NURS 432 Respiratory Review questions with
accurate answers
. The primary care provider orders the following mechanical ventilation
settings for a patient who weighs 75 kg and whose spontaneous
respiratory rate is 22 breaths/min. What arterial blood gas abnormality
may occur if the patient continues to be tachypneic at these ventilator
settings?Settings:
Tidal volume: 600 mL (8 mL per kg) FiO2: 0.5
Respiratory rate: 14 breaths/min Mode assist/control
Positive end-expiratory pressure: 10 cm H2O
A.Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis Ans✓✓✓ D. Respiratory alkalosis
1. A nurse answers a call light and finds a client anxious, short of breath,
reporting chest pain, and has a blood pressure of 88/52 mm Hg. What
action by the nurse takes priority?
a. Assess the client's lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs. Ans✓✓✓ ANS: B
This client has signs and symptoms of a pulmonary embolism, and the
most critical action is to notify the Rapid Response Team for speedy
,diagnosis and treatment. The other actions are appropriate also but are
not the priority.
1. A nurse is caring for five clients. For which clients would the nurse
assess a high risk for developing a pulmonary embolism (PE)? (Select
all that apply.)
a. Client who had a reaction to contrast dye yesterday
b. Client with a new spinal cord injury on a rotating bed
c. Middle-age client with an exacerbation of asthma
d. Older client who is 1 day post-hip replacement surgery
e. Young obese client with a fractured femur
f. Middle-age adult with a history of deep vein thrombosis Ans✓✓✓
ANS: B,D,E
Conditions that place clients at higher risk of developing PE include
prolonged immobility, central venous catheters, surgery, obesity,
advancing age, conditions that increase blood clotting, history of
thromboembolism, smoking, pregnancy, estrogen therapy, heart failure,
stroke, cancer (particularly lung or prostate), and trauma. A contrast dye
reaction and asthma pose no risk for PE.
10. A client with acute respiratory failure is on a ventilator and is
sedated. What care may the nurse delegate to the assistive personnel
AP)?
a. Assess the client for sedation needs.
b. Get family permission for restraints.
c. Provide frequent oral care per protocol.
,d. Use nonverbal pain assessment tools. Ans✓✓✓ ANS: C
The client on mechanical ventilation needs frequent oral care, which can
be delegated to the AP. The other actions fall within the scope of
practice of the nurse.
11. A nurse is caring for a client on mechanical ventilation. When
double-checking the ventilator settings with the respiratory therapist,
what would the nurse ensure?
a. The client is able to initiate spontaneous breaths.
b. The inspired oxygen has adequate humidification.
c. The upper peak airway pressure limit alarm is off.
d. The upper peak airway pressure limit alarm is on. Ans✓✓✓ ANS: D
The upper peak airway pressure limit alarm will sound when the airway
pressure reaches a preset maximum. This is critical to prevent
barotrauma to the lungs. Alarms are never be turned off. Initiating
spontaneous breathing is important for some modes of ventilation but
not others. Adequate humidification is important but does not take
priority over preventing injury.
12. A nurse is caring for a client on mechanical ventilation and finds the
client agitated and thrashing about. What action by the nurse is most
appropriate?
a. Assess the cause of the agitation.
b. Reassure the client that he or she is safe.
c. Restrain the client's hands.
d. Sedate the client immediately. Ans✓✓✓ ANS: A
, The nurse needs to determine the cause of the agitation. The inability to
communicate often makes clients anxious, even to the point of panic.
Pain, confusion, and hypoxia can also cause agitation. Once the nurse
determines the cause of the agitation, he or she can implement measures
to relieve the underlying cause. Reassurance is also important but may
not address the etiology of the agitation. Restraints and more sedation
may be necessary but not as a first step. Ensuring the client is adequately
oxygenated is the priority.
13. A nurse is preparing to admit a client on mechanical ventilation for
acute respiratory failure from the emergency department. What action
does the nurse take first?
a. Assessing that the ventilator settings are correct
b. Ensuring that there is a bag-valve-mask in the room
c. Obtaining personal protective equipment
d. Planning to suction the client upon arrival to the room Ans✓✓✓ ANS:
B
Having a bag-valve-mask device is critical in case the client needs
manual breathing. The respiratory therapist is usually primarily
responsible for setting up the ventilator, although the nurse would know
and check the settings. Personal protective equipment is important, but
ensuring client safety is the most important action. The client may or
may not need suctioning on arrival.
14. A client is on mechanical ventilation and the client's spouse wonders
why ranitidine is needed since the client "only has lung problems." What
response by the nurse is best?
a. "It will increase the motility of the gastrointestinal tract."
accurate answers
. The primary care provider orders the following mechanical ventilation
settings for a patient who weighs 75 kg and whose spontaneous
respiratory rate is 22 breaths/min. What arterial blood gas abnormality
may occur if the patient continues to be tachypneic at these ventilator
settings?Settings:
Tidal volume: 600 mL (8 mL per kg) FiO2: 0.5
Respiratory rate: 14 breaths/min Mode assist/control
Positive end-expiratory pressure: 10 cm H2O
A.Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis Ans✓✓✓ D. Respiratory alkalosis
1. A nurse answers a call light and finds a client anxious, short of breath,
reporting chest pain, and has a blood pressure of 88/52 mm Hg. What
action by the nurse takes priority?
a. Assess the client's lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs. Ans✓✓✓ ANS: B
This client has signs and symptoms of a pulmonary embolism, and the
most critical action is to notify the Rapid Response Team for speedy
,diagnosis and treatment. The other actions are appropriate also but are
not the priority.
1. A nurse is caring for five clients. For which clients would the nurse
assess a high risk for developing a pulmonary embolism (PE)? (Select
all that apply.)
a. Client who had a reaction to contrast dye yesterday
b. Client with a new spinal cord injury on a rotating bed
c. Middle-age client with an exacerbation of asthma
d. Older client who is 1 day post-hip replacement surgery
e. Young obese client with a fractured femur
f. Middle-age adult with a history of deep vein thrombosis Ans✓✓✓
ANS: B,D,E
Conditions that place clients at higher risk of developing PE include
prolonged immobility, central venous catheters, surgery, obesity,
advancing age, conditions that increase blood clotting, history of
thromboembolism, smoking, pregnancy, estrogen therapy, heart failure,
stroke, cancer (particularly lung or prostate), and trauma. A contrast dye
reaction and asthma pose no risk for PE.
10. A client with acute respiratory failure is on a ventilator and is
sedated. What care may the nurse delegate to the assistive personnel
AP)?
a. Assess the client for sedation needs.
b. Get family permission for restraints.
c. Provide frequent oral care per protocol.
,d. Use nonverbal pain assessment tools. Ans✓✓✓ ANS: C
The client on mechanical ventilation needs frequent oral care, which can
be delegated to the AP. The other actions fall within the scope of
practice of the nurse.
11. A nurse is caring for a client on mechanical ventilation. When
double-checking the ventilator settings with the respiratory therapist,
what would the nurse ensure?
a. The client is able to initiate spontaneous breaths.
b. The inspired oxygen has adequate humidification.
c. The upper peak airway pressure limit alarm is off.
d. The upper peak airway pressure limit alarm is on. Ans✓✓✓ ANS: D
The upper peak airway pressure limit alarm will sound when the airway
pressure reaches a preset maximum. This is critical to prevent
barotrauma to the lungs. Alarms are never be turned off. Initiating
spontaneous breathing is important for some modes of ventilation but
not others. Adequate humidification is important but does not take
priority over preventing injury.
12. A nurse is caring for a client on mechanical ventilation and finds the
client agitated and thrashing about. What action by the nurse is most
appropriate?
a. Assess the cause of the agitation.
b. Reassure the client that he or she is safe.
c. Restrain the client's hands.
d. Sedate the client immediately. Ans✓✓✓ ANS: A
, The nurse needs to determine the cause of the agitation. The inability to
communicate often makes clients anxious, even to the point of panic.
Pain, confusion, and hypoxia can also cause agitation. Once the nurse
determines the cause of the agitation, he or she can implement measures
to relieve the underlying cause. Reassurance is also important but may
not address the etiology of the agitation. Restraints and more sedation
may be necessary but not as a first step. Ensuring the client is adequately
oxygenated is the priority.
13. A nurse is preparing to admit a client on mechanical ventilation for
acute respiratory failure from the emergency department. What action
does the nurse take first?
a. Assessing that the ventilator settings are correct
b. Ensuring that there is a bag-valve-mask in the room
c. Obtaining personal protective equipment
d. Planning to suction the client upon arrival to the room Ans✓✓✓ ANS:
B
Having a bag-valve-mask device is critical in case the client needs
manual breathing. The respiratory therapist is usually primarily
responsible for setting up the ventilator, although the nurse would know
and check the settings. Personal protective equipment is important, but
ensuring client safety is the most important action. The client may or
may not need suctioning on arrival.
14. A client is on mechanical ventilation and the client's spouse wonders
why ranitidine is needed since the client "only has lung problems." What
response by the nurse is best?
a. "It will increase the motility of the gastrointestinal tract."
