Fundamentals Exam 2 Evolve (Clinical
Nursing Skills Book) UPDATED ACTUAL
Exam Questions and CORRECT Answers
Use of noninvasive positive-pressure ventilation (CPAP or BiPAP) has the potential to cause
carbon dioxide retention in selected patients. Patients with which of the following underlying
diagnoses are at greatest risk for carbon dioxide retention? - CORRECT ANSWER -
Chronic obstructive pulmonary disease
(Side Note: Patients diagnosed with COPD who have ventilatory failure are at risk to retain
carbon dioxide. Patients with heart failure, pulmonary fibrosis, or pulmonary edema are at
greatest risk for oxygen failure.)
A patient with pulmonary edema had BiPAP started 30 minutes ago. The nurse should inform the
patient that he will undergo which diagnostic test shortly? - CORRECT ANSWER -
Arterial blood gas
(Side Note: When a patient is placed on noninvasive positive-pressure ventilation (BiPAP), it is
necessary to evaluate the oxygenation and ventilation status of the patient. Although an arterial
blood gas is an invasive procedure, it is important to know the patient's oxygen and carbon
dioxide levels. Chest X-ray will provide information on fluid overload, and a pulmonary function
test is inappropriate when a patient is acutely ill. A pulse oximetry reading would yield
information on oxygenation.)
The low-pressure alarm has sounded on a patient's ventilator. The nurse should check for which
of the following situations? - CORRECT ANSWER - The ventilator circuit has a leak.
(Side Note: The two most common causes for the low-pressure alarm sounding (indicating a
sudden drop in pressure) are a leak in the ventilate circuit or the patient tube becoming
disconnected from the ventilator. Patient coughing or biting on the ET tube may cause the high
pressure alarm to sound. Secretions building up in the airway may cause a decrease in the
pressure but not a sudden drop. Suctioning is the correct way to address that situation when
identified.)
, A patient is to be placed on a ventilator. Which nursing action has been found to be most
effective in reducing ventilator-associated pneumonia? - CORRECT ANSWER -
Performing mouth care at least four times a day
(Side Note: Studies have shown that frequent mouth care decreases the incidence of ventilator-
associated pneumonia. The other procedures are important to do, but they do not affect the
incidence of ventilator-associated pneumonia.)
Which of the following are signs and symptoms of a tension pneumothorax? (Select all that
apply.) - CORRECT ANSWER - 1. Tachycardia
2. Distended neck veins
3. Hypotension
(Side Note: Distended neck veins, hypotension, and tachycardia are cardinal signs of a tension
pneumothorax. Option "C," hypertension, is not normally seen in a tension pneumothorax.)
Before discharge, the nurse designs a patient teaching plan to help the patient and family
correctly perform chest physiotherapy. Why is this teaching an important aspect of patient
safety? - CORRECT ANSWER - Because patients and families need to know changes or
effects associated with chest PT and when to notify the health care provider
A patient is receiving chest physiotherapy in the home setting. The home health nurse observes
the session and notes that the patient is not tolerating the procedure well. Which of the following
is the best choice for modifying care? - CORRECT ANSWER - Suggest using an Acapella
device.
(Side Note: An Acapella device in conjunction with CPT maneuvers provides airway vibration
and assists in clearing the airways. Reducing treatment sessions at all is not acceptable because
the patient needs the therapy. The nurse may shorten the session if the patient is able to clear the
airway with a shorter session. Administering a bronchodilator requires an order from the health
care provider; this would take some time, and the nurse can institute other therapies. Letting the
Nursing Skills Book) UPDATED ACTUAL
Exam Questions and CORRECT Answers
Use of noninvasive positive-pressure ventilation (CPAP or BiPAP) has the potential to cause
carbon dioxide retention in selected patients. Patients with which of the following underlying
diagnoses are at greatest risk for carbon dioxide retention? - CORRECT ANSWER -
Chronic obstructive pulmonary disease
(Side Note: Patients diagnosed with COPD who have ventilatory failure are at risk to retain
carbon dioxide. Patients with heart failure, pulmonary fibrosis, or pulmonary edema are at
greatest risk for oxygen failure.)
A patient with pulmonary edema had BiPAP started 30 minutes ago. The nurse should inform the
patient that he will undergo which diagnostic test shortly? - CORRECT ANSWER -
Arterial blood gas
(Side Note: When a patient is placed on noninvasive positive-pressure ventilation (BiPAP), it is
necessary to evaluate the oxygenation and ventilation status of the patient. Although an arterial
blood gas is an invasive procedure, it is important to know the patient's oxygen and carbon
dioxide levels. Chest X-ray will provide information on fluid overload, and a pulmonary function
test is inappropriate when a patient is acutely ill. A pulse oximetry reading would yield
information on oxygenation.)
The low-pressure alarm has sounded on a patient's ventilator. The nurse should check for which
of the following situations? - CORRECT ANSWER - The ventilator circuit has a leak.
(Side Note: The two most common causes for the low-pressure alarm sounding (indicating a
sudden drop in pressure) are a leak in the ventilate circuit or the patient tube becoming
disconnected from the ventilator. Patient coughing or biting on the ET tube may cause the high
pressure alarm to sound. Secretions building up in the airway may cause a decrease in the
pressure but not a sudden drop. Suctioning is the correct way to address that situation when
identified.)
, A patient is to be placed on a ventilator. Which nursing action has been found to be most
effective in reducing ventilator-associated pneumonia? - CORRECT ANSWER -
Performing mouth care at least four times a day
(Side Note: Studies have shown that frequent mouth care decreases the incidence of ventilator-
associated pneumonia. The other procedures are important to do, but they do not affect the
incidence of ventilator-associated pneumonia.)
Which of the following are signs and symptoms of a tension pneumothorax? (Select all that
apply.) - CORRECT ANSWER - 1. Tachycardia
2. Distended neck veins
3. Hypotension
(Side Note: Distended neck veins, hypotension, and tachycardia are cardinal signs of a tension
pneumothorax. Option "C," hypertension, is not normally seen in a tension pneumothorax.)
Before discharge, the nurse designs a patient teaching plan to help the patient and family
correctly perform chest physiotherapy. Why is this teaching an important aspect of patient
safety? - CORRECT ANSWER - Because patients and families need to know changes or
effects associated with chest PT and when to notify the health care provider
A patient is receiving chest physiotherapy in the home setting. The home health nurse observes
the session and notes that the patient is not tolerating the procedure well. Which of the following
is the best choice for modifying care? - CORRECT ANSWER - Suggest using an Acapella
device.
(Side Note: An Acapella device in conjunction with CPT maneuvers provides airway vibration
and assists in clearing the airways. Reducing treatment sessions at all is not acceptable because
the patient needs the therapy. The nurse may shorten the session if the patient is able to clear the
airway with a shorter session. Administering a bronchodilator requires an order from the health
care provider; this would take some time, and the nurse can institute other therapies. Letting the
