CCN Exam 1 With All Correct & 100% Verified Answers
|Actual Complete Exam |Already Graded A+
To evaluate the effectiveness of prescribed therapies for a patient with ventilatory failure, which
diagnostic test will be most useful to the nurse?
a. Chest x-rays
b. Pulse oximetry
c. Arterial blood gas (ABG) analysis
d. Pulmonary artery pressure monitoring ✔Correct Answer-ANS: C
ABG analysis is most useful in this setting because ventilatory failure causes problems with CO2
retention, and ABGs provide information about the PaCO2 and pH. The other tests also may be done
to help in assessing oxygenation or determining the cause of the patient's ventilatory failure.
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a
change in the patient's oxygen saturation (SpO2) from 94% to 88%. The nurse will
a. increase the oxygen flow rate.
b. suction the patient's oropharynx.
c. assist the patient to cough and deep breathe.
d. help the patient to sit in a more upright position. ✔Correct Answer-ANS: A
Increasing oxygen flow rate usually will improve oxygen 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 has a respiratory rate of 8 and an SpO2 of 89%. The patient is
increasingly lethargic. The nurse will anticipate assisting with
a. administration of 100% oxygen by non-rebreather mask.
b. endotracheal intubation and positive pressure ventilation.
c. insertion of a mini-tracheostomy with frequent suctioning.
d. initiation of bilevel positive pressure ventilation (BiPAP). ✔Correct Answer-ANS: B
The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation
with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful
because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate
removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. BiPAP
requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.
The pulse oximetry for a patient with right lower lobe pneumonia indicates an oxygen saturation of
90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is best for
the nurse to take?
a. Position the patient on the right side.
b. Place a humidifier in the patient's room.
c. Assist the patient with staged coughing.
d. Schedule a 2-hour rest period for the patient. ✔Correct Answer-ANS: C
The patient's assessment indicates that assisted coughing is needed to help remove secretions,
which will improve oxygenation. A 2-hour rest period at this time may allow the oxygen saturation to
drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on
the right side may cause a further decrease in oxygen saturation because perfusion will be directed
more toward the more poorly ventilated lung.
,When the nurse is caring for an obese patient with left lower lobe pneumonia, gas exchange will be
best when the patient is positioned
a. on the left side.
b. on the right side.
c. in the tripod position.
d. in the high-Fowler's position. ✔Correct Answer-ANS: B
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.
When admitting a patient in possible respiratory failure with a high PaCO2, which assessment
information will be of most concern to the nurse?
a. The patient is somnolent.
b. The patient's SpO2 is 90%.
c. The patient complains of weakness.
d. The patient's blood pressure is 162/94. ✔Correct Answer-ANS: A
Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2
and respiratory failure. 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 renal failure has the following
medications prescribed. Which medication should the nurse discuss with the health care provider
before administration?
a. ranitidine (Zantac) 50 mg IV
b. gentamicin (Garamycin) 60 mg IV
c. sucralfate (Carafate) 1 g per nasogastric tube
d. methylprednisolone (Solu-Medrol) 40 mg IV ✔Correct Answer-ANS: B
Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse
should clarify the drug and dosage with the health care provider before administration. The other
medications are appropriate for the patient with ARDS.
A patient develops increasing dyspnea and hypoxemia 2 days after having cardiac surgery. To
determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema
caused by left ventricular failure, the nurse will anticipate assisting with
a. inserting a pulmonary artery catheter.
b. obtaining a ventilation-perfusion scan.
c. drawing blood for arterial blood gases.
d. positioning the patient for a chest radiograph. ✔Correct Answer-ANS: A
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.
Which assessment finding by the nurse when caring for a patient with ARDS who is being treated
with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates that
the PEEP may need to be decreased?
a. The patient has subcutaneous emphysema.
b. The patient has a sinus bradycardia with a rate of 52.
c. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%.
d. The patient has bronchial breath sounds in both the lung fields. ✔Correct Answer-ANS: A
, The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and
PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be
addressed, but they are not indications that PEEP should be reduced.
Which statement by the nurse when explaining the purpose of positive end-expiratory pressure
(PEEP) to the family members of a patient with ARDS is correct?
a. "PEEP will prevent fibrosis of the lung from occurring."
b. "PEEP will push more air into the lungs during inhalation."
c. "PEEP allows the ventilator to deliver 100% oxygen to the lungs."
d. "PEEP prevents the lung air sacs from collapsing during exhalation." ✔Correct Answer-ANS: D
By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation.
PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or
change the fraction of inspired oxygen (FIO2) delivered to the patient.
When prone positioning is used in the care of a patient with acute respiratory distress syndrome
(ARDS), which information obtained by the nurse indicates that the positioning is effective?
a. The patient's PaO2 is 90 mm Hg, and the SaO2 is 92%.
b. Endotracheal suctioning results in minimal mucous return.
c. Sputum and blood cultures show no growth after 24 hours.
d. The skin on the patient's back is intact and without redness. ✔Correct Answer-ANS: A
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 obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis:
temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should
the nurse take next?
a. Administer the scheduled IV antibiotic.
b. Give the PRN acetaminophen (Tylenol) 650 mg.
c. Obtain oxygen saturation using pulse oximetry.
d. Notify the health care provider of the patient's vital signs. ✔Correct Answer-ANS: C
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. Administration of the scheduled antibiotic and
administration of Tylenol also will be done, but they are not the highest priority for a patient who
may be developing ARDS
To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the
plan of care for a patient who requires intubation and mechanical ventilation?
a. Avoid use of positive end-expiratory pressure (PEEP).
b. Suction every 2 hours.
c. Elevate head of bed to 30 to 45 degrees.
d. Give enteral feedings at no more than 10 mL/hr. ✔Correct Answer-ANS: C
Elevation of the head decreases the risk for aspiration. PEEP 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 has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which
action will be best for the nurse to include in the plan of care?
|Actual Complete Exam |Already Graded A+
To evaluate the effectiveness of prescribed therapies for a patient with ventilatory failure, which
diagnostic test will be most useful to the nurse?
a. Chest x-rays
b. Pulse oximetry
c. Arterial blood gas (ABG) analysis
d. Pulmonary artery pressure monitoring ✔Correct Answer-ANS: C
ABG analysis is most useful in this setting because ventilatory failure causes problems with CO2
retention, and ABGs provide information about the PaCO2 and pH. The other tests also may be done
to help in assessing oxygenation or determining the cause of the patient's ventilatory failure.
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a
change in the patient's oxygen saturation (SpO2) from 94% to 88%. The nurse will
a. increase the oxygen flow rate.
b. suction the patient's oropharynx.
c. assist the patient to cough and deep breathe.
d. help the patient to sit in a more upright position. ✔Correct Answer-ANS: A
Increasing oxygen flow rate usually will improve oxygen 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 has a respiratory rate of 8 and an SpO2 of 89%. The patient is
increasingly lethargic. The nurse will anticipate assisting with
a. administration of 100% oxygen by non-rebreather mask.
b. endotracheal intubation and positive pressure ventilation.
c. insertion of a mini-tracheostomy with frequent suctioning.
d. initiation of bilevel positive pressure ventilation (BiPAP). ✔Correct Answer-ANS: B
The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation
with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful
because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate
removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. BiPAP
requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.
The pulse oximetry for a patient with right lower lobe pneumonia indicates an oxygen saturation of
90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is best for
the nurse to take?
a. Position the patient on the right side.
b. Place a humidifier in the patient's room.
c. Assist the patient with staged coughing.
d. Schedule a 2-hour rest period for the patient. ✔Correct Answer-ANS: C
The patient's assessment indicates that assisted coughing is needed to help remove secretions,
which will improve oxygenation. A 2-hour rest period at this time may allow the oxygen saturation to
drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on
the right side may cause a further decrease in oxygen saturation because perfusion will be directed
more toward the more poorly ventilated lung.
,When the nurse is caring for an obese patient with left lower lobe pneumonia, gas exchange will be
best when the patient is positioned
a. on the left side.
b. on the right side.
c. in the tripod position.
d. in the high-Fowler's position. ✔Correct Answer-ANS: B
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.
When admitting a patient in possible respiratory failure with a high PaCO2, which assessment
information will be of most concern to the nurse?
a. The patient is somnolent.
b. The patient's SpO2 is 90%.
c. The patient complains of weakness.
d. The patient's blood pressure is 162/94. ✔Correct Answer-ANS: A
Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2
and respiratory failure. 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 renal failure has the following
medications prescribed. Which medication should the nurse discuss with the health care provider
before administration?
a. ranitidine (Zantac) 50 mg IV
b. gentamicin (Garamycin) 60 mg IV
c. sucralfate (Carafate) 1 g per nasogastric tube
d. methylprednisolone (Solu-Medrol) 40 mg IV ✔Correct Answer-ANS: B
Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse
should clarify the drug and dosage with the health care provider before administration. The other
medications are appropriate for the patient with ARDS.
A patient develops increasing dyspnea and hypoxemia 2 days after having cardiac surgery. To
determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema
caused by left ventricular failure, the nurse will anticipate assisting with
a. inserting a pulmonary artery catheter.
b. obtaining a ventilation-perfusion scan.
c. drawing blood for arterial blood gases.
d. positioning the patient for a chest radiograph. ✔Correct Answer-ANS: A
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.
Which assessment finding by the nurse when caring for a patient with ARDS who is being treated
with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates that
the PEEP may need to be decreased?
a. The patient has subcutaneous emphysema.
b. The patient has a sinus bradycardia with a rate of 52.
c. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%.
d. The patient has bronchial breath sounds in both the lung fields. ✔Correct Answer-ANS: A
, The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and
PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be
addressed, but they are not indications that PEEP should be reduced.
Which statement by the nurse when explaining the purpose of positive end-expiratory pressure
(PEEP) to the family members of a patient with ARDS is correct?
a. "PEEP will prevent fibrosis of the lung from occurring."
b. "PEEP will push more air into the lungs during inhalation."
c. "PEEP allows the ventilator to deliver 100% oxygen to the lungs."
d. "PEEP prevents the lung air sacs from collapsing during exhalation." ✔Correct Answer-ANS: D
By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation.
PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or
change the fraction of inspired oxygen (FIO2) delivered to the patient.
When prone positioning is used in the care of a patient with acute respiratory distress syndrome
(ARDS), which information obtained by the nurse indicates that the positioning is effective?
a. The patient's PaO2 is 90 mm Hg, and the SaO2 is 92%.
b. Endotracheal suctioning results in minimal mucous return.
c. Sputum and blood cultures show no growth after 24 hours.
d. The skin on the patient's back is intact and without redness. ✔Correct Answer-ANS: A
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 obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis:
temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should
the nurse take next?
a. Administer the scheduled IV antibiotic.
b. Give the PRN acetaminophen (Tylenol) 650 mg.
c. Obtain oxygen saturation using pulse oximetry.
d. Notify the health care provider of the patient's vital signs. ✔Correct Answer-ANS: C
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. Administration of the scheduled antibiotic and
administration of Tylenol also will be done, but they are not the highest priority for a patient who
may be developing ARDS
To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the
plan of care for a patient who requires intubation and mechanical ventilation?
a. Avoid use of positive end-expiratory pressure (PEEP).
b. Suction every 2 hours.
c. Elevate head of bed to 30 to 45 degrees.
d. Give enteral feedings at no more than 10 mL/hr. ✔Correct Answer-ANS: C
Elevation of the head decreases the risk for aspiration. PEEP 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 has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which
action will be best for the nurse to include in the plan of care?
