CCN exam 1 questions & answers
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 - ANSWERSANS: 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. - ANSWERSANS: 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). - ANSWERSANS: 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. - ANSWERSANS: 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. - ANSWERSANS: 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. - ANSWERSANS: 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 - ANSWERSANS: 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.
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 - ANSWERSANS: 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. - ANSWERSANS: 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). - ANSWERSANS: 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. - ANSWERSANS: 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. - ANSWERSANS: 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. - ANSWERSANS: 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 - ANSWERSANS: 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.
