Quiz 1

Question 1

A nurse is caring for a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective?

A. Heart rate 110/min
B. Restlessness
C. Pink mucous membranes
D. Respiratory rate 28/min

Answer 1

C. Pink mucous membranes

Question 2

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client’s heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?

A. Obtain a cardiology consult.
B. Perform pre-oxygenation prior to suctioning.
C. Suction the client less frequently.
D. Administer an antidysrhythmic medication.

Answer 2

B. Perform pre-oxygenation prior to suctioning.

Question 3

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator associated pneumonia?

A. Position the head of the client’s bed in the flat position.
B. Brush the client’s teeth with a suction toothbrush every 12 hr.
C. Provide humidity by maintaining moisture within the ventilator tubing.
D. Turn the client every 4 hr.

Answer 3

B. Brush the client’s teeth with a suction toothbrush every 12 hr.

Question 4

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. The client receives a prescription for vecuronium. The nurse recognizes that this medication is for which of the following purposes?

A. Decrease respiratory secretions.
B. Induce sedation
C. Suppress respiratory effort
D. Decrease chest wall compliance

Answer 4

C. Suppress respiratory effort

Question 5

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

A. Administer low-flow oxygen continuously via nasal cannula.
B. Offer high-protein and high-carbohydrate foods frequently.
C. Place in a prone position.
D. Encourage oral intake of at least 3,000 mL of fluids per day.

Answer 5

C. Place in a prone position.

Question 6

Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)?

A.24-year-old male admitted with blunt chest trauma and aspiration
B.56-year-old male with a history of alcohol abuse and chronic pancreatitis
C.72-year-old male post heart valve surgery receiving 1 unit of packed red blood cells
D.82-year-old female on antibiotics for pneumonia

Answer 6

A.24-year-old male admitted with blunt chest trauma and aspiration

Question 7

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22, PacO₂ 68 mm Hg, Base excess -2, PaO₂ 78 mm Hg, Saturation 80%, Bicarbonate 26 mEq/L.

A. Metabolic alkalosis.
B. uncompensated Respiratory acidosis.
C. Metabolic acidosis.
D. Respiratory alkalosis.

Answer 7

B. uncompensated Respiratory acidosis.

Question 8

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)

A. Severe dyspnea
B. Nausea
C. Decreased level of consciousness
D. Headache
E. Hypotension

Answer 8

A. Severe dyspnea
C. Decreased level of consciousness
D. Headache
E. Hypotension

Question 9

A nurse is caring for a client with a tracheostomy. The client’s partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client’s discharge?

A. Performing the procedure independently
B. Attending a class given about tracheostomy care
C. Verbalizing all steps in the procedure
D. Asking appropriate questions about suctioning

Answer 9

A. Performing the procedure independently

Question 10

A nurse is planning care for a client who is to receive a competitive neuromuscular blocking agent. Which of the following items should the nurse plan to have at the client’s bedside?

A. Bag-valve-mask device
B. Temporary pacemaker
C. Urinary catheter insertion tray
D. Central venous catheterization tray

Answer 10

A. Bag-valve-mask device

Question 11

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention?

a. Assess for indications of pulmonary embolism.
b. Prepare for mechanical ventilation.
c. Prepare to administer a sedative.
d. Administer oxygen via face mask.

Answer 11

d. Administer oxygen via face mask.

Question 12

A nurse in the PACU is assessing a client who has an endotracheal (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

A. Blockage of the ET tube by the client’s tongue
B. Movement of the ET tube into the right main bronchus
C. Infection of the vocal cords
D. Passage of the ET tube into the esophagus

Answer 12

B. Movement of the ET tube into the right main bronchus

Question 13

A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.)

A. Elevate the head of the bed to at least 30 degrees.
B. Verify the prescribed ventilator settings daily.
C. Apply restraints if the client becomes agitated.
D. Administer pantoprazole as prescribed.
E. Reposition the endotracheal tube to the opposite side of the mouth daily.

Answer 13

A. Elevate the head of the bed to at least 30 degrees.
D. Administer pantoprazole as prescribed.
E. Reposition the endotracheal tube to the opposite side of the mouth daily.

Question 14

A nurse is monitoring an older adult client immediately following a bronchoscopy. The nurse’s priority is to monitor the client for which of the following?

a. Observing for confusion
b. Auscultating breath sounds
c. Confirming the gag reflex
d. Measuring blood pressure

Answer 14

c. Confirming the gag reflex

Question 15

The nurse is admitting a patient with possible respiratory failure and a high PaCO2. Which assessment information would the nurse immediately report to the health care provider?

a. The patient appears somnolent.
b. The patient reports feeling weak.
c. The patient‘s blood pressure is 164/98.
d. The patient‘s oxygen saturation is 90%.

Answer 15

a. The patient appears somnolent.

Question 16

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
beats/min.

Answer 16

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

Question 17

Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure?

a. Chest x-ray
b. O2 saturation
c. Arterial blood gas
d. Central venous pressure monitoring

Answer 17

c. Arterial blood gas

Question 18

Prone positioning is being used for a patient with acute respiratory distress syndrome (ARDS). 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 18

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

Question 19

Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/VN) working in the intensive care unit?

a. Assess breath sounds every hour.
b. Monitor central venous pressures.
c. Place patient in the prone position.
d. Insert an indwelling urinary catheter.

Answer 19

d. Insert an indwelling urinary catheter.

Question 20

The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider?

a. Red-brown drainage from nasogastric tube
b. Blood urea nitrogen (BUN) level 32 mg/dL
c. Scattered coarse crackles heard throughout lungs
d. Arterial blood gases: pH of 7.31, PaCO2 of 50, and PaO2 of 68

Answer 20

a. Red-brown drainage from nasogastric tube

Question 21

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 21

C. Use pulse oximetry to check the oxygen saturation.

Question 22

The nurse reviews the electronic health record for a patient scheduled for a total hip replacement. Which assessment data shown in the accompanying figure increase the patient‘s risk for respiratory failure after surgery?

a. Older age and anemia
b. Albumin level and weight loss
c. Recent arthroscopic procedure
d. Confusion and disorientation to time

Answer 22

b. Albumin level and weight loss

Question 23

An elderly postoperative patient without known respiratory or central nervous system disease cannot be extubated in the post-anesthesia recovery unit due to abnormal ABG results. The patient does not respond to the nurse’s commands and has a respiratory rate of 10. What ABG results might the nurse expect?

Answer 23

A. pH 7.28, PaO2 80 mmHg, PaCO2 55 mmHg, HCO3 22 mmHg, SaO2 92%

Question 24

A patient being mechanically ventilated develops hypotension after the respiratory therapist implements the most recent physician orders. The nurse suspects which ventilator setting mode might be the cause?

Answer 24

A. Positive end expiratory pressure PEEP

Question 25

A patient being mechanically ventilated requires increasing PEEP for worsening ARDS. The order for PEEP is now at 20 cm of H2O. The nurse will need to contact the physician immediately if the patient develops which finding?

a. lung sounds greater on one side than the other
b. lung sounds with crackles
c. diminished peripheral pulses
d. high-pressure alarm

Answer 25

a. lung sounds greater on one side than the other

Question 26

A patient presents to the emergency department complaining of sudden onset of increased weakness and tingling of the lower extremities that has progressed to the upper arms. The patient is diagnosed with Guillain-Barré syndrome. The patient’s respiratory rate is 8; blood pressure is 86/48. The patient is being prepared for intubation. What would the nurse anticipate the blood gases to reveal?

Answer 26

High PaCO2

Question 27

A patient who is septic is restless and agitated. The chest X-ray results indicate bilateral patchy infiltrates. As the patient’s condition continues to deteriorate, which finding would raise the nurse’s concern that the patient is developing acute respiratory distress syndrome (ARDS)?

Answer 27

D. Refractory hypoxemia

Question 28

The nurse is concerned that an intubated patient is experiencing a cuff leak. Which assessment data would support the nurse’s concern?

Answer 28

B. A hissing sound heard over the trachea on expiration

Question 29

The health care team plans to begin weaning a patient diagnosed with sepsis from the mechanical ventilator. The nurse would review the medical record to assess for achievement of which criteria? (Select all that apply.)

A. The patient’s hemoglobin is over 8 mg/dL.
B. Sepsis has improved.
C. The patient is hemodynamically stable on a moderate dose of vasopressor.
D. The patient is able to initiate inspiratory effort.
E. The patient is quiet and sleeps most of the time.

Answer 29

A. The patient’s hemoglobin is over 8 mg/dL.
B. Sepsis has improved.
D. The patient is able to initiate inspiratory effort.

Question 30

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Answer 30

D. Administer 100% oxygen supply 2 min prior to suction and after suctioning.