Answers)
Nurse admits patient to med surg unit. Resp rate of 38. Patient using chest muscles to
breathe, pulse ox of 87 on room air, pink frothy sputum. What intervention would you
implement first? - O2 at 2 Liters/Min
Caring for pt. who is intubated and receiving mechanical ventilation. What action by the
nurse would decrease the patient's incidence of developing ventilator associated
pneumonia? - Put head of bed at 30-45 degrees.
The nurse is administering acetylcysteine (muca-mist) as nebulizer treatment to patient.
Which should the nurse have available for adverse effect on the patient? - Suction
equipment
Patient coming in with SOB and resp. rate of 32. ABG results PH 7.3 (acid), Co2-50 Bicarb-28,
PO2-70
Resp. Acidosis, what orders do you anticipate carrying out? - Apply O2 and give med-neb
treatment.
You have 4 patients in a long term care facility. Which would you check first? - COPD patient
with resp rate of 30, O2 of 87 and on 3 Liters of O2 complaining of dyspnea.
Caring for newly intubated patient getting mechanical ventilation. Pt.'s wife was not at hosp.
when this occurred. Wife appears angry and states "What have you all done to him?" What
would be your response as a nurse? - Explain to the patient why the patient had to be
intubated, continue to update patient's wife on condition and plan of care, I'm sorry that you
walked in on him like that, I understand this must have been very frightening.
Patient has SOB, edema in legs and face and has the following labs: BUN-95 (high),
Creatinine of 9.2, Potassium of 6.0 (high). What are you going to do - Give Kexolate, prepare
the patient a central line for dialysis. Cardiac monitoring.
Working with a UAP, what task can be delegated? - Instill non-prescription eye drops in
patient's eyes.