lOMoARcPSD|26582732
NR 342 2025 COMPLEX REVIEW TEST 1 WITH ANSWERS
1. Different invasive lines for pt who is in icu and just had a cabg, cardiac status, other vital
functions. - nurse should always assess vital signs and chest dressing first
Post-op cabg (sata)
- 1. Hemodynamic monitoring (co)
- 2. An arterial line for continuous bp monitoring
- 3. Pleural and mediastinal chest tubes for chest drainage
- 4. Continuous ecg monitoring
- 5. An endotracheal tube connected to mechanical ventilation
- 6. Epicardial pacing wires for emergency pacing of the heart - 7. Urinary catheter to monitor urine output
2. Ni for pts on ventilators to prevent complications. Sata. May develop peptic ulcers, ni and drugs to administer –
administer pantoprazole, reposition endotracheal tube daily, raise hob, monitor for skin irritations in the mouth.
Minimizing sedation, spontaneous awakening trials (sats), early exercise and mobilization, use of et tube with
subglottic secretion drainage ports for the pt likely to be intubated greater than 48-72 hrs, elevate hob greater than
30-45 degrees, oral care with chlorhexidine and no routine changes of the patient ventilation circuit tubing, turn pt
q2hrs.
1. Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia
(vap)? (select all that apply.)
a. Obtain arterial blood gases daily.
b. Provide a “sedation holiday” daily.
c. Give prescribed pantoprazole (protonix).
d. Elevate the head of the bed to at least 30 degrees.
e. Provide oral care daily with chlorhexidine (0.12%) solution. Ans: b, c, d, e
All these interventions are part of the ventilator bundle that is recommended to prevent vap. Arterial blood gases
may be done daily but are not always necessary and do not help prevent vap.
3.pt with copd show signs of anxiety, what ni we perform. What do we do first elevate
hob 30 to 45
- interventions for copd patient who is anxious (pg 572)
● Identify when level of anxiety changes to determine possible precipitating factors
● Use calm, reassuring approach to provide reassurance
● Stay w/ pt to promote safety and reduce fear
● Encourage verbalization of feelings, precipitations, and fears to identify problem areas so appropriate planning
can take place
● Provide factual info concerning diagnosis, treatment, and prognosis to help pt know what to expect
● Instruct pt in the use of relaxation techniques to relieve and promote ease of respirations
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, lOMoARcPSD|26582732
- provide better comfort for copd patient
-copd – manifestations, chronic intermittent cough, dyspnea, wheezing, chest tightness, fatigue, weight loss,
anorexia
Nursing interventions/teaching, stop smoking, avoid environmental pollutants, avoid others who are sick, practice
good hh, take meds as prescribed, exercise regularly, maintain a healthy weight.
Influenza and pneumococcal vaccines are recommended
Pursed lip breathing, huff breathing to clear secretions, chest physiotherapy, postural drainage, percussion vibration
medical interventions including medications: bronchodilators, o2 therapy complications: exacerbations from copd,
cor pulmonale, acute respiratory failure.
The nurse observes a new onset of agitation and confusion in a patient with chronic obstructive pulmonary
disease (copd). Which action should the nurse take first? A. Observe for facial symmetry.
b. Notify the health care provider.
c. Attempt to calm and reorient the patient.
d. Assess oxygenation using pulse oximetry. Ans: d
Because agitation and confusion are often the initial indicators of hypoxemia, the nurse’s initial action should be to
assess o2 saturation. The other actions are appropriate, but assessment of oxygenation takes priority over other
assessments and notification of the health care provider.
4. Abg
Know abgs. Compensated vs uncompensated - ph will be normal or close to normal abg’s –
interpretation and/or expected findings for a client condition/disease process normal
findings:
Ph- 7.35-7.45 (hydrogen)
Paco2 : (carbon dioxide) 35-45mmhg
Hco3 (bicarbonate) 22-26mmol/l
Rome -respiratory opposite, metabolic equal.
Respiratory acidosis: ph below 7.35, co2 above 45, bicarb within range. Treatment is 2-4l o2, lift head of the bed,
increase oral fluids, turn cough deep breath, maintain airway.
Respiratory alkalosis: ph above 7.35, co2 below 35, bicarb within range. “paper bag” -rebreather, watch potassium
and calcium levels, monitor for overventilation.
Metabolic acidosis: ph below 7.35, co2 within range, hco3 below 22. Insulin to reduce ketones for dka, antidiarrheal,
fall precautions, iv isotonic/hypertonic, sodium bicarb, hyperkalemia.
Metabolic alkalosis: ph above 7.45, co2 within range, hco2 above 26. Antiemetic, stop diuretics, watch for signs
avoid foods that cause gas(cabbage, beans, cauliflower_ of distress, watch potassium and calcium, hypokalemia.
5. Visitation policies for pts in icu – ebp pg 1537 critical care ch 65
- Lack of visitations causes mental complications
- Individualized to the patient’s needs. (icu is more restrictive)
● evidence suggests several positive benefits of flexible visitations for the patient:
O decrease anxiety confusion and
agitation o fewer cardiovascular
complications o shorter icu length of stay
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
The family members of a patient who has been admitted to the intensive care unit (icu) with multiple traumatic
injuries have just arrived in the icu waiting room. Which action should the nurse take first? A. Explain icu
visitation policies and encourage family visits.
b. Escort the family from the waiting room to the patient’s bedside.
c. Describe the patient’s injuries and the care that is being provided.
d. Invite the family to participate in an interprofessional care conference. Ans: c
Lack of information is a major source of anxiety for family members and should be addressed first. Family members
should be prepared for the patient’s appearance and the icu environment before visiting the patient for the first
time. Icu visiting should be individualized to each patient and family rather than being dictated by rigid visitation
policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial
action by the nurse.
6.situation where an ethical consult is necessary. Reason for initiation one
● the decision to use, withhold, or stop mechanical ventilation must be made carefully, respecting the wishes
of the patient. When the interprofessional care team, patient, and/or caregiver disagree over the treatment plan
that the patient desires, conferences are essential to keep the lines of communication open and discuss options. You
may need to consult the agency’s ethics committee for assistance.
-request for ethic consultation often involve clarification of issues regarding decision making capacity, inform
consent, advance directives and withdrawal of treatment.
Situations in which ethics consultation may be considered
• Disagreement or conflict exists on whether to pursue aggressive life-sustaining treatment in a seriously ill
patient, such as cardiopulmonary resuscitation, or emphasize comfort and palliative care.
• Family demands to provide life-sustaining treatment, such as mechanical ventilation or tube feeding, which the
physician and nurses consider futile.
• Competing family members are present and want to make critical decisions on behalf of the patient.
• A seriously ill patient is incapacitated and does not have a surrogate decision maker or an advance directive.
7. Purpose and reason for obtaining an advance directive.
● are written documents that provide information about the patient’s wishes and his or her designated
spokesperson.
8: dysrhythmias in post op cabg patient, what kind of dysrhythmias can you expect on this pts.
Downloaded by NELSON KIIRU ()
NR 342 2025 COMPLEX REVIEW TEST 1 WITH ANSWERS
1. Different invasive lines for pt who is in icu and just had a cabg, cardiac status, other vital
functions. - nurse should always assess vital signs and chest dressing first
Post-op cabg (sata)
- 1. Hemodynamic monitoring (co)
- 2. An arterial line for continuous bp monitoring
- 3. Pleural and mediastinal chest tubes for chest drainage
- 4. Continuous ecg monitoring
- 5. An endotracheal tube connected to mechanical ventilation
- 6. Epicardial pacing wires for emergency pacing of the heart - 7. Urinary catheter to monitor urine output
2. Ni for pts on ventilators to prevent complications. Sata. May develop peptic ulcers, ni and drugs to administer –
administer pantoprazole, reposition endotracheal tube daily, raise hob, monitor for skin irritations in the mouth.
Minimizing sedation, spontaneous awakening trials (sats), early exercise and mobilization, use of et tube with
subglottic secretion drainage ports for the pt likely to be intubated greater than 48-72 hrs, elevate hob greater than
30-45 degrees, oral care with chlorhexidine and no routine changes of the patient ventilation circuit tubing, turn pt
q2hrs.
1. Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia
(vap)? (select all that apply.)
a. Obtain arterial blood gases daily.
b. Provide a “sedation holiday” daily.
c. Give prescribed pantoprazole (protonix).
d. Elevate the head of the bed to at least 30 degrees.
e. Provide oral care daily with chlorhexidine (0.12%) solution. Ans: b, c, d, e
All these interventions are part of the ventilator bundle that is recommended to prevent vap. Arterial blood gases
may be done daily but are not always necessary and do not help prevent vap.
3.pt with copd show signs of anxiety, what ni we perform. What do we do first elevate
hob 30 to 45
- interventions for copd patient who is anxious (pg 572)
● Identify when level of anxiety changes to determine possible precipitating factors
● Use calm, reassuring approach to provide reassurance
● Stay w/ pt to promote safety and reduce fear
● Encourage verbalization of feelings, precipitations, and fears to identify problem areas so appropriate planning
can take place
● Provide factual info concerning diagnosis, treatment, and prognosis to help pt know what to expect
● Instruct pt in the use of relaxation techniques to relieve and promote ease of respirations
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
- provide better comfort for copd patient
-copd – manifestations, chronic intermittent cough, dyspnea, wheezing, chest tightness, fatigue, weight loss,
anorexia
Nursing interventions/teaching, stop smoking, avoid environmental pollutants, avoid others who are sick, practice
good hh, take meds as prescribed, exercise regularly, maintain a healthy weight.
Influenza and pneumococcal vaccines are recommended
Pursed lip breathing, huff breathing to clear secretions, chest physiotherapy, postural drainage, percussion vibration
medical interventions including medications: bronchodilators, o2 therapy complications: exacerbations from copd,
cor pulmonale, acute respiratory failure.
The nurse observes a new onset of agitation and confusion in a patient with chronic obstructive pulmonary
disease (copd). Which action should the nurse take first? A. Observe for facial symmetry.
b. Notify the health care provider.
c. Attempt to calm and reorient the patient.
d. Assess oxygenation using pulse oximetry. Ans: d
Because agitation and confusion are often the initial indicators of hypoxemia, the nurse’s initial action should be to
assess o2 saturation. The other actions are appropriate, but assessment of oxygenation takes priority over other
assessments and notification of the health care provider.
4. Abg
Know abgs. Compensated vs uncompensated - ph will be normal or close to normal abg’s –
interpretation and/or expected findings for a client condition/disease process normal
findings:
Ph- 7.35-7.45 (hydrogen)
Paco2 : (carbon dioxide) 35-45mmhg
Hco3 (bicarbonate) 22-26mmol/l
Rome -respiratory opposite, metabolic equal.
Respiratory acidosis: ph below 7.35, co2 above 45, bicarb within range. Treatment is 2-4l o2, lift head of the bed,
increase oral fluids, turn cough deep breath, maintain airway.
Respiratory alkalosis: ph above 7.35, co2 below 35, bicarb within range. “paper bag” -rebreather, watch potassium
and calcium levels, monitor for overventilation.
Metabolic acidosis: ph below 7.35, co2 within range, hco3 below 22. Insulin to reduce ketones for dka, antidiarrheal,
fall precautions, iv isotonic/hypertonic, sodium bicarb, hyperkalemia.
Metabolic alkalosis: ph above 7.45, co2 within range, hco2 above 26. Antiemetic, stop diuretics, watch for signs
avoid foods that cause gas(cabbage, beans, cauliflower_ of distress, watch potassium and calcium, hypokalemia.
5. Visitation policies for pts in icu – ebp pg 1537 critical care ch 65
- Lack of visitations causes mental complications
- Individualized to the patient’s needs. (icu is more restrictive)
● evidence suggests several positive benefits of flexible visitations for the patient:
O decrease anxiety confusion and
agitation o fewer cardiovascular
complications o shorter icu length of stay
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
The family members of a patient who has been admitted to the intensive care unit (icu) with multiple traumatic
injuries have just arrived in the icu waiting room. Which action should the nurse take first? A. Explain icu
visitation policies and encourage family visits.
b. Escort the family from the waiting room to the patient’s bedside.
c. Describe the patient’s injuries and the care that is being provided.
d. Invite the family to participate in an interprofessional care conference. Ans: c
Lack of information is a major source of anxiety for family members and should be addressed first. Family members
should be prepared for the patient’s appearance and the icu environment before visiting the patient for the first
time. Icu visiting should be individualized to each patient and family rather than being dictated by rigid visitation
policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial
action by the nurse.
6.situation where an ethical consult is necessary. Reason for initiation one
● the decision to use, withhold, or stop mechanical ventilation must be made carefully, respecting the wishes
of the patient. When the interprofessional care team, patient, and/or caregiver disagree over the treatment plan
that the patient desires, conferences are essential to keep the lines of communication open and discuss options. You
may need to consult the agency’s ethics committee for assistance.
-request for ethic consultation often involve clarification of issues regarding decision making capacity, inform
consent, advance directives and withdrawal of treatment.
Situations in which ethics consultation may be considered
• Disagreement or conflict exists on whether to pursue aggressive life-sustaining treatment in a seriously ill
patient, such as cardiopulmonary resuscitation, or emphasize comfort and palliative care.
• Family demands to provide life-sustaining treatment, such as mechanical ventilation or tube feeding, which the
physician and nurses consider futile.
• Competing family members are present and want to make critical decisions on behalf of the patient.
• A seriously ill patient is incapacitated and does not have a surrogate decision maker or an advance directive.
7. Purpose and reason for obtaining an advance directive.
● are written documents that provide information about the patient’s wishes and his or her designated
spokesperson.
8: dysrhythmias in post op cabg patient, what kind of dysrhythmias can you expect on this pts.
Downloaded by NELSON KIIRU ()
