Chapter 3 My Nursing Test Banks

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e
Chapter 3

Question 1

Type: MCSA

A patient is diagnosed with type I hypoxemic failure. The nurse realizes that this type of respiratory failure is linked to:

1. Muscular failure to move the air into and out of the lungs

2. Failure of the neurological system to stimulate respirations

3. Skeletal alterations of the thoracic region that limit air movement

4. Breakdown of oxygen transport from the alveolus to arterial flow

Correct Answer: 4

Rationale 1: Muscular failure to move the air into and out of the lungs is not linked to type I hypoxemic failure.

Rationale 2: Failure of the neurological system to stimulate respirations is not linked to type I hypoxemic failure.

Rationale 3: Skeletal alterations of the thoracic region that limit air movement is not linked to type I hypoxemic failure.

Rationale 4: Type I hypoxemic failure is linked to a breakdown of oxygen transport from the alveolus to arterial flow.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3-1: Discuss the pathophysiology of ALI/ARDS.

Question 2

Type: MCSA

The nurse is reviewing the health history of a patient diagnosed with an acute lung injury for a cause of the disease process. Which statement correctly identifies the cause for this type of lung injury?

1. Acute lung injury can be caused indirectly from sepsis, systemic inflammatory response syndrome, or pancreatitis.

2. Acute lung injury is a single organ dysfunction syndrome that has a chronic onset.

3. Acute lung injury is caused by few infiltrates on chest radiography.

4. Acute lung injury is caused by right ventricular failure.

Correct Answer: 1

Rationale 1: This statement reflects indirect causes of acute lung injury.

Rationale 2: This statement does not correctly identify the cause of acute lung injury.

Rationale 3: This statement does not correctly identify the cause of acute lung injury.

Rationale 4: This statement does not correctly identify the cause of acute lung injury.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-1: Discuss the pathophysiology of ALI/ARDS.

Question 3

Type: MCSA

In caring for a brain-injured patient with damage to the cortex, which changes in respiratory and ventilatory efforts would the nurse expect to observe?

1. Increased rate of breathing per minute

2. Increased respiratory effort by the use of chest and diaphragm muscles

3. Decreased voluntary initiation of ventilatory effort

4. Decrease in CO2 in blood analysis

Correct Answer: 3

Rationale 1: This would not occur because of damage to the cerebral cortex.

Rationale 2: This would not occur because of damage to the cerebral cortex.

Rationale 3: The cerebral cortex regulates voluntary ventilatory effort. In the patient with injury to the cortex, voluntary initiation of respirations will decrease.

Rationale 4: This would not occur because of damage to the cerebral cortex.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-1: Discuss the pathophysiology of ALI/ARDS.

Question 4

Type: MCSA

Which arterial blood gas results would indicate the development of acute lung injury?

1. pH 7.4, PaCO2 40 mm Hg, PaO2 96, HCO3 24 mEq, SaO2 94%

2. pH 7.31, PaCO2 50 mm Hg, PaO2 70 mm Hg, HCO3 20 mEq, SaO2 90%

3. ph 7.49, PaCO2 32 mm Hg, PaO2 75 mm Hg, HCO3 22 mEq, SaO2 90%

4. pH 7.29, PCO2 28 mm Hg, PaO2 97 mm Hg, HCO3, 16 mEq, SaO2 94%

Correct Answer: 3

Rationale 1: This would be considered a normal blood gas.

Rationale 2: This would be seen in the proliferative phase of acute lung injury.

Rationale 3: This blood gas would be seen in the patient who has tachypnea and has respiratory alkalosis with hypoxemia.

Rationale 4: This blood gas would not occur in early acute lung injury.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-1: Discuss the pathophysiology of ALI/ARDS.

Question 5

Type: MCMA

When assessing a patient with type I hypoxemic failure, the nurse would evaluate for which contributing health problem?

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

Standard Text: Select all that apply.

1. Acute respiratory distress syndrome

2. Asthma

3. Cardiogenic pulmonary edema

4. Pneumonia

5. Narcotic overdose

Correct Answer: 1,3,4

Rationale 1: This health problem contributes to the development of type I hypoxemic failure.

Rationale 2: Asthma does not contribute to the development of type I hypoxemic failure.

Rationale 3: This health problem contributes to the development of type I hypoxemic failure.

Rationale 4: This health problem contributes to the development of type I hypoxemic failure.

Rationale 5: This health problem does not contribute to the development of type I hypoxemic failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-1: Discuss the pathophysiology of ALI/ARDS.

Question 6

Type: MCMA

The nurse is concerned that which patients are at risk for developing type II hypoxemic hypercapneic failure?

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

Standard Text: Select all that apply.

1. A 5-year-old male with a 5-year history of muscular dystrophy

2. A 34-year-old female patient who is 3 days post-op open cholecystectomy

3. A 24-year-old male newly admitted with possible Guillain-Barr syndrome

4. A 72-year-old female with kyphosis

5. An 85-year-old patient admitted with aspiration pneumonia

Correct Answer: 1,3,4

Rationale 1: This is an example of type II hypoxemic hypercapneic failure because this condition interferes with the musculoskeletal or anatomical lung function.

Rationale 2: The post-op patient can develop atelectasis if respiratory hygiene is not done. Atelectasis is a transportation issue that diminishes the oxygen transportation by fluid accumulation and is not a type II hypoxemic hypercapneic failure.

Rationale 3: This is an example of type II hypoxemic hypercapneic failure because this condition interferes with the musculoskeletal or anatomical lung function.

Rationale 4: This is an example of type II hypoxemic hypercapneic failure because this condition interferes with the musculoskeletal or anatomical lung function.

Rationale 5: Aspiration pneumonia is not an example of type II hypoxemic hypercapneic failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-1: Discuss the pathophysiology of ALI/ARDS.

Question 7

Type: MCSA

What will the nurse assess in a patient experiencing the fibrotic phase of acute lung injury?

1. Pulmonary occlusive pressures are less than 18 mm Hg.

2. Bilateral fluid can be seen on radiographic exams.

3. Severe bleeding is noted from all body orifices.

4. Fever and leukocytosis are present.

Correct Answer: 4

Rationale 1: This is not an assessment finding in the fibrotic phase of acute lung injury.

Rationale 2: This is not an assessment finding in the fibrotic phase of acute lung injury.

Rationale 3: This is not an assessment finding in the fibrotic phase of acute lung injury.

Rationale 4: During the fibrotic phase (the final phase) there is altered healing that results from the development of fibrotic tissue in the alveolar capillary membrane. This disfigurement contributes to the decrease in lung compliance and worsening pulmonary hypertension; leukocytosis, continuing infiltrates, and fever occur.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-2: Identify the clinical signs and symptoms of ALI/ARDS.

Question 8

Type: MCSA

What will the nurse expect to assess in a patient with respiratory failure and hypoxemia?

1. Exertional dyspnea, circumoral cyanosis, distal cyanosis

2. Subcutaneous emphysema, absent breath sounds, sharp chest pain

3. Agitation, disorientation, lethargy, chest pain

4. Rales, distended neck veins, orthostatic hypotension

Correct Answer: 3

Rationale 1: This would not be assessed in a patient with respiratory failure and hypoxemia.

Rationale 2: These are not symptoms of respiratory failure and hypoxemia.

Rationale 3: Due to the hypoxia, the brain receives diminished oxygen and personality, perception, and the levels of consciousness are altered. Decreased respiratory reserves lead to hypoxia of the heart, which also requires higher percentages of oxygen to function. The anginal pain is a result of cardiac hypoxia.

Rationale 4: These are not symptoms of respiratory failure and hypoxemia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-2: Identify the clinical signs and symptoms of ALI/ARDS.

Question 9

Type: MCSA

Which patient would the nurse identify as benefiting from the use of noninvasive ventilation (NIV)?

1. A 55-year-old female with an acute exacerbation of asthma

2. A 57-year-old male with a history of sleep apnea

3. A 48-year-old female with an acute myocardial infarction

4. A 72-year-old male with sepsis

Correct Answer: 2

Rationale 1: Noninvasive ventilation is not used for an acute exacerbation of asthma.

Rationale 2: A patient with sleep apnea would benefit from the use of noninvasive ventilation.

Rationale 3: Noninvasive ventilation is not indicated in the treatment of acute myocardial infarction.

Rationale 4: Noninvasive ventilation is not indicated in the treatment of sepsis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-3: Describe indications and contraindications for noninvasive ventilation.

Question 10

Type: MCMA

When planning care for a patient who is mechanically ventilated, the nurse will include interventions to address which potential complications?

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

Standard Text: Select all that apply.

1. Cardiovascular compromise

2. Community acquired pneumonia (CAP)

3. Barotrauma

4. Volutrauma

5. Anxiety from lack of synchrony with the ventilator

Correct Answer: 1,3,4,5

Rationale 1: The patient who is mechanically ventilated is at risk for cardiovascular compromise.

Rationale 2: The patient who is mechanically ventilated is not at risk for this type of pneumonia.

Rationale 3: The patient who is mechanically ventilated is at risk for barotrauma.

Rationale 4: The patient who is mechanically ventilated is at risk for volutrauma.

Rationale 5: The patient who is mechanically ventilated is at risk for anxiety from lack of synchrony with the ventilator.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3-3: Describe indications and contraindications for noninvasive ventilation.

Question 11

Type: MCSA

The nurse instructs a patient on the advantages of noninvasive mechanical ventilation (NIV). Which patient statement reflects a need for additional teaching?

1. I will not have to have a tube down my throat for it to work.

2. I will probably recover faster, so I can get out of the hospital faster.

3. I am more likely to have fewer complications such as pneumonia.

4. Noninvasive ventilation is not uncomfortable and I wont have to be admitted to ICU to use it.

Correct Answer: 4

Rationale 1: This statement does not reflect the need for additional teaching.

Rationale 2: This statement does not reflect the need for additional teaching.

Rationale 3: This statement does not reflect the need for additional teaching.

Rationale 4: Although the technique is not invasive, it still can be uncomfortable. In addition, admission to the ICU may be necessary for close and intensive respiratory management. This statement reflects the need for additional teaching.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3-3: Describe indications and contraindications for noninvasive ventilation.

Question 12

Type: MCSA

The nurse is suctioning an intubated, mechanically ventilated patient. Complications that should be observed for include:

1. Dysrhythmias

2. Hyperthermia

3. Hematuria

4. Decreased urinary output

Correct Answer: 1

Rationale 1: Dysrhythmias can occur as a side effect of suctioning due to hypoxia.

Rationale 2: Hyperthermia is not a side effect of suctioning.

Rationale 3: Hematuria is not a side effect of suctioning.

Rationale 4: Decreased urinary output is not a consequence of suctioning.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3-4: Differentiate settings for mechanical ventilation, explaining indications or guidelines pertinent to each setting.

Question 13

Type: MCSA

The nurse is explaining the purpose of a tracheostomy tube for mechanical ventilation. Which patient statement indicated the need for additional teaching? The tracheostomy tube is:

1. Used for long-term management, usually more than 2 or 3 weeks.

2. Helpful in allowing the respiratory muscles to be strengthened by increasing resistance to airflow.

3. Easier to use when there are increased secretions that need to be removed by suctioning.

4. Generally a method that allows oral nutrition to be resumed.

Correct Answer: 2

Rationale 1: This statement would not indicate the need for additional teaching.

Rationale 2: The tracheostomy reduces dead space, allowing the flow of air more easily into the airways so there is a decreased resistance to airflow. This statement indicates that additional teaching is needed.

Rationale 3: This statement would not indicate the need for additional teaching.

Rationale 4: This statement would not indicate the need for additional teaching.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3-4: Differentiate settings for mechanical ventilation, explaining indications or guidelines pertinent to each setting.

Question 14

Type: MCSA

Which setting on a ventilator would require a nursing intervention to improve the outcome for a 60 kg patient with acute lung injury (ALI)?

1. FiO2 = 0.30 or 30%

2. Tidal volume (VT) = 900 mL

3. Respiratory rate = 15 per minute, when the CO2 levels are elevated

4. Inspiratory: Expiratory ratio (I:E) = 1:2

Correct Answer: 2

Rationale 1: The patient with ALI needs supplemental oxygen to help maintain PaO2.

Rationale 2: VT is the volume of gas delivered in one ventilatory cycle. VT is normally 7 mL/kg of body weight or around 500 mL. In mechanical ventilation, the volume is kept at 58 mL/kg in order to prevent trauma to lung tissues. In ALI, lower volumes are preferred. The nurse would need to discuss reducing the tidal volume with members of the multidisciplinary team.

Rationale 3: No action is needed by the nurse. The rate is increased to allow the blow off of CO2; therefore, a rate 15 per minute is adequate for the patient with ALI.

Rationale 4: It would not benefit the patient to alter the I:E ration while the tidal volume for this patient is excessive.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-4: Differentiate settings for mechanical ventilation, explaining indications or guidelines pertinent to each setting.

Question 15

Type: MCSA

Which statement made by a new graduate nurse about invasive mechanical ventilation techniques is incorrect and requires additional teaching?

1. Assist control mode refers to the patient receiving a set total lung capacity (TLC) but the rate can be modified by the patients own rate of breathing.

2. Total control mode controls both the rate and volume that are preset and delivered without the machine responding to any of the patients own breaths.

3. Synchronized intermittent mandatory ventilation (SIMV) refers to the patient setting an independent rate but limited tidal volume based on the patients own strength. A minimum rate is also used as a backup to prevent hypoventilation.

4. Continuous positive airway pressure will increase the residual capacity and keep the alveoli open. Rate and volume are controlled by the patient. This is one step in the weaning process.

Correct Answer: 1

Rationale 1: It is the tidal volume that is set, not the total lung capacity. In addition, all ventilations, whether machine generated or spontaneous by the patient, will have the same tidal volume.

Rationale 2: This is a correct statement and does not require additional teaching.

Rationale 3: This is a correct statement and does not require additional teaching.

Rationale 4: This is a correct statement and does not require additional teaching.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3-4: Differentiate settings for mechanical ventilation, explaining indications or guidelines pertinent to each setting.

Question 16

Type: MCSA

A patient with ARDS is on a mechanical ventilator and is becoming increasingly restless with a heart rate of 128. The SaO2 is 88% and the ventilator settings are FiO2 50%; PEEP 8 cm; AC 10 with a total respiratory rate of 30; and a tidal volume of 700 mL. There are coarse rhonchi audible in all lung fields. The appropriate nursing action would be to:

1. Hyperoxygenate with 100% oxygen and suction the patient.

2. Administer the ordered neuromuscular blockade medications.

3. Increase the FiO2 to 60% and tidal volume to 750 mL for 2 minutes.

4. Increase the PEEP to 10 cm and sedate the patient.

Correct Answer: 1

Rationale 1: The patient needs to be suctioned as evidenced by the symptoms of hypoxialow SaO2 and tachycardia. The presence of rhonchi is most likely obstructing the airway.

Rationale 2: Paralyzing the patient is not appropriate because there are indications suctioning needs to be done. Paralyzing agents are used for ventilator synchrony.

Rationale 3: Changing ventilator settings are not indicated at this time.

Rationale 4: Sedation or changing the PEEP is not appropriate.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-4: Differentiate settings for mechanical ventilation, explaining indications or guidelines pertinent to each setting.

Question 17

Type: MCSA

The nurse receives the following ABG result.
pH = 7.00

PaCO2 = 50 mm Hg

PaO2 = 89 mm Hg

SaO2 = 90%

Based on the results, what would the nurse expect to do first?

1. Check the last dose of CNS depressant drug.

2. Assess lung sounds and vital signs.

3. Review the history for asthma or emphysema.

4. Apply oxygen per nasal cannula at 2 L/min.

Correct Answer: 2

Rationale 1: This can be done after the patient assessment is done.

Rationale 2: Assess lung sounds and vital signs because patient assessment is always performed first before actions are implemented. Both the pH and PaCO2 reflect respiratory acidosis caused by decreased respiratory effectiveness. Changes in breath sounds and vital signs can identify respiratory acidosis.

Rationale 3: This can be done some other time.

Rationale 4: Further assessment is needed before this is implemented.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-6: Prioritize nursing care for patients with ALI/ARDS.

Question 18

Type: MCMA

Which assessment findings would indicate to the nurse that a patient was experiencing respiratory distress?

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

Standard Text: Select all that apply.

1. Tachycardia

2. Use of abdominal muscles

3. Intercostal muscle retractions

4. Bradypnea

5. Jugular vein distention

Correct Answer: 1,2,3

Rationale 1: This symptom would be present in a patient in respiratory distress.

Rationale 2: This symptom would be present in a patient in respiratory distress.

Rationale 3: This symptom would be present in a patient in respiratory distress.

Rationale 4: The patient in respiratory distress would have rapid respirations.

Rationale 5: Jugular vein distention is not a symptom of respiratory distress.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-6: Prioritize nursing care for patients with ALI/ARDS.

Question 19

Type: MCSA

Arterial blood gas (ABG) results of an intubated, mechanically ventilated patient are: pH 7.33; PaO2 50; PaCO 49; Bicarbonate 27.The nurse would anticipate the priority action would be to:

1. Increase respiratory rate and FiO2.

2. Increase IV fluids.

3. Add positive end expiratory pressure.

4. Decrease the respiratory rate and FiO2.

Correct Answer: 1

Rationale 1: This patient is in respiratory acidosis due to inadequate ventilation. The correct action would be to increase rate and FiO2.

Rationale 2: Administering IV fluids would not be appropriate because this would interfere with oxygenation.

Rationale 3: Positive end expiratory pressure is usually prescribed during the weaning process. This patient is not being weaned from the ventilator.

Rationale 4: This would not improve the patients ABG or respiratory status.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-4: Differentiate settings for mechanical ventilation, explaining indications or guidelines pertinent to each setting.

Question 20

Type: MCSA

Which nursing action would best optimize overall oxygenation and ventilation in the patient with acute respiratory distress syndrome (ARDS)?

1. Provide adequate rest and recovery time between procedures.

2. Hyperventilate the patient before and after suctioning.

3. Administer sedation frequently.

4. Suction the patient as needed.

Correct Answer: 1

Rationale 1: This allows the oxygen supply and demand to stay balanced. Too much activity can lower supply too quickly and result in hypoxemia. Spacing out nursing activities and care are less stressful to the patient and decreases oxygen consumption.

Rationale 2: This procedure does lower O2 supply and increases O2 demand.

Rationale 3: Sedation will allow the patient to rest but does not directly balance oxygen supply and demand.

Rationale 4: This activity actually decreases supply and increases demand.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-6: Prioritize nursing care for patients with ALI/ARDS.

Question 21

Type: MCSA

A patient with ARDS has PEEP added to the mechanical ventilation therapy. Which assessment finding indicates that the use of PEEP has been effective?

1. PCO2 of 52 mm Hg

2. A PO2 of 92 mm Hg

3. A respiratory rate of 33

4. A urine output of 50 cc/hr

Correct Answer: 2

Rationale 1: The effectiveness of PEEP is not directly measured by pCO2 levels.

Rationale 2: PEEP causes the alveoli to remain open at the end of expiration, providing better oxygenation. Therefore, the PaO2 will be increased to normal level.

Rationale 3: PEEP does not affect respiratory rate. Tachypnea indicates that the patient is hypoxic.

Rationale 4: PEEP causes intrathoracic pressure, which decreases perfusion to the kidneys and would decrease urine output.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3-6: Prioritize nursing care for patients with ALI/ARDS.

Question 22

Type: MCMA

Which assessment findings indicate a patient is ready to be weaned off mechanical ventilation?

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

Standard Text: Select all that apply.

1. Unstable hemodynamics

2. Rapid shallow breathing index of 40

3. A spontaneous tidal volume of 600 cc

4. An SaO2 of 95%

5. A respiratory rate of 18 on CPAP

Correct Answer: 3,4,5

Rationale 1: The patient must be hemodynamically stable before being weaned from mechanical ventilation.

Rationale 2: A rapid shallow breathing index of less than 105 indicates a readiness to wean from mechanical ventilation.

Rationale 3: A tidal volume of greater than 5 mL/kg indicates a readiness to wean from mechanical ventilation.

Rationale 4: An oxygen saturation of greater than 90% indicates a readiness to wean from mechanical ventilation.

Rationale 5: A respiratory rate of less than 35 indicates a readiness to wean from mechanical ventilation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-5: Compare and contrast common practices of weaning patients from mechanical ventilation.

Question 23

Type: MCSA

During multidisciplinary rounds, a discussion is held regarding the use of medications in acute respiratory distress syndrome (ARDS). Which statement is most accurate based upon published research findings?

1. Corticosteroids are used for their anti-inflammatory property to manage the cytokine-mediated inflammatory response in ARDS.

2. Exogenous surfactant therapy is more beneficial to adult patients with ARDS than when it is given to neonates.

3. Cytokine inhibitors were shown to decrease mortality rates.

4. Inhaled nitrous oxide promotes blood flow to ventilated areas of the lungs.

Correct Answer: 4

Rationale 1: The use of corticosteroids is controversial with conflicting studies on its effectiveness in improving outcomes.

Rationale 2: Surfactant therapy has proven very helpful in neonates but not in adults with ARDS.

Rationale 3: Cytokine inhibitor study was stopped after 28 days when designated outcomes were not met and an increased mortality was noted.

Rationale 4: Inhaled nitrous oxide improves oxygenation by promoting blood flow to well ventilated areas of the lung, but has not been proven to improve outcomes at this time. It is proposed as a rescue therapy for refractory cases of ARDS.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3-6: Prioritize nursing care for patients with ALI/ARDS.

Question 24

Type: MCMA

What assessment findings indicate that a patient is in the fibroproliferative phase of acute respiratory distress syndrome?

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

Standard Text: Select all that apply.

1. Crackles on auscultation

2. Agitation

3. Peripheral edema

4. Fever

5. Increased heart rate and drop in blood pressure

Correct Answer: 1,2,3

Rationale 1: This is an assessment finding consistent with the fibroproliferative phase of acute respiratory distress syndrome.

Rationale 2: This is an assessment finding consistent with the fibroproliferative phase of acute respiratory distress syndrome.

Rationale 3: Peripheral edema is an assessment finding consistent with right-sided heart failure which is an assessment finding of the fibroproliferative phase of acute respiratory distress syndrome.

Rationale 4: This is an assessment finding that is not consistent with the fibroproliferative phase of acute respiratory distress syndrome.

Rationale 5: This is an assessment finding that is not consistent with the fibroproliferative phase of acute respiratory distress syndrome.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-2: Identify the clinical signs and symptoms of ALI/ARDS.

Question 25

Type: MCMA

A patient in the recovery phase of acute respiratory distress syndrome continues to experience difficulty with breathing. The nurse explains to a colleague that this phase is characterized by:

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

Standard Text: Select all that apply.

1. Development of fibrotic tissue in the alveolar capillary membrane resulting in alveolar disfigurement

2. Decreased lung compliance

3. Worsening pulmonary hypertension

4. Increased dead space ventilation

5. Formation of hyaline membranes

Correct Answer: 1,2,3,4

Rationale 1: This is a pathophysiological change that occurs in the recovery phase of acute respiratory distress syndrome.

Rationale 2: This is a pathophysiological change that occurs in the recovery phase of acute respiratory distress syndrome.

Rationale 3: This is a pathophysiological change that occurs in the recovery phase of acute respiratory distress syndrome.

Rationale 4: This is a pathophysiological change that occurs in the recovery phase of acute respiratory distress syndrome.

Rationale 5: This is not a pathophysiological change that occurs in the recovery phase of acute respiratory distress syndrome.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-1: Discuss the pathophysiology of ALI/ARDS.

Question 26

Type: MCMA

What is particularly important for the nurse to assess in a patient who is beginning noninvasive ventilatory support?

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

Standard Text: Select all that apply.

1. Patient orientation and level of alertness

2. Respiratory pattern, depth

3. Status of skin of the nose

4. Bowel sounds and presence of insufflation

5. Peripheral pulses

Correct Answer: 1,2,3,4

Rationale 1: The nurse needs to ensure that the patient remains alert enough to manage the airway and remove the mask if emesis occurs.

Rationale 2: It is important for the nurse to monitor respiratory pattern, depth, and effort.

Rationale 3: Pressure ulcers on the bridge of the nose are common and care should be taken to assess the skin.

Rationale 4: Forcing air into the oropharynx makes gastric insufflation a potential complication of noninvasive ventilation. The nurse needs to monitor the patient for gastric distention.

Rationale 5: The nurse does not need to assess peripheral pulses because the patient is on noninvasive ventilation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3-3: Describe indications and contraindications for noninvasive ventilation.

Question 27

Type: MCMA

The high-pressure alarm on a patients mechanical ventilator is alarming. What 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. Assess if the patient needs to be suctioned.

2. Assess if the patient is biting the tube.

3. Assess if the patient has rolled onto the tube.

4. Assess for a mucous plug.

5. Assess for respiration synchrony with the ventilator.

Correct Answer: 1,2,3,4

Rationale 1: High-pressure alarms should signal the nurse to check the patient to determine if suctioning is needed.

Rationale 2: High-pressure alarms should signal the nurse to check if the patient is biting the endotracheal tube.

Rationale 3: High-pressure alarms should signal the nurse to check if the patient has rolled onto the endotracheal tube.

Rationale 4: High-pressure alarms should signal the nurse to assess if the patient is experiencing a mucous plug.

Rationale 5: A high-pressure alarm does not indicate asynchronous respirations.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-4: Differentiate settings for mechanical ventilation, explaining indications or guidelines pertinent to each setting.

Question 28

Type: MCMA

A patient being mechanically ventilated is being considered for weaning. What interventions will the nurse take at this time?

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

Standard Text: Select all that apply.

1. Prepare the patient to be placed on CPAP for 2 hours.

2. Prepare the patient to be placed on a T-piece for 2 hours.

3. Measure rapid shallow breathing index after 2 hours on a T-piece.

4. Lower the ventilator settings.

5. Set the ventilator to synchronized intermittent mandatory ventilation.

Correct Answer: 1,2,3

Rationale 1: If the patient is suitable for weaning, he or she may be placed on CPAP at 5 cm H2O at 5 cm H2O for 2 hours.

Rationale 2: If the patient is suitable for weaning, he or she may be placed on a T-piece for 2 hours.

Rationale 3: After using a T-piece for 2 hours, the patients rapid shallow breathing index should be assessed to determine if the patient can be extubated.

Rationale 4: This is a traditional approach to weaning and is not often utilized today.

Rationale 5: Recently synchronized intermittent mandatory ventilation is being used less as a step in weaning.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-5: Compare and contrast common practices of weaning patients from mechanical ventilation.

Question 29

Type: MCMA

The nurse is caring for a patient with acute respiratory distress syndrome who is being mechanically ventilated. What actions will the nurse take to prevent ventilator induced injury?

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

Standard Text: Select all that apply.

1. Keep the tidal volume between 4 and 8 mL/kg.

2. Keep the plateau pressure 30 cm H2O.

3. Keep FiO2 60%.

4. Assess arterial blood gas values for a PaCO2 to be between 60100.

5. Set PEEP at 515 cm H2O.

Correct Answer: 1,2,4

Rationale 1: This ventilator setting will prevent ventilator induced injury.

Rationale 2: This ventilator setting will prevent ventilator induced injury.

Rationale 3: This ventilator setting will reduce the risk of oxygen toxicity.

Rationale 4: Permissive hypercapnea prevents ventilator induced injury.

Rationale 5: This ventilator setting will recruit alveoli and improve oxygenation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-6: Prioritize nursing care for patients with ALI/ARDS.

Question 30

Type: MCMA

The nurse recognizes that utilizing the prone position to enhance oxygenation in a patient with acute respiratory distress syndrome is contraindicated when the patient has:

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

Standard Text: Select all that apply.

1. A spinal injury

2. Increased intracranial pressure

3. A heart rate of 120 beats per minute with a blood pressure of 80/48 mm Hg

4. Abdominal compartment syndrome

5. Begun weaning off of mechanical ventilation

Correct Answer: 1,2,3,4

Rationale 1: Contraindications for the prone position include spinal injuries.

Rationale 2: The prone position is contraindicated in a patient with increased intracranial pressure.

Rationale 3: The prone position is contraindicated in patients who are hemodynamically unstable.

Rationale 4: The prone position is contraindicated in patients with abdominal compartment syndrome.

Rationale 5: Weaning from mechanical ventilation is not a contraindication for using the prone position.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3-6: Prioritize nursing care for patients with ALI/ARDS.

Question 31

Type: MCMA

A patient with acute lung injury is being started on enteral nutrition. Which interventions will the nurse provide to ensure nutritional support for this patient?

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

Standard Text: Select all that apply.

1. Withhold the use of the nasogastric tube until radiographic placement is confirmed.

2. Monitor for diarrhea.

3. Assess for gastric residual.

4. Keep the head of the bed elevated to at least 30 degrees.

5. Ensure the tube feeding continues uninterrupted.

Correct Answer: 1,2,3,4

Rationale 1: Radiography is the gold standard to confirm placement of a nasogastric tube.

Rationale 2: Monitoring for diarrhea is assessing the patient for tolerance of the tube feeding.

Rationale 3: Assess for gastric residual is done when monitoring the patient for tolerance of the tube feeding.

Rationale 4: Keeping the head of the bed elevated to at least 30 degrees reduces the risk of aspiration of tube feeding contents.

Rationale 5: The tube feeding should be discontinued when suctioning, turning, and during extubation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3-6: Prioritize nursing care for patients with ALI/ARDS.

Perrin, Understanding the Essentials of Critical Care Nursing, 2/e Test Bank

Copyright 2012 by Pearson Education, Inc.

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