Nursing
8/29/23, nComplexnOxygenationnATInPracticenMCQnQuestionsnannAnswersn
n11:46nAM ATInOxygenationnPracticen9nATInOxygenationnPracticen
9
PasadenanUniversity
Nursingn(NURS50)
Detailedn Answern Key
ComplexnOyxgenationnATInPractice
1.nnAnnursenisnconductingnanprimarynsurveynofnanclientnwhonhasnsustainednlife-
threateningninjuriesnduentonanmotor-
vehiclen crash.nIdentifynthensequencenofnactionsnthennursenshouldntake.n(Moventhenactionsnintonthenboxnonnt
henright,nplacingn themninnthenselectednordernofnperformance.nUsenallnthensteps.)
C.n Opennthenairwaynusingnanjaw-thrustnmaneuver.
D.n Determineneffectivenessnofnventilatornefforts.
B.n EstablishnIVnaccess.
A.n PerformnanGlasgownComa nScalenassessment.
E.n Removenclothingnfornanthoroughnassessment.
2.nAnnursenisncaringnfornanclientnwhonhasnactivenpulmonaryntuberculosisn(TB)nandnisntonbenstartednonnintraveno
usn rifampinntherapy.nThennursenshouldninstructnthenclientnthatnthisnmedicationncanncausenwhichnofnthenfollowin
gnadversen effects?
A. Constipation
Rationale:nRifampinndoesnnotncausenconstipation.nMorencommonngastrointestinalneffectsnarendiarrheana
ndn nausea.
B. Blackncolorednstools
Rationale:nItnisnmostncommonlynironnsupplementsnthatncausenstoolsntonturnnblack,nnotnrifampin.
C. Stainingnofnteeth
Rationale:nTeethnmaynbenstainednfromntakingnliquidnironnpreparations,nnotnfromntakingnrifampin.
D. Bodyn secretionsn turningn an red-orangen color
Rationale:nRifampinnisnusedninncombinationnwithnothernmedicinesntontreatnTB.nRifampinnwillncausenthen
urine,n stool,nsaliva,nsputum,nsweat,nandntearsntonturnnreddish-orangentonreddish-brown.
3.nAnnursenisncaringnfornanclientnwhonhasnreturnednfromnthensurgicalnsuitenfollowingnsurgerynfornanfracturednma
ndible.n Thenclientnhadnintermaxillarynfixationntonrepairnandnstabilizenthenfracture.nWhichnofnthenfollowingnaction
snisnthenpriorityn fornthennursentontake?
A. Preventn aspiration.
Rationale:nWhennusingnthenairway,nbreathing,ncirculationnapproachntonclientncare,nthennursenshouldn d
eterminenthatnthenpriorityngoalnisntonpreventnthenclientnfromnaspirating.nBecausenthenclient'snj
awsn arenwiredntogether,naspirationnofnemesisnisnanpossibility.nTherefore,nthenclientnshouldn
bengivenn medicationnfornnausea,nandnwirencuttersnshouldnbenkeptnatnthenbedsideninncasen
ofnvomiting.
B. Ensuren adequaten nutrition.
Rationale:
Created non:08/03/2018 Pagen1
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9
Detailedn Answern Key
ComplexnOyxgenationnATInPractice
ThenclientnshouldnbenNPOninitiallynafternsurgerynuntilnthengagnreflexnhasnreturned.nOncenthe
nclientn isnablentoneat,nthenclientnmaynadvancentonancalorie-appropriate,nhigh-
proteinnliquidndiet.nHowever,n thisnisnnotnthenprioritynatnthisntime.
C. Promotenoralnhygiene
Rationale:nThenclientnwillnhavenannincisionninsidenthenmouth.nWhilenitnisnimportantnthatnthenclientnreceiv
en frequentnmouthncleaning,nthisnisnnotnthenprioritynatnthisntime.
D. Relieventhenclient'snpain.
Rationale:nWhilenthenclientnmaynbeninnpainnandnwillnneedntonbenmedicated,nthisnisnnotnthenprioritynatnthisntim
e.
4.nAnnursencaringnfornanclientnwhonhasnhypertensionnandnasksnthennursenaboutnanprescriptionnfornpropranolol.n Th
ennursen shouldninformnthenclientnthatnthisnmedicationnisncontraindicatedninnclientsnwhonhavenanhistorynofnwhic
hnofnthenfollowingn conditions?
A. Asthma
Rationale:nPropranolol,nanbeta-
blocker,nisncontraindicatedninnclientsnwhonhavenasthmanbecausenitncanncausen bronchospas
ms.nPropranolol nblocksnthensympatheticnstimulation,nwhichnpreventsnsmoothnmusclen relaxati
on.
B. Glaucoma
Rationale:nBeta-
blockersnarencontraindicatedninnclientsnwhonhavencardiogenicnshock,nbutnarennotn contraindi
catedninn anclientnwhonhasnglaucoma.
C. Depression
Rationale:nBeta-
blockersnarencontraindicatedninnclientsnwhonhavenAVnheartnblock,nbutnarennotn contraindica
tedninnclientsnwhonhavendepression.
D. Migraines
Rationale:nBeta-blockersnarenusednfornprophylacticntreatmentnofnmigrainenheadaches.
5.nAnnursenisncaringnfornanclientnwhonhasnacutenrespiratoryndistressnsyndromen(ARDS),nandnrequiresnmechanic
aln ventilation.nThenclientnreceivesnanprescriptionnfornpancuronium.n Thennursenrecognizesnthatnthisnmedicationni
snforn whichnofnthenfollowingnpurposes?
A. Decreasenchestnwallncompliance
Rationale:nNeuromuscularnblockingnagents,nsuchnasnpancuronium,ninducenparalysisnbynrelaxingnskeletal
n muscles,n whichnimprovesnchestnwallncompliance.
B. Suppressn respiratoryn effort
Rationale:nNeuromuscularnblockingnagents,nsuchnasnpancuronium,ninducenparalysisnandnsuppressnthe
n client'snrespiratoryneffortsntonthenpointnofnapnea,nallowingnthenmechanicalnventilatorntontak
enovern thenworknofnbreathingnfornthenclient.nThisntherapynisnespeciallynhelpfulnfornanclientnw
honhasnARDS
Created non:08/03/2018 Pagen2
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9
Detailedn Answern Key
ComplexnOyxgenationnATInPractice
andnpoornlungncompliance.
C. Inducensedation
Rationale:nNeuromuscularnblockingnagents,nsuchnasnpancuronium,ninducenparalysisnandn havennonseda
tiven effectnatnall.n Ansedativenornanalgesicnshouldnbenprescribednasnannadjunctntonthenpan
curonium.
D. Decreasen respiratoryn secretions
Rationale:nNeuromuscularnblockingnagents,nsuchnasnpancuronium,ninducenparalysis.nAnnadverseneffect
nofn thisnmedicationnisnincreasednproductionnofnrespiratorynsecretions.
6.nAnnursenisncaringnfornanclientnwhonexperiencednanlaceratednspleennandnhasnbeennonnbedrestnfornseveralndays.
nThen nursenauscultatesndecreasednbreathnsoundsninnthenlowernlobesnofnbothnlungs.nThennursenshouldnrealiz
enthatnthisn findingnisnmostnlikelynannindicationnofnwhichnofnthenfollowingnconditions?
A. Annuppernrespiratoryninfection
Rationale:nAlthoughnthenspleennplaysnanroleninnimmunitynagainstnbacterialninfections,nthennursenwould
nben morenconcernednaboutnthenrisknofnannuppernrespiratoryninfectionninnanclientnwhonhasnu
ndergonen splenectomy,nornremovalnofnthenspleen.
B. Pulmonaryn edema
Rationale:nPulmonarynedemanmayndevelopninnanclientnwhonisnonnbedrestnfollowingntrauma,nbutnthisnisn
notnthen mostnlikelyncausenofndecreasednbreathnsoundsninnthisnclient.
C. Atelectasis
Rationale:nAtelectasisnisnthencollapsenofnpartnornallnofnanlungnbynblockagenofnthenairnpassagesn(bron
chusnorn bronchioles)nornbynhypoventilation.nProlongednbedrestnwithnfewnchangesninnpositi
on,nineffectiven coughing,nandnunderlyingnlungndiseasenarenrisknfactorsnfornthendevelopm
entnofnatelectasis.
D. Delayedn gastricn emptying
Rationale:nAlthoughndelayedngastricnemptyingnmaynresultninnineffectivencoughing,nthisnisnnotnthenmost
nlikelyn causenofndecreasednbreathnsoundsninnthisnclient.
7.nAnnursenisnobservingnthenclosednchestndrainagensystemnofnanclientnwhonisn24nhrnpostnthoracotomy.nThennurse
nnotesn slow,nsteadynbubblingninnthensuctionncontrolnchamber.nWhichnofnthenfollowingnactionsnshouldnthennur
sentake?
A. Checknthentubingnconnectionsnfornleaks.
Rationale:nThisnactionnisnusedntondeterminenwhynanwaternsealnchambernhasncontinuousnbubbling,nnot
nslow,n steadynbubbling.
B. Checknthensuctionncontrolnoutletnonnthenwall.
Rationale:nThisnactionnisnusedntondeterminenwhynansuctionncontrolnchambernthatnisnhookedntonwalln
suctionn hasnlittlenornnonbubbling.
Created non:08/03/2018 Pagen3
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9
Detailedn Answern Key
ComplexnOyxgenationnATInPractice
C. Clampnthenchestntube.
Rationale:nThennursenshouldnbrieflynclampnthenchestntubentonchecknfornairnleaksnorntonchangenthendrai
nagen system.nThisnisnnotnannappropriatenactionnfornthennursentontakenatnthisntime.
D. Continuentonmonitornthenclient'snrespiratorynstatus.
Rationale:nSlow,nsteadynbubblingninnthensuctionncontrolnchambernisnannexpectednfinding.nTherefore,nth
en nursenshouldncontinuentonmonitornthenclient'snrespiratorynstatus.
8.nAnnursenisnreviewingnthenlaboratorynfindingsnfornanclientnwhondevelopednfatnembolismnsyndromen(FES)nfollowin
gnan fracture.nWhichnofnthenfollowingnlaboratorynfindingsnshouldnthennursenexpect?
A. Decreasedn serumn calciumn level
Rationale:nAndecreasednserumncalciumnlevelnisnannexpectednfindingnfornFES,nalthoughnthenreasonnfornt
hisn findingnisnunknown.
B. Decreasednlevelnofnserumnlipids
Rationale:nAnnincreasenserumnlipidnlevelnisnannexpectednfindingnfornFES,nalthoughnthenreasonnfornthisnf
indingn isnunknown.
C. Decreasedn erythrocyten sedimentationn raten (ESR)
Rationale:nAnnincreasednESRnisnannexpectednfindingnfornFES,nalthoughnthenreasonnfornthisnfindingnis
n unknown.
D. Increasedn plateletn count
Rationale:nAndecreasednplateletncountnisnannexpectednfindingnfornFES,nalthoughnthenreasonnfornthisnfindingni
sn unknown.
9.nAnnursenisncaringnfornanclientnwhonisnunconsciousnandnhasnanbreathingnpatternncharacterizednbynalternatingnpe
riodsnofn hyperventilationnandnapnea.nThennursenshouldndocumentnthatnthenclientnhasnwhichnofnthenfollowingnr
espiratoryn alterations?
A. Kussmauln respirations
Rationale:nKussmaulnrespirationsnarendeep,nrapid,nregularnrespirationsnandnarencommonlynseenninnclien
tsn whonarenexperiencingnmetabolicnacidosis.
B. Apneusticn respirations
Rationale:nApneusticnrespirationsnarencharacterizednbynanprolongedninspiratorynphasenalternatingnwithn
expiratorynpauses.
C. Cheyne-Stokesn respirations
Rationale:nCheyne-
Stokesnrespirationsn(CSR)narencharacterizednbynanrhythmicnincreasen(tonthenpointnofn hyper
ventilation)nandndecreasen(tonthenpointnofnapnea)ninnthenratenandndepthnofnrespiration.nCSR
Created non:08/03/2018 Pagen4
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8/29/23, nComplexnOxygenationnATInPracticenMCQnQuestionsnannAnswersn
n11:46nAM ATInOxygenationnPracticen9nATInOxygenationnPracticen
9
PasadenanUniversity
Nursingn(NURS50)
Detailedn Answern Key
ComplexnOyxgenationnATInPractice
1.nnAnnursenisnconductingnanprimarynsurveynofnanclientnwhonhasnsustainednlife-
threateningninjuriesnduentonanmotor-
vehiclen crash.nIdentifynthensequencenofnactionsnthennursenshouldntake.n(Moventhenactionsnintonthenboxnonnt
henright,nplacingn themninnthenselectednordernofnperformance.nUsenallnthensteps.)
C.n Opennthenairwaynusingnanjaw-thrustnmaneuver.
D.n Determineneffectivenessnofnventilatornefforts.
B.n EstablishnIVnaccess.
A.n PerformnanGlasgownComa nScalenassessment.
E.n Removenclothingnfornanthoroughnassessment.
2.nAnnursenisncaringnfornanclientnwhonhasnactivenpulmonaryntuberculosisn(TB)nandnisntonbenstartednonnintraveno
usn rifampinntherapy.nThennursenshouldninstructnthenclientnthatnthisnmedicationncanncausenwhichnofnthenfollowin
gnadversen effects?
A. Constipation
Rationale:nRifampinndoesnnotncausenconstipation.nMorencommonngastrointestinalneffectsnarendiarrheana
ndn nausea.
B. Blackncolorednstools
Rationale:nItnisnmostncommonlynironnsupplementsnthatncausenstoolsntonturnnblack,nnotnrifampin.
C. Stainingnofnteeth
Rationale:nTeethnmaynbenstainednfromntakingnliquidnironnpreparations,nnotnfromntakingnrifampin.
D. Bodyn secretionsn turningn an red-orangen color
Rationale:nRifampinnisnusedninncombinationnwithnothernmedicinesntontreatnTB.nRifampinnwillncausenthen
urine,n stool,nsaliva,nsputum,nsweat,nandntearsntonturnnreddish-orangentonreddish-brown.
3.nAnnursenisncaringnfornanclientnwhonhasnreturnednfromnthensurgicalnsuitenfollowingnsurgerynfornanfracturednma
ndible.n Thenclientnhadnintermaxillarynfixationntonrepairnandnstabilizenthenfracture.nWhichnofnthenfollowingnaction
snisnthenpriorityn fornthennursentontake?
A. Preventn aspiration.
Rationale:nWhennusingnthenairway,nbreathing,ncirculationnapproachntonclientncare,nthennursenshouldn d
eterminenthatnthenpriorityngoalnisntonpreventnthenclientnfromnaspirating.nBecausenthenclient'snj
awsn arenwiredntogether,naspirationnofnemesisnisnanpossibility.nTherefore,nthenclientnshouldn
bengivenn medicationnfornnausea,nandnwirencuttersnshouldnbenkeptnatnthenbedsideninncasen
ofnvomiting.
B. Ensuren adequaten nutrition.
Rationale:
Created non:08/03/2018 Pagen1
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,8/29/23,n11:46nAM ATInOxygenationnPracticen9nATInOxygenationnPracticen
9
Detailedn Answern Key
ComplexnOyxgenationnATInPractice
ThenclientnshouldnbenNPOninitiallynafternsurgerynuntilnthengagnreflexnhasnreturned.nOncenthe
nclientn isnablentoneat,nthenclientnmaynadvancentonancalorie-appropriate,nhigh-
proteinnliquidndiet.nHowever,n thisnisnnotnthenprioritynatnthisntime.
C. Promotenoralnhygiene
Rationale:nThenclientnwillnhavenannincisionninsidenthenmouth.nWhilenitnisnimportantnthatnthenclientnreceiv
en frequentnmouthncleaning,nthisnisnnotnthenprioritynatnthisntime.
D. Relieventhenclient'snpain.
Rationale:nWhilenthenclientnmaynbeninnpainnandnwillnneedntonbenmedicated,nthisnisnnotnthenprioritynatnthisntim
e.
4.nAnnursencaringnfornanclientnwhonhasnhypertensionnandnasksnthennursenaboutnanprescriptionnfornpropranolol.n Th
ennursen shouldninformnthenclientnthatnthisnmedicationnisncontraindicatedninnclientsnwhonhavenanhistorynofnwhic
hnofnthenfollowingn conditions?
A. Asthma
Rationale:nPropranolol,nanbeta-
blocker,nisncontraindicatedninnclientsnwhonhavenasthmanbecausenitncanncausen bronchospas
ms.nPropranolol nblocksnthensympatheticnstimulation,nwhichnpreventsnsmoothnmusclen relaxati
on.
B. Glaucoma
Rationale:nBeta-
blockersnarencontraindicatedninnclientsnwhonhavencardiogenicnshock,nbutnarennotn contraindi
catedninn anclientnwhonhasnglaucoma.
C. Depression
Rationale:nBeta-
blockersnarencontraindicatedninnclientsnwhonhavenAVnheartnblock,nbutnarennotn contraindica
tedninnclientsnwhonhavendepression.
D. Migraines
Rationale:nBeta-blockersnarenusednfornprophylacticntreatmentnofnmigrainenheadaches.
5.nAnnursenisncaringnfornanclientnwhonhasnacutenrespiratoryndistressnsyndromen(ARDS),nandnrequiresnmechanic
aln ventilation.nThenclientnreceivesnanprescriptionnfornpancuronium.n Thennursenrecognizesnthatnthisnmedicationni
snforn whichnofnthenfollowingnpurposes?
A. Decreasenchestnwallncompliance
Rationale:nNeuromuscularnblockingnagents,nsuchnasnpancuronium,ninducenparalysisnbynrelaxingnskeletal
n muscles,n whichnimprovesnchestnwallncompliance.
B. Suppressn respiratoryn effort
Rationale:nNeuromuscularnblockingnagents,nsuchnasnpancuronium,ninducenparalysisnandnsuppressnthe
n client'snrespiratoryneffortsntonthenpointnofnapnea,nallowingnthenmechanicalnventilatorntontak
enovern thenworknofnbreathingnfornthenclient.nThisntherapynisnespeciallynhelpfulnfornanclientnw
honhasnARDS
Created non:08/03/2018 Pagen2
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,8/29/23,n11:46nAM ATInOxygenationnPracticen9nATInOxygenationnPracticen
9
Detailedn Answern Key
ComplexnOyxgenationnATInPractice
andnpoornlungncompliance.
C. Inducensedation
Rationale:nNeuromuscularnblockingnagents,nsuchnasnpancuronium,ninducenparalysisnandn havennonseda
tiven effectnatnall.n Ansedativenornanalgesicnshouldnbenprescribednasnannadjunctntonthenpan
curonium.
D. Decreasen respiratoryn secretions
Rationale:nNeuromuscularnblockingnagents,nsuchnasnpancuronium,ninducenparalysis.nAnnadverseneffect
nofn thisnmedicationnisnincreasednproductionnofnrespiratorynsecretions.
6.nAnnursenisncaringnfornanclientnwhonexperiencednanlaceratednspleennandnhasnbeennonnbedrestnfornseveralndays.
nThen nursenauscultatesndecreasednbreathnsoundsninnthenlowernlobesnofnbothnlungs.nThennursenshouldnrealiz
enthatnthisn findingnisnmostnlikelynannindicationnofnwhichnofnthenfollowingnconditions?
A. Annuppernrespiratoryninfection
Rationale:nAlthoughnthenspleennplaysnanroleninnimmunitynagainstnbacterialninfections,nthennursenwould
nben morenconcernednaboutnthenrisknofnannuppernrespiratoryninfectionninnanclientnwhonhasnu
ndergonen splenectomy,nornremovalnofnthenspleen.
B. Pulmonaryn edema
Rationale:nPulmonarynedemanmayndevelopninnanclientnwhonisnonnbedrestnfollowingntrauma,nbutnthisnisn
notnthen mostnlikelyncausenofndecreasednbreathnsoundsninnthisnclient.
C. Atelectasis
Rationale:nAtelectasisnisnthencollapsenofnpartnornallnofnanlungnbynblockagenofnthenairnpassagesn(bron
chusnorn bronchioles)nornbynhypoventilation.nProlongednbedrestnwithnfewnchangesninnpositi
on,nineffectiven coughing,nandnunderlyingnlungndiseasenarenrisknfactorsnfornthendevelopm
entnofnatelectasis.
D. Delayedn gastricn emptying
Rationale:nAlthoughndelayedngastricnemptyingnmaynresultninnineffectivencoughing,nthisnisnnotnthenmost
nlikelyn causenofndecreasednbreathnsoundsninnthisnclient.
7.nAnnursenisnobservingnthenclosednchestndrainagensystemnofnanclientnwhonisn24nhrnpostnthoracotomy.nThennurse
nnotesn slow,nsteadynbubblingninnthensuctionncontrolnchamber.nWhichnofnthenfollowingnactionsnshouldnthennur
sentake?
A. Checknthentubingnconnectionsnfornleaks.
Rationale:nThisnactionnisnusedntondeterminenwhynanwaternsealnchambernhasncontinuousnbubbling,nnot
nslow,n steadynbubbling.
B. Checknthensuctionncontrolnoutletnonnthenwall.
Rationale:nThisnactionnisnusedntondeterminenwhynansuctionncontrolnchambernthatnisnhookedntonwalln
suctionn hasnlittlenornnonbubbling.
Created non:08/03/2018 Pagen3
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, 8/29/23,n11:46nAM ATInOxygenationnPracticen9nATInOxygenationnPracticen
9
Detailedn Answern Key
ComplexnOyxgenationnATInPractice
C. Clampnthenchestntube.
Rationale:nThennursenshouldnbrieflynclampnthenchestntubentonchecknfornairnleaksnorntonchangenthendrai
nagen system.nThisnisnnotnannappropriatenactionnfornthennursentontakenatnthisntime.
D. Continuentonmonitornthenclient'snrespiratorynstatus.
Rationale:nSlow,nsteadynbubblingninnthensuctionncontrolnchambernisnannexpectednfinding.nTherefore,nth
en nursenshouldncontinuentonmonitornthenclient'snrespiratorynstatus.
8.nAnnursenisnreviewingnthenlaboratorynfindingsnfornanclientnwhondevelopednfatnembolismnsyndromen(FES)nfollowin
gnan fracture.nWhichnofnthenfollowingnlaboratorynfindingsnshouldnthennursenexpect?
A. Decreasedn serumn calciumn level
Rationale:nAndecreasednserumncalciumnlevelnisnannexpectednfindingnfornFES,nalthoughnthenreasonnfornt
hisn findingnisnunknown.
B. Decreasednlevelnofnserumnlipids
Rationale:nAnnincreasenserumnlipidnlevelnisnannexpectednfindingnfornFES,nalthoughnthenreasonnfornthisnf
indingn isnunknown.
C. Decreasedn erythrocyten sedimentationn raten (ESR)
Rationale:nAnnincreasednESRnisnannexpectednfindingnfornFES,nalthoughnthenreasonnfornthisnfindingnis
n unknown.
D. Increasedn plateletn count
Rationale:nAndecreasednplateletncountnisnannexpectednfindingnfornFES,nalthoughnthenreasonnfornthisnfindingni
sn unknown.
9.nAnnursenisncaringnfornanclientnwhonisnunconsciousnandnhasnanbreathingnpatternncharacterizednbynalternatingnpe
riodsnofn hyperventilationnandnapnea.nThennursenshouldndocumentnthatnthenclientnhasnwhichnofnthenfollowingnr
espiratoryn alterations?
A. Kussmauln respirations
Rationale:nKussmaulnrespirationsnarendeep,nrapid,nregularnrespirationsnandnarencommonlynseenninnclien
tsn whonarenexperiencingnmetabolicnacidosis.
B. Apneusticn respirations
Rationale:nApneusticnrespirationsnarencharacterizednbynanprolongedninspiratorynphasenalternatingnwithn
expiratorynpauses.
C. Cheyne-Stokesn respirations
Rationale:nCheyne-
Stokesnrespirationsn(CSR)narencharacterizednbynanrhythmicnincreasen(tonthenpointnofn hyper
ventilation)nandndecreasen(tonthenpointnofnapnea)ninnthenratenandndepthnofnrespiration.nCSR
Created non:08/03/2018 Pagen4
about:blank 4/33
