Exam 2: Mechanical Ventilation (NCLEX)
1. The peak pressure alarm is sounding on A
the ventilator of the client with a recent tra- The client must always be assessed before
cheostomy. What intervention should be attention is turned to equipment.
done first?
A. Assess the client's respiratory status
B. Decrease the sensitivity of the alarm
C. Ensure that the connecting tubing is not
kinked
D. Suction the client
2. The client with respiratory failure has been C
intubated and placed on a ventilator and High levels of oxygen delivery can result in
is requiring 100% oxygen delivery to main- collapsed alveoli and absorption atelectasis.
tain adequate oxygenation. Twenty-four PEEP can help alveoli remain properly inflat-
hours later, the nurse notes new-onset ed.
crackles and decreased breath sounds,
and the most recent ABGs show a PaO2
level of 95 mm Hg. The ventilator is not
set to provide positive end-expiratory pres-
sure (PEEP). Why is the nurse concerned?
A. The low PaO2 level may result in oxygen
toxicity
B. The 100% oxygen delivery requirement
indicates immediate extubation
C. Lung sounds may indicate absorption
atelectasis
D. The level of oxygen delivery may indi-
cate absorption atelectasis
3. D
, Exam 2: Mechanical Ventilation (NCLEX)
The medical nurse is creating the care plan
of an adult patient requiring mechanical
ventilation. What nursing action is most
appropriate?
A) Keep the patient in a low Fowlers posi-
tion.
B) Perform tracheostomy care at least once
per day.
C) Maintain continuous bedrest.
D) Monitor cuff pressure every 8 hours.
4. The acute medical nurse is preparing to B
wean a patient from the ventilator. Which
assessment parameter is most important
for the nurse to assess?
A) Fluid intake for the last 24 hours
B) Baseline arterial blood gas (ABG) levels
C) Prior outcomes of weaning
D) Electrocardiogram (ECG) results
5. A patient recovering from thoracic surgery D
is on long-term mechanical ventilation and
becomes very frustrated when he tries to
communicate. What intervention should
the nurse perform to assist the patient?
A) Assure the patient that everything will
be all right and that remaining calm is the
best strategy.
B) Ask a family member to interpret what
the patient is trying to communicate.
, Exam 2: Mechanical Ventilation (NCLEX)
C) Ask the physician to wean the patient
off the mechanical ventilator to allow the
patient to speak freely.
D) Express empathy and then encourage
the patient to write, use a picture board, or
spell words with an alphabet board.
6. The physician has ordered continuous pos- B
itive airway pressure (CPAP) with the deliv-
ery of a patients high-flow oxygen therapy.
The patient asks the nurse what the ben-
efit of CPAP is. What would be the nurses
best response?
A) CPAP allows a higher percentage of oxy-
gen to be safely used.
B) CPAP allows a lower percentage of oxy-
gen to be used with a similar effect.
C) CPAP allows for greater humidification
of the oxygen that is administered.
D) CPAP allows for the elimination of bac-
terial growth in oxygen delivery systems.
7. The nurse is caring for a patient who is A
ready to be weaned from the ventilator.
In preparing to assist in the collaborative
process of weaning the patient from a ven-
tilator, the nurse is aware that the weaning
of the patient will progress in what order?
A) Removal from the ventilator, tube, and
then oxygen
1. The peak pressure alarm is sounding on A
the ventilator of the client with a recent tra- The client must always be assessed before
cheostomy. What intervention should be attention is turned to equipment.
done first?
A. Assess the client's respiratory status
B. Decrease the sensitivity of the alarm
C. Ensure that the connecting tubing is not
kinked
D. Suction the client
2. The client with respiratory failure has been C
intubated and placed on a ventilator and High levels of oxygen delivery can result in
is requiring 100% oxygen delivery to main- collapsed alveoli and absorption atelectasis.
tain adequate oxygenation. Twenty-four PEEP can help alveoli remain properly inflat-
hours later, the nurse notes new-onset ed.
crackles and decreased breath sounds,
and the most recent ABGs show a PaO2
level of 95 mm Hg. The ventilator is not
set to provide positive end-expiratory pres-
sure (PEEP). Why is the nurse concerned?
A. The low PaO2 level may result in oxygen
toxicity
B. The 100% oxygen delivery requirement
indicates immediate extubation
C. Lung sounds may indicate absorption
atelectasis
D. The level of oxygen delivery may indi-
cate absorption atelectasis
3. D
, Exam 2: Mechanical Ventilation (NCLEX)
The medical nurse is creating the care plan
of an adult patient requiring mechanical
ventilation. What nursing action is most
appropriate?
A) Keep the patient in a low Fowlers posi-
tion.
B) Perform tracheostomy care at least once
per day.
C) Maintain continuous bedrest.
D) Monitor cuff pressure every 8 hours.
4. The acute medical nurse is preparing to B
wean a patient from the ventilator. Which
assessment parameter is most important
for the nurse to assess?
A) Fluid intake for the last 24 hours
B) Baseline arterial blood gas (ABG) levels
C) Prior outcomes of weaning
D) Electrocardiogram (ECG) results
5. A patient recovering from thoracic surgery D
is on long-term mechanical ventilation and
becomes very frustrated when he tries to
communicate. What intervention should
the nurse perform to assist the patient?
A) Assure the patient that everything will
be all right and that remaining calm is the
best strategy.
B) Ask a family member to interpret what
the patient is trying to communicate.
, Exam 2: Mechanical Ventilation (NCLEX)
C) Ask the physician to wean the patient
off the mechanical ventilator to allow the
patient to speak freely.
D) Express empathy and then encourage
the patient to write, use a picture board, or
spell words with an alphabet board.
6. The physician has ordered continuous pos- B
itive airway pressure (CPAP) with the deliv-
ery of a patients high-flow oxygen therapy.
The patient asks the nurse what the ben-
efit of CPAP is. What would be the nurses
best response?
A) CPAP allows a higher percentage of oxy-
gen to be safely used.
B) CPAP allows a lower percentage of oxy-
gen to be used with a similar effect.
C) CPAP allows for greater humidification
of the oxygen that is administered.
D) CPAP allows for the elimination of bac-
terial growth in oxygen delivery systems.
7. The nurse is caring for a patient who is A
ready to be weaned from the ventilator.
In preparing to assist in the collaborative
process of weaning the patient from a ven-
tilator, the nurse is aware that the weaning
of the patient will progress in what order?
A) Removal from the ventilator, tube, and
then oxygen
