Mastering Critical Care: Verified Respiratory Practice Questions and Answers (100% Accuracy) | 2025/2026 Edition

Mastering Critical Care: Verified Respiratory Practice Questions and Answers (100% Accuracy) | 2025/2026 Edition When suctioning a client with an endotracheal tube, the nurse observes a decrease in the client’s heart rate. What is the most appropriate intervention? - Continue the suctioning process - Immediately notify the healthcare provider - Stop the suctioning and provide reoxygenation to the client - Ensure suctioning is completed within 15 seconds A client with a fractured rib is being assessed for respiratory status. What observation is expected? - Slow and deep breathing patterns - Rapid, deep breathing - Paradoxical breathing movements - Pain, particularly during inhalation A client who sustained chest trauma from a motor vehicle accident has been intubated. When the ventilator’s high-pressure alarm sounds, the nurse notes absent breath sounds in the right upper lung. This finding most likely indicates which condition? - Right-sided pneumothorax - Pulmonary embolism - Displacement of the endotracheal tube - Acute respiratory distress syndrome (ARDS) While caring for a client with multiple trauma, the nurse monitors for the earliest sign of ARDS. What is the expected finding? - Bilateral wheezing sounds 1 - Inspiratory crackles - Intercostal muscle retractions - Increased respiratory rate A nurse is explaining chest physiotherapy and postural drainage to a client with thick mucus in the lower airways. After the client is positioned, what action will the nurse take to loosen the secretions? - Use palpation techniques and check for clubbing - Perform percussion and vibration - Hyperoxygenate and suction the airway - Administer bronchodilators and measure peak flow For a client recovering from a pulmonary embolism, which symptom is the most commonly reported? - A sensation of being overheated and flushed - Sudden fever with chills - Sudden onset of chest pain - Shortness of breath when taking deep breaths To deliver an accurate oxygen concentration for a client with COPD, what oxygen delivery system would the nurse use? - Face tent - Venturi mask - Aerosol mask - Tracheostomy collar When the low-pressure alarm on a ventilator is triggered and the cause cannot be identified, what is the nurse’s priority action? - Begin administering oxygen - Check the client’s vital signs - Manually ventilate the client 2 - Initiate cardiopulmonary resuscitation (CPR) Mechanical ventilation is indicated when profound hypoxia or respiratory distress persists. This is confirmed by: pH <7.3 PaO2 <50 PaCO2 >50 The ventilator mode synchronized intermittent mandatory ventilation (SIMV) serves which purpose? Allows the ventilator to deliver set breaths while the patient breathes spontaneously between them at varying volumes, often used during the weaning process. Clinical signs of hypoxemia can be remembered using the RAT BED mnemonic. These include: Restlessness, Anxiety, Tachycardia (early), Bradycardia (late), Extreme restlessness, Dyspnea/Dysrhythmias To reduce risks during open suctioning for a client with a tracheostomy on a ventilator, what is the correct approach? - Perform subglottal suctioning first - Set the suction pressure to 60–80 mmHg - Lubricate the suction catheter with water-soluble gel - Limit suction passes to 10 seconds or less Should routine suctioning be performed on an intubated patient? - False - True **Explanation:** Assess the need before suctioning. If a ventilator’s low-pressure alarm sounds, what is the initial step? - Silence the alarm and perform suctioning 3 - Manually ventilate the patient - Hyperventilate the patient and assess lung sounds - Check all tube connections For a client with COPD on a ventilator, which finding requires urgent intervention? - Urine output of 400 mL in 8 hours - Absence of breath sounds on one side - Mild pitting edema (1+) - Abdominal distention What is the primary benefit of adding positive end-expiratory pressure (PEEP) to a ventilator’s settings? - Enhancing FiO2 delivery - Preventing alveolar collapse during exhalation - Reducing lung tissue trauma - Increasing lung inflation PEEP is primarily used to: - Increase functional residual capacity and oxygenation levels - Enhance FiO2 and support weaning - Determine synchronization between patient and ventilator - Assess readiness for extubation For clients with artificial airways, what is an essential nursing intervention during suctioning? - Maintain cuff pressure at 30 cm H2O - Perform suctioning every 2 hours - Avoid dislodgement by limiting oral care - Monitor for cardiac dysrhythmias 4 When preparing a client in the ICU for oral endotracheal intubation, what is the correct positioning? - Place the client supine with the head extended and neck flexed - Ask the client to push the tongue forward during insertion - Position the client with the head hanging off the bed edge - Reassure the client that speech is possible immediately after the procedure 1) A nurse is caring for a patient with ARDS. The nurse views the ABG. What value should the nurse report to the physician? pH: 7.35 PaCO2: 26mmhg PaO2:95 HCO3: 22 a) PaCO2 b)pH c)HCO3 d)PaO2 a The normal range for PaCO2 is 35-45. This patient is experiencing a superimposed respiratory alkalosis likely due to hyperventilation. The nurse should report the PaCO2 to the physician. 2) A nurse must position the patient prone after his diagnosis of acute respiratory distress syndrome (ARDS). Which of the following is a benefit of using this position? Select all that apply. A)Decreased atelectasis B)Reduced need for endotracheal intubation c)Mobilization of secretions d)Decreased pleural pressure e)Increased response to corticosteroid therapy a, c, d 5 Decreased atelectasis", "Mobilization of secretions" and "Decreased pleural pressure" are correct. Prone positioning, or placing the patient face down with the head turned to the side, helps with pulmonary function in the patient diagnosed with ARDS. When the patient is placed in a prone position, the heart and diaphragm are not pressing against the lungs, which means that pleural pressure is reduced. When there is less pressure exerted on the lungs, atelectasis decreases. Studies have shown that many patients in the prone position have increased lung secretions, which improves oxygenation. -"Reduced need for endotracheal intubation" is incorrect. The prone position has not been shown to decrease the likelihood of intubation. -"Increased response to corticosteroid therapy" is incorrect because positioning does not change the body's response to steroid therapy. 3) A 25-year-old patient in the ICU is being treated for acute respiratory distress syndrome (ARDS). The patient is on a ventilator and requires 80 percent FiO2. Which information would the nurse most likely need to report about the patient to the respiratory therapist working with her? a)The patient needs endotracheal suctioning b)The patient needs more oxygen because of his saturation c)The patient needs an arterial blood gas drawn d)The patient needs a hemoglobin level drawn c 4) A patient who has recovered from ARDS in the ICU is now malnourished and has lost a significant amount of weight. The physician orders TPN to add nutrition for the patient, who then develops re feeding syndrome. Which of the following signs or symptoms would the nurse expect to see with re feeding syndrome? Select all that apply. a. Impaired mental status b. Insulin resistance c. Seizures d. Persistent weight loss e. Constipation a,b,c 6 impaired mental status", "Insulin resistance" and "Seizures" are correct. Re-feeding syndrome can occur as a response to nutrient reintroduction after a period of starvation. When an extremely malnourished patient receives TPN, the body has to adjust to receiving nutrients again, which can cause shifts in electrolytes in the body. These shifts in electrolytes can result in sudden and often fatal complications. Signs and symptoms of re-feeding syndrome include confusion and impaired mental status, insulin resistance, seizures, coma and death. -"Persistent weight loss" is incorrect because by the time a patient develops re-feeding syndrome, the onset of symptoms is so sudden that weight loss cannot be measured as part of the syndrome. -"Constipation" is incorrect, as it is not a symptom of refeeding syndrome. 5) A nurse is caring for a patient with ARDS. Which of the following clinical indicators would signify that this client is in respiratory failure? Select all that apply. a. Pulse oximetry of 94% on room air b. A PaO2 level below 60 mmHg c. An ABG pH level of 7.35 d. A pCO2 level over 50 mmHg e. A respiratory rate of over 16/minute b, d Respiratory diseases can cause such compromise that the patient will suffer symptoms; however, there are certain clinical indicators that can clarify whether the patient is actually in respiratory failure. Clinical indicators of respiratory failure include pulse oximetry of less than 91% on room air, PaO2 level less than 60 mmHg, and a pCO2 level of over 50 mmHg. 6) A nurse is caring for a patient who is in respiratory distress because of ARDS. Which of the following nursing diagnoses would most likely be associated with this condition? a. Ineffective thermoregulation b. Impaired urinary elimination c. Ineffective tissue perfusion d. Disturbed personal identity c 7 7) A nurse walks into a client who is in respiratory distress. The client has a tracheal deviation to the right side. The nurse knows to prepare for which of the following emergent procedures? a. Chest tube insertion on the left side. b. Chest tube insertion on the right side. c. Intubation d. Tracheostomy a Tracheal deviation indicates a pneumothorax, the direction of the deviation indicates the side the pneumothorax is on. If the trachea is deviating to the right, then the pneumo is on the left. The treatment for this is a chest tube on the side of trhe deflated lung. 8) A 26-year-old patient is admitted to the hospital in severe respiratory distress. His oxygen saturations are 80% despite supplemental oxygen provided by a facemask. The provider decides to intubate the patient to help with his breathing oxygenation. Which medication would the nurse most likely administer when assisting with intubation? a. Modafinil (Provigil) b. Phentermine (Adipex-P) c. Etomidate (Amidate) d. Zolpidem (Ambien) c "Etomidate (Amidate)" is correct. Intubation is most often performed by inserting a tube into the mouth and passing it into the trachea in order to provide support for a patient's breathing. Most registered nurses do not perform endotracheal intubation, but they can assist the provider or respiratory therapist with placing the tube. The nurse may give medications to sedate the patient during the procedure, since it can be traumatic for the patient. Some medications given for sedation include etomidate, ketamine or midazolam. Midazolam (Versed) is used less often due to its need for titration based on weight, which is an extra step that is undesirable during rapid intubation. This extra step can cause delays and errors during intubation. -"Zolpidem (Ambien)" is incorrect because this is an oral tablet used to induce sleep for the patient suffering from insomnia. This medication is not potent or rapid enough to be used for intubation. -"Phentermine (Adipex-P)" is incorrect because this is a stimulant, not a sedative and would not be used during intubation. 8 -"Modafinil (Provigil)" is incorrect because this is a stimulant drug. Stimulants produce the opposite effect of what is necessary for patient intubation. : A 64-year-old man with moderate chronic obstructive pulmonary disease presents to your office complaining that for the past 5 days, he has been experiencing worsening shortness of breath. He denies having fevers or chills, but he does report increasing purulent sputum production. He visited his 6-year old grandson this past weekend, and the child had symptoms of an upper respiratory infection. The patient's vital signs are normal except that oxygen saturation on room air is 88%. Examination reveals bilateral expiratory wheezing. A chest radiograph is normal. Results of laboratory testing are as follows: white blood cell count, 12,500/mm3; arterial blood gas pH, 7.35; arterial oxygen tension (PaO2), 65 mm Hg; and carbon dioxide tension (PCO2), 60 mm Hg. You arrange for hospital admission. Which of the following is the most appropriate step to take next for this patient after he is admitted to the hospital? a. c A 73-year-old man with hypertension, coronary artery disease, and diabetes mellitus presents to your office complaining of a cough and shortness of breath. He reports that for the past 3 or 4 days, he has been experiencing progressive dyspnea on exertion, and he now has mild dyspnea at rest. He also states that he has been having fevers, chills, and purulent sputum production over this period. He denies having come into contact with anyone who was sick. Results of physical examination are as follows: blood pressure, 124/87 mm Hg; heart rate, 95 beats/min; respiratory rate, 26 breaths/min; temperature, 101.3° F (38.5° C); and oxygen saturation on room air, 88%. The patient exhibits tachypnea without the use of accessory muscles. Bronchial breath sounds are noted over the right lower lung zones consistent with consolidation. A chest radiograph in the office confirms a right lower lobe infiltrate. You plan to admit the c You're providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the patient is developing acute respiratory distress syndrome (ARDS)? A. The patient is experiencing bradypnea. B. The patient is tired and confused. 9 C. The patient's PaO2 remains at 45 mmHg. D. The patient's blood pressure is 180/96. c A hallmark sign and symptom found in ARDS is refractory hypoxemia. This is where that although the patient is receiving a high amount of oxygen the patient is STILL hypoxic You're teaching a class on critical care concepts to a group of new nurses. You're discussing the topic of acute respiratory distress syndrome (ARDS). At the beginning of the lecture, you assess the new nurses understanding of this condition. Which statement by a new nurse demonstrates he understands the condition? A. "This condition develops because the exocrine glands start to work incorrectly leading to thick, copious mucous to collect in the alveoli sacs." B. "ARDS is a pulmonary disease that gradually causes chronic obstruction of airflow from the lungs." C. "Acute respiratory distress syndrome occurs due to the collapsing of a lung because air has accumulated in the pleural space." D. "This condition develops because alveolar-capillary membrane permeability has changed leading to f luid collecting in the alveoli sacs." D ARDS is a type of respiratory failure that occurs when the capillary membrane that surrounds the alveoli sac becomes damaged, which causes fluid to leak into the alveoli sac During the exudative phase of acute respiratory distress syndrome (ARDS), the patient's lung cells that produce surfactant have become damaged. As the nurse, you know this will lead to? A. bronchoconstriction B. atelectasis C. upper airway blockage D. pulmonary edema b 10 Surfactant decreases surface tension in the lungs. Therefore, the alveoli sacs will stay stable when a person exhales. If there is a decrease in surfactant production this creates an unpredictable alveoli sac that can easily collapse A patient has been hospitalized in the ICU for a near-drowning event. The patient's respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS? A. infiltrates only on the upper lobes B. enlargement of the heart with bilateral lower lobe infiltrates C. white-out infiltrates bilaterally D. normal chest x-ray c. Which patient below is at MOST risk for developing ARDS and has the worst prognosis? A. A 52-year-old male patient with a pneumothorax. B. A 48-year-old male being treated for diabetic ketoacidosis. C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection. D. A 30-year-old female with cystic fibrosis. c 7. As the nurse, you know that acute respiratory distress syndrome (ARDS) can be caused by direct or indirect lung injury. Select below all the INDIRECT causes of ARDS A. Drowning B. Aspiration C. Sepsis D. Blood transfusion E. Pneumonia F. Pancreatitis C, D, F 11 Indirect causes are processes that can cause inflammation OUTSIDE of the lungs....so the issue arises somewhere outside the lungs A patient is on mechanical ventilation with PEEP (positive end-expiratory pressure). Which finding below indicates the patient is developing a complication related to their therapy and requires immediate treatment? A. HCO3 26 mmHg B. Blood pressure 70/45 C. PaO2 80 mmHg D. PaCO2 38 mmHg B. Mechanical ventilation with PEEP can cause issues with intrathoracic pressure and decrease the cardiac output You are caring for a patient with acute respiratory distress syndrome. As the nurse, you know that prone positioning can be beneficial for some patients with this condition. Which findings below indicate this type of positioning was beneficial for your patient with ARDS? A. Improvement in lung sounds B. Development of a V/Q mismatch C. PaO2 increased from 59 mmHg to 82 mmHg D. PEEP needs to be titrated to 15 mmHg of water A and C. Prone positioning helps improve PaO2 without actually giving the patient high concentrations of oxygen. It helps improves perfusion and ventilation (hence correcting the V/Q mismatch). You're precepting a nursing student who is assisting you to care for a patient on mechanical ventilation with PEEP for treatment of ARDS. The student asks you why the PEEP setting is at 10 mmHg. Your response is: A. "This pressure setting assists the patient with breathing in and out and helps improve airflow." 12 B. "This pressure setting will help prevent a decrease in cardiac output and hyperinflation of the lungs." C. "This pressure setting helps prevent fluid from filling the alveoli sacs." D. "This pressure setting helps open the alveoli sacs that are collapsed during exhalation." d The Emergency Department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of pneumothorax? a. low respiratory rate b. diminished breath sounds c. presence of a barrel chest e. a sucking sound at the site of injury b. The nurse instructs a client to use the pursed lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote? a. promote oxygen intake b. strengthen the diaphragm c. strengthen the intercostal muscles d. promote carbon dioxide elimination d The nurse is caring for a client after a bronchoscopy and biopsy. Which of the following findings should be reported immediately? a. dry cough b. hematuria c. bronchospasm e. blood-streaked sputum c A patient has an oral endotracheal (ET) tube inserted to relieve an upper airway obstruction and to facilitate secretion removal. The first responsibility of the nurse immediately following placement of the tube is to? 13 A. suction the tube to remove secretions. B. secure the tube to the face with adhesive tape. C. place an end tidal CO2 detector on the ET tube. PetCO2 D. assess for bilateral breath sounds and symmetric chest movement. c Although his oxygen saturation is above 92%, an orally intubated, mechanically ventilated patient is restless and very anxious. What intervention should be used first to decrease the risk of accidental extubation? a. Obtain an order and apply soft wrist restraints. b. Remind the patient that he needs the tube inserted to breathe. c. Administer sedatives and have a caregiver stay with the patient. d. Move the patient to an area close to the nurses' station for closer observation. c A patient in acute respiratory failure is receiving assist-control mechanical ventilation with a peak end expiration. A pressure (PEEP) of 10 cm H2O. A sign that alerts the nurse to undesirable effects of increased airway and thoracic pressure is? a. decreased BP. b. decreased PaO2. c. increased crackles. d. decreased spontaneous respirations. a Identify key assessments for determining the oxygenation and ventilation status of a mechanically ventilated patient. Oxygen Saturation (SpO2), Respiratory Rate, ABGs, Heart rate and rhythm, Mental Status What is the difference between CPAP and BiPAP? CPAP provides a continuous pressure and the same amount of pressure during inspiration and expiration and does not include oxygen. Pressures are in "cm of water". 10 cm of H20 means enough pressure to move a volume of water 10 cm. -BiPAP provides a different pressure during inspiration than expiration and includes oxygen. Inspiratory pressures are generally higher than expiratory pressures. 14 During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for? cy of airway. nce of a neck injury. logic status with the Glasgow Coma Scale. rospinal fluid leakage from the ears or nose. a After interpreting ABGs as respiratory acidosis the nurse SBARs the surgeon with the results and with a recommendation to: A. keep the current ventilator settings. B. decrease the FiO2 C. increase the respiratory rate D. decrease the respiratory rate E. decrease the tidal volume INTERVENTIONS- ARDS c Often needs intubation & conventional mechanical ventilation with positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP). Airway pressure release ventilation (APRV) & high-frequency oscillatory ventilation are alternative modes of mechanical ventilation that improve oxygenation & ventilation in patients with moderate to severe ARDS. -Sedation & paralysis may be needed for adequate ventilation & to reduce tissue oxygen needs. -Side effects of PEEP is tension pneumothorax, assess lung sounds hourly & suction as often as needed to maintain a patent airway. Corticosteriods are used to manage ARDS b/c they decrease WBC movement, reduce inflammation, & stabilize capillary membranes. 15 -Antibiotics are used to treat infections when organisms are identified. Intubation Immediately after an ET tube is inserted, placement should be verified. The most accurate ways to verify placement are by checking end-tidal carbon dioxide levels & by chest x-ray. Assess for breath sounds bilaterally, symmetric chest movement, & air emerging from the ET tube. If breath sounds & chest wall movement are absent on the left side, the tube may be in the right main stem bronchi. MODES OF VENTILATION Assist-control (AC) ventilation- used often as a resting mode. Ventilator takes over the work of breathing for the patient. Tidal volume & ventilatory rate are preset. If patient doesn't have spontaneous breaths, a ventilatory pattern is established by the ventilator. Disadvantage- the ventilator continues to deliver a preset tidal volume even when the patient's spontaneous breathing rate increases. This can cause hyperventilation & respiratory alkalosis. -Synchronized intermittent mandatory ventilation (SIMV)- similar to AC in that tidal volume & ventilatory rate are preset. If patient doesn't breathe, a ventilatory pattern is established by the ventilator. SIMV allows spontaneous breathing at the patient's own rate & tidal volume between the ventilator breaths. Can be used as a main ventilatory mode or as a weaning mode. Bi-Level positive airway pressure (BiPAP)- provides noninvasive pressure suppose ventilation by nasal mask or face-mask. Most often used for patients with sleep apnea, but may also be used for patients with respiratory muscle fatigue to avoid more invasive ventilation methods. Pneumothorax Often caused by blunt chest trauma & may occur with some degree of hemothorax. Can also occur as a complication of medical procedures. Can be open (pleural cavity is exposed to outside air, as through an open wound in the chest wall) or closed (such as when a patient with COPD has a spontaneous pneumothorax). Assessment findings commonly include: -Reduced breath sounds on auscultation; hyperresonance on percussion; prominence of the involved side of the chest, which moves poorly with respirations; deviation of the trachea away from (closed) or toward (open) the affected side. 16 Patient may have pleuritic pain, tachypnea, & subcutaneous emphysema (air under the skin in the subcutaneous tissues). -An ultrasound exam or a chest x-ray is used for diagnosis. Chest tubes may be needed to allow the air to escape & the lung to re-inflate. The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus. The client's international normalized ratio (INR) is 2.0. What is the nurse's best action? a. Increase the heparin dose. b. Increase the warfarin dose. c. Continue the current therapy. d. Discontinue the heparin. d INR reaches a therapeutic level between 2 and 3. It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurse's priority action? a. Monitor the client's oxygenation. b. Teach the client about potential side effects. c. Monitor the IV insertion site. d. Monitor for bleeding. A Airway and breathing are the top priority. The nurse would also need to monitor for bleeding when administering fibrinolytic therapy, and would monitor the IV site as well. Teaching the client is also a need, however. Oxygenation is the highest priority. A client is admitted owing to difficulty breathing. The nurse assesses the client's color, lung sounds, and pulse oximetry reading. The pulse oximetry is 90%. What is the nurse's next action? a. Give an intermittent positive-pressure breathing treatment. b. Administer a rescue inhaler. c. Call for a chest x-ray. d. Assess an arterial blood gas. d 17 The nurse notes that each time the mechanical ventilator delivers a breath to a client with acute respiratory distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the nurse's best intervention? a. Suction the client. b. Perform chest physiotherapy. c. Administer an inhaler. d. Assess the airway. D An increase in peak inspiratory pressure (PIP) in the ARDS client is indicative of decreased lung compliance, making it more difficult to ventilate diseased lungs. The nurse first should assess the airway to make sure no sputum is present in the airway and that no kinks are noted in the tubing. The nurse is not able to make changes in the ventilator settings, so an order is needed to increase inspiratory pressure to oxygenate the client. The nurse is caring for several clients on the respiratory floor. Which client does the nurse assess most carefully for the development of acute respiratory distress syndrome (ARDS)? a. Older adult with COPD b. Middle-aged client receiving a blood transfusion c. Older adult who has aspirated his tube feeding d. Young adult with a broken leg from a motorcycle acciden c The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation and positive end-expiratory pressure (PEEP). The alarm sounds, indicating decreased pressure in the system. What is the nurse's best action? a. Change the client's position. b. Suction the client. c. Assess lung sounds. d. Turn off the pressure alarm. c The nurse is caring for a client who is intubated with an endotracheal tube and on a mechanical ventilator. The client is able to make sounds. What is the nurse's first action? a. Check cuff inflation on the endotracheal tube. 18 b. Listen carefully to the client. c. Call the health care provider. d. Auscultate the lungs A If the client has the cuff on the endotracheal tube inflated, the cuff should prevent air from going around the cuff and through the vocal cords. If the client can talk with the cuff inflated, the cuff probably has a leak, causing it to become deflated and allowing air to pass through. The risk is that the client will not receive the prescribed tidal volume. Which assessment finding of a client requires the nurse's immediate action? a. Being intubated for 4 days b. Uneven breath sounds c. Wheezing on auscultation d. Having the endotracheal (ET) tube taped to the lower jaw D The endotracheal tube can be taped to the upper lip but should never be taped to the lower jaw because the lower jaw moves too much. The other clients need to be assessed by the nurse, but the one with the ET tube taped to the jaw requires immediate action. The nurse is caring for a client who is receiving mechanical ventilation accompanied by positive end expiratory pressure (PEEP). What assessment findings require immediate intervention? a. Blood pressure drop from 110/90 mm Hg to 80/50 mm/Hg b. Pulse oximetry value of 96% c. Arterial blood gas (ABG): pH, 7.40; PaO2, 80 mm Hg; PaCO2, 45 mm Hg; HCO3-, 26 mEq/L d. Urinary output of 30 mL/hr A Increased intrathoracic pressure can inhibit blood return to the heart and cause decreased cardiac output. This manifests with a drop in blood pressure. The pulse oximetry reading, ABGs, and urinary output are all normal. The client receiving mechanical ventilation has become more restless over the course of the shift. Which is the nurse's first action? a. Sedate the client. b. Call the health care provider. c. Assess the client for pain. 19 d. Assess the client's oxygenation. d A client is admitted to the emergency department several hours after a motor vehicle crash. The car's driver-side airbag was activated during the accident. Which assessment requires the nurse's immediate intervention? a. Disorientation b. Hemoptysis c. Pulse oximetry reading of 94% d. Chest pain with movement b The nurse assesses a client admitted for chest trauma who reports dyspnea. The nurse finds tracheal deviation and a pulse oximetry reading of 86%. What is the nurse's priority intervention? a. Notify the health care provider and document the symptoms. b. Intubate the client and prepare for mechanical ventilation. c. Administer oxygen and prepare for chest tube insertion. d. Administer an intermittent positive-pressure breathing treatment. c The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation. The client's oxygen saturation has dropped from 94% to 86%. What is the priority action by the nurse? a. Encourage the client to take deep, controlled breaths. b. Document findings and continue to monitor the client. c. Notify the health care provider and prepare for intubation. d. Stabilize the chest wall with rib binders. c The nurse auscultates the lungs of a client on mechanical ventilation and hears vesicular breath sounds throughout the right side but decreased sounds on the left side of the chest. What is the nurse's best action? a. Turn the client to the right side. b. Elevate the head of the bed. c. Assess placement of the endotracheal (ET) tube. 20 d. Suction the client. c A client admitted with respiratory difficulty and decreased oxygen saturation keeps pulling off the oxygen mask. What action does the nurse take? a. Stays with the client and replaces the oxygen mask b. Asks the client's spouse to hold the oxygen mask in place c. Restrains the client per facility policy d. Contacts the health care provider and requests sedation a The nurse is assessing arterial blood gases (ABGs). The client with which ABG reading requires the nurse's immediate attention? a. pH, 7.32; PaCO2, 55 mm Hg; PaO2, 70 mm Hg b. pH, 7.45; PaCO2, 42 mm Hg; PaO2, 70 mm Hg c. pH, 7.48; PaCO2, 38 mm Hg; PaO2, 60 mm Hg d. pH, 7.55; PaCO2, 32 mm Hg; PaO2, 50 mm Hg : D This client has the most severe hypoxia and respiratory alkalosis, indicated by low partial pressure of arterial carbon dioxide (PaCO2) values on ABG analysis. Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)? (Select all that apply.) a. Wheezes throughout lung fields b. Hemoptysis c. Sharp chest pain d. Flattened neck veins e. Hypotension f. Pitting edema b, c, e Which clients are at highest risk for pulmonary embolism (PE)? (Select all that apply) a. Middle-aged client awaiting surgery b. Older adult with a 20-pack-year history of smoking 21 c. Client who has been on bedrest for 3 weeks d. Obese client who has elevated platelets e. Middle-aged client with diabetes mellitus type 1 f. Older adult who has just had abdominal surgery B, C, D, F A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)? (Select all that apply.) a. Oxygen administered at 100%, PaO2 60 b. Increased dyspnea c. Anxiety d. Chest pain e. Pitting pedal edema f. Clubbing of fingertips a, b, c The nurse is caring for a client on a ventilator when the high-pressure alarm sounds. What actions are most appropriate? (Select all that apply.) a. Assess the tubing for kinks. b. Assess whether the tubing has become disconnected. c. Determine the need for suctioning. d. Call the health care provider. e. Call the Rapid Response Team. f. Auscultate the client's lungs. a, c, f The nurse is caring for a client with a high risk for pulmonary embolism (PE). Which prevention measures does the nurse add to the client's care plan? (Select all that apply.) a. Use antiembolism stockings. b. Massage calf muscles per client request. c. Maintain supine position with the legs flat. d. Turn every 2 hours if client is in bed. e. Refrain from active range-of-motion exercises. a, d 22 The high-pressure alarm of a pt's mechanical ventilator goes off. What are the potential causes for this occurrence? Mucus plus -Patient's fighting the ventilator -Bronchospasm -Patient is coughing A post op patient reports sudden onset of SOB & pleuritic chest pain. Assessment findings include diaphoresis, hypotension, crackles in the left lower lobe, & pulse ox of 85%. What does the nurse suspect this pt has? PE A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and reports acute chest pain. What action should a nurse take first? a) Administer a heparin bolus and begin an infusion at 500 units/hour. b) Administer analgesics, as ordered. c) Initiate oxygen therapy. d) Perform nasopharyngeal suctioning. c On entering the room of a client with chronic obstructive pulmonary disease (COPD), the nurse notices that the client is receiving oxygen at 4 L/minute by way of a nasal cannula. The nurse's actions should be based on which statement? a) The flow rate is too low b) The flow rate is too high c) The client shouldn't receive oxygen d) The flow rate is correct b) The flow rate is too high The administration of oxygen at 1 to 2 L/ minute by way of a nasal cannula is recommended for clients with COPD: therefore, a rate of 4 L/minute is too high. The normal mechanism that stimulates breathing is a rise in blood carbon dioxide. Clients with COPD retain blood carbon dioxide, so their mechanism for stimulating breathing is a low blood oxygen level. High levels of oxygen may cause hypoventilation and 23 apnea. Oxygen delivered at 1 to 2 L/ minute should aid in oxygenation without causing hypoventilation. Oxygen therapy is the only therapy that has been demonstrated to be life-preserving for patients with COPD Which treatment would the nurse expect for a client with spontaneous pneumothorax? a) Hyperbaric chamber b) Antibiotics c) Chest tube placement d) Bronchodilators c A client presents with shortness of breath and absent breath sounds on the right side, from the apex to the base. Which condition would best explain this? a) Spontaneous pneumothorax b) Chronic bronchitis c) Pneumonia d) Acute asthma a When a chest tube is accidentally dislodged from a client, which intervention should the nurse perform f irst? a) Cover the chest tube insertion site opening with petroleum gauze, and apply pressure b) Auscultate the lung fields for breath sounds c) Wipe the chest tube with alcohol and reinsert d) Notify the physician a 24