Week 5 – Airway/Respiratory

Question 1

The nurse cares for a patient who is orally intubated on mechanical ventilation. Which action is most important for the nurse to take?

a. Limit noise and cluster activities.
b. Use the open-suction technique.
c. Maintain head of bed elevation at 30 degrees.
d. Administer morphine for discomfort.

Answer 1

c. Maintain head of bed elevation at 30 degrees.

(open-suction is not what we prefer, its the closed-suction technique.

Question 2

Which of the following arterial blood gases (ABGS) should the nurse anticipate in the client with a nasogastric tube attache to continuous suction?

a. pH 7.25, PCO2 55, HCO3 24
b. pH 7.30, PCO2 38, HCO3 20
c. pH 7.48, PCO2 30, HCO3 23
d. pH 7.49, PCO2 38, HCO3 30

Answer 2

not about how to identity what clinical situation could cause something,

c. pH 7.49, PCO2 38, and HCO3 30

Question 3

To determine whether the ventricular rhythm on an ECG tracing is regular or irregular, compare ______ intervals.

a. PR
b. R to R
c. TP
d. P to P

Answer 3

b. R to R.

Question 4

The nurse obtains a six-second rhythm strip and charts the following analysis: atrial rate 70, regular; ventricular rate 40, regular; ORS 0.04 sec; no relationship between P waves and QRS complexes; atria and ventricles beating independently of each other. Which of the following would be a correct interpretation of this rhythm strip?

a. Sinus dysrhythmias
b. Third-degree heart block.
c. Wenckebach phenomenon.
d. Premature ventricular contractions.

Answer 4

B. Third- degree heart block.

key= atria and ventricle beating independently of eachother.

Question 5

Which of the following ECG characteristics is consistent with a diagnosis of ventricular tachycardia (VT)

a. Unmeasurable rate and rhythm
b. Rate 150 beats/min; inverted P wave.
c. Rate 200 beats/min; P wave not visible.
d. Rate 125 beats/min; normal QRS complex

Answer 5

c. Rate 200 beats/min; P wave not visible.

Question 6

What is the cause of hypercapnic respiratory failure?

a. Acute respiratory distress syndrome (ARDS)
b. Asthma
c. Pneumonia
d. Pulmonary emboli

Answer 6

b. Asthma

Question 7

What is an early sign of acute respiratory failure?

a. Coma
b. Cyanosis
c. Restlessness
d. Paradoxical breathing

Answer 7

c. Restlessness

Question 8

Which type of oxygen delivery system should be chosen for patients in acute respiratory failure?
a. Should always be a low-flow device, such as a nasal
cannula
b. Should correct the partial pressure of oxygen in arterial
blood (PaO2) to a normal level as quickly as possible
c. Should administer positive-pressure ventilation to preventCO2 narcosis
d. Should maintain the PaO2 at 60 mm Hg or higher at thelowest fraction of inspired oxygen (FiO2) possible

Answer 8

d. Should maintain the PaO2 at 60 mm Hg or higher at the

lowest fraction of inspired oxygen (FiO2) possible

Question 9

What are the early clinical manifestations of ARDS?

a. Dyspnea and tachypnea
b. Cyanosis and apprehension
c. Hypotension and tachycardia
d. Respiratory distress and frothy sputum

Answer 9

a. Dyspnea and tachypnea