NUR417 / NUR 417 EXAM 2
Care of Adult II
Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
100% Guarantee Pass.
Expert Verified Explanation
Multiple choice (single best answer)
Select All That Apply (SATA)
Fill-in-the-blank
Case Studies/Scenario-Based Questions
,A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD)
from mechanical ventilation. Which patient assessment finding indicates that the weaning
protocol should be stopped?
a. The patient's heart rate is 97 beats/min.
b. The patient's oxygen saturation is 93%.
c. The patient respiratory rate is 32 breaths/min.
d. The patient's spontaneous tidal volume is 450 mL.
ANSWER
C
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 educator is evaluating the performance of a new registered nurse (RN) who is
providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak
end-expiratory pressure (PEEP). Which action indicates that the new RN is safe?
a. The RN plans to suction the patient every 1 to 2 hours.
b. The RN uses a closed-suction technique to suction the patient.
c. The RN tapes the connection between the ventilator tubing and the ET.
d. The RN changes the ventilator circuit tubing routinely every 48 hours.
ANSWER
B
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.
,After change-of-shift report on a ventilator weaning unit, which patient should the nurse
assess first?
a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the
ventilator
b. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2)
monitoring
c. Patient who was successfully weaned and extubated 4 hours ago and has no urine output
for the last 6 hours
d. Patient with a central venous O2 saturation (ScvO2) of 69% while on bilevel positive
airway pressure (BiPAP)
ANSWER
C
The decreased urine output may indicate acute kidney injury or that the patient's cardiac
output and perfusion of vital organs have decreased. Any of these causes would require rapid
action. The data about the other patients indicate that their conditions are stable and do not
require immediate assessment or changes in their care. Continuous PETCO2 monitoring is
frequently used when patients are intubated. The rest mode should be used to allow patient
recovery after a failed SBT, and an ScvO2 of 69% is within normal limits.
DIF: Cognitive Level: Apply (application)
A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD)
from mechanical ventilation. Which patient assessment finding indicates that the weaning
protocol should be stopped?
a. The patient's heart rate is 97 beats/min.
b. The patient's oxygen saturation is 93%.
c. The patient respiratory rate is 32 breaths/min.
d. The patient's spontaneous tidal volume is 450 mL.
ANSWER
C
, 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.
A patient who is receiving positive pressure ventilation is scheduled for a spontaneous
breathing trial (SBT). Which finding by the nurse is most likely to result in postponing the
SBT?
a. New ST segment elevation is noted on the cardiac monitor.
b. Enteral feedings are being given through an orogastric tube.
c. Scattered rhonchi are heard when auscultating breath sounds.
d. hydromorphone (Dilaudid) is being used to treat postoperative pain
Answer
A. ) new st segment elevation
Myocardial ischemia is a contraindication for ventilator weaning. The ST segment elevation
is an indication that weaning should be postponed until further investigation and/or
treatment for myocardial ischemia can be done. Ventilator weaning can proceed when
opioids are used for pain management, abnormal lung sounds are present, or enteral feedings
are being used.
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?
a. Reposition the patient every 1 to 2 hours.
b. Increase suctioning frequency to every hour.
c. Add additional water to the patient's enteral feedings.
d. Instill 5 mL of sterile saline into the ET before suctioning.
ANSWER
C
Care of Adult II
Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
100% Guarantee Pass.
Expert Verified Explanation
Multiple choice (single best answer)
Select All That Apply (SATA)
Fill-in-the-blank
Case Studies/Scenario-Based Questions
,A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD)
from mechanical ventilation. Which patient assessment finding indicates that the weaning
protocol should be stopped?
a. The patient's heart rate is 97 beats/min.
b. The patient's oxygen saturation is 93%.
c. The patient respiratory rate is 32 breaths/min.
d. The patient's spontaneous tidal volume is 450 mL.
ANSWER
C
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 educator is evaluating the performance of a new registered nurse (RN) who is
providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak
end-expiratory pressure (PEEP). Which action indicates that the new RN is safe?
a. The RN plans to suction the patient every 1 to 2 hours.
b. The RN uses a closed-suction technique to suction the patient.
c. The RN tapes the connection between the ventilator tubing and the ET.
d. The RN changes the ventilator circuit tubing routinely every 48 hours.
ANSWER
B
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.
,After change-of-shift report on a ventilator weaning unit, which patient should the nurse
assess first?
a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the
ventilator
b. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2)
monitoring
c. Patient who was successfully weaned and extubated 4 hours ago and has no urine output
for the last 6 hours
d. Patient with a central venous O2 saturation (ScvO2) of 69% while on bilevel positive
airway pressure (BiPAP)
ANSWER
C
The decreased urine output may indicate acute kidney injury or that the patient's cardiac
output and perfusion of vital organs have decreased. Any of these causes would require rapid
action. The data about the other patients indicate that their conditions are stable and do not
require immediate assessment or changes in their care. Continuous PETCO2 monitoring is
frequently used when patients are intubated. The rest mode should be used to allow patient
recovery after a failed SBT, and an ScvO2 of 69% is within normal limits.
DIF: Cognitive Level: Apply (application)
A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD)
from mechanical ventilation. Which patient assessment finding indicates that the weaning
protocol should be stopped?
a. The patient's heart rate is 97 beats/min.
b. The patient's oxygen saturation is 93%.
c. The patient respiratory rate is 32 breaths/min.
d. The patient's spontaneous tidal volume is 450 mL.
ANSWER
C
, 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.
A patient who is receiving positive pressure ventilation is scheduled for a spontaneous
breathing trial (SBT). Which finding by the nurse is most likely to result in postponing the
SBT?
a. New ST segment elevation is noted on the cardiac monitor.
b. Enteral feedings are being given through an orogastric tube.
c. Scattered rhonchi are heard when auscultating breath sounds.
d. hydromorphone (Dilaudid) is being used to treat postoperative pain
Answer
A. ) new st segment elevation
Myocardial ischemia is a contraindication for ventilator weaning. The ST segment elevation
is an indication that weaning should be postponed until further investigation and/or
treatment for myocardial ischemia can be done. Ventilator weaning can proceed when
opioids are used for pain management, abnormal lung sounds are present, or enteral feedings
are being used.
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?
a. Reposition the patient every 1 to 2 hours.
b. Increase suctioning frequency to every hour.
c. Add additional water to the patient's enteral feedings.
d. Instill 5 mL of sterile saline into the ET before suctioning.
ANSWER
C
