Quiz 1

Question 1

Your patient is hypoxic and is give oxygen via nasal cannula. As the nurse how would you know your interventions have been effective?

Answer 1

*Assess the mouth
*mucus membranes pink
*normal cap refill
*oxygen saturation improved

Question 2

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

Answer 2

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?

Answer 3

Brush the client’s teeth with suction toothbrush every 12hrs

Question 4

A patient with ARDS is being given vecuronium bromide. What is it for? What does it do? Monitor for what?

Answer 4

*It is used for endotracheal tube placement.
*This drug is a paralytic
*Monitor for Respiratory Depression

Question 5

What patients are at higher risk for ARDS?

Answer 5

*HX Aspiration
*trauma or injury
*sepsis

Question 6

A nurse is planning care for a client who as ARDS. Which of the following interventions should the nurse include in the plan?

Answer 6

Place patient in a prone position

Question 7

What tool do we use to determine if we can take a patient of a vent?

Answer 7

ABGS

Question 8

Uncompensated ABGS

Answer 8

The PH is outside of range and either HCO3 or the PAO2 is outside of range

Question 9

Partially Compensated ABGS

Answer 9

The PH, HCO3 and PAO2 are outside of the normal range

Question 10

Fully compensated

Answer 10

PH is within range, But PAO2 and HCO3 are both out of range

Question 11

Early Signs of ARDS

Answer 11

Confusion
tachypnea
scattered crackles
tachycardia
hypertension
pallor

Question 12

Late signs of ARDS

Answer 12

confusion
stupor
bradypnea
diffuse crackles
bradycardia
hypotension
cyanosis
dysrhythmias

Question 13

A nurse is caring for a client with a tracheostomy. The client’s partners 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?

Answer 13

Performing the procedure independently.

Question 14

A nurse is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent (vecuronium) . Which of the following items should the nurse place at the clients bedside?

Answer 14

Bag valve mask (BVM)
Reversal agents: neostigmine and atropine

Question 15

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?

Answer 15

Administer oxygen via face mask

Question 16

A nurse in the PACU is assessing a client who has an endotracheal tube (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?

Answer 16

Movement of the ET tube into the right main bronchus

Question 17

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.)

Answer 17

• Elevate HOB to at least 30 degrees
• Administer Pantoprazole
• Reposition the endotracheal tube to the opposite side of the mouth every 12 hrs

Question 18

A nurse is caring for a client who just had a flexible bronchoscopy. Which of the following nursing actions is
appropriate?

Answer 18

withhold food and liquids until the client’s gag reflex has returned

Question 19

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

Answer 19

Respiratory acidosis

Question 20

A patient with ARDS has high levels of peep. What can be the complication of this

Answer 20

Emphysema, if developed PEEP needs to be decreased

Question 21

A patient has ARDS. What ABG values can be checked to see if placing the patient prone is effective for improved oxygenation

Answer 21

PAO2 is 80-100mmHg
SAO2>95%

Question 22

A patient has ARDS and is on a mechanical ventilator. WHat can the RN delegate to the LVN

Answer 22

Placement of the foley catheter

Question 23

A patient with ARDS is on a positive pressure vent. The patient has and NG tube with red/brown drainage. What do you suspect

Answer 23

A GI bleed (From stress ulcers)

Question 24

A newly admitted patient is in respiratory distress and is not breathing well. What action should the nurse take first

Answer 24

Use pulse Oximeter to assess SPO2

Question 25

An 81-year-old patient with a broken hip. What do we expect to check, or which findings are significant

Answer 25

Check albumin level
weight loss of 15lbs in 1 week

Question 26

Normal ranges for ABG

Answer 26

Ph: 7.35-7.45
PAO2: 80-100
SAO2: >95%
PACO2: 35-45
HCO3: 22-26

Question 27

An increase in PEEP can cause what

Answer 27

hypotension: due to pressure on the vena cava.
(can also cause emphysema and pneumothorax)

Question 28

You notice the water level on the PEEP is decreasing. The ARDS is worsening, and you hear lung sounds greater on one side. What is it and what do you do?

Answer 28

Pneumothorax
Call the doc and RT ASAP

Question 29

A patient has Gillian-barre syndrome and is hypoventilating. What will you see in the ABGS?

Answer 29

High PAO2 (respiratory acidosis)

Question 30

What is the hallmark manifestation of ARDS

Answer 30

Refractory Hypoxemia

Question 31

A pt has an endotracheal tube, as the RN how do you determine the cuff is leaking

Answer 31

• you can hear hissing sounds with or without a stethoscope
• decrease in SAO2

Question 32

(SATA) A patient that was diagnosed with sepsis is being weaned off mechanical ventilation. What criteria shows improvement?

Answer 32

HBG >7.5
No sepsis or systemic problems
Able to initiate respiratory and expiratory efforts

Question 33

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

Answer 33

Admister 100% oxygen supply 2 mins prior to suction and after suctioning.