WCU N480: WEEK 1&2 (EXAM 1) QUESTIONS &
ANSWERS SOLVED 100% CORRECT.
When the low-pressure alarm on the ventilator sounds, what does this
indicate? Answer - The low-pressure alarm means that the ventilator has a
leak. Either the ventilator tubing has come apart or the tubing detached from
the client.
A client is receiving mechanical ventilation and develops acute respiratory
distress. What is the priority? Answer - Initiate bag-valve-mask ventilation
A client comes into the ER in severe respiratory distress following left-sided
blunt chest trauma. The nurse notes absent breath sounds on the clients left
side and a tracheal shift to the right. What procedure should the nurse prepare
for? Answer - Chest tube insertion.
The client's manifestations indicate pneumothorax.
A nurse is reviewing a client's lab report. The client's ABG levels are pH 7.5,
PaCO2 32mmHg, and HCO3 24mEq/L. The nurse should determine that the
client has which acid-base imbalance? Answer - respiratory alkalosis
A nurse is preparing to assist a provider with an arterial blood withdrawal from
a clients radial artery for ABG measurement. Which of the following actions
should the nurse plan to take? Answer - Perform an Allen's test prior to
obtaining the specimen
,A nurse is caring for a client who is extremely anxious and is hyperventilating.
The clients ABG results are pH 7.50, PaCO2 27mmHg, and HCO3 25mEq/l. The
nurse should identify that the client has which of the following acid-base
imbalances? Answer - Respiratory alkalosis
A nurse is caring for a client who has a pelvic fracture. The client reports
sudden SOB, stabbing chest pain, and feelings of doom. The client is
experiencing which complication? Answer - pulmonary embolus
A nurse is caring for a client who is scheduled to have his chest tube removed.
which of the following actions should the nurse take? Answer - Instruct the
client to perform the Valsalva maneuver during removal.
This maintains the appropriate amount of negative pressure in the chest in
order to prevent air entry into the pleural space.
A nurse is planning care for a client following placement of a chest tube 1 hr
ago. Which of the following actions should the nurse include in the plan of
care? Answer - Tape all connections between the chest tube and drainage
system.
This ensures that the system is airtight and prevents the chest tubing from
accidentally disconnecting.
How often should you turn a patient to prevent skin breakdown? Answer - Q2
hours
Why should you assess skin under tubes and devices? Answer - To access for
skin breakdown
, What nursing interventions help prevent infection for a patient on a ventilator?
Answer - Hand hygiene
suction oral/bronchial secretions
oral care
assess for VAP (ventilator associated pneumonia)
How to prevent venous thromboembolism (VTE) Answer - anticoagulants
compression devices
How can the nurse avoid alarm fatigue? Answer - Ask the provider to put in
orders that allow alarm settings to tailor to the client's condition. Example: if
patients heart rate stays between 55-65 and the alarm is set to go off when the
heart rate is <60, the RN can ask the provider to have the settings changed to
alarm <55 instead
What is CVP? Answer - Central Venous Pressure: The amount of blood going
back into the heart
What does it mean when CVP is high? Answer - Over hydration.
What does it mean when CVP is low? Answer - Severe dehydration.
What is cardiac output? Answer - Volume of blood ejected by the heart in one
minute:
cardiac output = heart rate x stroke volume
What is systemic vascular resistance? Answer - Resistance to blood flow by all
systemic vasculature
ANSWERS SOLVED 100% CORRECT.
When the low-pressure alarm on the ventilator sounds, what does this
indicate? Answer - The low-pressure alarm means that the ventilator has a
leak. Either the ventilator tubing has come apart or the tubing detached from
the client.
A client is receiving mechanical ventilation and develops acute respiratory
distress. What is the priority? Answer - Initiate bag-valve-mask ventilation
A client comes into the ER in severe respiratory distress following left-sided
blunt chest trauma. The nurse notes absent breath sounds on the clients left
side and a tracheal shift to the right. What procedure should the nurse prepare
for? Answer - Chest tube insertion.
The client's manifestations indicate pneumothorax.
A nurse is reviewing a client's lab report. The client's ABG levels are pH 7.5,
PaCO2 32mmHg, and HCO3 24mEq/L. The nurse should determine that the
client has which acid-base imbalance? Answer - respiratory alkalosis
A nurse is preparing to assist a provider with an arterial blood withdrawal from
a clients radial artery for ABG measurement. Which of the following actions
should the nurse plan to take? Answer - Perform an Allen's test prior to
obtaining the specimen
,A nurse is caring for a client who is extremely anxious and is hyperventilating.
The clients ABG results are pH 7.50, PaCO2 27mmHg, and HCO3 25mEq/l. The
nurse should identify that the client has which of the following acid-base
imbalances? Answer - Respiratory alkalosis
A nurse is caring for a client who has a pelvic fracture. The client reports
sudden SOB, stabbing chest pain, and feelings of doom. The client is
experiencing which complication? Answer - pulmonary embolus
A nurse is caring for a client who is scheduled to have his chest tube removed.
which of the following actions should the nurse take? Answer - Instruct the
client to perform the Valsalva maneuver during removal.
This maintains the appropriate amount of negative pressure in the chest in
order to prevent air entry into the pleural space.
A nurse is planning care for a client following placement of a chest tube 1 hr
ago. Which of the following actions should the nurse include in the plan of
care? Answer - Tape all connections between the chest tube and drainage
system.
This ensures that the system is airtight and prevents the chest tubing from
accidentally disconnecting.
How often should you turn a patient to prevent skin breakdown? Answer - Q2
hours
Why should you assess skin under tubes and devices? Answer - To access for
skin breakdown
, What nursing interventions help prevent infection for a patient on a ventilator?
Answer - Hand hygiene
suction oral/bronchial secretions
oral care
assess for VAP (ventilator associated pneumonia)
How to prevent venous thromboembolism (VTE) Answer - anticoagulants
compression devices
How can the nurse avoid alarm fatigue? Answer - Ask the provider to put in
orders that allow alarm settings to tailor to the client's condition. Example: if
patients heart rate stays between 55-65 and the alarm is set to go off when the
heart rate is <60, the RN can ask the provider to have the settings changed to
alarm <55 instead
What is CVP? Answer - Central Venous Pressure: The amount of blood going
back into the heart
What does it mean when CVP is high? Answer - Over hydration.
What does it mean when CVP is low? Answer - Severe dehydration.
What is cardiac output? Answer - Volume of blood ejected by the heart in one
minute:
cardiac output = heart rate x stroke volume
What is systemic vascular resistance? Answer - Resistance to blood flow by all
systemic vasculature
