PT3 Respiratory Lewis NCLEX questions and answers

d. Leave the call light in the patient's hand. Your patient is receiving mechanical ventilation which of the following actions is appropriate for the nursing diagnosis anxiety related to inability to communicate with fear of suffocation? a. Restrain patient to prevent accidental removal of tubes. b. Monitor vital signs hourly. c. Assure the patient that everything will be alright. d. Leave the call light in the patient's hand. d. Peep prevents the air sacs from collapsing during exhalation. Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to a family member of a patient with ARDS (acute respiratory distress syndrome)? 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 air sacs from collapsing during exhalation. c. The patient has asymmetrical chest expansion Which assessment data would indicate a patient diagnosed with ARDS has experienced complications secondary to the ventilator? a. The patient's urine output was 100mls in 2 hours b. Pulse ox reading is 90% c. The patient has asymmetrical chest expansion d. The telemetry shows sinus tachycardia c. The student puts on clean gloves then uses a sterile catheter to suction An RN is observing a student nurse suctioning a patient with a tracheostomy, which action by the nurse requires the RN to intervene? a. The student pre-oxygenates the patient for 2 minutes before functioning b. The student applies suction for 5-10 seconds while withdrawing the catheter c. The student puts on clean gloves then uses a sterile catheter to suction d. The student inserts the catheter 5 inches into the tracheostomy 2. pneumothorax. 5. A patient diagnosed with ARDS is being mechanically ventilated with 12 cm of PEEP. On assessment, the nurse notes deterioration of vital signs and absent breath sounds in the right lung field. The most likely cause for this finding may be a (an) 1. deterioration of the disease. 2. pneumothorax.- 3. decreased cardiac output. 4. obstructed endotracheal tube. d. Verify tidal volume- 6. The nurse notes the following ventilator assist change orders, mode is assist control, which is CMV (constant...) fio2 of 60, Tidal volume of 1600 mls, what nursing intervention is indicated: a. Carry out orders as written b. Verify resp rate of 12 c. Verify the mode d. Verify tidal volume- c. Change the ventilator settings so the patient can breathe spontaneously between set breaths. A patient is being manually weaned from mechanical ventilation. Which of the following should the nurse do to support the patient at this time? a. Turn off the ventilator for the prescribed period of time. b. Calmly reassure the patient and place them on CPAP for one hour prior to extubation. - c. Change the ventilator settings so the patient can breathe spontaneously between set breaths. d. Have intubation equipment at the bedside. b. Your husband may have sleep apnea. Can you tell me more about his behavior?- A patient at the clinic tells the nurse she is exhausted because her husband keeps her awake at night with his loud snoring, jerking, and gasping while he sleeps. The most appropriate response by the nurse is: a. Many obese people snore, is your husband overweight? b. Your husband may have sleep apnea. Can you tell me more about his behavior?- c. have the patient drink a small amount of colored water and observe for coughing and assess for the presence of colored sputum.* The nurse is caring for a spontaneously breathing patient who has a tracheostomy. To determine that the patient can protect the airway when eating without having the tracheostomy cuff inflated, the nurse will deflate the cuff and a. ask the patient to say a few sentences. b. monitor for signs of respiratory distress. c. have the patient drink a small amount of colored water and observe for coughing and assess for the presence of colored sputum.* d. auscultate the lungs for crackles after having the patient take a few sips of water. Pre-oxygenate for several breaths.* Auscultation of the thorax reveals bilateral bronchi in the anterior lungs field, you determine this patient needs to be suctioned. Which of the following strategies would you use? a. Place the patient in a supine position. b. Apply suction continuously. c. Suction for 45 seconds. d. Pre-oxygenate for several breaths.* a. The respiratory rate is 32 breaths/min.* Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The respiratory rate is 32 breaths/min.* b. The pulse oximeter shows a SpO2 of 95%. c. The patient has not been d. suctioned for the last 6 hours. e. The lungs have occasional audible expiratory wheezes. a. Attempt to reinsert the tube* A patient with an uncuffed tracheostomy tube coughs violently during a suctioning and dislodges the trach tube. What action should the nurse take 1st? a. Attempt to reinsert the tube* b. Call the physician c. Observe and document d. Apply oxygen mask at 6L. Assess for the cause of the alarm* (check the patient) The nurse responds to a ventilator pressure alarm by going into the patient's room. What should the nurse's first action be? Which actions should the nurse initiate to reduce the risk for ventilator-associated pneumonia (VAP)? Select all that apply. a. Obtain arterial blood gases daily. b. Elevate the head of the bed to at least 30°. (30-45 degrees) c. Give prescribed pantoprazole (Protonix). * (prevents or treats stress ulcers) d. Provide oral care with chlorhexidine (0.12%) BID. (twice a day - q12 hrs) Decrease the respiratory rate Four hours after mechanical ventilation is initiated for a patient with COPD, the patient's arterial blood gas results in a pH of 7.51, paO2 of 81 mmHg, paCO2 of 26, bicarb of 23, the nurse will anticipate the need to: Manually ventilate the patient with 100% oxygen. The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). The oxygen saturation rate is 82%. Which action should the nurse take next? c. Ensure the airway is clear and patent* A patient who is endotracheally intubated with mechanical ventilation has a decreasing oxygen saturation level with an increase in heart rate, which of the following should the nurse do first? a. Notify respiratory therapy to adjust the settings b. Auscultate lung sounds c. Ensure the airway is clear and patent* d. Reposition the patient b. ventilate with a manual resuscitation bag* The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first? a. notify the respiratory therapist immediately b. ventilate with a manual resuscitation bag* c. request STAT ABG d. auscultate the client's lung sounds Prevent alveolar collapse by keeping the lungs partially expanded during expiration * The nurse anticipates that PEEP will be used when a patient with acute respiratory distress syndrome is placed on the mechanical ventilator in order to: a. Prevent the fibrotic infiltration of the lung tissue b. Apply positive pressure during inhalation to fully inflate the lungs c. Apply delivery of 100% oxygen to the lungs under pressure d. Prevent alveolar collapse by keeping the lungs partially expanded during expiration * c. Injury to the alveolar capillary membrane* The nurse recognizes that the primary physiologic problem initiated in the pulmonary changes occuring in an acute respiratory distress syndrome is; a. Increased production of surfactant (it's the opposite) b. Remodeling of the lungs by fibrotic tissue (this occurs in late late ARDs) c. Injury to the alveolar capillary membrane* d. Capillary damage from pulmonary hypertension (occurs from pulmonary edema and overtime from pulmonary hypertension) b. Hypoxemia* A patient is demonstrating signs and symptoms of oxygen failure, the nurse realizes that this patient's primary problem is a. Acidosis b. Hypoxemia* c. Respiratory Alkalosis d. Hypercapnia a. Pneumonia with sepsis* Of the following patient diagnoses, the nurse realizes that the one that is most predisposed to developing this has acute lung injury/ARDs would be the patient that is admitted with : a. Pneumonia with sepsis* b. Drug overdosed c. Severe head injury d. Severe chest contusion b. Hypoxemia refractory to oxygen therapy* (because oxygen can't get through the fluid in the alveoli) The nurse is caring for a patient with ARDs, which finding would indicate that this disease is progressing a.Increased lung compliance a. Respiratory alkalosis b. Hypoxemia refractory to oxygen therapy* (because oxygen can't get through the fluid in the alveoli) c. Respiratory acidosis