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NUR 417
NUR 417 Care of Adult II Exam 2: Care of Adult II – 2025
Actual Questions and Answers- Concordia University St.
Paul.
1. 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.: 1. Verbally
coach the patient to breathe with the ventilator.
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
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the ventilator. the other actions may also be helpful if the verbal coaching is
ineffective in reducing the patient's anxiety.
2. 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.: 2. Using
a closed-suction technique when suctioning is needed.
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.
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Ventilator tubing changes increase the risk for ventilator-associated
pneumonia and are not indicated routinely.
3. 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.: 1.
New dysrhythmias are observed on the cardiac monitor.
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.
5. After change-of-shift report, which patient would the nurse assess first?
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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): 3. Patient who was successfully weaned and extubated 4
hours ago and has no urine output for the last 6 hours
5. 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%.
NUR 417
NUR 417
NUR 417 Care of Adult II Exam 2: Care of Adult II – 2025
Actual Questions and Answers- Concordia University St.
Paul.
1. 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.: 1. Verbally
coach the patient to breathe with the ventilator.
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
NUR 417
, 2
NUR 417
the ventilator. the other actions may also be helpful if the verbal coaching is
ineffective in reducing the patient's anxiety.
2. 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.: 2. Using
a closed-suction technique when suctioning is needed.
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.
NUR 417
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NUR 417
Ventilator tubing changes increase the risk for ventilator-associated
pneumonia and are not indicated routinely.
3. 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.: 1.
New dysrhythmias are observed on the cardiac monitor.
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.
5. After change-of-shift report, which patient would the nurse assess first?
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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): 3. Patient who was successfully weaned and extubated 4
hours ago and has no urine output for the last 6 hours
5. 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%.
NUR 417
