NUR 504 Exam 3 Questions With Complete Solutions
A 100-kg client has developed ARDS and needs mechanical
ventilation. Which of the
following are potentially correct ventilator management
choices? (Select all that apply.)
a. Tidal volume: 600 mL
b. Volume-controlled ventilation
c. PEEP based on oxygen saturation
d. Suctioning every hour
e. High-frequency oscillatory ventilation
f. Limited turning for ventilator pressures Correct Answers
ANS: A, C, E
The client with ARDS who needs mechanical ventilation
benefits from "open lung" and lung
protective strategies, such as using low tidal volumes (6 mL/kg
body weight).
Pressure-controlled ventilation is preferred due to the high
pressures often required in these
clients. PEEP usually starts at 5 cm H2O and adjusted to keep
oxygen saturations in an
acceptable range. Suctioning may need to be frequent due to
secretions, but is not scheduled
hourly. High-frequency oscillatory ventilation is an alternative
to traditional modes of
ventilation. Early mobility is encouraged as is turning and
positioning the client.
A charge nurse is rounding on several older clients on
ventilators in the Intensive Care Unit
,whom the nurse identifies as being at high risk for ventilator-
associated pneumonia. To reduce
this risk, what activity would the nurse delegate to the assistive
personnel (AP)?
a. Encourage between-meal snacks.
b. Monitor temperature every 4 hours.
c. Provide oral care every 4 hours.
d. Report any new onset of cough. Correct Answers ANS: C
Oral colonization by gram-negative bacteria is a risk factor for
health care-associated
pneumonia. Good, frequent oral care can help prevent this from
developing and is a task that
can be delegated to the AP. Encouraging good nutrition is
important, but this will not prevent
pneumonia. Monitoring temperature and reporting new cough in
clients are important to
detect the onset of possible pneumonia but do not prevent it.
A client has a platelet count of 9000/mm3
(9 × 109/L). The nurse finds the client confused and
mumbling. What nursing action takes priority at this time?
a. Call the Rapid Response Team.
b. Take a set of vital signs.
c. Institute bleeding precautions.
d. Place the client on bedrest. Correct Answers ANS: A
With a platelet count this low, the client is at high risk of
spontaneous bleeding. The most
disastrous complication would be intracranial bleeding. The
nurse needs to call the Rapid
Response Team as this client has manifestations of a sudden
neurologic change. Bleeding
,precautions will not address the immediate situation. Placing the
client on bedrest is
important, but the critical action is to call for immediate medical
attention.
A client has a tracheostomy that is 3 days old. Upon assessment,
the nurse notes that the
client's face is puffy and the eyelids are swollen. What action by
the nurse takes best?
a. Assess the client's oxygen saturation.
b. Notify the Rapid Response Team.
c. Oxygenate the client with a bag-valve-mask.
d. Palpate the skin of the upper chest. Correct Answers ANS: A
This client may have subcutaneous emphysema, which is air that
leaks into the tissues
surrounding the tracheostomy. The nurse would first assess the
client's oxygen saturation and
other indicators of oxygenation. If the client is stable, the nurse
can palpate the skin of the
upper chest to feel for the air. If the client is unstable, the nurse
calls the Rapid Response
Team. Using a bag-valve-mask device may or may not be
appropriate for the unstable client.
A client has a tracheostomy tube in place. When the nurse
suctions the client, food particles
are noted. What action by the nurse is best?
a. Elevate the head of the client's bed.
b. Measure and compare cuff pressures.
c. Place the client on NPO status.
, d. Request that the client have a swallow study. Correct Answers
ANS: B
Constant pressure from the tracheostomy tube cuff can cause
tracheomalacia, leading to
dilation of the tracheal passage. This can be manifested by food
particles seen in secretions or
by noting that larger and larger amounts of pressure are needed
to keep the tracheostomy cuff
inflated. The nurse would measure the pressures and compare
them to previous ones to detect
a trend. Elevating the head of the bed, placing the client on NPO
status, and requesting a
swallow study will not correct this situation.
A client is admitted with a possible diagnosis of diabetes
insipidus (DI). What assessment findings would the nurse
expect? (Select all that apply.)
a. Hypotension
b. Increased urinary output
c. Concentrated urine
d. Decreased thirst
e. Poor skin turgor
f. Bradycardia Correct Answers ANS: A, B, E
The client who has DI has excessive urination and dehydration.
Clients who are dehydrated
have decreased blood pressure, increased pulse (tachycardia),
and poor skin turgor. The urine
is dilute with a low specific gravity.
A client is being treated for diabetes insipidus (DI) with
synthetic vasopressin (desmopressin).
A 100-kg client has developed ARDS and needs mechanical
ventilation. Which of the
following are potentially correct ventilator management
choices? (Select all that apply.)
a. Tidal volume: 600 mL
b. Volume-controlled ventilation
c. PEEP based on oxygen saturation
d. Suctioning every hour
e. High-frequency oscillatory ventilation
f. Limited turning for ventilator pressures Correct Answers
ANS: A, C, E
The client with ARDS who needs mechanical ventilation
benefits from "open lung" and lung
protective strategies, such as using low tidal volumes (6 mL/kg
body weight).
Pressure-controlled ventilation is preferred due to the high
pressures often required in these
clients. PEEP usually starts at 5 cm H2O and adjusted to keep
oxygen saturations in an
acceptable range. Suctioning may need to be frequent due to
secretions, but is not scheduled
hourly. High-frequency oscillatory ventilation is an alternative
to traditional modes of
ventilation. Early mobility is encouraged as is turning and
positioning the client.
A charge nurse is rounding on several older clients on
ventilators in the Intensive Care Unit
,whom the nurse identifies as being at high risk for ventilator-
associated pneumonia. To reduce
this risk, what activity would the nurse delegate to the assistive
personnel (AP)?
a. Encourage between-meal snacks.
b. Monitor temperature every 4 hours.
c. Provide oral care every 4 hours.
d. Report any new onset of cough. Correct Answers ANS: C
Oral colonization by gram-negative bacteria is a risk factor for
health care-associated
pneumonia. Good, frequent oral care can help prevent this from
developing and is a task that
can be delegated to the AP. Encouraging good nutrition is
important, but this will not prevent
pneumonia. Monitoring temperature and reporting new cough in
clients are important to
detect the onset of possible pneumonia but do not prevent it.
A client has a platelet count of 9000/mm3
(9 × 109/L). The nurse finds the client confused and
mumbling. What nursing action takes priority at this time?
a. Call the Rapid Response Team.
b. Take a set of vital signs.
c. Institute bleeding precautions.
d. Place the client on bedrest. Correct Answers ANS: A
With a platelet count this low, the client is at high risk of
spontaneous bleeding. The most
disastrous complication would be intracranial bleeding. The
nurse needs to call the Rapid
Response Team as this client has manifestations of a sudden
neurologic change. Bleeding
,precautions will not address the immediate situation. Placing the
client on bedrest is
important, but the critical action is to call for immediate medical
attention.
A client has a tracheostomy that is 3 days old. Upon assessment,
the nurse notes that the
client's face is puffy and the eyelids are swollen. What action by
the nurse takes best?
a. Assess the client's oxygen saturation.
b. Notify the Rapid Response Team.
c. Oxygenate the client with a bag-valve-mask.
d. Palpate the skin of the upper chest. Correct Answers ANS: A
This client may have subcutaneous emphysema, which is air that
leaks into the tissues
surrounding the tracheostomy. The nurse would first assess the
client's oxygen saturation and
other indicators of oxygenation. If the client is stable, the nurse
can palpate the skin of the
upper chest to feel for the air. If the client is unstable, the nurse
calls the Rapid Response
Team. Using a bag-valve-mask device may or may not be
appropriate for the unstable client.
A client has a tracheostomy tube in place. When the nurse
suctions the client, food particles
are noted. What action by the nurse is best?
a. Elevate the head of the client's bed.
b. Measure and compare cuff pressures.
c. Place the client on NPO status.
, d. Request that the client have a swallow study. Correct Answers
ANS: B
Constant pressure from the tracheostomy tube cuff can cause
tracheomalacia, leading to
dilation of the tracheal passage. This can be manifested by food
particles seen in secretions or
by noting that larger and larger amounts of pressure are needed
to keep the tracheostomy cuff
inflated. The nurse would measure the pressures and compare
them to previous ones to detect
a trend. Elevating the head of the bed, placing the client on NPO
status, and requesting a
swallow study will not correct this situation.
A client is admitted with a possible diagnosis of diabetes
insipidus (DI). What assessment findings would the nurse
expect? (Select all that apply.)
a. Hypotension
b. Increased urinary output
c. Concentrated urine
d. Decreased thirst
e. Poor skin turgor
f. Bradycardia Correct Answers ANS: A, B, E
The client who has DI has excessive urination and dehydration.
Clients who are dehydrated
have decreased blood pressure, increased pulse (tachycardia),
and poor skin turgor. The urine
is dilute with a low specific gravity.
A client is being treated for diabetes insipidus (DI) with
synthetic vasopressin (desmopressin).
