NR 341 COMPLEX EXAM 1 QUESTIONS WITH
COMPLETE SOLUTIONS
advocacy Correct Answers represent for patient
Airway Adjuncts Correct Answers •Oral & Nasopharyngeal
airways
oral: no intact gag or cough reflex
alarms in respiratory Correct Answers •Never turn off*
•Manually ventilate if unsure of problem
•if goes off-- assess patient *- if stable then troubleshoot. if you
still cannot find problem then ambu bag until respiratory comes
•Low pressure alarm: low volume exhaled, disconnections, tube
is dislodged
•High pressure alarm: increased secretions, kink in tubing, biting
on tube, coughing (bronchospasm)
•Apnea alarm: no respirations
apnea alarm Correct Answers no respirations
artificial airways Correct Answers -Oropharyngeal
-Nasopharyngeal
-Endotracheal
-Tracheostomy
should not be used for no more than 50 days
*chest x-ray to verify placement (gold standard)
End tidal CO2 detector: purple to gold or yellow (second option
for placement)
,autonomy Correct Answers Autonomy-Self-determination
(advance directives/POA (healthcare ploxy))
ploxy goes into effect when patient can no longer make
decisions
patient can change person anytime they want
does not have to be family member
beneficence Correct Answers doing good- intent to benefit
Benzodiazepine AE Correct Answers Paradoxical (opposite)
effect
hypotension
tachycardia
delirium
respiratory depression
Benzodiazepine desired effect Correct Answers treat delirium
maintain anesthesia and amnesia
Benzodiazepine reversal agent Correct Answers Flumazenil
(Romazicon)
Benzodiazepines Correct Answers Anxiety
sedation
pain
alcohol withdrawal
Midazolam
Lorazepam
, Bi-level Continuous Airway Pressure (BiPAP) Correct Answers
two types of pressure. Higher pressure on inhalation, low
pressure on exhalation.
Want to make sure able to remove to prevent aspiration
complications of mechanical ventilation Correct Answers
Unplanned extubation: patient pulls out tube, not sedated
enough, severely agitated, improper monitoring, improper use of
restraints
Vent associated pneumonia (VAP): preventable nosocomial
infection
Stress ulcers: PPI/TPN/enteral feedings
Oxygen toxicity: 50% or greater FiO2. can see hypoxia,
crackles, dyspnea
Mucosal damage: reposition side to side every 24 hours. Every
shiftà document where tube is located / placement
Laryngeal injury: cuff is too inflated
Hypotension: high PEEP levels
ETT malposition: look at number at lip and teeth and chart every
shift for placement
If self extubate: assess patient
Confidentiality Correct Answers Protect information
COPD & Emphysema Correct Answers COPD: mucus
production
hypoxemia, hyperventilation, accessory muscle use, secretions,
rhonchi
EMPYSEMIA: alveoli are damage and hyperinflated
COMPLETE SOLUTIONS
advocacy Correct Answers represent for patient
Airway Adjuncts Correct Answers •Oral & Nasopharyngeal
airways
oral: no intact gag or cough reflex
alarms in respiratory Correct Answers •Never turn off*
•Manually ventilate if unsure of problem
•if goes off-- assess patient *- if stable then troubleshoot. if you
still cannot find problem then ambu bag until respiratory comes
•Low pressure alarm: low volume exhaled, disconnections, tube
is dislodged
•High pressure alarm: increased secretions, kink in tubing, biting
on tube, coughing (bronchospasm)
•Apnea alarm: no respirations
apnea alarm Correct Answers no respirations
artificial airways Correct Answers -Oropharyngeal
-Nasopharyngeal
-Endotracheal
-Tracheostomy
should not be used for no more than 50 days
*chest x-ray to verify placement (gold standard)
End tidal CO2 detector: purple to gold or yellow (second option
for placement)
,autonomy Correct Answers Autonomy-Self-determination
(advance directives/POA (healthcare ploxy))
ploxy goes into effect when patient can no longer make
decisions
patient can change person anytime they want
does not have to be family member
beneficence Correct Answers doing good- intent to benefit
Benzodiazepine AE Correct Answers Paradoxical (opposite)
effect
hypotension
tachycardia
delirium
respiratory depression
Benzodiazepine desired effect Correct Answers treat delirium
maintain anesthesia and amnesia
Benzodiazepine reversal agent Correct Answers Flumazenil
(Romazicon)
Benzodiazepines Correct Answers Anxiety
sedation
pain
alcohol withdrawal
Midazolam
Lorazepam
, Bi-level Continuous Airway Pressure (BiPAP) Correct Answers
two types of pressure. Higher pressure on inhalation, low
pressure on exhalation.
Want to make sure able to remove to prevent aspiration
complications of mechanical ventilation Correct Answers
Unplanned extubation: patient pulls out tube, not sedated
enough, severely agitated, improper monitoring, improper use of
restraints
Vent associated pneumonia (VAP): preventable nosocomial
infection
Stress ulcers: PPI/TPN/enteral feedings
Oxygen toxicity: 50% or greater FiO2. can see hypoxia,
crackles, dyspnea
Mucosal damage: reposition side to side every 24 hours. Every
shiftà document where tube is located / placement
Laryngeal injury: cuff is too inflated
Hypotension: high PEEP levels
ETT malposition: look at number at lip and teeth and chart every
shift for placement
If self extubate: assess patient
Confidentiality Correct Answers Protect information
COPD & Emphysema Correct Answers COPD: mucus
production
hypoxemia, hyperventilation, accessory muscle use, secretions,
rhonchi
EMPYSEMIA: alveoli are damage and hyperinflated
