Chapter 10 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 10

Question 1

Type: MCMA

The nurse is assessing a patient with an endotracheal tube and notes decreased breath sounds on the left with normal sounds on the right. Which condition may cause this?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pressure from a right pneumothorax

2. Misplacement of the endotracheal tube

3. High pulmonary pressures

4. Partial obstruction of the endotracheal tube

5. A large infiltrate in the left lung

Correct Answer: 2,5

Rationale 1: A right pneumothorax would present with decreased sounds on the right.

Rationale 2: The right bronchus is larger than the left bronchus and is at almost a straight angle with the trachea. This anatomical difference makes it easy for the tip of the endotracheal tube to slip into the right bronchus, depriving the left lung from air. This results in decreased breath sounds on the left.

Rationale 3: High pulmonary pressures would affect both sides equally.

Rationale 4: A partially obstructed endotracheal tube would affect both sides equally.

Rationale 5: A large infiltrate in the left lung will decrease air movement through the tissues. This change in air movement will decrease breath sounds on the affected side.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-1

Question 2

Type: MCSA

A patient with pulmonary edema has a respiratory rate of 28 per minute. The nurse plans care for this patient based on which change in the lungs?

1. Decreased work of breathing

2. Reduced muscle activity

3. Dehydration of lung tissues

4. Decreased compliance

Correct Answer: 4

Rationale 1: A respiratory rate of 28 is evidence of increased work of breathing.

Rationale 2: It requires more muscle activity to breath at a rate of 28.

Rationale 3: Pulmonary edema results from retention of fluid in the lung tissues.

Rationale 4: Decreased compliance increases the work of breathing and causes a decreased tidal volume. The breathing rate increases to compensate for the decreased tidal volume. Examples of pulmonary disorders causing decreased lung compliance include pulmonary edema.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-1

Question 3

Type: MCSA

The patient has been diagnosed with early stage pneumonia. The nurse would anticipate which laboratory results?

1. Increased PaO2 and increased PaCO2

2. Decreased PaO2 and normal PaCO2

3. Normal PaO2 and elevated PaCO2

4. Decreased PaO2 and increased PaCO2

Correct Answer: 2

Rationale 1: Presence of pneumonia will not result in an increase in oxygen.

Rationale 2: In the early stages of pneumonia the alveolar surface area is reduced and the alveolarcapillary membrane begins to thicken causing diffusion abnormalities. Oxygen and carbon dioxide do not diffuse at the same rate. Carbon dioxide diffuses 20 times faster than oxygen; therefore, hypoxemia may be present with a normal PaCO2. Only when the condition progresses untreated will the PaCO2 rise.

Rationale 3: PaCO2 will rise only after the disease has progressed.

Rationale 4: Oxygen will decrease, but PaCO2 will not rise initially.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-2

Question 4

Type: MCMA

The nurse is assessing an 80-year-old patient who has no underlying respiratory pathology but whose carbon dioxide level is slightly elevated. The nurse would contribute this increase to which changes associated with normal aging?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Increase in alveolarcapillary membrane thins

2. Increase in total lung surface area

3. Increase in size of the airways

4. Increase in air trapping

5. Overgrowth of alveoli

Correct Answer: 3,4

Rationale 1: The alveolarcapillary membrane thickens with aging, which may result in hypoxemia and/or hypercapnia if the older patient becomes ill.

Rationale 2: As a person ages there is a normal decrease in the total lung surface area.

Rationale 3: Aging results in an increase in size of the airways, which increases dead space ventilation. This can lead to carbon dioxide retention.

Rationale 4: Older patients may have increased air trapping due to normal loss of terminal airway supportive structures.

Rationale 5: As a person ages, alveoli are destroyed. Overgrowth does not occur.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-2

Question 5

Type: MCSA

The arterial blood gases of a patient with a large mass in the right lung show increasing hypoxemia and the patient will be intubated for placement on a mechanical ventilator. In which position should the nurse place this patient until intubation is begun?

1. Flat in bed lying on the left side

2. Flat in bed lying on the right side

3. Lying on the left side with the head of the bed elevated to 30 degrees

4. Lying on the right side with the head of the bed elevated 30 degrees

Correct Answer: 3

Rationale 1: Being placed flat in bed will not improve ventilation perfusion. The patient should benefit from being on the left side.

Rationale 2: This position will not take advantage of gravity or of the bodys natural ventilation tendencies.

Rationale 3: Positioning the patient at 30 degrees and left side down will lower the diaphragm allowing more expansion and redirect blood flow to the healthy lung because of gravity. Air is naturally drawn toward the diaphragm and because blood is gravity dependent the ventilationperfusion ratio will be improved.

Rationale 4: If the right lung is not capable of normal ventilation, redirecting blood flow would result in a mismatch.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10-3

Question 6

Type: MCSA

A patient, diagnosed with diabetic ketoacidosis, presents with Kussmaul respirations at a rate of 28. A newly licensed nurse asks the patient to try to slow his breathing. What instruction should the preceptor provide?

1. Keep trying to slow the patients respirations because breathing so fast is hard on his heart.

2. If he keeps breathing like that he will develop respiratory acidosis.

3. Let the patient set his respiratory rate as rapid breathing helps to compensate for his acidosis.

4. The patient is breathing deeply to help offset diabetes-induced hypoxemia.

Correct Answer: 3

Rationale 1: Breathing rapidly does increase strain on the heart, but the rapid respirations in this situation are helpful to the patient and should not be discouraged.

Rationale 2: Breathing rapidly and deeply as in Kussmauls respirations will not result in respiratory acidosis.

Rationale 3: A patient with diabetic ketoacidosis has a primary metabolic acidosis. As a compensatory mechanism to regain acidbase homeostasis, alveolar hyperventilation occurs in an attempt to blow off carbon dioxide and drive the pH upward toward alkaline. The respiratory buffer system is a rapid-response compensatory mechanism for metabolic acidbase disturbances.

Rationale 4: The patient does not have diabetes-induced hypoxemia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10-4

Question 7

Type: MCSA

A postoperative patients nasogastric drainage has been 500 mL in the last 8 hours. The nurse would assess this patient for findings associated with which acidbase imbalance?

1. Metabolic alkalosis

2. Metabolic acidosis

3. Respiratory acidosis

4. Respiratory alkalosis

Correct Answer: 1

Rationale 1: The loss of gastric fluid from nasogastric suction can result in metabolic alkalosis.

Rationale 2: Loss of body fluids from lower abdominal drains would result in loss of bicarbonate and produce metabolic acidosis.

Rationale 3: The respiratory system is not involved in the development of this acidbase imbalance.

Rationale 4: The respiratory system is not involved in this acidbase imbalance.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-4

Question 8

Type: MCSA

A patient was extubated in the postanesthesia recovery room prior to transfer to the intensive care unit (ICU). Upon admission to the ICU the patient is sedated, but will arouse when stimulated. Blood pressure is 106/68 mm/Hg, heart rate is 68 and regular, temperature is 97.8 F, and respirations are 12 bpm. The nurse would monitor this patient for which changes in arterial blood gases?

1. Increase in pH and decrease in PaCO2

2. Increase in pH and increase in HCO3

3. Decrease in pH and increase in PaCO2

4. Decrease in pH and decrease in HCO3

Correct Answer: 3

Rationale 1: An increase in pH and decrease in PaCO2 indicates respiratory alkalosis is occurring. This is not the expected change with this patient.

Rationale 2: These ABG results indicate metabolic alkalosis. This is not the expected change with this patient.

Rationale 3: The patient is at risk for respiratory acidosis, which is associated with these ABG changes, as a result of decreased, shallow respirations that can cause alveolar hypoventilation. Carbon dioxide is not being blown off and carbonic acid levels can rise.

Rationale 4: These ABG results indicate metabolic acidosis. This is not the expected change in this patient.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-4

Question 9

Type: MCSA

A patients arterial blood gases (ABGs) are as follows:

pH 7.30, PaCO2 30 mm Hg, HCO3 14 mEq/L, and PaO2 50. The nurse evaluates these ABGs as representing which acidbase imbalance?

1. Uncompensated respiratory alkalosis with moderate hypoxemia

2. Compensated metabolic acidosis with severe hypoxemia

3. Partially compensated metabolic acidosis with moderate hypoxemia

4. Partially compensated respiratory alkalosis with mild hypoxemia

Correct Answer: 3

Rationale 1: These ABGs do not represent an uncompensated state.

Rationale 2: These ABGs do not represent a fully compensated state because the pH is not normal.

Rationale 3: The patient has a partially compensated metabolic acidosis with moderate hypoxemia because the pH is still within the acid range. The HCO3 is the primary acidic metabolic component causing the acidic pH. In an attempt to correct the metabolic acidosis, the CO2 is being blown off as indicated by the alkaline PaCO2. The PaO2 falls within the moderate range of hypoxemia (60 to 40 mm Hg).

Rationale 4: These ABGs do not indicate respiratory alkalosis.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-5

Question 10

Type: MCSA

A patients PaO2 level is 76 mm Hg. The nurse would be least concerned regarding this finding in which patient?

1. The patient is 83 years old.

2. The patient is recovering from anesthesia.

3. The patient is a smoker.

4. The patient is intubated.

Correct Answer: 1

Rationale 1: Age affects normal ABG values. The older adult has a 25 to 30% decrease in PaO2 between the ages of 30 and 80 years.

Rationale 2: Low oxygen levels in a patient who is recovering from anesthesia would alert the nurse to a possible problem.

Rationale 3: Smoking can decrease oxygenation, but the nurse would be concerned if the level was this low.

Rationale 4: The patient who is intubated should have a PaO2 higher than 76 mm Hg. The nurse would be concerned about an obstruction in the tube or developing pathology.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-5

Question 11

Type: MCSA

The nurse is assessing the nutritional intake of a patient diagnosed with chronic carbon dioxide retention. Which patient report indicates the patient requires additional information about dietary choices?

1. I try to eat salad with lunch every day.

2. I drink a cup of coffee in the morning with breakfast.

3. I usually eat a sandwich and pasta salad for lunch.

4. I have been trying to increase the protein in my diet.

Correct Answer: 3

Rationale 1: Salad is a low fat, high fiber option that would benefit this patients nutrition.

Rationale 2: There is no indication that coffee is not appropriate for this patient.

Rationale 3: The patient who retains carbon dioxide should avoid high carbohydrate meals. Carbohydrates increase the overall carbon dioxide load in the body.

Rationale 4: A proteincalorie deficit weakens muscles, including respiratory muscles. The patients attempts to increase protein in the diet should be reinforced.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10-6

Question 12

Type: MCSA

The patient complains that he awakens two or three times every night because he is so short of breath. The nurse would ask additional assessment questions about which condition?

1. Paroxysmal nocturnal dyspnea

2. Pneumonia

3. Stroke

4. Kidney infection

Correct Answer: 1

Rationale 1: The patient is describing episodes of paroxysmal nocturnal dyspnea, which is related to left ventricular failure. The prolonged supine position allows dependent fluid from the lower extremities to recirculate causing volume overload and sudden severe dyspnea.

Rationale 2: Pneumonia results in consolidation of lung tissue. It is not associated with sudden dyspnea during the night.

Rationale 3: There is no indication that a neurological problem is causing this patients symptoms.

Rationale 4: There is no indication that this patient is experiencing shortness of breath at night due to a kidney infection. Kidney infection might result in need to urinate frequently during the night.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 

Question 13

Type: MCSA

The nurse is auscultating a patients lung fields and hears a coarse sound like bubbling water. The sounds are heard best on expiration and in the center of the patients chest. How should the nurse document these sounds?

1. Crackles

2. Rhonchi

3. Wheeze

4. Stridor

Correct Answer: 2

Rationale 1: Crackles are discrete, delicate popping sounds heard best on inspiration.

Rationale 2: Rhonchi are course bubbly sounds that frequently occur during expiration and are heard over the larger airways.

Rationale 3: Wheezes are musical sounds that may be high-pitched or low-pitched. They are heard both on inspiration and expiration and are of long duration.

Rationale 4: Stridor is a type of wheeze. It is high-pitched, inspiratory, and heard best over the neck.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-6

Question 14

Type: MCSA

The nurse is planning to use a respiratory spirometer to measure the amount of air that moves in and out of a patients lungs with each normal breath. How will the nurse document the results of this test?

1. Tidal volume

2. Vital capacity

3. Forced expiratory volume

4. Minute ventilation

Correct Answer: 1

Rationale 1: Tidal volume is the amount of air that moves in and out of the lungs with each normal breath.

Rationale 2: Vital capacity is the maximum amount of air expired after a maximal inspiration.

Rationale 3: Forced expiratory volume testing generally is not conducted as a bedside trending parameter.

Rationale 4: Minute ventilation is the total volume of expired air in 1 minute and is not a direct measurement but a simple calculation.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-7

Question 15

Type: MCSA

A patient is undergoing testing to differentiate her airway disorder as being restrictive or obstructive. The nurse would evaluate a normal result on which test to indicate a restrictive disorder is present?

1. Vital capacity

2. Tidal volume

3. Minute ventilation

4. Forced expiratory volume

Correct Answer: 4

Rationale 1: Vital capacity is the maximum amount of air expired after a maximal inspiration. Vital capacity decreases in the presence of restrictive pulmonary diseases.

Rationale 2: Tidal volume is the amount of air that moves in and out of the lungs with each normal breath. Tidal volume decreases when lung diseases exist. Results do not differentiate between restrictive and obstructive disorders.

Rationale 3: Minute ventilation measures total lung ventilation changes. It may be abnormal in either restrictive or obstructive diseases.

Rationale 4: Forced expiratory volume measures how rapidly a person can forcefully exhale air after a maximal inhalation, measuring volume over time. Patients who have a restrictive airway problem are able to push air forcefully out of their lungs at a normal rate.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-7

Question 16

Type: MCSA

A 40-year-old postoperative patient has a hemoglobin level of 8 g/dL and a SaO2 of 95 percent. Considering all aspects, what conclusion would the nurse make about this patients condition?

1. The patient is stable and at no special risk.

2. Oxygenation is adequate for a postoperative patient.

3. This patient has a potential risk of hypoxia.

4. The patients SaO2 is higher than expected for the patients age.

Correct Answer: 3

Rationale 1: This patients test results do indicate a risk potential.

Rationale 2: It is not possible to accurately assess this patients true oxygenation status from the test results provided.

Rationale 3: The patient has a potential risk for hypoxia because SaO2 is the measure of percentage of oxygen combined with hemoglobin compared to the total amount it could carry. Although the patients SaO2 is within normal range, the hemoglobin is only 8 g/dL, indicating that all 8 grams are adequately being saturated. Should the patients oxygen demand increase, as it frequently will in a postoperative patient, the potential for hypoxia may exist because of the lower hemoglobin and inability to carry more oxygen to meet the demand.

Rationale 4: The SaO2 is within normal limits for the patients age; however, its accuracy is at doubt.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-8

Question 17

Type: MCMA

A nurse is participating on a committee charged with the task of choosing capnography equipment for a new emergency department. The nurse should present which information regarding these choices?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Sidestream analyzers provide direct real-time measurements of ETCO2.

2. Mainstream analyzers require the patient to be intubated.

3. Colorimetric capnography is useful for determining accurate placement of endotracheal tubes.

4. Mainstream analyzers provide continuous ETCO2 measurements.

5. Colorimetric measurement provides a wide range of color results that are compared to a standard chart.

Correct Answer: 2,3,4

Rationale 1: The major disadvantage of sidestream analyzers is that values are indirect estimated measurements.

Rationale 2: A major disadvantage to the mainstream technique is that it requires the patient to be intubated.

Rationale 3: Colorimetric capnography can be used in the ED or in the field to determine accurate placement of endotracheal tubes.

Rationale 4: Mainstream analyzers are placed in-line as part of the airway circuit and continuously measure the ETCO2. The measurement is real-time.

Rationale 5: Colorimetric measurement responds to the patients exhaled CO2 with three color ranges.

Global Rationale: 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10-8

Question 18

Type: MCMA

A patient with severe chronic respiratory illness suddenly develops a high fever. The nurse would plan care for this patient based upon which understanding of the fevers impact on the oxyhemoglobin dissociation curve?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The curve will shift to the right.

2. Additional oxygen will be released to the tissues.

3. Life-threatening tissue hypoxia may occur.

4. The change will be similar to what occurs with alkalosis.

5. Hemoglobin will bind more readily to oxygen.

Correct Answer: 1,2,3

Rationale 1: Increased temperature causes increased oxygen demand which shifts the curve to the right.

Rationale 2: Increasing body temperature increases oxygen demand, so additional oxygen will be released to the tissue to meet this demand.

Rationale 3: Severe and rapid shifts in the curve can result in life-threatening tissue hypoxia.

Rationale 4: Alkalosis causes an opposite response in the oxyhemoglobin dissociation curve and inhibits oxygen release at the tissue level.

Rationale 5: Hemoglobin binds more readily to oxygen in the lungs when the patient is hypothermic.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10-3

Question 19

Type: MCMA

A patients PaO2 is 88 mm Hg while on FiO2 of 0.50. What can the nurse conclude about this patients intrapulmonary shunt?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The shunt is estimated to be 176.

2. The shunt is estimated to be 568.

3. The shunt is below the minimum acceptable level.

4. This data has little use in determining oxygenation status of the patient who is retaining CO2.

5. No determination of intrapulmonary shunt can be made from this data.

Correct Answer: 1,3

Rationale 1: Calculating the P/F ratio is the simplest way to estimate intrapulmonary shunt. In this case the value is 176.

Rationale 2: This is not a valid estimation of intrapulmonary shunt.

Rationale 3: The minimum acceptable level is higher than this estimation of intrapulmonary shunt.

Rationale 4: As long as the PaCO2 is stable this estimation is valid and is applicable to oxygenation status.

Rationale 5: Intrapulmonary shunt can be estimated by comparing this data.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-3

Question 20

Type: MCSA

A nurse who is evaluating a patients arterial blood gases has determined that the patients pH is acidic. What is the next question the nurse would ask in this interpretation?

1. Is the patient symptomatic of an acidic condition?

2. Which individual ABG component matches the pH acidbase state?

3. Is the PaCO2 within normal range?

4. Is HCO3 within normal range?

Correct Answer: 3

Rationale 1: The patients symptoms are not considered at this point in the evaluation.

Rationale 2: The nurse has not yet assessed the components, so this question is premature.

Rationale 3: After determining the pH status, the next step is evaluation of PaCO2.

Rationale 4: The HCO3 is not assessed at this point.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10-5

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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