NU455 Practice Exam 1 With
Correct Answers
A patient in the ICU is mechanically ventilated. Which of the following
interventions is most important to prevent ventilator-associated pneumonia
(VAP)?
A) Perform oropharyngeal suctioning every 2 hours.
B) Administer antibiotics prophylactically.
C) Elevate the head of the bed to 30-45 degrees.
D) Change the ventilator tubing every shift. - ANSWER C) Elevate the head of
the bed to 30-45 degrees.
Rationale: Elevating the head of the bed helps reduce the risk of aspiration,
which can contribute to VAP.
A patient with acute respiratory distress syndrome (ARDS) is placed on
mechanical ventilation. What is the primary goal of ventilation in ARDS
patients?
A) To maintain high oxygen levels at any cost.
B) To provide adequate oxygenation while minimizing lung injury.
C) To increase tidal volume to improve oxygenation.
,D) To maintain normal carbon dioxide levels. - ANSWER B) To provide
adequate oxygenation while minimizing lung injury.
Rationale: In ARDS, protective lung strategies, such as low tidal volumes, are
used to minimize further lung injury while ensuring adequate oxygenation.
While assessing a patient's arterial blood gases (ABGs), the nurse notes the
following results: pH 7.29, PaCO2 50 mm Hg, HCO3 24 mEq/L. What
condition does this patient most likely have?
A) Metabolic acidosis
B) Respiratory acidosis
C) Respiratory alkalosis
D) Metabolic alkalosis - ANSWER B) Respiratory acidosis
Rationale: The low pH (7.29) and high PaCO2 (50 mm Hg) indicate respiratory
acidosis, typically caused by hypoventilation or impaired gas exchange.
A nurse is caring for a patient with a pulmonary embolism (PE). Which of the
following is the most common sign or symptom of PE?
A) Wheezing
B) Hemoptysis
,C) Sudden onset of shortness of breath
D) Fever - ANSWER C) Sudden onset of shortness of breath
Rationale: The sudden onset of dyspnea is the most common symptom of a
pulmonary embolism, due to blockage of the pulmonary circulation.
A patient has a chest tube in place after a pneumothorax. The nurse observes
continuous bubbling in the water seal chamber. What is the most appropriate
action?
A) Increase suction.
B) Clamp the chest tube.
C) Check for air leaks in the system.
D) Encourage the patient to cough and deep breathe. - ANSWER C) Check for
air leaks in the system.
Rationale: Continuous bubbling in the water seal chamber usually indicates
an air leak in the system that should be identified and resolved.
A patient is in acute respiratory failure with hypoxemia. Which of the
following ABG results would the nurse expect to see?
A) pH 7.40, PaO2 95 mm Hg, PaCO2 40 mm Hg
, B) pH 7.35, PaO2 80 mm Hg, PaCO2 45 mm Hg
C) pH 7.25, PaO2 55 mm Hg, PaCO2 30 mm Hg
D) pH 7.50, PaO2 105 mm Hg, PaCO2 25 mm Hg - ANSWER C) pH 7.25, PaO2
55 mm Hg, PaCO2 30 mm Hg
Rationale: These ABG results indicate hypoxemia (PaO2 < 60 mm Hg), with
compensatory hyperventilation, leading to a low PaCO2.
A patient with hypercarbia presents to the emergency department. What
would the nurse expect the ABG results to show?
A) Elevated pH, decreased PaCO2
B) Decreased pH, increased PaCO2
C) Decreased pH, decreased HCO3
D) Normal pH, normal PaCO2 - ANSWER B) Decreased pH, increased PaCO2
Rationale: Hypercarbia (increased PaCO2) leads to respiratory acidosis,
characterized by a low pH and elevated CO2 levels.
A patient is being treated for ARDS and has a PaO2 of 55 mm Hg despite
receiving 100% oxygen. Which of the following interventions is most likely to
improve this patient's oxygenation?
Correct Answers
A patient in the ICU is mechanically ventilated. Which of the following
interventions is most important to prevent ventilator-associated pneumonia
(VAP)?
A) Perform oropharyngeal suctioning every 2 hours.
B) Administer antibiotics prophylactically.
C) Elevate the head of the bed to 30-45 degrees.
D) Change the ventilator tubing every shift. - ANSWER C) Elevate the head of
the bed to 30-45 degrees.
Rationale: Elevating the head of the bed helps reduce the risk of aspiration,
which can contribute to VAP.
A patient with acute respiratory distress syndrome (ARDS) is placed on
mechanical ventilation. What is the primary goal of ventilation in ARDS
patients?
A) To maintain high oxygen levels at any cost.
B) To provide adequate oxygenation while minimizing lung injury.
C) To increase tidal volume to improve oxygenation.
,D) To maintain normal carbon dioxide levels. - ANSWER B) To provide
adequate oxygenation while minimizing lung injury.
Rationale: In ARDS, protective lung strategies, such as low tidal volumes, are
used to minimize further lung injury while ensuring adequate oxygenation.
While assessing a patient's arterial blood gases (ABGs), the nurse notes the
following results: pH 7.29, PaCO2 50 mm Hg, HCO3 24 mEq/L. What
condition does this patient most likely have?
A) Metabolic acidosis
B) Respiratory acidosis
C) Respiratory alkalosis
D) Metabolic alkalosis - ANSWER B) Respiratory acidosis
Rationale: The low pH (7.29) and high PaCO2 (50 mm Hg) indicate respiratory
acidosis, typically caused by hypoventilation or impaired gas exchange.
A nurse is caring for a patient with a pulmonary embolism (PE). Which of the
following is the most common sign or symptom of PE?
A) Wheezing
B) Hemoptysis
,C) Sudden onset of shortness of breath
D) Fever - ANSWER C) Sudden onset of shortness of breath
Rationale: The sudden onset of dyspnea is the most common symptom of a
pulmonary embolism, due to blockage of the pulmonary circulation.
A patient has a chest tube in place after a pneumothorax. The nurse observes
continuous bubbling in the water seal chamber. What is the most appropriate
action?
A) Increase suction.
B) Clamp the chest tube.
C) Check for air leaks in the system.
D) Encourage the patient to cough and deep breathe. - ANSWER C) Check for
air leaks in the system.
Rationale: Continuous bubbling in the water seal chamber usually indicates
an air leak in the system that should be identified and resolved.
A patient is in acute respiratory failure with hypoxemia. Which of the
following ABG results would the nurse expect to see?
A) pH 7.40, PaO2 95 mm Hg, PaCO2 40 mm Hg
, B) pH 7.35, PaO2 80 mm Hg, PaCO2 45 mm Hg
C) pH 7.25, PaO2 55 mm Hg, PaCO2 30 mm Hg
D) pH 7.50, PaO2 105 mm Hg, PaCO2 25 mm Hg - ANSWER C) pH 7.25, PaO2
55 mm Hg, PaCO2 30 mm Hg
Rationale: These ABG results indicate hypoxemia (PaO2 < 60 mm Hg), with
compensatory hyperventilation, leading to a low PaCO2.
A patient with hypercarbia presents to the emergency department. What
would the nurse expect the ABG results to show?
A) Elevated pH, decreased PaCO2
B) Decreased pH, increased PaCO2
C) Decreased pH, decreased HCO3
D) Normal pH, normal PaCO2 - ANSWER B) Decreased pH, increased PaCO2
Rationale: Hypercarbia (increased PaCO2) leads to respiratory acidosis,
characterized by a low pH and elevated CO2 levels.
A patient is being treated for ARDS and has a PaO2 of 55 mm Hg despite
receiving 100% oxygen. Which of the following interventions is most likely to
improve this patient's oxygenation?
