CRITICAL CARE NURSING (Respiratory)PRACTICE
EXAM 1 QUESTIONS AND ANSWERS.
The nurse is assessing arterial blood gases (ABGs). The client with which
ABG reading requires the nurse's immediate attention?
a. pH, 7.32; PaCO2, 55 mm Hg; PaO2, 70 mm Hg
b. pH, 7.45; PaCO2, 42 mm Hg; PaO2, 70 mm Hg
c. pH, 7.48; PaCO2, 38 mm Hg; PaO2, 60 mm Hg
d. pH, 7.55; PaCO2, 32 mm Hg; PaO2, 50 mm Hg
Verified Answer -: D
This client has the most severe hypoxia and respiratory alkalosis,
indicated by low partial pressure of arterial carbon dioxide (PaCO2)
values on ABG analysis.
Which symptoms in a client assist the nurse in confirming the diagnosis
of pulmonary embolus (PE)? (Select all that apply.)
a. Wheezes throughout lung fields
b. Hemoptysis
c. Sharp chest pain
d. Flattened neck veins
e. Hypotension
f. Pitting edema
Verified Answer -b, c, e
Which clients are at highest risk for pulmonary embolism (PE)? (Select
all that apply)
a. Middle-aged client awaiting surgery
,b. Older adult with a 20-pack-year history of smoking
c. Client who has been on bedrest for 3 weeks
d. Obese client who has elevated platelets
e. Middle-aged client with diabetes mellitus type 1
f. Older adult who has just had abdominal surgery
Verified Answer -B, C, D, F
A client admitted for difficulty breathing becomes worse. Which
assessment findings indicate that the client has developed acute
respiratory distress syndrome (ARDS)? (Select all that apply.)
a. Oxygen administered at 100%, PaO2 60
b. Increased dyspnea
c. Anxiety
d. Chest pain
e. Pitting pedal edema
f. Clubbing of fingertips
Verified Answer -a, b, c
The nurse is caring for a client on a ventilator when the high-pressure
alarm sounds. What actions are most appropriate? (Select all that apply.)
a. Assess the tubing for kinks.
b. Assess whether the tubing has become disconnected.
c. Determine the need for suctioning.
d. Call the health care provider.
e. Call the Rapid Response Team.
,f. Auscultate the client's lungs.
Verified Answer -a, c, f
The nurse is caring for a client with a high risk for pulmonary embolism
(PE). Which prevention measures does the nurse add to the client's care
plan? (Select all that apply.)
a. Use antiembolism stockings.
b. Massage calf muscles per client request.
c. Maintain supine position with the legs flat.
d. Turn every 2 hours if client is in bed.
e. Refrain from active range-of-motion exercises.
Verified Answer -a, d
The high-pressure alarm of a pt's mechanical ventilator goes off. What
are the potential causes for this occurrence?
Verified Answer -Mucus plus
-Patient's fighting the ventilator
-Bronchospasm
-Patient is coughing
A post op patient reports sudden onset of SOB & pleuritic chest pain.
Assessment findings include diaphoresis, hypotension, crackles in the left
lower lobe, & pulse ox of 85%. What does the nurse suspect this pt has?
Verified Answer -PE
A client who underwent surgery 12 hours ago has difficulty breathing. He
has petechiae over his chest and reports acute chest pain. What action
should a nurse take first?
, a) Administer a heparin bolus and begin an infusion at 500 units/hour.
b) Administer analgesics, as ordered.
c) Initiate oxygen therapy.
d) Perform nasopharyngeal suctioning.
Verified Answer -c
On entering the room of a client with chronic obstructive pulmonary
disease (COPD), the nurse notices that the client is receiving oxygen at 4
L/minute by way of a nasal cannula. The nurse's actions should be based
on which statement?
a) The flow rate is too low
b) The flow rate is too high
c) The client shouldn't receive oxygen
d) The flow rate is correct
Verified Answer -b) The flow rate is too high
The administration of oxygen at 1 to 2 L/ minute by way of a nasal
cannula is recommended for clients with COPD: therefore, a rate of 4
L/minute is too high. The normal mechanism that stimulates breathing
is a rise in blood carbon dioxide. Clients with COPD retain blood carbon
dioxide, so their mechanism for stimulating breathing is a low blood
oxygen level. High levels of oxygen may cause hypoventilation and
apnea. Oxygen delivered at 1 to 2 L/ minute should aid in oxygenation
without causing hypoventilation. Oxygen therapy is the only therapy that
has been demonstrated to be life-preserving for patients with COPD
EXAM 1 QUESTIONS AND ANSWERS.
The nurse is assessing arterial blood gases (ABGs). The client with which
ABG reading requires the nurse's immediate attention?
a. pH, 7.32; PaCO2, 55 mm Hg; PaO2, 70 mm Hg
b. pH, 7.45; PaCO2, 42 mm Hg; PaO2, 70 mm Hg
c. pH, 7.48; PaCO2, 38 mm Hg; PaO2, 60 mm Hg
d. pH, 7.55; PaCO2, 32 mm Hg; PaO2, 50 mm Hg
Verified Answer -: D
This client has the most severe hypoxia and respiratory alkalosis,
indicated by low partial pressure of arterial carbon dioxide (PaCO2)
values on ABG analysis.
Which symptoms in a client assist the nurse in confirming the diagnosis
of pulmonary embolus (PE)? (Select all that apply.)
a. Wheezes throughout lung fields
b. Hemoptysis
c. Sharp chest pain
d. Flattened neck veins
e. Hypotension
f. Pitting edema
Verified Answer -b, c, e
Which clients are at highest risk for pulmonary embolism (PE)? (Select
all that apply)
a. Middle-aged client awaiting surgery
,b. Older adult with a 20-pack-year history of smoking
c. Client who has been on bedrest for 3 weeks
d. Obese client who has elevated platelets
e. Middle-aged client with diabetes mellitus type 1
f. Older adult who has just had abdominal surgery
Verified Answer -B, C, D, F
A client admitted for difficulty breathing becomes worse. Which
assessment findings indicate that the client has developed acute
respiratory distress syndrome (ARDS)? (Select all that apply.)
a. Oxygen administered at 100%, PaO2 60
b. Increased dyspnea
c. Anxiety
d. Chest pain
e. Pitting pedal edema
f. Clubbing of fingertips
Verified Answer -a, b, c
The nurse is caring for a client on a ventilator when the high-pressure
alarm sounds. What actions are most appropriate? (Select all that apply.)
a. Assess the tubing for kinks.
b. Assess whether the tubing has become disconnected.
c. Determine the need for suctioning.
d. Call the health care provider.
e. Call the Rapid Response Team.
,f. Auscultate the client's lungs.
Verified Answer -a, c, f
The nurse is caring for a client with a high risk for pulmonary embolism
(PE). Which prevention measures does the nurse add to the client's care
plan? (Select all that apply.)
a. Use antiembolism stockings.
b. Massage calf muscles per client request.
c. Maintain supine position with the legs flat.
d. Turn every 2 hours if client is in bed.
e. Refrain from active range-of-motion exercises.
Verified Answer -a, d
The high-pressure alarm of a pt's mechanical ventilator goes off. What
are the potential causes for this occurrence?
Verified Answer -Mucus plus
-Patient's fighting the ventilator
-Bronchospasm
-Patient is coughing
A post op patient reports sudden onset of SOB & pleuritic chest pain.
Assessment findings include diaphoresis, hypotension, crackles in the left
lower lobe, & pulse ox of 85%. What does the nurse suspect this pt has?
Verified Answer -PE
A client who underwent surgery 12 hours ago has difficulty breathing. He
has petechiae over his chest and reports acute chest pain. What action
should a nurse take first?
, a) Administer a heparin bolus and begin an infusion at 500 units/hour.
b) Administer analgesics, as ordered.
c) Initiate oxygen therapy.
d) Perform nasopharyngeal suctioning.
Verified Answer -c
On entering the room of a client with chronic obstructive pulmonary
disease (COPD), the nurse notices that the client is receiving oxygen at 4
L/minute by way of a nasal cannula. The nurse's actions should be based
on which statement?
a) The flow rate is too low
b) The flow rate is too high
c) The client shouldn't receive oxygen
d) The flow rate is correct
Verified Answer -b) The flow rate is too high
The administration of oxygen at 1 to 2 L/ minute by way of a nasal
cannula is recommended for clients with COPD: therefore, a rate of 4
L/minute is too high. The normal mechanism that stimulates breathing
is a rise in blood carbon dioxide. Clients with COPD retain blood carbon
dioxide, so their mechanism for stimulating breathing is a low blood
oxygen level. High levels of oxygen may cause hypoventilation and
apnea. Oxygen delivered at 1 to 2 L/ minute should aid in oxygenation
without causing hypoventilation. Oxygen therapy is the only therapy that
has been demonstrated to be life-preserving for patients with COPD
