Chapter 28 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 28

Question 1

Type: MCSA

A patient is ready to begin weaning from mechanical ventilation. The nurse would prepare to assist respiratory therapy with which procedure?

1. Applying a T-tube set

2. Insertion of a short one-way valve

3. Tracheostomy insertion

4. Insertion of a new endotracheal tube

Correct Answer: 1

Rationale 1: The T-piece or T-tube is placed on the patients endotracheal tube and attached to oxygen. The ventilator is removed for short periods and oxygen is delivered using the T-piece. The time the patient is off the ventilator is increased over time.

Rationale 2: One-way valves are used in the treatment of pneumothorax.

Rationale 3: Tracheostomies are performed when patients require long-term mechanical ventilation. They are not performed as part of the weaning process.

Rationale 4: The endotracheal tube is not changed prior to weaning.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 28-6

Question 2

Type: MCMA

The nurse will assess for which complications in the patient who has a nasal endotracheal tube in place?

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

Standard Text: Select all that apply.

1. Tracheoesophageal fistula

2. Wound infection

3. Pressure necrosis of the nares

4. Sinusitis

5. Obstruction of the tube

Correct Answer: 1,3,4,5

Rationale 1: The patient with a nasal endotracheal tube can develop a tracheoesophageal fistula from the pressure exerted against the tissues by the tube.

Rationale 2: There is no incision or wound associated with an endotracheal tube.

Rationale 3: The patient with a nasal endotracheal tube can experience pressure necrosis of the nares from the pressure exerted against the tissues by the tube.

Rationale 4: The patient with a nasal endotracheal tube can experience sinusitis if sinus drainage is blocked.

Rationale 5: The tube can be displaced or obstructed.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-6

Question 3

Type: MCMA

Which instructions should the nurse include when providing discharge teaching to a patient recovering from acute respiratory distress syndrome (ARDS)?

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

Standard Text: Select all that apply.

1. You should avoid smoking and air pollution.

2. Lifestyle modifications to decrease oxygen demands will be necessary.

3. It is important for you to restrict fluid intake to avoid congestive failure.

4. You and your family should get annual influenza immunizations.

5. You must avoid large gatherings of people.

Correct Answer: 1,2,4

Rationale 1: Pollution and smoke can further damage already traumatized lung tissue and therefore should be avoided.

Rationale 2: The patient will need to make lifestyle modifications to conserve energy and oxygen demands because lung tissues are still recovering from the damage of the disease processes. Exertional dyspnea will continue to increase if additional demands are made on the pulmonary and cardiovascular systems, which have been impacted by the damage from ARDS. Role changes, increased rest, and decreased activities are needed.

Rationale 3: Fluid restriction is not indicated in most cases.

Rationale 4: Immunizations (for pneumonia and flu) are encouraged to minimize additional insults to lung tissue, as the lung tissue will require up to 6 months to recover.

Rationale 5: These patients are not necessarily immunocompromised. This advice would be provided on a case-by-case basis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-1

Question 4

Type: MCSA

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

1. pH 7.28; PaO2 80 mmHg; PaCO2 55 mmHg; HCO3 22 mmHg; SaO2 92%

2. pH 7.35; PaO2 58mmHg; PaCO2 36 mmHg; HCO3 25 mmHg; SaO2 85%

3. pH 7.42; PaO2 52mmHg; PaCO2 45 mmHg; HCO3 26 mmHg; SaO2 82%

4. pH 7.44; PaO2 59mmHg; PaCO2 50 mmHg; HCO3 25 mmHg; SaO2 89%

Correct Answer: 1

Rationale 1: The nurse would expect the oversedated, nonresponsive patient to potentially have hypercapnia resulting from residual intraoperative medications and the inability to rid him- or herself of CO2.

Rationale 2: These results would indicate hypoxemic respiratory failure, an unlikely finding in a patient with no prior respiratory history.

Rationale 3: These results would indicate hypoxemic respiratory failure, an unlikely finding in a patient with no prior respiratory history.

Rationale 4: These results would indicate hypoxemic respiratory failure, an unlikely finding in a patient with no prior respiratory history.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-1

Question 5

Type: MCMA

A patient is admitted with pulmonary edema. Which portions of the admission assessment have priority?

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

Standard Text: Select all that apply.

1. Cardiac history

2. Pulmonary history

3. Renal history

4. Family history of genetic illnesses

5. Vaccination status

Correct Answer: 1,2

Rationale 1: Cardiogenic pulmonary edema is one of the two major categories of pulmonary edema. Discovering the etiology will help guide treatment.

Rationale 2: A history of pulmonary disorder may help guide treatment for this event.

Rationale 3: Renal history is important but is not a priority assessment at this time. Renal history will not guide treatment.

Rationale 4: Family history is important but is not a high priority at this time. Family history will not guide treatment.

Rationale 5: Vaccination status is important but is not a priority assessment at this time. Vaccination status will not guide therapy.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-2

Question 6

Type: MCSA

The family of an elderly patient diagnosed with pulmonary edema asks the nurse what the diagnosis means. How should the nurse respond?

1. It is too much fluid in the lungs.

2. It is a narrowing of the coronary vessels that causes the heart to stop working correctly.

3. It is a disorder that rarely affects individuals older than 60.

4. It is caused by working too hard when one is younger.

Correct Answer: 1

Rationale 1: Pulmonary edema is the accumulation of excess fluid in the lungs caused by cardiac and noncardiac factors. Heart failure is often seen in individuals older than 65 and is a common cause of pulmonary edema in elders.

Rationale 2: A narrowing of the coronary vessels, i.e., a potential heart attack, could contribute to heart failure, which could cause pulmonary edema, but there is no evidence in this case that this is the cause.

Rationale 3: Heart failure is often seen in individuals older than 65 and is a common cause of pulmonary edema in elders.

Rationale 4: There is no evidence that pulmonary edema is related to an individuals work history earlier in life.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-2

Question 7

Type: MCSA

A patient diagnosed with sepsis suddenly develops dyspnea, crackles, hypertension, bounding pulses, agitation, and confusion. The nurse suspects that which condition has developed?

1. Noncardiogenic pulmonary edema

2. Right-sided heart failure

3. Left-sided heart failure

4. Constrictive pericarditis

Correct Answer: 1

Rationale 1: The septic patient who suddenly develops these symptoms has probably developed noncardiogenic pulmonary edema. Agitation and confusion are often among the first signs of developing hypoxemia, which would be common to both cardiogenic and noncardiogenic pulmonary edema. Hypertension and bounding pulses are more common with noncardiogenic pulmonary edema.

Rationale 2: Right-sided heart failure is a cardiogenic cause of pulmonary edema, which is not well supported by this assessment.

Rationale 3: Left-sided heart failure is a cardiogenic cause of pulmonary edema, which is not well supported by this assessment.

Rationale 4: Constrictive pericarditis is a cardiogenic cause of pulmonary edema, which is not well supported by this assessment.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-2

Question 8

Type: MCSA

A patient being ventilated mechanically develops respiratory alkalosis. The high-pressure alarm has sounded frequently for this patient. The nurse knows this is a common problem in patients with which ventilator settings?

1. Assist-control mode

2. SIMV mode with the set rate too low

3. Pressure-support mode

4. Pressure-control mode

Correct Answer: 1

Rationale 1: A frequent problem with assist-control mode is patient-ventilator asynchrony and the possibility of respiratory alkalosis.

Rationale 2: If the SIMV rate is too low, the patient may become hypoxic and acidotic. If the rate is set too high, the patient may develop respiratory alkalosis.

Rationale 3: Hypoventilation is a more common problem with pressure-support mode.

Rationale 4: Respiratory acidosis is a more common problem with pressure-control mode.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-5

Question 9

Type: MCSA

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

1. PEEP

2. SIMV mode

3. Assist-control mode

4. Pressure-controlled settings

Correct Answer: 1

Rationale 1: Increasing PEEP levels can cause declining blood pressure.

Rationale 2: SIMV mode is not a common cause of hypotension.

Rationale 3: Assist-control mode is not a common cause of hypotension.

Rationale 4: Changing pressure-controlled settings is not a common cause of hypotension.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-5

Question 10

Type: MCSA

A patient is being mechanically ventilated with SIMV at a rate of 25. The nurse would question this order for which reason?

1. The rate could be too high for this mode.

2. The patient will be more comfortable with a different mode.

3. The patient is not receiving enough sedation.

4. SIMV is always used in combination with PEEP.

Correct Answer: 1

Rationale 1: SIMV is usually set so that the patient can breathe over the set rate to exercise the respiratory muscles. A rate of 25 will not allow this and could also establish auto PEEP.

Rationale 2: The patient will not necessarily be more comfortable with a different mode. SIMV is the most commonly used mode in an ICU setting.

Rationale 3: Too much sedation is contraindicated in SIMV so that the patient will initiate breaths on his or her own.

Rationale 4: PEEP can be used with any of the modes.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-5

Question 11

Type: MCSA

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 which condition develops?

1. Lung sounds greater on one side than the other

2. Lung sounds with crackles

3. Diminished peripheral pulses

4. High-pressure alarm

Correct Answer: 1

Rationale 1: A potential complication from increasing PEEP is a pneumothorax. The nurse needs to be alert to diminishing or absent lung sounds on one side of the chest.

Rationale 2: Crackles relate to increased fluid in the lungs, which would not occur in this instance.

Rationale 3: Diminished peripheral pulses are not related to the use of PEEP.

Rationale 4: A low-pressure alarm would be more likely to sound.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-5

Question 12

Type: MCSA

A patient being mechanically ventilated suddenly develops cardiac arrhythmias from increasingly higher PEEP. The patient most likely has which underlying physiologic issues?

1. Decreased cardiac output and acidosis

2. Increased cardiac output and alkalosis

3. Decreased cardiac output and renal failure

4. Increased cardiac output and electrolyte disturbance

Correct Answer: 1

Rationale 1: Increasingly higher PEEP with decreased cardiac output and acidosis may predispose the patient to cardiac arrhythmias.

Rationale 2: Increased cardiac output is not as likely to result in arrhythmia as another underlying condition.

Rationale 3: Renal failure is not a specific risk factor for the development of arrhythmia in mechanically ventilated patients.

Rationale 4: Increased cardiac output is not as likely to result in arrhythmia as another underlying condition.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-5

Question 13

Type: MCSA

A patient being mechanically ventilated has the following ventilator settings: SIMV 16, PEEP 20 cm of H2O, FiO2 45%, tidal volume .450 liters. What concerns will the nurse have for this patient?

1. Barotrauma

2. Volutrauma

3. Sinusitis

4. Oxygen toxicity

Correct Answer: 1

Rationale 1: This patient will be at risk for barotraumas due to the high PEEP levels.

Rationale 2: The tidal volume is within a standard setting. However, if it were high, it could lead to volutrauma.

Rationale 3: Sinusitis is a potential complication in ventilated patients, but this patient should not have any higher risk for this.

Rationale 4: The FiO2 is set at 45%, which is not high. A FiO2 greater than 50% for an extended period can lead to oxygen toxicity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-5

Question 14

Type: MCMA

A patient requires endotracheal intubation. Which equipment should the nurse prepare?

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

Standard Text: Select all that apply.

1. Flexible stylet

2. Suction catheters

3. Petroleum-based lubricant

4. Sterile gloves

5. Irrigation tipped 5 mL syringe

Correct Answer: 1,2

Rationale 1: The stylet is used to stiffen the tube for insertion.

Rationale 2: The patient may require suctioning. This equipment should be prepared.

Rationale 3: The lubricant should be water-based.

Rationale 4: Nonsterile gloves can be used for intubation.

Rationale 5: Cuff inflation requires a 10 mL syringe. It should have a Luer-Lok tip.

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: 28-6

Question 15

Type: MCSA

The chest X-ray of a patient who was recently intubated shows the endotracheal tube located in the right bronchus. The nurse recognizes that which intervention should be implemented?

1. The tube needs to be withdrawn slightly.

2. The tube needs to be inserted further.

3. The tube is correctly placed.

4. The tube is incorrectly attached to the ventilator.

Correct Answer: 1

Rationale 1: The right bronchus is easy to intubate due to the anatomy of the lung. If the tube is located in the right bronchus, it will need to be withdrawn slightly so that both lungs can be ventilated.

Rationale 2: The tube does not need to be inserted further.

Rationale 3: The tube is not correctly placed.

Rationale 4: This finding does not mean that the tube is incorrectly attached to the ventilator.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-2

Question 16

Type: MCSA

A patient who is intubated is demonstrating rhonchi and has a pulse oximeter reading of 92%, soft abdomen, heart rate 88 bpm, and blood pressure 98/54 mmHg. Which intervention is the nurses first priority?

1. Suction the patient.

2. Contact the physician.

3. Increase the oxygen.

4. Start dopamine.

Correct Answer: 1

Rationale 1: The presence of rhonchi suggests the patient needs to be suctioned.

Rationale 2: The assessment data indicate an issue that can be taken care of by the nurse.

Rationale 3: The assessment data indicate sufficient oxygenation.

Rationale 4: The relative hypotension can be caused by the ventilation; the patient does not require dopamine for blood pressure

support.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-6

Question 17

Type: MCSA

Which physicians order should the nurse question for a patient who is intubated and being mechanically ventilated?

1. Endotracheal suctioning every hour

2. Endotracheal suctioning as needed

3. NPO status

4. Intake and output every 4 hours

Correct Answer: 1

Rationale 1: Suctioning of a patient should always be based on patient need and not routinely ordered.

Rationale 2: PRN suctioning is appropriate for this patient.

Rationale 3: NPO status is appropriate for the ventilated patient.

Rationale 4: Intake and output monitoring is appropriate for this patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-6

Question 18

Type: MCSA

A patient being mechanically ventilated is receiving PEEP of 10 cm of H2O. The nurse ensures that which intervention is performed for this patient?

1. Closed system suctioning

2. Oral care daily

3. Placement of a nasogastric tube

4. Daily measurement of vital signs

Correct Answer: 1

Rationale 1: Closed system suctioning should be performed for patients with high PEEP and to decrease the risk of nosocomial infection.

Rationale 2: Oral care should be more frequent and is appropriate to all patients, especially those who are intubated.

Rationale 3: There is no indication that this patient requires a nasogastric tube.

Rationale 4: With high levels of PEEP, frequent vital signs and assessments are required to detect any potential complications.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-6

Question 19

Type: MCSA

A patient being mechanically ventilated is demonstrating hypoxia, with a pulse oximeter reading of 88%. After ensuring the integrity of the ventilator tubing and assessing the patient, the nurse auscultates adventitious lung sounds. Which action should the nurse take next?

1. Suction the patient.

2. Contact the physician.

3. Turn the patient on the side.

4. Silence the alarm.

Correct Answer: 1

Rationale 1: When the tubing integrity is intact and the pulse oximeter reading falls to 88% with adventitious breath sounds, the patient needs to be suctioned.

Rationale 2: The physician does not need to be contacted unless the nursing actions are unsuccessful at resolving the hypoxia.

Rationale 3: Turning the patient on the side has no purpose.

Rationale 4: Silencing the alarm will not resolve the issue.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-6

Question 20

Type: MCSA

The family of a mechanically ventilated patient receiving a chest tube asks why the tube is necessary. What is the nurses most accurate response?

1. The chest tube helps to decompress the lung and prevents further complications.

2. The chest tube helps the patient breathe more easily when on a ventilator.

3. The chest tube is an elective procedure that many physicians like to perform.

4. The chest tube is required to provide PEEP to the patient.

Correct Answer: 1

Rationale 1: The chest tube is indicated for a pneumothorax that can be spontaneous or brought on by increasingly higher PEEP.

Rationale 2: A chest tube does not directly assist a patient with breathing more easily on a ventilator, but it does allow the lung to expand more fully, which helps with the patients overall oxygenation.

Rationale 3: A chest tube is not an elective procedure.

Rationale 4: PEEP can be provided with or without a chest tube.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-6

Question 21

Type: MCSA

Which patient should the nurse assess first?

1. Patient with a chest tube complaining of difficulty breathing

2. Patient with a tracheostomy who is on oxygen via trach mask

3. Patient preparing for discharge following a lengthy hospital stay for ARDS

4. Patient complaining of incisional pain

Correct Answer: 1

Rationale 1: The nurse should assess this patient because of the many potential complications that will need to be evaluated.

Rationale 2: This patient, who is having no problems, will be the nurses third priority.

Rationale 3: The patient preparing for discharge will need to be assessed but is the lowest priority.

Rationale 4: This patient will need to be assessed for pain medication and is second in priority.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 28-6

Question 22

Type: MCSA

A patient presents with PaO2 of 54 mmHg and an arterial oxygen saturation of 80%. The nurse assesses for which most likely cause of this type of acute respiratory failure?

1. Cervical spinal cord injury

2. Pneumothorax

3. Obesity

4. Oversedation

Correct Answer: 2

Rationale 1: A PaO2 of 54 mmHg and an arterial oxygen saturation of 80% are indicative of hypoxemic respiratory failure. Cervical spine injury results in depressed respiratory center drive, which is a cause of hypoventilation failure.

Rationale 2: A PaO2 of 54 mmHg and an arterial oxygen saturation of 80% are indicative of hypoxemic respiratory failure and can be caused by conditions such as pneumothorax.

Rationale 3: A PaO2 of 54 mmHg and an arterial oxygen saturation of 80% are indicative of hypoxemic respiratory failure and can be caused by conditions that would lower the patients oxygen content. Obesity is a cause of hypercapnia respiratory failure.

Rationale 4: A PaO2 of 54 mmHg and an arterial oxygen saturation of 80% are indicative of hypoxemic respiratory failure and can be caused by conditions that would lower the patients oxygen content. Oversedation is a cause of hypercapnia respiratory failure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 28-1

Question 23

Type: MCSA

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-Barr syndrome. The patients 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?

1. High pH

2. High PaCO2

3. High HCO3

4. Low PaCO2

Correct Answer: 2

Rationale 1: The nurse would anticipate the pH to be low (acidic) because a high level of CO2 will increase the acidity of the blood.

Rationale 2: The nurse would anticipate the patient with progressing Guillain-Barr to have hypoventilation, which results in high PaCO2 levels. The respiratory rate of 8 also would indicate hypoventilation.

Rationale 3: There is no indication that Guillian Barr and hypoventilation would result in metabolic changes causing high HCO3.

Rationale 4: A low PaCO2 results with tachypnea, which this patient does not have.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-1

Question 24

Type: MCSA

A patient was admitted 3 days ago with a myocardial infarction (MI) and has developed pulmonary edema. How would the nurse explain this condition to the patient and family?

1. The pulmonary system has an excessive amount of fluid that has been building over the last several days, and now the heart is no longer able to keep up with the demands.

2. The cardiac muscle has been injured and is not able to efficiently pump the blood through the patients system, resulting in an increased pressure in the pulmonary system.

3. The pulmonary system was injured first due to hypoxia, which caused the heart attack.

4. The cardiac muscle is working too hard to push fluids through the pulmonary system and there is fluid excess as a result.

Correct Answer: 2

Rationale 1: The pulmonary fluid overload is a direct result of the MI, not building up over several days.

Rationale 2: During an MI, the cardiac muscle is injured and is not able to efficiently pump blood through the system. This decrease in pumping action results in an increased pulmonary pressure, which causes fluid to fill the interstitial spaces.

Rationale 3: The pulmonary system did not cause the MI; the MI causes pulmonary edema.

Rationale 4: It is not that the cardiac muscle is working too hard, but that it is not working as well as it used to.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-3

Question 25

Type: MCSA

The nurse is giving a report to the oncoming ICU shift for the most recent admission. The nurse indicates the patient is hypotensive, has an S3 heart sound, has crackles, has pink frothy sputum, and the skin is diaphoretic and cool. The oncoming shift recognizes which differences between cardiogenic pulmonary edema (CPE) and noncardiogenic pulmonary edema (NCPE)?

1. NCPE patients are hypotensive, have an S3 heart sound, and have a cough.

2. CPE patients are hypotensive, have an S3 heart sound, and have dry skin.

3. NCPE patients are hypertensive, have bounding pulses, and have jugular vein distension (JVD).

4. CPE patients are hypotensive, have an S3 heart sound, and are cool and diaphoretic.

Correct Answer: 4

Rationale 1: NCPE patients are more likely to be hypertensive, and S3 heart sounds are not common.

Rationale 2: CPE patients are more likely to be diaphoretic.

Rationale 3: JVD is a much more common finding in CPE.

Rationale 4: This patient has CPE, as evidenced by the symptoms of hypotension, an S3 heart sound, and being cool and diaphoretic. Crackles and pink frothy sputum are found in both CPE and NCPE.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-3

Question 26

Type: MCSA

A student is accompanying the nurse today. A newly admitted ICU patient with a diagnosis of pulmonary edema has an elevated jugular vein distension (JVD) and an S3. Based on these assessment findings, the nurse indicates to the student that this is which type of pulmonary edema?

1. Neurogenic

2. Cardiogenic

3. High altitude

4. Excessive IV fluid administration

Correct Answer: 2

Rationale 1: Cardiogenic pulmonary edema patients have elevated JVD and an S3 extra heart sound. Neurogenic is a type of noncardiogenic pulmonary edema.

Rationale 2: Cardiogenic pulmonary edema patients have elevated JVD and an S3 extra heart sound. Patients with cardiogenic-related pulmonary edema may also have hypotension with tachycardia instead of tachycardia with hypertension found with noncardiogenic causes.

Rationale 3: Cardiogenic pulmonary edema patients have elevated JVD and an S3 extra heart sound. High-altitude is a type of noncardiogenic pulmonary edema.

Rationale 4: Cardiogenic pulmonary edema patients have elevated JVD and an S3 extra heart sound. Excessive IV fluid administration causes noncardiogenic pulmonary edema.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-3

Question 27

Type: MCSA

A patient who was in a motor vehicle accident 1 day ago has been diagnosed with lung contusions. The patient develops increasing respiratory distress. The nurse recognizes that which factor will differentiate a diagnosis of acute lung injury (ALI) from a diagnosis of acute respiratory distress syndrome (ARDS)?

1. ALI patients have fewer injuries than ARDS patients.

2. ARDS patients have a lower respiratory rate than ALI patients.

3. ARDS and ALI differ only in the extent of hypoxemia.

4. ALI patients have more inflammation than ARDS patients.

Correct Answer: 3

Rationale 1: Both disorders develop from injury to the lung. Extent of injury is not the determining factor between the two disorders.

Rationale 2: Respiratory rate is not a determining factor between ALI and ARDS.

Rationale 3: The difference between ALI and ARDS is based on the extent of hypoxemia. ALI is a less severe disease process.

Rationale 4: Extent of inflammation is not a determining factor between ALI and ARDS.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 28-4

Question 28

Type: MCSA

A patient has just been diagnosed with acute respiratory distress syndrome (ARDS). The nurse is aware that both acute lung injury (ALI) and ARDS patients often require which priority intervention?

1. Placement on a mechanical ventilator

2. Preparation of a living will

3. Frequent hydration with ice chips

4. Frequent suctioning to keep the airway clear

Correct Answer: 1

Rationale 1: ALI and ARDS patients usually require mechanical ventilation to support their respiratory status.

Rationale 2: Both ALI and ARDS are serious disorders, but preparation of a living will is not a priority.

Rationale 3: Ice chips may make the patient more comfortable, or the patient may not be able to tolerate them. This is an individual intervention and is not the nurses current priority.

Rationale 4: ALI and ARDs patients may require frequent suctioning, but some do not. This is a patient-specific intervention.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 28-4

Question 29

Type: MCSA

A patient who is septic is restless and agitated. The chest X-ray results indicate bilateral patchy infiltrates. As the patients condition continues to deteriorate, which finding would raise the nurses concern that the patient is developing ARDS?

1. Hypertension

2. Hyperventilation

3. Decreasing HCO3

4. Refractory hypoxemia

Correct Answer: 4

Rationale 1: As the patients condition deteriorates, hypotension develops.

Rationale 2: Hyperventilation is an early sign of ARDS.

Rationale 3: The worsening patient will eventually develop respiratory acidosis. The HCO3 may increase as the body attempts to compensate.

Rationale 4: The hallmark manifestation of ARDS is hypoxemia that is refractory to standard oxygen therapies.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-4

Question 30

Type: MCMA

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

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

Standard Text: Select all that apply.

1. Increased temperature

2. The patient saying, My neck hurts

3. Edema of the upper extremities

4. A hissing sound heard over the trachea on expiration

5. Bubbling secretions at the corner of the patients mouth

Correct Answer: 2,4,5

Rationale 1: An increased temperature could result from pneumonia or other infection but is not directly associated with a cuff leak.

Rationale 2: The patients ability to speak indicates air is leaking around the endotracheal tube.

Rationale 3: Patients on a mechanical ventilator often develop edema of the upper extremities. This finding is not associated with cuff leak.

Rationale 4: Any sound of escaping air heard on expiration could be caused by too low a volume in the ET cuff. This could be related to a cuff leak.

Rationale 5: Bubbling oral secretions may indicate cuff leak.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-6

Question 31

Type: FIB

Arterial blood gases reveal that a patients PaO2 is 84% on room air. The patients FaO2/FiO2 ratio is ______.

Standard Text:

Correct Answer: 400

Rationale : Room air contains 21% oxygen. That number is used as the FiO2 in this equation. 84/0.21 = 400

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 28-1

Question 32

Type: FIB

A patient who has cardiogenic pulmonary edema is receiving intravenous dopamine at a rate of 195 mcg/min. The patient weighs 65 kg. The nurse would increase surveillance for tachycardia and dysrhythmias if the dopamine rate must be increased to a rate greater than ________ mcg/min.

Standard Text:

Correct Answer: 325

Rationale : The risk for tachycardia and dysrhythmia increases if dopamine is infused at a rate greater than 5 mcg/kg/min. 5 mcg/min x 65 kg = 325 mcg/min

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 28-2

Question 33

Type: MCMA

Which interventions should the nurse plan to help reduce a patients risk of developing ventilator-associated pneumonia?

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

Standard Text: Select all that apply.

1. Brush the patients teeth every 4 hours.

2. Regularly drain any accumulated water from ventilator tubing.

3. Place a nasogastric tube to keep the stomach decompressed.

4. Keep the head of the bed at 30 to 45 degrees.

5. Wash the hands before and after patient contact.

Correct Answer: 2,4,5

Rationale 1: Tooth brushing should occur twice a day.

Rationale 2: Water condenses in ventilator tubing and can be a reservoir for pathogens. The water should be removed regularly.

Rationale 3: Gastric tubes should not be placed nasally.

Rationale 4: Elevation of the head of the bed helps to reduce aspiration.

Rationale 5: Standard precautions, including hand washing, are effective in reducing infections, including ventilator-associated pneumonia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 28-6

Question 34

Type: MCMA

A patient who is being mechanically ventilated also has a pleural chest tube. The nurse becomes concerned that the chest tube is not functioning correctly. Which actions should the nurse take?

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

Standard Text: Select all that apply.

1. Look for tidaling in the tube.

2. Look for tidaling in the diagnostic fluid chamber.

3. Clamp the chest tube and monitor patient response.

4. Disconnect the suction source.

5. Increase the suction

Correct Answer: 1,2

Rationale 1: If fluid is present in the tubing, tidaling should occur as pressure within the thoracic cavity changes.

Rationale 2: Many chest tube drainage units have a diagnostic fluid chamber. Tidaling should occur in this chamber.

Rationale 3: The chest tube should not be clamped for any reason unless it is being removed.

Rationale 4: Disconnecting the suction source will not help assess if the chest tube is functioning correctly.

Rationale 5: Increasing the suction is not indicated and may damage lung tissue.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 28-6

Question 35

Type: MCMA

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?

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

Standard Text: Select all that apply.

1. The patients hemoglobin is over 8 mg/dL.

2. Sepsis has improved.

3. The patient is hemodynamically stable on a moderate dose of vasopressor.

4. The patient is able to initiate inspiratory effort.

5. The patient is quiet and sleeps most of the time.

Correct Answer: 1,2,4

Rationale 1: The patient must have sufficient oxygen-carrying capacity for weaning to be successful.

Rationale 2: It is important to determine that the underlying cause of the respiratory failure has improved.

Rationale 3: The patient should require no vasopressor, or only a low dose, to be hemodynamically stable.

Rationale 4: The patient must be able to breathe independently when weaned from the mechanical ventilator.

Rationale 5: The patient should be awake and able to participate in the weaning process.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 28-6

 

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