NUR 417 Exam 2 Part 1 | Questions, Answers and Rationales

NUR 417 Exam 2 Part 1 | Questions, Answers and Rationales Which action would the nurse take to verify the correct placement of an oral endotracheal tube (ET) immediately after insertion and before securing the tube? 1. Obtain a portable chest x-ray. 2. Use an end-tidal CO2 monitor. 3. Auscultate for bilateral breath sounds. 4. Observe for symmetrical chest movement. End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion are also used, but they are not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured. Which action would the nurse take to maintain proper endotracheal tube (ET) cuff pressure when a patient is on mechanical ventilation? 1. Inflate the cuff with a minimum of 10 mL of air. 2. Inflate the cuff until the pilot balloon is firm on palpation. 3. Inject air into the cuff until a manometer shows 15 mm Hg pressure. 4. Inject air into the cuff until a slight leak is heard only at peak inflation. The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patient's size. Cuff pressure should be maintained at 20 to 30 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon. The nurse notes premature ventricular contractions (PVCs) on the monitor while suctioning a patient's endotracheal tube. Which action would the nurse take? 1. Plan to suction the patient more frequently. 2. Decrease the suction pressure to 80 mm Hg. 3. Give antidysrhythmic medications per protocol. 4. Ventilate the patient with 100% oxygen. Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. the nurse should stop suctioning and ventilate the patient with 100% O2. There is no indication that more frequent suctioning is needed. Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the suctioning is stopped, and patient is well oxygenated. Which assessment finding for a patient receiving mechanical ventilation indicates the need for suctioning? 1. The patient was last suctioned 6 hours ago. 2. The patient's oxygen saturation drops to 93%. 3. The patient's respiratory rate is 32 breaths/min. 4. The patient has occasional audible expiratory wheezes. The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed and not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance. Suctioning the patient may induce bronchospasm and increase wheezing. An O2 saturation of 93% is acceptable and does not suggest that immediate suctioning is needed. The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will most directly treat this finding? 1. Reposition the patient every 1 to 2 hours. 2. Increase suctioning frequency to every hour. 3. Add additional water to the patient's enteral feedings. 4. Instill 5 mL of sterile saline into the ET before suctioning. Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions. Four hours after mechanical ventilation is initiated, a patient's arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). What change should the nurse anticipate to the ventilator settings? 1. Increase the FIO2. 2. Increase the tidal volume. 3. Increase the respiratory rate. 4. Decrease the respiratory rate. The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. the PaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal volume would further lower the PaCO2. The nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD) and weighs 68-kg from mechanical ventilation. Which finding indicates that the weaning protocol should be stopped? 1. The patient's heart rate is 97 beats/min. 2. The patient's oxygen saturation is 93%. 3. The patient respiratory rate is 32 breaths/min. 4. The patient's spontaneous tidal volume is 450 mL. Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. the patient's heart rate is within normal limits, but the nurse should continue to monitor it. An O2 saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable range. The nurse responding to a ventilator alarm finds the patient lying in bed gasping and the endotracheal tube on the floor. Which action would the nurse take next? 1. Activate the rapid response team. 2. Provide reassurance to the patient. 3. Call the health care provider to reinsert the tube. 4. Manually ventilate the patient with 100% oxygen. The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team are also appropriate after the nurse has stabilized the patient's oxygenation. The nurse notes that a patient's endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark, and the patient is anxious and restless. Which action would the nurse take next? 1. Check the O2 saturation. 2. Offer reassurance to the patient. 3. Listen to the patient's breath sounds. 4. Notify the patient's health care provider. The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. the other actions are also appropriate, but detection and correction of tube malposition are the most critical actions. The charge nurse is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education? 1. The RN increases the FIO2 to 100% before suctioning. 2. The RN secures a bite block in place using adhesive tape. 3. The RN asks for assistance to resecure the endotracheal tube. 4. The RN positions the patient with the head of bed at 10 degrees. The head of the patient's bed should be positioned at 30 to 45 degrees to prevent ventilator-associated pneumonia. the other actions by the new RN are appropriate. A patient who is orally intubated and receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action would the nurse take first? 1. Verbally coach the patient to breathe with the ventilator. 2. Sedate the patient with the ordered PRN lorazepam (Ativan). 3. Manually ventilate the patient with a bag-valve-mask device. 4. Increase the rate for the ordered propofol (Diprivan) infusion. The initial response by the nurse should be to try to decrease the patient's anxiety by coaching the patient about how to coordinate respirations with the ventilator. the other actions may also be helpful if the verbal coaching is ineffective in reducing the patient's anxiety. A patient is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action by the nurse promotes patient safety? 1. Planning to suction the patient at least every 1 to 2 hours. 2. Using a closed-suction technique when suctioning is needed. 3. Changing the ventilator circuit tubing routinely every 48 hours. 4. Taping the connection between the ventilator tubing and the ET. The closed-suction technique is used when patients require high levels of PEEP (10 cm H2O) to prevent the loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be scheduled routinely, but it should be done only when patient assessment data indicate the need for suctioning. Taping connections between the ET and ventilator tubing would restrict the ability of the tubing to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for ventilator-associated pneumonia and are not indicated routinely. Which finding by the nurse should result in postponing the spontaneous breathing trial for a patient receiving positive pressure ventilation? 1. New dysrhythmias are observed on the cardiac monitor. 2. Enteral nutrition is being given through an orogastric tube. 3. Scattered rhonchi are heard when auscultating breath sounds 4. Hydromorphone (Dilaudid) is being used to treat postoperative pain. New dysrhythmias may indicate cardiac ischemia and weaning should be postponed until further investigation and/or treatment can be done. Ventilator weaning can proceed when opioids are used for pain management, abnormal lung sounds are present, or enteral nutrition is being delivered. After change-of-shift report, which patient would the nurse assess first? 1. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator 2. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring 3. Patient who was successfully weaned and extubated 4 hours ago and has no urine output for the last 6 hours 4. Patient with an O2 saturation (SaO2) of 93% while on bilevel positive airway pressure (BiPAP) A patient on a positive pressure ventilator is receiving a neuromuscular blocking agent (NMBA) to prevent asynchronous breathing. Which situation requires action by the nurse? 1. No sedative is ordered for the patient. 2. The patient does not respond to voice. 3. The patient's oxygen saturation is 90% to 93%. 4. The patient has no cough reflex when suctioned. Because neuromuscular blockade is extremely anxiety provoking, it is essential that patients who are receiving neuromuscular blockade receive concurrent sedation and analgesia. Absence of response to stimuli is expected in patients receiving neuromuscular blockade. the O2 saturation is adequate. Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway? 1. Weak cough effort 2. Profuse green sputum 3. Respiratory rate of 28 breaths/minute 4. Resting pulse oximetry (SpO2) of 85% The weak cough effort indicates that the patient is unable to clear the airway effectively. the other data suggest problems with gas exchange and breathing pattern. A patient with bacterial pneumonia has coarse crackles and thick sputum. Which intervention would the nurse plan to promote airway clearance? 1. Restrict oral fluids during the day. 2. Encourage pursed-lip breathing technique. 3. Help the patient to splint the chest when coughing. 4. Encourage the patient to wear the nasal O2 cannula. Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal O2 will improve gas exchange but will not improve airway clearance. Pursed-lip breathing is used to improve gas exchange in patients with chronic obstructive pulmonary disease but will not improve airway clearance. Which finding will be most useful in evaluating the effectiveness of treatment for a patient with impaired gas exchange? 1. Even, unlabored respirations 2. Pulse oximetry reading of 92% 3. Absence of wheezes or crackles 4. Respiratory rate of 18 breaths/min The best data for evaluation of gas exchange are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue. Which diagnostic test would provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure? 1. Chest x-ray 2. O2 saturation 3. Arterial blood gases 4. Central venous pressure Arterial blood gas (ABG) analysis is the most specific information because ventilatory failure causes problems with CO2 retention, and ABGs give information about the PaCO2 and pH. Chest x-ray, oxygen saturation, and central venous pressure monitoring may also be done to help in assessing oxygenation or determining the cause of the patient's ventilatory failure. A patient who was admitted with a pulmonary embolism has a change in oxygen saturation (SpO2) from 94% to 88%. Which action would the nurse take? 1. Suction the patient's oropharynx. 2. Increase the prescribed O2 flow rate. 3. Teach the patient to cough and deep breathe. 4. Help the patient to sit in an upright position. Increasing O2 flowrate will usually improve O2 saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation. A patient with respiratory failure is increasingly lethargic, with a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 78%. Which intervention would the nurse anticipate? 1. Administration of 100% O2 by non-rebreather mask 2. Endotracheal intubation and positive pressure ventilation 3. Insertion of a mini-tracheostomy with frequent suctioning 4. Initiation of continuous positive pressure ventilation (CPAP) The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Giving high-flow O2 will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will promote removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange. The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes and a weak cough effort. Which action would the nurse take? 1. Position the patient on the left side. 2. Assist the patient with staged coughing. 3. Place a humidifier in the patient's room. 4. Schedule a 4-hour rest period for the patient. The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 4-hour rest period at this time may allow the O2 saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the left side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung. A nurse is caring for a patient with right lower lobe pneumonia who is obese. Which position will provide the best gas exchange? 1. On the left side 2. On the right side 3. In the tripod position 4. In the high-Fowler's position The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions. The nurse is admitting a patient with possible respiratory failure and a high PaCO2. Which assessment information would the nurse immediately report to the health care provider? 1. The patient appears somnolent (sleepy;drowsy). 2. The patient reports feeling weak. 3. The patient's blood pressure is 164/98. 4. The patient's oxygen saturation is 90%. Increasing somnolence will decrease the patient's respiratory rate and effort and further increase the PaCO2. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest. A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has several drugs prescribed. Which drug would the nurse discuss with the health care provider before giving? 1. Vancomycin (Vancocin) 2. Pantoprazole (Protonix) 3. Sucralfate (Carafate) 4. Methylprednisolone (Solu-Medrol) Vancomycin is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other drugs are appropriate for the patient with ARDS. A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. Which procedure would the nurse anticipate assisting with to determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure? 1. Obtaining a ventilation-perfusion scan 2. Drawing blood for arterial blood gases 3. Positioning the patient for a chest x-ray 4. Inserting a pulmonary artery catheter Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema. A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? 1. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. 2. The patient has subcutaneous emphysema on the upper thorax. 3. The patient has bronchial breath sounds in both the lung fields. 4. The patient has a first-degree atrioventricular heart block with a rate of 58 beats/min. The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns that need to be addressed, but they are not specific indications that PEEP should be reduced. Which statement by the nurse to the patient's caregiver about the purpose of positive end-expiratory pressure (PEEP) is accurate? 1. "PEEP will push more air into the lungs during inhalation." 2. "PEEP prevents the lung air sacs from collapsing during exhalation." 3. "PEEP will prevent lung damage while the patient is on the ventilator." 4. "PEEP allows the breathing machine to deliver 100% O2 to the lungs." By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage (e.g., fibrotic changes that occur with ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient. Prone positioning is being used for a patient with acute respiratory distress syndrome (ARDS). Which information obtained by the nurse indicates that the positioning is effective? 1. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. 2. Endotracheal suctioning results in clear mucous return. 3. Sputum and blood cultures show no growth after 48 hours. 4. The skin on the patient's back is intact and without redness. The purpose of prone positioning is to improve the patient's oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective. The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2 F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action would the nurse take next? 1. Give the scheduled IV antibiotic. 2. Give the PRN acetaminophen (Tylenol). 3. Obtain oxygen saturation using pulse oximetry. 4. Notify the health care provider of these findings. The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Giving the scheduled antibiotic and the PRN acetaminophen will also be done, but they are not the highest priority for a patient who may be developing ARDS. A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? 1. Elevate head of bed to 30 to 45 degrees. 2. Give enteral feedings at no more than 10 mL/hr. 3. Suction the endotracheal tube every 2 to 4 hours. 4. Limit the use of positive end-expiratory pressure. Elevation of the head decreases the risk for aspiration. Positive end-expiratory pressure is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient's high energy needs. A patient admitted with acute respiratory failure is unable to clear thick secretions from the airway. Which nursing intervention would specifically address this patient problem? 1. Encourage use of the incentive spirometer. 2. Offer the patient fluids at frequent intervals. 3. Teach the patient the importance of ambulation. 4. Titrate oxygen level to keep O2 saturation above 93%. Thick, viscous secretions are hard to expel. Adequate fluid intake (2 to 3 L/day) keeps secretions thin and easier to remove, so the best action will be to encourage the patient to improve oral fluid intake. Patients should be instructed to use the incentive spirometer on a regular basis (e.g., every hour) to facilitate the clearance of the secretions. The other actions may be helpful in improving the patient's gas exchange, but they do not address the thick secretions that are causing the poor airway clearance. A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next? 1. Increase the tidal volume and respiratory rate. 2. Decrease the fraction of inspired oxygen (FIO2). 3. Perform endotracheal suctioning more frequently. 4. Lower the positive end-expiratory pressure (PEEP). Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for another pneumothorax. After receiving change-of-shift report on a medical unit, which patient would the nurse assess first? 1. A patient with cystic fibrosis who has thick, green-colored sputum 2. A patient with pneumonia who has crackles bilaterally in the lung bases 3. A patient with emphysema who has an oxygen saturation of 90% to 92% 4. A patient with septicemia who has intercostal and suprasternal retractions This patient's history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of O2 and use of positive-pressure ventilation. The other patients should also be assessed, but their assessment data are typical of their disease processes and do not suggest deterioration in their status. A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department reporting shortness of breath on minimal exertion. Which assessment finding by the nurse would be most important to report to the health care provider? 1. The patient has bibasilar lung crackles. 2. The patient is sitting in the tripod position. 3. The patient's respiratory rate is 10 breaths/min. 4. The patient's pulse oximetry shows a 91% O2 saturation. A drop in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore, immediate action such as positive-pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An O2 saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation. The nurse observes a new onset of agitation and confusion in a patient with chronic obstructive pulmonary disease (COPD). Which action would the nurse take first? 1. Test for facial symmetry. 2. Notify the health care provider. 3. Attempt to calm and reorient the patient. 4. Assess oxygenation using pulse oximetry. Because agitation and confusion are often the initial indicators of hypoxemia, the nurse's initial action should be to assess O2 saturation. The other actions are appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider. The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? 1. The patient's PaO2 is 45 mm Hg. 2. The patient's PaCO2 is 33 mm Hg. 3. The patient's respirations are shallow. 4. The patient's respiratory rate is 32 breaths/min. The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient's poor oxygenation. The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider? 1. Persistent cough of blood-tinged sputum 2. Scattered crackles in the posterior lung bases 3. Oxygen saturation 90% on 100% O2 by non-rebreather mask 4. Temperature 101.5 F (38.6 C) after 2 days of IV antibiotics The patient's low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do need continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite a high O2 flowrate. Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/VN) working in the intensive care unit? 1. Assess breath sounds every hour. 2. Monitor central venous pressures. 3. Place patient in the prone position. 4. Insert an indwelling urinary catheter. Insertion of indwelling urinary catheters is included in LPN/VN education and scope of practice and can be safely delegated to an LPN/VN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff and should be supervised by an RN. Assessment of breath sounds and obtaining central venous pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient. A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation