Chapter 6 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 6

Question 1

Type: MCSA

A patient in the emergency department (ED) becomes suddenly unresponsive. CPR is initiated. Arterial blood gas results reveal pH 7.225, PaCO2 55, HCO3 15, PaO2 45, SaO2 76 percent. The nurse would prepare for which priority intervention?

1. Call for a rapid response team.

2. Auscultate the patients lungs.

3. Place the patient on a 50 percent humidified mask.

4. Administer endotracheal intubation.

Correct Answer: 4

Rationale 1: This situation is not uncommon in the ED and personnel should be prepared to intervene without the support of a rapid response team.

Rationale 2: Auscultation of the lungs is not the priority.

Rationale 3: A humidified mask will not be effective for the patient who is not ventilating well.

Rationale 4: The patient is unresponsive. Based on the blood gas results, it is obvious that the patient is suffering from acute ventilatory failure and is in urgent need of intubation and mechanical ventilation.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6-1

Question 2

Type: MCMA

An adult patient has suffered a respiratory arrest and requires endotracheal intubation. The nurse should obtain which equipment for this procedure?

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

Standard Text: Select all that apply.

1. Topical anesthetic

2. Magill forceps

3. Cuffless endotracheal tube

4. Oxygen cannula

5. Water-soluble lubricant

Correct Answer: 1,2,5

Rationale 1: A topical anesthetic may be administered to decrease gagging.

Rationale 2: Magill forceps may be used to help guide the tube through the larynx.

Rationale 3: Since this patient is an adult a soft-cuffed ET tube will be used.

Rationale 4: Although an oxygen source would be appropriate for providing manual bagging of the patient, a nasal cannula is useless for this patient.

Rationale 5: Water-soluble lubricant can be used to help advance the endotracheal tube.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6-2

Question 3

Type: MCSA

A patient aspirated while eating and suffered a respiratory arrest. A code blue was called, the obstruction was removed, but the patient required endotracheal intubation. Postintubation the nurse hears breath sounds bilaterally, but the carbon dioxide monitor indicates a higher than expected level. Which patient history could account for this discrepancy?

1. The patients original admittance diagnosis was dehydration.

2. The patients wife reports, We were talking and laughing when he choked.

3. The patient has history of calcium deficiency requiring dietary supplementation.

4. The patients wife says, He had some heartburn earlier, so the nurse had given him a lemon-lime soda to drink with his supper.

Correct Answer: 4

Rationale 1: Dehydration would not result in high carbon dioxide levels.

Rationale 2: Laughing and talking while eating could explain why the obstruction occurred, but would not explain why the discrepancy between auscultation and carbon dioxide monitor.

Rationale 3: Calcium deficiency is not related to the discrepancy in this scenario.

Rationale 4: Drinking a carbonated beverage just before intubation can cause a false positive carbon dioxide monitor report.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-2

Question 4

Type: MCSA

The nurse manager teaches newly hired nurses about findings associated with barotrauma. The manager would include that this complication is most common in which type of mechanical ventilation?

1. Volume

2. Time

3. Pressure

4. Flow

Correct Answer: 1

Rationale 1: Volume-cycled ventilation delivers a preset volume of gas to the lungs. Volume ventilation has the potential to generate high pressures, especially in less compliant lungs in order to deliver the set volume, which increases the risk of barotrauma.

Rationale 2: Time-cycled ventilators also limit the maximum amount of pressure that can be delivered, which offers protection against barotrauma.

Rationale 3: Pressure-cycled ventilation is increasingly used as a method to protect the injured lung from further damage from high pressures.

Rationale 4: Flow-cycled ventilators augment the patients inspiratory effort as long as the patient continues to inhale at a certain flow rate. The risk of barotrauma is not as significant as with another type of ventilator.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-2

Question 5

Type: MCSA

The nurse notes these ventilator setting change orders. What nursing intervention is indicated?

1. Carry out the orders as written.

2. Verify the respiratory rate.

3. Verify the mode.

4. Verify the tidal volume.

Correct Answer: 4

Rationale 1: These orders are not safe and should not be carried out without question.

Rationale 2: Ventilator rate of 12 is appropriate for ventilator assist control mode.

Rationale 3: Assist-control mode allows the patient to maintain some control over rate of breathing and is an appropriate mode in many cases.

Rationale 4: The nurse should contact the physician to request a reduction in tidal volume. Normal tidal volume should range from 7 to 9 mL/kg (approximately 600 to 800 mL in an adult). Therefore, the ordered tidal volume is very high, which could result in barotrauma. The possibility exists of an entry error in the order.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-4

Question 6

Type: MCSA

The nurse caring for a patient who is ventilated via the assist-control mode monitors for which complication specifically related to this intervention?

1. Pneumonia

2. Anxiety

3. Pneumothorax

4. Respiratory alkalosis

Correct Answer: 4

Rationale 1: Ventilator associated pneumonia is a risk for all modes of mechanical ventilation.

Rationale 2: Anxiety may be present with all modes of mechanical ventilation and is not specific to the mode used with this patient.

Rationale 3: Pneumothorax is a risk of all mechanical ventilation modes if the tidal volume is not appropriate for the patient.

Rationale 4: With assist-control, every breath is a ventilator breath. Therefore, if a patient attempts to initiate spontaneous breaths, each attempt will result in a breath of full tidal volume. The ultimate effect, if untreated, is hyperventilation. Hyperventilation causes the patient to blow off carbon dioxide, leading to the development of respiratory alkalosis.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4

Question 7

Type: MCSA

The nurse is admitting a patient who sustained a traumatic brain injury and who is now deeply sedated. The nurse would anticipate managing which mode of ventilation during this patients initial care?

1. Pressure support ventilation

2. Assist-control ventilation

3. Pressure support ventilation (PSV)

4. Synchronized intermittent mandatory ventilation (SIMV)

Correct Answer: 2

Rationale 1: Pressure support ventilation requires that the patient have spontaneous respiratory effort. That will not be the case with a deeply sedated patient.

Rationale 2: With assist-control ventilation, every breath is a machine breath. At the appropriate settings, this is desirable for a deeply sedated head-injured patient who is unlikely to initiate spontaneous breaths.

Rationale 3: PSV is an adjunctive weaning mode which requires spontaneous breathing attempts which would not be present in a deeply sedated patient.

Rationale 4: SIMV relies on the patient spontaneously breathing through the circuit to do much of the work of breathing. This will not happen in a deeply sedated patient.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-3

Question 8

Type: MCSA

The nurse is preparing to care for a patient returning from elective surgery who will require mechanical ventilation for a few more hours. The nurse would initiate which ventilator setting orders without question?

1. SIMV with a rate of 12, tidal volume 750 mL, FIO2 0.60

2. Assist-control with a rate of 16, tidal volume 1,000 mL, FIO2 0.40

3. Assist-control with a rate of 20, tidal volume 1,200 mL, FIO2 0.60

4. SIMV with a rate of 4, tidal volume 1,200 mL, FIO2 0.60

Correct Answer: 1

Rationale 1: It is most likely that the ventilator settings would include the SIMV mode, which is often used for weaning patients from ventilators. A tidal volume of 750 is appropriate for an adult and FIO2 of 0.60 is reasonable.

Rationale 2: Assist control mode would not be a likely choice since it is anticipated that this patient will only require mechanical ventilation for a few more hours. Tidal volume of 1,000 mL is too high.

Rationale 3: Assist control mode would not be a likely choice for a patient only expected to need mechanical ventilation for a few more hours.

Rationale 4: It is most likely that the ventilator settings would include the SIMV mode, which is often used for weaning patients from ventilators. The SIMV mode with a tidal volume of 1,200 mL is too high.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6-4

Question 9

Type: MCSA

A patients ventilator settings are going to be modified to include positive end expiratory pressure (PEEP). What nursing action is most important?

1. Suction the patient before and after the change.

2. Monitor vital signs frequently.

3. Notify the physician of abrupt increases in oxygenation.

4. Monitor breath sounds at least every 15 minutes.

Correct Answer: 2

Rationale 1: The nurse is expected to suction the patient as needed. However, this does not imply that it should be done before and after instituting PEEP.

Rationale 2: It is most important for the nurse to monitor vital signs frequently because the addition of PEEP increases intrathoracic pressure, which decreases venous return and, therefore, compromises cardiac output.

Rationale 3: The nurse would not notify the physician of an abrupt increase in oxygenation. This would be a desirable outcome.

Rationale 4: Although the nurse would certainly auscultate breath sounds on a routine basis, it would not typically be expected every 15 minutes and would not be particularly associated with instituting PEEP.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-4

Question 10

Type: MCSA

The nurse responds to a ventilator pressure alarm by going to the patients room. What should be the nurses first action?

1. Turn off the ventilator alarm to help calm the patient.

2. Administer intravenous sedation according to prn prescription.

3. Assess for the cause of the alarm.

4. Manually bag the patient until the cause of the alarm is detected.

Correct Answer: 3

Rationale 1: The ventilator alarm should not be turned off. Most systems have a mechanism by which the alarm can be temporarily muted. Attending to the alarm is not the nurses priority action.

Rationale 2: The nurse cannot ascertain the need for sedation without additional action.

Rationale 3: The nurses first action should always be to assess the patient.

Rationale 4: Manual bagging would be used after the patient is assessed and if the nurse could not quickly discover the reason for the alarm. This step is not indicated at this time.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-4

Question 11

Type: MCSA

A patient who has been extubated postoperatively is retaining carbon dioxide. In order to avoid reintubating this patient the nurse would expect to manage which intervention?

1. Insertion of an oral airway

2. Insertion of a nasal airway

3. Use of noninvasive intermittent positive pressure ventilation (NIPPV)

4. Use of continuous positive airway ventilation (CPAP)

Correct Answer: 3

Rationale 1: Inserting an oral airway may be indicated, but it will not reduce the retention of carbon dioxide if used alone.

Rationale 2: A nasal airway may be indicated, but will not reverse carbon dioxide retention alone.

Rationale 3: In the ICU setting, noninvasive intermittent positive pressure ventilation is used for patients in acute respiratory distress as a treatment option to avoid intubation. Noninvasive positive pressure ventilation has been used successfully for patients with hypercapnic failure.

Rationale 4: Continuous positive airway pressure ventilation is most commonly used to treat obstructive sleep apnea. It does not provide assisted ventilation on inspiration as does NIPPV.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6-5

Question 12

Type: MCSA

A patient in respiratory failure has a heart rate of 124, respirations of 24, blood pressure of 168/98, blood pH of 7.28 and oxygen saturation of 84%. The patient is can be aroused, but returns to sleep quickly. Noninvasive intermittent positive pressure (NIPPV) is initiated. On reassessment, which findings would the nurse evaluate as indicating that this therapy is having the desired outcomes?

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

1. Respiratory rate is 22.

2. The patient is not using accessory muscles.

3. The patient is somnolent.

4. Blood pH is 7.26.

5. O2 saturation is 90%.

Correct Answer: 1,2,5

Rationale 1: The respiratory rate is trending downward which is an indicator that NIPPV is being effective.

Rationale 2: Decreased use of accessory muscles indicates the patient is not working as hard to breath. This is a positive effect of NIPPV.

Rationale 3: NIPPV should help reduce carbon dioxide retention which would manifest as the patient being easier to arouse.

Rationale 4: A blood pH of 7.26 would indicate worsening acidosis, possibly caused by retaining carbon dioxide.

Rationale 5: Improved oxygenation would indicate the therapy is working.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6-5

Question 13

Type: MCMA

A patient who is mechanically ventilated requires a high level of PEEP. The nurse would monitor for which findings indicating possible barotrauma?

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

Standard Text: Select all that apply.

1. Sudden increase in systolic blood pressure.

2. Absent breath sounds.

3. Subcutaneous emphysema across the anterior chest.

4. Patient is somnolent.

5. Sudden deterioration of ABGs.

Correct Answer: 2,3,5

Rationale 1: Deterioration of blood pressure that occurs suddenly may indicate barotrauma.

Rationale 2: Sudden absence of breath sounds may indicate barotrauma.

Rationale 3: Development of subcutaneous emphysema on the anterior neck or chest may be related to barotrauma.

Rationale 4: Sudden onset of agitation is a more likely manifestation of barotrauma.

Rationale 5: Barotrauma will result in sudden deterioration of ABGs.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-6

Question 14

Type: MCSA

The nurse monitors all mechanically ventilated patients for the development of oxygen toxicity. Which patient would the nurse determine to be at highest risk?

1. The patient has required FiO2 of 0.7 for the first 2 hours after being intubated.

2. A patient has required FiO2 of 1.0 for the last 8 hours.

3. The patients ventilator was set at FiO2 of 0.4 for the last 2 days.

4. The patient has required FiO2 of 0.8 for 24 hours after intubation.

Correct Answer: 2

Rationale 1: While this FiO2 is high the length of time it was used is short so the risk of oxygen toxicity is not high.

Rationale 2: The use of FiO2 of 1.0 can cause pulmonary changes within 6 hours.

Rationale 3: This FiO2 does not represent a high risk for oxygen toxicity.

Rationale 4: This is a high FiO2 but the duration is rather short. This patient is not at highest risk for oxygen toxicity.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-6

Question 15

Type: MCMA

A patient is being admitted to the intensive care unit after being resuscitated in the emergency department. The patient is being mechanically ventilated. Which information provided by the transferring nurse would the nurse evaluate as increasing this patients risk of developing ventilator associated pneumonia (VAP)?

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

Standard Text: Select all that apply.

1. The patient is intubated nasally.

2. The patient arrested after having a myocardial infarction.

3. The patient required placement of a nasogastric tube to relieve persistent gastric distention.

4. The patients home medications include a proton pump inhibitor.

5. The patient has a history of COPD.

Correct Answer: 1,3,4,5

Rationale 1: The presence of an endotracheal tube is a risk factor for VAP.

Rationale 2: There is no particular increase in risk because the etiology of the arrest was a myocardial infarction.

Rationale 3: Placement of a nasogastric tube increases risk for gastroesophageal reflux.

Rationale 4: Medications to prevent stress ulcer formation create an alkaline pH in which bacteria multiply.

Rationale 5: COPD increases risk for VAP.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-6

Question 16

Type: MCSA

Which nursing intervention will help to decrease the risk of tracheal and laryngeal injuries in an intubated patient?

1. Use an endotracheal tube equipped for continuous removal of subglottic secretions.

2. Deflate the cuff for 5 minutes every 8 hours.

3. Use the minimal occluding pressure technique to maintain cuff pressure at 20 to 25 mm Hg.

4. Test cuff pressure by assessing firmness of the inflation balloon.

Correct Answer: 3

Rationale 1: Removal of subglottic secretions will help prevent ventilator associated pneumonia but will not protect the integrity of the tracheal and laryngeal tissues.

Rationale 2: Deflating the cuff will allow pooled secretions to enter the lower airways and increases risk for ventilator associated pneumonia. There is no evidence that decreasing cuff pressure this infrequently will protect tracheal or laryngeal tissues.

Rationale 3: The minimal occluding pressure technique can be used and cuff pressures should be maintained in the 20 to 25 mm Hg range.

Rationale 4: Firmness of the inflation balloon is a subjective measure of cuff pressure. The pressure should be checked at least once per shift via a cuff manometer.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-7

Question 17

Type: MCSA

A patient who is endotracheally intubated and on mechanical ventilation has a decreasing oxygen saturation level with an increasing heart rate. What is the nurses priority action?

1. Ensure the airway is clear.

2. Auscultate lung sounds.

3. Reposition the patient.

4. Reposition the endotracheal tube.

Correct Answer: 1

Rationale 1: Airway clearance is a top-priority nursing goal in management of the patient with an artificial airway. If airway patency is not maintained, the patients breathing and cardiovascular status eventually will fail as a result of hypoxia or hypercapnia.

Rationale 2: Auscultation of lung sounds is an important intervention for this patient, but is not the first priority.

Rationale 3: Repositioning the patient may improve alertness and therefore oxygenation if the patient is on an assist ventilator mode. However, repositioning is not the first nursing priority.

Rationale 4: Repositioning the airway may be indicated, but the nurse must take another action to determine if that is the correct intervention.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-7

Question 18

Type: MCMA

The health care team has planned to begin weaning a patient from the mechanical ventilator in the morning. The nurse should alert the team to which situations that could decrease the chance of successful weaning?

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

Standard Text: Select all that apply.

1. The patient has developed a fever.

2. The patient was suctioned twice during the night for a small amount of thin secretions.

3. ABGs reveal a pH of 7.34.

4. The patient is constipated.

5. The patients serum sodium level is 138 mEq/L.

Correct Answer: 1,4

Rationale 1: Fever increases metabolic rate and decreases the chance of successful weaning.

Rationale 2: It is normal for the patient to require suctioning. Twice during the night is not excessive and the secretions are thin. This finding should not impede weaning.

Rationale 3: pH between 7.30 and 7.45 offer the best chance of successful weaning.

Rationale 4: Bowel problems such a diarrhea or constipation can decrease successful weaning.

Rationale 5: Normal electrolyte measurements, such as this normal sodium level, increase the chance that weaning will be successful.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-9

Question 19

Type: MCSA

A patient is being manually weaned from mechanical ventilation. What nursing intervention is indicated?

1. Suction the patient once the ventilator is removed.

2. Have intubation equipment at the bedside.

3. Project a calm and confident manner.

4. Change the ventilator settings so the patient can breathe spontaneously between set breaths.

Correct Answer: 3

Rationale 1: Suctioning removes oxygen as well as removing secretions. If suctioning is needed it should be done prior to the weaning period.

Rationale 2: The patient remains intubated during this weaning so having intubation equipment at the bedside is not necessary.

Rationale 3: The nurses calm and confident presence is reassuring to the patient during this stressful time.

Rationale 4: Manual weaning involves removing the patient from the ventilator so settings are not changed.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6-9

Question 20

Type: MCSA

A patient who will require long-term mechanical ventilation has had a tracheostomy for 2 weeks. The nurse is concerned that stoma erosion is occurring. Which nursing assessment would support the nurses concern?

1. Secretions are present at the stoma opening.

2. Granulation tissue is noted at the stoma site.

3. The patient has developed a dry cough.

4. The skin at the stoma opening is flaky.

Correct Answer: 1

Rationale 1: The presence of excessive secretions at the stoma opening indicates that the stoma size in increasing.

Rationale 2: Granulation tissue is more likely to result in obstruction or stricture.

Rationale 3: Dry cough does not indicate stoma erosion.

Rationale 4: Flakiness indicates dryness. In stoma erosion the skin is excoriated from constant moisture.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-7

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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