assigned to provide nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced
LPN/LVN? Select all that apply.
1. Auscultating breath sounds
2. Administering medications via metered-dose inhaler (MDI)
3. Completing in-depth admission assessment
4. Checking oxygen saturation using pulse oximetry
5. Developing the nursing care plan
6. Evaluating the patient’s technique for using MDIs

Answer 4

Ans: 1, 2, 4 The experienced LPN/LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/LVN. Independently completing the admission assessment, developing the nursing care plan, and evaluating a
patient’s abilities require additional education and skills within the scope of practice of the professional RN. Focus: Assignment, Supervision.

Question 5

The nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns the nurse immediately?

1. Fine bibasilar crackles
2. Respiratory rate of 8 breaths/min
3. The patient sitting up and leaning over the nightstand
4. A large barrel chest

Answer 5

Ans: 2 For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This
patient’s oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respiratory rate. If the nurse does not intervene,
the patient is at risk for respiratory arrest. Crackles, barrel chest, and assumption of a sitting position leaning over the nightstand are common in patients with chronic emphysema. Focus: Prioritization; Test Taking Tip:
Immediate or priority concerns are issues that can threaten life or limb. In this case, the nurse should remember the normal drive to breathe and recognize
that this patient’s drive is different. With a respiratory rate so low, the patient is at risk for a respiratory arrest.

Question 6

The unlicensed assistive personnel (UAP) tells the nurse that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should the nurse suggest to the UAP to improve the patient’s comfort for this problem?

1. Humidify the patient’s oxygen.
2. Use a simple face mask instead of a nasal cannula.
3. Provide the patient with an extra pillow.
4. Have the patient sit up in a chair at the bedside.

Answer 6

Ans: 1 When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Applying water-soluble jelly to the nares can
also help decrease mucosal irritation. None of the other options will treat the problem.
Focus: Prioritization.

Question 7

The RN is teaching an unlicensed assistive personnel (UAP) to check oxygen saturation by pulse oximetry. What will the nurse be sure to tell the UAP about patients with darker skin?

1. “Be aware that patients with darker skin usually show a 3% to 5% higher oxygen saturation compared with light-skinned patients.”
2. “Usually dark-skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients.”
3. “With a dark-skinned patient, you may get more accurate results by measuring pulse oximetry on the patient’s toes.”
4. “More accurate results may result from continuous pulse oximetry monitoring than spot checking when a patient has darker skin.”

Answer 7

Ans: 2 Teach the UAP that compared with light-skinned adults, adults with dark skin usually show a lower oxygen saturation (3% to 5% lower) as measured by pulse oximetry; this results from deeper coloration of the nail bed and does not reflect true oxygen status. None of the other responses are correct. Focus: Supervision.

Question 8

The nurse is caring for a patient after thoracentesis. Which actions can be delegated from the nurse to the unlicensed assistive personnel (UAP)? Select all that apply.

1. Assess puncture site and dressing for leakage.
2. Check vital signs every 15 minutes for 1 hour.
3. Auscultate for absent or reduced lung sounds.
4. Remind the patient to take deep breaths.
5. Take the specimens to the laboratory.
6. Teach the patient symptoms of pneumothorax.

Answer 8

Ans: 2, 4, 5 Checking vital signs, carrying specimens to the lab, and reminding patients about what has already been taught are actions that are within the scope of practice for UAP. Assessing and teaching patients
requires additional knowledge and training that is within the scope of practice for professional nurses. Focus: Delegation.

Question 9

The nurse is supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause the nurse to
intervene?
1. Suctioning the tracheostomy tube before performing tracheostomy care
2. Removing old dressings and cleaning off excess secretions
3. Removing the inner cannula and cleaning using standard precautions
4. Replacing the inner cannula and cleaning the stoma site

Answer 9

Ans: 3 When tracheostomy care is performed, a sterile field is set up, and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for
organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate. Focus: Delegation, Supervision.

Question 10

The nurse is supervising an RN who floated from the medical-surgical unit to the emergency department. The float nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which directions would the supervising nurse clearly provide to the RN? Select all that apply.

1. Position the patient supine and turned on his side.
2. Apply direct lateral pressure to the nose for 5 minutes.
3. Maintain standard body substance precautions.
4. Apply ice or cool compresses to the nose.
5. Instruct the patient not to blow the nose for several hours.
6. Teach the patient to avoid vigorous nose blowing.

Answer 10

Ans: 2, 3, 4, 5, 6 The correct position for a patient with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and to avoid aspiration. All of the other instructions are appropriate
according to best practice for emergency care of a patient with an anterior nosebleed. Focus: Assignment, Supervision.

Question 11

A patient with a diagnosis of sleep apnea has a problem with sleep deprivation related to a disrupted sleep cycle. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?

1. Discussing weight-loss strategies such as diet and exercise with the patient
2. Teaching the patient how to set up the bilevel positive airway pressure (BiPAP) machine before sleeping
3. Reminding the patient to sleep on his side instead of his back
4. Administering modafinil to promote daytime wakefulness

Answer 11

Ans: 3 The UAP can remind patients about actions that have already been taught by the nurse and are part of the patient’s plan of care. Discussing and teaching require additional education and training. These actions are within the scope of practice of the RN. The RN can administer or assign medication administration to an LPN/LVN. Focus: Delegation, Supervision.

Question 12

The nurse is acting as preceptor for a newly-graduated RN during the second week of orientation. The nurse would assign and supervise the new RN to provide nursing care for which patients? Select all that apply.

1. A 38-year-old patient with moderate persistent asthma awaiting discharge
2. A 63-year-old patient with a tracheostomy needing tracheostomy care every shift
3. A 56-year-old patient with lung cancer who has just undergone left lower lobectomy
4. A 49-year-old patient just admitted with a new diagnosis of esophageal cancer
5. A 76-year-old patient newly diagnosed with type 2 diabetes
6. A 69-year-old patient with emphysema to be discharged tomorrow

Answer 12

Ans: 1, 2, 6 The new RN is at an early point in orientation. The most appropriate patients to assign to the new RN are those in stable condition who require routine care. The patient with the lobectomy will require the care
of an experienced nurse, who will perform frequent assessments and monitoring for postoperative complications. The patient admitted with newly
diagnosed esophageal cancer will also benefit from care by an experienced nurse. This patient may have questions and needs a comprehensive admission assessment. The newly diagnosed diabetic patient will need much teaching as well as careful monitoring. As the new nurse advances through orientation, the preceptor will want to work with him or her in providing
care for patients with more complex needs. F ocus: Assignment, Delegation, Supervision.

Question 13

The nurse is providing care for a patient with recently diagnosed asthma. Which key points would the nurse be sure to include in the teaching plan for this patient? Select all that apply.
1. Avoid potential environmental asthma triggers such as smoke.
2. Use the inhaler 30 minutes before exercising to prevent bronchospasm.
3. Wash all bedding in cold water to reduce and destroy dust mites.
4. Be sure to get at least 8 hours of rest and sleep every night.
5. Avoid foods prepared with monosodium glutamate (MSG).
6. Keep a symptom and intervention diary to learn specific triggers for your
asthma.

Answer 13

Ans: 1, 2, 4, 5, 6 Bedding should be washed in hot water to destroy dust mites. All of the other points are ccurate and appropriate to a teaching plan for a patient with a new diagnosis of asthma. Focus: Prioritization.

Question 14

The nurse is the team leader RN working with a student nurse. The student nurse is to teach a patient how to use a metered-dose inhaler (MDI) without a spacer. Put in correct order the steps that the student nurse should teach the patient.

1. Remove the inhaler cap and shake the inhaler.
2. Open your mouth and place the mouthpiece 1 to 2 inches (2.5 to 5.0 cm) away.
3. Breathe out completely.
4. Hold your breath for at least 10 seconds.
5. Press down firmly on the canister and breathe deeply through your mouth.
6. Wait at least 1 minute between puffs.

Answer 14

Ans: 1, 3, 2, 5, 4, 6 Before each use, the cap is removed, and the inhaler is shaken according to the instructions in the package insert. Next the patient should breathe out completely. As the patient begins to breathe in deeply through the mouth, the canister should be pressed down to release 1 puff (dose) of the medication. The patient should continue to breathe in slowly over 3 to 5 seconds and then hold the breath for at least 10 seconds to allow
the medication to reach deep into the lungs. The patient should wait at least 1 minute between puffs from the inhaler. Focus: Prioritization.

Question 15

A patient has chronic obstructive pulmonary disease (COPD). Which intervention for airway management should the nurse delegate to the unlicensed assistive personnel (UAP)?

1. Assisting the patient to sit up on the side of the bed
2. Instructing the patient to cough effectively
3. Teaching the patient to use incentive spirometry
4. Auscultating breath sounds every 4 hours

Answer 15

Ans: 1 Assisting patients with positioning and activities of daily living is within the educational preparation and scope of practice of UAPs. Teaching, instructing, and assessing patients all require additional education and skills and are more appropriate to the scope of practice of licensed nurses. Focus: Delegation, Supervision.

Question 16

A patient with chronic obstructive pulmonary disease (COPD) has rapid shallow respirations. Which is an appropriate action to assign to the experienced LPN/LVN under RN supervision?
1. Observing how well the patient performs pursed-lip breathing
2. Planning a nursing care regimen that gradually increases activity tolerance
3. Assisting the patient with basic activities of daily living (ADLs)
4. Consulting with the physical therapy department about reconditioning
exercises

Answer 16

Ans: 1 Experienced LPNs/LVNs can use observation of patients to gather data regarding how well patients perform interventions that have already been taught. Assisting patients with ADLs is more appropriately delegated to UAPs. Planning and consulting require additional education and skills, appropriate to the RN’s scope of practice. Focus: Delegation, Supervision.

Question 17

A patient with chronic obstructive pulmonary disease (COPD) tells the unlicensed assistive personnel (UAP) that he did not get his annual flu shot this year and has not had a pneumonia vaccination. Which vital sign change will be most important for the nurse to instruct the UAP to report?

1. Blood pressure of 152/84 mm Hg
2. Respiratory rate of 27 breaths/min
3. Heart rate of 92 beats/min
4. Oral temperature of 101.2°F (38.4°C)

Answer 17

Ans: 4 A patient who did not have the pneumonia vaccination or flu shot is at increased risk for developing pneumonia or influenza. An elevated temperature indicates some form of infection, which may be respiratory in origin. All of the other vital sign values are slightly elevated and should be followed up on but are not a cause for immediate concern. Focus: Prioritization, Delegation, Supervision.

Question 18

The nurse is responsible for the care of a postoperative patient with a thoracotomy. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?

1. Instructing the patient to alternate rest and activity periods
2. Encouraging, monitoring, and recording nutritional intake
3. Monitoring cardiorespiratory response to activity
4. Planning activities for periods when the patient has the most energy

Answer 18

Ans: 2 The UAP’s training includes how to monitor and record intake and output. After the nurse has taught the patient about the importance of adequate nutritional intake for energy, the UAP can remind and encourage
the patient to take in adequate nutrition. Instructing patients and planning activities require more education and skill and are appropriate to the RN’s scope of practice. Monitoring the patient’s cardiovascular response to activity is a complex process requiring additional education, training, and skill, and falls within the RN’s scope of practice. Focus: Delegation, Supervision.

Question 19

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately?

1. Chest tube drainage of 10 to 15 mL/hr
2. Continuous bubbling in the water-seal chamber
3. Reports of pain at the chest tube site
4. Chest tube dressing dated yesterday

Answer 19

Ans: 2 Continuous bubbling indicates an air leak that must be identified. With the health care provider’s (HCP’s) order, an RN can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require the RN to notify the HCP. If the air bubbling does not stop when the RN applies
the padded clamp, the air leak is between the clamp and the drainage system, and the RN must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not 145changed daily but may be reinforced. The patient’s reports of pain need to be assessed and treated. This is important but is not as urgent as investigating a chest tube leak. Focus: Delegation, Supervision.

Question 20

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

1. A 68-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory
2. A 57-year-old patient with chronic obstructive pulmonary disease (COPD) and a pulse oximetry reading from the previous shift of 90% saturation
3. A 72-year-old patient with pneumonia who needs to be started on IV antibiotics
4. A 51-year-old patient with asthma who reports shortness of breath after using a bronchodilator inhaler

Answer 20

Ans: 4 The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient’s needs are urgent. The other patients need to be
assessed as soon as possible, but none of their situations is urgent. In patients with COPD, pulse oximetry oxygen saturations of more than 90% are
acceptable. Focus: Prioritization.

Question 21

The nurse is initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should the nurse delegate to the
unlicensed assistive personnel (UAP)?
1. Teaching the patient about the importance of adequate fluid intake and hydration
2. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed
3. Reminding the patient to use an incentive spirometer every 1 to 2 hours while awake
4. Encouraging the patient to take a deep breath, hold it for 2 seconds, and then cough two or three times in succession

Answer 21

Ans: 3 UAPs can remind the patient to perform actions that are already part of the plan of care. Assisting the patient into the best position to facilitate coughing requires specialized knowledge and understanding that is beyond the scope of practice of the basic UAP. However, an experienced UAP could assist the patient with positioning after the UAP and the patient had been
taught the proper technique. UAPs would still be under the supervision of the RN. Teaching patients about adequate fluid intake and techniques that facilitate coughing requires additional education and skill and is within the scope of practice of the RN. Focus: Delegation, Supervision.

Question 22

The unlicensed assistive personnel (UAP) is assisting with feeding for a patient with severe end-stage chronic obstructive pulmonary disease (COPD). Which instruction will the nurse provide the UAP?

1. Encourage the patient to eat foods that are high in calories and protein.
2. Feed the patient as quickly as possible to prevent early satiety.
3. Offer lots of fluids between bites of food.
4. Try to get the patient to eat everything on the tray.

Answer 22

Ans: 1 Patients with COPD often have food intolerance, nausea, early satiety (feeling too “full” to eat), poor appetite, and meal-related dyspnea. The increased work of breathing raises calorie and protein needs, which can lead to protein-calorie malnutrition. Urging the patient to eat high-calorie, high-protein foods can be done by the UAP after the nurse has taught the patient about the importance of this strategy to prevent weight loss. Feeding the patient too rapidly will tire him or her. If early satiety is a problem, avoid fluids before or during the meal or provide smaller, more frequent meals.
Focus: Delegation, Supervision.

Question 23

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months of experience) floated from the surgical unit to the medical unit?

1. A 58-year-old patient on airborne precautions for tuberculosis (TB)
2. A 65-year-old patient who just returned from bronchoscopy and biopsy
3. A 72-year-old patient who needs teaching about the use of incentive spirometry
4. A 69-year-old patient with chronic obstructive pulmonary disease (COPD) who is ventilator dependent

Answer 23

Ans: 3 Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. Also, a fairly new nurse
should be assigned more stable and less complicated patients. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized and careful assessment and monitoring after the procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses. Focus: Assignment.

Question 24

When a patient with tuberculosis (TB) is being prepared for discharge, which statement by the patient indicates a need for further teaching?

1. “Everyone in my family needs to go and see the doctor for TB testing.”
2. “I will continue to take my isoniazid until I am feeling completely well.”
3. “I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag.”
4. “I will change my diet to include more foods rich in iron, protein, and vitamin C.”

Answer 24

Ans: 2 Patients taking isoniazid must continue taking the drug for 6 months. The other three statements are accurate and indicate an understanding of TB. Family members should be tested because of their repeated exposure to the patient. Covering the nose and mouth when sneezing or coughing and placing tissues in plastic bags help prevent transmission of the causative
organism. The dietary changes are recommended for patients with TB. Focus: Prioritization.

Question 25

The nurse is admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient’s history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus?

1. The patient was recently in a motor vehicle crash.
2. The patient participated in an aerobic exercise program for 6 months.
3. The patient gave birth to her youngest child 1 year ago.
4. The patient was on bed rest for 6 hours after a diagnostic procedure.

Answer 25

Ans: 1 Patients who have recently experienced trauma are at risk for deep vein thrombosis (DVT) and pulmonary embolus (PE). None of the other findings are risk factors for PE. Prolonged immobilization is also a risk factor for DVT and PE, but this period of bed rest was very short. Focus: Prioritization.i

Question 26

Which intervention for a patient with a pulmonary embolus would the RN assign to the LPN/LVN on the patient care team?

1. Evaluating the patient’s reports of chest pain
2. Monitoring laboratory values for changes in oxygenation
3. Assessing for symptoms of respiratory failure
4. Auscultating the lungs for crackles

Answer 26

Ans: 4 An LPN/LVN who has been trained to auscultate lung sounds can gather data by routine assessment and observation under the supervision of an RN. Independently evaluating patients, assessing for symptoms of respiratory failure, and monitoring and interpreting laboratory values require additional education and skill, appropriate to the scope of practice of the RN. Focus: Assignment, Supervision

Question 27

A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would the nurse give the unlicensed assistive personnel (UAP) who will help the patient with activities of daily living
(ADLs)? Select all that apply.
1. Use a lift sheet when moving and positioning the patient in bed.
2. Use an electric razor when shaving the patient each day.
3. Use a soft-bristled toothbrush or tooth sponge for oral care.
4. Use a rectal thermometer to obtain a more accurate body temperature.
5. Be sure the patient’s footwear has a firm sole when the patient ambulates.
6. Assess the patient for any signs or symptoms of bleeding.

Answer 27

Ans: 1, 2, 3, 5 While a patient is receiving anticoagulation therapy, it is important to avoid trauma to the rectal tissue, which could cause bleeding (e.g., avoid rectal thermometers and enemas). Assessment of patients is
within the scope of practice for professional nurses. All of the other instructions are appropriate for the UAP when caring for a patient receiving anticoagulants. Focus: Delegation, Supervision.

Question 28

A patient with chronic obstructive pulmonary disease (COPD) tells the nurse that he is always tired. What advice would the nurse give this patient to cope with his fatigue? Select all that apply.

1. Do not rush through your morning activities of daily living.
2. Avoid working with the arms raised.
3. Eat three large meals every day focusing on calories and protein.
4. Organize your work area so that what you use most is easy to reach.
5. Get all of your activities accomplished then take a nap.
6. Don’t hold your breath while performing any activities.

Answer 28

Ans: 1, 2, 4, 6 Patients with COPD often have chronic fatigue. Teach them to not rush through activities but to pace activities with periods of rest. Encourage patients to avoid working with their arms raised. Activities
involving the arms decrease exercise tolerance because the accessory muscles are used to stabilize the arms and shoulders rather than to assist breathing. Smaller more frequent meals may be less tiring. Teach the patient to avoid breath-holding while performing any activity because this interferes with gas exchange. Focus: Prioritization

Question 29

A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements continue to show poor oxygenation. Which action does the nurse anticipate
that the health care provider will prescribe?
1. Perform endotracheal intubation and initiate mechanical ventilation.
2. Immediately begin continuous positive airway pressure (CPAP) via the patient’s nose and mouth.
3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT).
4. Call a code for respiratory arrest.

Answer 29

Ans: 1 A nonrebreather mask can deliver nearly 100% oxygen. When the patient’s oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient’s
work of breathing. Focus: Prioritization.

Question 30

The nurse is the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with acute respiratory distress syndrome (ARDS) who has just been intubated in
preparation for mechanical ventilation. The preceptor observes the RN performing all of these actions. For which action must the preceptor intervene immediately?
1. Assesses for bilateral breath sounds and symmetrical chest movement
2. Uses an end-tidal carbon dioxide detector to confirm endotracheal tube (ET) position
3. Marks the tube 1 cm from where it touches the incisor tooth or nares
4. Orders chest radiography to verify that tube placement is correct

Answer 30

Ans: 3 The ET should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after ET placement. The priority at this time is to verify that the tube has been correctly placed. Use of an end-tidal carbon dioxide detector is the gold standard for evaluating and confirming ET position in patients who have adequate tissue perfusion. Focus: Delegation, Supervision, Prioritization.

Question 31

The nurse is assigned to provide nursing care for a patient receiving
mechanical ventilation. Which action should the nurse delegate to an
experienced unlicensed assistive personnel (UAP)?
1. Assessing the patient’s respiratory status every 4 hours
2. Taking vital signs and pulse oximetry readings every 4 hours
3. Checking the ventilator settings to make sure they are as prescribed
4. Observing whether the patient’s tube needs suctioning every 2 hours

Answer 31

Ans: 2 The UAP’s educational preparation includes measuring vital signs,
and an experienced UAP would have been taught and 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. Focus: Delegation, Supervision

Question 32

After the respiratory therapist performs suctioning on a patient who is intubated, the unlicensed assistive personnel (UAP) measures vital signs for the patient. Which vital sign value should the UAP be instructed to report to the RN immediately?

1. Heart rate of 98 beats/min
2. Respiratory rate of 24 breaths/min
3. Blood pressure of 168/90 mm Hg
4. Tympanic temperature of 101.4°F (38.6°C)

Answer 32

Ans: 4 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 parts of the respiratory system. The other vital signs are important and should be followed up on but are not of as urgent concern. Focus: Prioritization.

Question 33

The nurse is making a home visit to a 50-year-old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism (venous thromboembolism). The patient’s only medication is
enoxaparin subcutaneously. Which assessment information will the nurse
need to communicate to the health care provider?
1. The patient says that her right leg aches all night.
2. The right calf is warm to the touch and is larger than the left calf.
3. The patient is unable to remember her husband’s first name.
4. There are multiple ecchymotic areas on the patient’s abdomen.

Answer 33

Ans: 3 Confusion in a patient this age is unusual and may be an indication of intracerebral bleeding associated with enoxaparin use. The right leg
symptoms are consistent with a resolving deep vein thrombosis; the patient may need teaching about keeping the right leg elevated above the heart to
reduce swelling and pain. The presence of ecchymoses may point to a need to do more patient teaching about avoiding injury while taking anticoagulants but does not indicate that the health care provider needs to be called. Focus: Prioritization.

Question 34

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?

1. Reassure the patient that the ventilator will do the work of breathing for him.
2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm.
3. Increase the fraction of inspired oxygen (F io 2 ) on the ventilator to 100% in preparation for endotracheal suctioning.
4. Insert an oral airway to prevent the patient from biting on the endotracheal tube.

Answer 34

Ans: 2 Manual ventilation of the patient will allow the nurse to deliver an F io 2 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. Focus: Prioritization.

Question 35

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?

1. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes.
2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs.
3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation.
4. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (F io 2 ) and call the health care provider to discuss the patient’s status.

Answer 35

Ans: 4 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 F io 2 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. Focus: Prioritization.

Question 36

The nurse has just finished assisting the health care provider with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient
assessment information is most important to report to the health care provider (HCP)?
1. The patient starts crying and says she can’t go on with treatment much longer.
2. The patient reports sharp, stabbing chest pain with every deep breath.
3. The blood pressure is 100/48 mm Hg, and the heart rate is 102 beats/min.
4. The dressing at the thoracentesis site has 1 cm of bloody drainage.

Answer 36

Ans: 3 Removal of large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space, causing hypotension and tachycardia. The patient may need to receive IV fluids to correct this. The other data indicate that the patient needs ongoing monitoring or interventions but would not be unusual findings for a patient with this diagnosis or after this procedure. Focus: Prioritization

Question 37

The nurse is 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?

1. Administer ordered antibiotics as scheduled.
2. Hyperoxygenate the patient before suctioning.
3. Maintain the head of bed at a 30- to 45-degree angle.
4. Suction the airway when coarse crackles are audible.

Answer 37

. Ans: 3 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. Focus: Prioritization; Test Taking Tip:
Prevention of VAP has been a subject of research; as a result, a ventilator 148bundle order set has been developed to apply to patients placed on ventilators with the goal of prevention of VAP.

Question 38

The critical care charge nurse is responsible for the care of four patients receiving mechanical ventilation. Which patient is most at risk for failure to wean and ventilator dependence?

1. A 68-year-old patient with a history of smoking and emphysema
2. A 57-year-old patient who experienced a cardiac arrest
3. A 49-year-old postoperative patient who had a colectomy
4. A 29-year-old patient who is recovering from flail chest

Answer 38

Ans: 1 Older patients, especially those who have smoked or who have chronic lung problems such as COPD, are at risk for ventilator dependence and failure to wean. Age-related changes, such as chest wall stiffness,
reduced ventilatory muscle strength, and decreased lung elasticity, reduce the likelihood of weaning. Younger patients without respiratory illnesses are
likely to wean from the ventilator without difficulty. Focus: Prioritization.

Question 39

After extubation of a patient, which finding would the nurse report to the health care provider immediately?

1. Respiratory rate of 25 breaths/min
2. Patient has difficulty speaking
3. Oxygen saturation of 93%
4. Crowing noise during inspiration

Answer 39

Ans: 4 Stridor is a high-pitched, crowing noise during inspiration caused by laryngospasm or edema around the glottis. It is a symptom that the patient may need to be reintubated. When stridor or other symptoms of obstruction occur after extubation, respond by immediately calling the Rapid Response Team before the airway becomes completely obstructed. It is common for
patients to be hoarse and have a sore throat for a few days after extubation. A respiratory rate of 25 breaths/min should be rechecked but is not an
immediate danger, and an oxygen saturation of 93% is low normal. Focus: Prioritization.

Question 40

The RN is supervising a nursing student who will suction a patient on a mechanical ventilator. Which actions indicate that the student has a correct
understanding of this procedure? Select all that apply.
1. The student nurse uses a sterile catheter and glove.
2. The student nurse applies suction while inserting the catheter.
3. The student nurse applies suction during catheter removal.
4. The student nurses uses a twirling motion when withdrawing the catheter.
5. The student nurse uses a no. 12 French catheter.
6. The student nurse applies suction for at least 20 seconds.

Answer 40

Ans: 1, 3, 4, 5 The standard size catheter for an adult is a no. 12 or 14 French. Infection is possible because each catheter pass can introduce bacteria into the trachea. In the hospital, use sterile technique for suctioning and for all suctioning equipment (e.g., suction catheters, gloves, saline or water). Apply suction only during catheter withdrawal and use a twirling motion to prevent the catheter from grabbing tracheal mucosa and leading to damage to tracheal tissue. Apply suction for no more than 10 seconds to minimize hypoxemia during suctioning. Focus: Prioritization.