CC exam 2

Deviation of the trachea occurs in which conditions? (Select all that apply.) a. Pneumothorax b. Pulmonary fibrosis c. Chronic obstructive pulmonary disease d. Emphysema e. Pleural effusion

ANS: A, B, E Assessment of tracheal position assists in the diagnosis of pneumothorax, unilateral pneumonia, pulmonary fibrosis, and pleural effusion.

Which oxygen delivery device is considered a low-flow system? a. Nasal cannula b. Simple face mask c. Reservoir cannula d. Air-entrainment nebulizer

ANS: A A low-flow oxygen delivery system provides supplemental oxygen directly into the patient's airway at a flow of 8 L/min or less. Because this flow is insufficient to meet the patient's inspiratory volume requirements, it results in a variable FiO2 as the supplemental oxygen is mixed with room air. A nasal cannula is a low-flow oxygen delivery system.

Which route for endotracheal (ET) tube placement is usually used in an emergency intubation? a. Orotracheal b. Nasotracheal c. Nasopharyngeal d. Trachea

ANS: A An endotracheal tube (ETT) may be placed through the orotracheal or the nasotracheal route. In most situations involving emergency placement, the orotracheal route is used because it is simpler and allows the use of a larger diameter ETT. Nasotracheal intubation provides greater patient comfort over time and is preferred in patients with a jaw fracture.

The nurse is performing a pulmonary assessment on a patient with a pleural effusion. Which finding is unexpected? a. Increased diaphragmatic excursion b. Decreased tactile fremitus c. Dull percussion tones d. Pleural friction rub

ANS: A Assessment findings associated with pleural effusion include dullness on percussion, decreased tactile fremitus, pleural friction rub, and decreased diaphragmatic excursion. Increased diaphragmatic excursion is not associated with acute bronchitis.

Which statement describes the assist-control mode of ventilation? a. It delivers gas at preset volume, at a set rate, and in response to the patient's inspiratory efforts. b. It delivers gas at a preset volume, allowing the patient to breathe spontaneously at his or her own volume. c. It applies positive pressure during both ventilator breaths and spontaneous breaths. d. It delivers gas at preset rate and tidal volume regardless of the patient's inspiratory efforts.

ANS: A Continuous mandatory (volume or pressure) ventilation (CMV), also known as assist-control (AC) ventilation, delivers gas at preset tidal volume or pressure (depending on selected cycling variable) in response to patient's inspiratory efforts and initiates breath if patient fails to do so within preset time.

A patient has the following arterial blood gas (ABG) values: pH, 7.20; PaO2, 106 mm Hg; pCO2, 35 mm Hg; and , 11 mEq/L. What symptom would be most consistent with the ABG values? a. Diarrhea b. Shortness of breath c. Central cyanosis d. Peripheral cyanosis

ANS: A Diarrhea is one mechanism by which the body can lose large amounts of . The other choices are indications of hypoxia, which is not indicated with a PaO2 of 106 mm Hg.

When assessing a patient, the use of observation is referred to as what technique? a. Inspection b. Palpation c. Percussion d. Auscultation

ANS: A Inspection is the process of looking intently at the patient. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

Severe coughing and shortness of breath during a thoracentesis are indicative of what complication? a. Re-expansion pulmonary edema b. Pleural infection c. Pneumothorax d. Hemothorax

ANS: A Re-expansion pulmonary edema can occur when a large amount of effusion fluid (~1000 to 1500 mL) is removed from the pleural space. Removal of the fluid increases the negative intrapleural pressure, which can lead to edema when the lung does not re-expand to fill the space. The patient experiences severe coughing and shortness of breath. The onset of these symptoms is an indication to discontinue the thoracentesis.

A patient is admitted with acute lung failure secondary to pneumonia. Arterial blood gas (ABG) values on the current ventilator settings are pH, 7.37; PaCO2, 50 mm Hg; and HCO3¯, 27 mEq/L. What is the correct interpretation of the patient's ABG values? a. Compensated respiratory acidosis b. Compensated metabolic alkalosis c. Uncompensated respiratory alkalosis d. Uncompensated metabolic acidosis

ANS: A The ABG values reflect a compensated respiratory acidosis. Values include a pH of 7.35 to 7.39, PaCO2 above 45 mm Hg, and above 26 mEq/L. Uncompensated respiratory alkalosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and of 22 to 26 mEq/L. Compensated metabolic alkalosis values include a pH of 7.41 to 7.45, PaCO2 above 45 mm Hg, and above 26 mEq/L. Uncompensated metabolic acidosis values include a pH above 7.35, PaCO2 of 35 to 45 mm Hg, and below 22 mEq/L.

When assessing an intubated patient, the nurse notes normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest. What problem should the nurse suspect? a. Right mainstem intubation b. Left pneumothorax c. Right hemothorax d. Gastric intubation

ANS: A The finding of normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest in a newly intubated patient is probably caused by a right mainstem intubation.

On admission, a patient presents with a respiratory rate of 28 breaths/min, heart rate of 108 beats/min in sinus tachycardia, and a blood pressure of 140/72 mm Hg. The patient's arterial blood gas (ABG) values on room air are PaO2, 60 mm Hg; pH, 7.32; PaCO2, 45 mm Hg; and , 26 mEq/L. What action should the nurse anticipate for this patient? a. Initiate oxygen therapy. b. Prepare for emergency intubation. c. Administer 1 ampule of sodium bicarbonate. d. Initiate capnography.

ANS: A The patient is hypoxemic and oxygen therapy should be initiated at this time. The patient's arterial blood gas (ABG) values do not warrant intubation at this time. Sodium bicarbonate is not indicated because this patient has a normal bicarbonate level. Capnography would not be indicated at this time as the patient's CO2 is normal. A repeat ABG may be ordered to assess the patient's ongoing respiratory status.

Ventilation-perfusion (V/Q) scans are ordered to evaluate the possibility of which of the following? a. Pulmonary emboli b. Acute myocardial infarction c. Emphysema d. Acute respiratory distress syndrome

ANS: A This test is ordered for the evaluation of pulmonary emboli. Electrocardiography or cardiac enzymes are ordered to evaluate for myocardial infarction; arterial blood gas analysis, chest radiography, and pulmonary function tests are ordered to evaluate for emphysema. Chest radiography and hemodynamic monitoring are ordered for evaluation of acute respiratory distress syndrome.

A patient presents moderately short of breath and dyspneic. A chest radiographic examination reveals a large right pleural effusion with significant atelectasis. The practitioner would be most likely to prescribe which procedure? a. Thoracentesis b. Bronchoscopy c. Ventilation-perfusion (V/Q) scan d. Repeat chest radiograph

ANS: A Thoracentesis is a procedure that can be performed at the bedside for the removal of fluid or air from the pleural space. It is used most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema. No evidence is present that would necessitate a V/Q scan. A bronchoscopy cannot assist in fluid removal. A problem with this chest radiograph is not indicated.

A patient presents with absent lung sounds in the left lower lung fields, moderate shortness of breath, and dyspnea. The nurse suspects pneumothorax and notifies the practitioner. Orders for a STAT chest radiography and reading are obtained. Which finding best supports the nurse's suspicions? a. Blackness in the left lower lung area b. Whiteness in the left lower lung area c. Blunted costophrenic angles d. Elevated left hemidiaphragm

ANS: A With a pneumothorax, the pleural edges become evident as one looks through and between the images of the ribs on the film. A thin line appears just parallel to the chest wall, indicating where the lung markings have pulled away from the chest wall. In addition, the collapsed lung will be manifested as an area of increased density separated by an area of radiolucency (blackness).

A patient just involved in a motor vehicle accident has sustained blunt chest trauma as part of his injuries. The nurse notes absent breath sounds on the left side. A left-sided pneumothorax is suspected and is further validated when assessment of the trachea reveals what finding? a. A shift to the right b. A shift to the left c. No deviation d. Subcutaneous emphysema

ANS: A With a pneumothorax, the trachea shifts to the opposite side of the problem; with atelectasis, the trachea shifts to the same side as the problem. Subcutaneous emphysema is more commonly related to a pneumomediastinum and is not specifically related to the trachea but to air trapped in the mediastinum and general neck area.

Which interventions minimize the complications associated with suctioning an artificial airway? (Select all that apply.) a. Hyperoxygenate the patient prior to the start of the procedure b. Hyperoxygenate the patient after each pass of the suction catheter c. Limit the duration of each suction pass to 20 seconds d. Instill 5 to 10 mL of normal saline to facilitate secretion removal e. Use intermittent suction to avoid damaging tracheal tissue

ANS: A, B Hyperoxygenation and limiting the number of passes help avoid desaturation. There is no evidence to suggest that intermittent suction reduces damage, and saline instillation can actually increase the risk for infection.

Which of the following are complications of endotracheal tubes? (Select all that apply.) a. Tracheoesophageal fistula b. Cricoid abscess c. Tracheal stenosis d. Tube obstruction e. Hemorrhage

ANS: A, B, C, D Complications of endotracheal tubes include tube obstruction, tube displacement, sinusitis and nasal injury, tracheoesophageal fistula, mucosal lesions, laryngeal or tracheal stenosis, and cricoid abscess. Hemorrhage is a complication of tracheostomy tubes.

How does the patient history assist the nurse in developing the management plan? (Select all that apply.) a. Provides direction for the rest of the assessment b. Exposes key clinical manifestations c. Aids in developing the plan of care d. The degree of the patient's distress determines the extent of the interview e. Determines length of stay in the hospital setting

ANS: A, B, C, D The initial presentation of the patient determines the rapidity and direction of the interview. For a patient in acute distress, the history should be curtailed to just a few questions about the patient's chief complaint and precipitating events.

Nursing management of a patient undergoing a diagnostic procedure entails what nursing actions? (Select all that apply.) a. Positioning the patient for the procedure b. Monitoring the patient's responses to the procedure c. Monitoring vital signs d. Teaching the patient about the procedure e. Medicating the patient before and after procedure

ANS: A, B, C, D, E Preparing the patient includes teaching the patient about the procedure, answering any questions, and positioning the patient for the procedure. Monitoring the patient's responses to the procedure includes observing the patient for signs of pain and anxiety and monitoring vital signs, breath sounds, and oxygen saturation. Assessing the patient after the procedure includes observing for complications of the procedure and medicating the patient for any postprocedural discomfort.

What are the clinical manifestations associated with oxygen toxicity? (Select all that apply.) a. Substernal chest pain that increases with deep breathing b. Moist cough and tracheal irritation c. Pleuritic pain occurring on inhalation, followed by dyspnea d. Increasing CO2 e. Sore throat and eye and ear discomfort

ANS: A, C, E A number of clinical manifestations are associated with oxygen toxicity. The first symptom is substernal chest pain that is exacerbated by deep breathing. A dry cough and tracheal irritation follow. Eventually, definite pleuritic pain occurs on inhalation followed by dyspnea. Upper airway changes may include a sensation of nasal stuffiness, sore throat, and eye and ear discomforts.

A patient with chronic obstructive pulmonary disease (COPD) requires intubation. After the practitioner intubates the patient, the nurse auscultates for breath sounds. Breath sounds are questionable in this patient. Which action would best assist in determining endotracheal tube placement in this patient? a. Stat chest radiographic examination b. End-tidal CO2 monitor c. Ventilation-perfusion (V/Q) scan d. Pulmonary artery catheter insertion

ANS: B Although a stat chest radiography examination would be helpful, it has a long turnaround time, and the patient's respiratory status can deteriorate quickly. An end-tidal CO2 monitor gives an immediate response, and the tube can then be reinserted without delay if incorrectly placed. The other tests are not for endotracheal tube placement.

The nurse is performing a pulmonary assessment on a patient with acute bronchitis. Which finding is unexpected? a. Rasping productive cough b. Decreased tactile fremitus c. Resonant percussion tones d. Crackles and wheezes

ANS: B Assessment findings associated with acute bronchitis include rasping productive cough, resonance on percussion, crackles and wheezes, and normal to increased tactile fremitus. Decreased tactile fremitus is not associated with acute bronchitis.

A bronchoscopy is indicated for a patient with what condition? a. Pulmonary edema b. Ineffective clearance of secretions c. Upper gastrointestinal bleed d. Instillation of surfactant

ANS: B Bronchoscopy visualizes the bronchial tree. If secretions are present, they can be removed by suctioning and sent for culture to help adjust antibiotic therapy.

A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. When entering the room, the ventilator inoperative alarm sounds. What action should the nurse take FIRST? a. Troubleshoot the ventilator until the problem is found. b. Take the patient off the ventilator and manually ventilate. c. Call the respiratory therapist for help. d. Silence the ventilator alarms until the problem is resolved.

ANS: B Ensure emergency equipment is at bedside at all times (eg, manual resuscitation bag connected to oxygen, masks, suction equipment or supplies), including preparations for power failures. If the ventilator malfunctions, the patient should be removed from the ventilator and ventilated manually with a manual resuscitation bag.

A patient was taken to surgery for a left lung resection. The patient returned to the unit 30 minutes ago. Upon completion of the assessment, the nurse notices that the chest tube has drained 150 mL of red fluid in the past 30 minutes. The nurse contacts the physician and suspects that the patient has developed what complication? a. Pulmonary edema b. Hemorrhage c. Acute lung failure d. Bronchopleural fistula

ANS: B Hemorrhage is an early, life-threatening complication that can occur after a lung resection. It can result from bronchial or intercostal artery bleeding or disruption of a suture or clip around a pulmonary vessel. Excessive chest tube drainage can signal excessive bleeding. During the immediate postoperative period, chest tube drainage should be measured every 15 minutes; this frequency should be decreased as the patient stabilizes. If chest tube loss is greater than 100 mL/h, fresh blood is noted, or a sudden increase in drainage occurs, hemorrhage should be suspected.

A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure limit alarm keeps alarming. What would cause this problem? a. A leak in the patient's endotracheal (ET) tube cuff b. A kink in the ventilator tubing c. The patient is disconnected from the ventilator d. A faulty oxygen filter

ANS: B High-pressure alarms will sound because of improper alarm setting; airway obstruction resulting from patient fighting ventilator (holding breath as ventilator delivers Vt); patient circuit collapse; kinked tubing; the endotracheal tube in the right mainstem bronchus or against the carina; cuff herniation; increased airway resistance resulting from bronchospasm, airway secretions, plugs, and coughing; water from the humidifier in the ventilator tubing; and decreased lung compliance resulting from tension pneumothorax, change in patient position, acute respiratory distress syndrome, pulmonary edema, atelectasis, pneumonia, or abdominal distention.

Which medication can cause bronchospasms and should be administered with a bronchodilator? a. Beta-2 agonist b. Mucloytics c. Anticholinergic agents d. Xanthines

ANS: B Mucolytics may be administered with a bronchodilator because it can cause bronchospasms and inhibit ciliary function. Treatment is considered effective when bronchorrhea develops and coughing occurs. Beta-2 agonists are used to relax bronchial smooth muscle and dilate airways to prevent bronchospasms. Anticholinergic agents are used to block the constriction of bronchial smooth muscle and reduce mucus production. Xanthines are used to dilate bronchial smooth muscle and reverse diaphragmatic muscle fatigue.

Which patient would be considered hypoxemic? a. A 70-year-old man with a PaO2 of 72 b. A 50-year-old woman with a PaO2 of 65 c. An 84-year-old man with a PaO2 of 96 d. A 68-year-old woman with a PaO2 of 80

ANS: B Normal PaO2 is 80 to 100 mm Hg in persons younger than 60 years. The formula for determining PaO2 for a person older than 60 years of age is 80 mm Hg minus 1 mm Hg for every year of age above 60 years of age, for example, 70 years old = 80 mm Hg - 10 mm Hg = 70 mm Hg; 84 years old = 80 mm Hg - 20 mm Hg = 60 mm Hg; and 68 years old = 80 mm Hg - 8 mm Hg = 72 mm Hg.

When assessing a patient, the use of touch to judge the character of the body surface and underlying organs is known as what technique? a. Inspection b. Palpation c. Percussion d. Auscultation

ANS: B Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

What nursing interventions should be included in the nursing management of the patient receiving a neuromuscular blocking agent? a. Withholding all sedation and narcotics b. Protecting the patient from the environment c. Keeping the patient supine d. Speaking to the patient only when necessary

ANS: B Patient safety is a major concern for the patient receiving a neuromuscular blocking agent because these patients are unable to protect themselves from the environment. Special precautions should be taken to protect the patient at all times.

Patient safety precautions when working with oxygen include which action? a. Observing for signs of oxygen-associated hyperventilation b. Ensuring the oxygen device is properly positioned c. Removal of all oxygen devices when eating d. Administration of oxygen at the nurse's discretion

ANS: B Patient safety precautions when working with oxygen involve administration of oxygen and monitoring of its effectiveness. Activities include restricting smoking, administering supplemental oxygen as ordered, observing for signs of oxygen-induced hypoventilation, monitoring the patient's ability to tolerate removal of oxygen while eating, and changing the oxygen delivery device from a mask to nasal prongs during meals as tolerated.

What chest radiography finding is consistent with a left pneumothorax? a. Flattening of the diaphragm b. Shifting of the mediastinum to the right c. Presence of a gastric air bubble d. Increased radiolucency of the left lung field

ANS: B Shifting of the mediastinal structures away from the area of involvement is a sign of a pneumothorax.

A patient's pulse oximeter alarm goes off. The monitor reads 82%. What is the first action the nurse should perform? a. Prepare to intubate. b. Assess the patient's condition. c. Turn off the alarm and reapply the oximeter sensor. d. Increase O2 level to 4L/NC.

ANS: B The first nursing action would be to assess the patient to see if there is a change in his or her condition. If the patient is stable, then the nurse would turn off the alarm and reapply the oximeter sensor. The pulse oximeter cannot differentiate between normal and abnormal hemoglobin. Elevated levels of abnormal hemoglobin falsely elevate the SpO2. The ability of a pulse oximeter to detect hypoventilation is accurate only when the patient is breathing room air. Because most critically ill patients require some form of oxygen therapy, pulse oximetry is not a reliable method of detecting hypercapnia and should not be used for this purpose.

A patient presents with the following arterial blood gas (ABG) values: pH, 7.20; PaO2, 106 mm Hg; PaCO2, 35 mm Hg; and , 11 mEq/L. What is the interpretation of the patient's ABG? a. Uncompensated respiratory acidosis b. Uncompensated metabolic acidosis c. Uncompensated metabolic alkalosis d. Uncompensated respiratory alkalosis

ANS: B The pH indicates acidosis, and the is markedly decreased, indicating a metabolic disorder. Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and below 22 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and of 22 to 26 mEq/L. Uncompensated respiratory alkalosis values include a pH above 7.45, PaCO2 below 35 mm Hg, and of 22 to 26 mEq/L. Uncompensated metabolic alkalosis values include a pH above 7.45, PaCO2 of 35 to 45 mm Hg, and above 26 mEq/L.

The patient's arterial blood gas (ABG) values on room air are PaO2, 40 mm Hg; pH, 7.10; PaCO2, 44 mm Hg; and , 16 mEq/L. What is the interpretation of the patient's ABG? a. Uncompensated respiratory acidosis b. Uncompensated metabolic acidosis c. Compensated metabolic acidosis d. Compensated respiratory acidosis

ANS: B The pH is below normal range (7.35 to7.45), so this is uncompensated acidosis. The PaCO2 normal and the is markedly low. This indicates uncompensated metabolic acidosis. Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and below 22 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and of 22 to 26 mEq/L. Compensated metabolic acidosis values include a pH of 7.35 to 7.39, PaCO2 below 35 mm Hg, and below 22 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.35, PaCO2 above 45 mm Hg, and above 26 mEq/L.

The patient's arterial blood gas (ABG) values on room air are PaO2, 70 mm Hg; pH, 7.31; PaCO2, 52 mm Hg; and , 24 mEq/L. What is the interpretation of the patient's ABG? a. Uncompensated metabolic alkalosis b. Uncompensated respiratory acidosis c. Compensated respiratory acidosis d. Compensated respiratory alkalosis

ANS: B The pH is closer to the acidic level, so the primary disorder is acidosis. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and of 22 to 26 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.39, PaCO2 greater than 45 mm Hg, and greater than 26 mEq/L. Compensated respiratory alkalosis values include a pH of 7.41 to 7.45, PaCO2 below 35 mm Hg, and below 22 mEq/L. Uncompensated metabolic alkalosis values include a pH above 7.45, PaCO2 of 35 to 45 mm Hg, and above 26 mEq/L.

Which ventilator phase variable initiates the change from exhalation to inspiration? a. Cycle b. Trigger c. Flow d. Pressure

ANS: B The phase variable that initiates the change from exhalation to inspiration is called the trigger. Breaths may be pressure triggered or flow triggered based on the sensitivity setting of the ventilator and the patient's inspiratory effort or time triggered based on the rate setting of the ventilator.

A patient was admitted with acute lung failure. The patient has been on a ventilator for 3 days and is being considered for weaning. Which criteria would indicate that the patient is ready to be weaned? a. FiO2 greater than 50% b. Rapid shallow breathing index less than 105 c. Minute ventilation greater than 10 L/min d. Vital capacity/kg greater than or equal to 15 mL

ANS: B The rapid shallow breathing index (RSBI) has been shown to be predictive of weaning success. To calculate the RSBI, the patient's respiratory rate and minute ventilation are measured for 1 minute during spontaneous breathing. The measured respiratory rate is then divided by the tidal volume (expressed in liters). An RSBI less than 105 is considered predictive of weaning success. If the patient meets criteria for weaning readiness and has an RSBI less than 105, a spontaneous breathing trial can be performed.

What is the therapeutic blood level for theophylline (Xanthines)? a. 5 to 10 mg/dL b. 10 to 20 mg/dL c. 20 to 30 mg/dL d. 35 to 45 mg/dL

ANS: B Therapeutic blood level for theophylline is 10 to 20 mg/dL.

Which statements regarding rotation therapies are accurate? (Select all that apply.) a. Continuous lateral rotation therapy (CLRT) can be effective for improving oxygenation if used for at least 18 hours/day. b. Kinetic therapy can decrease the incidence of ventilator-acquired pneumonia in neurologic and postoperative patients. c. Use of rotational therapy eliminates the need for other pressure ulcer prevention strategies. d. CLRT helps avoid hemodynamic instability secondary to the continuous, gentle turning of the patient. e. CLRT has minimal pulmonary benefits for critically ill patients.

ANS: B, E Studies have found that to achieve benefits with rotation therapy, rotation must be aggressive, and the patient must be at least 40 degrees per side, with a total arc of at least 80 degrees for at least 18 hours a day. Kinetic therapy has been shown to decrease the incidence of ventilator-acquired pneumonia, particularly in neurologic and postoperative patients. Complications of the procedure include dislodgment or obstruction of tubes, drains, and lines; hemodynamic instability; and pressure ulcers. Lateral rotation does not replace manual repositioning to prevent pressure ulcers. Continuous lateral rotation therapy (CLRT) has been shown to be of minimal pulmonary benefit for the critically ill patients.

Which arterial blood gas (ABG) values represent uncompensated metabolic acidosis? a. pH, 7.29; PaCO2, 57 mm Hg; , 22 mEq/L b. pH, 7.36; PaCO2, 33 mm Hg; , 18 mEq/L c. pH, 7.22; PaCO2, 42 mm Hg; , 18 mEq/L d. pH, 7.52; PaCO2, 38 mm Hg; , 29 mEq/L

ANS: C A pH of 7.22 is below normal, reflecting acidosis. The metabolic component () is low, indicating that the acidosis is metabolic in origin. Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and below 22 mEq/L.

What is an indication for a pneumonectomy? a. Peripheral granulomas b. Bronchiectasis c. Unilateral tuberculosis d. Single lung abscess

ANS: C A pneumonectomy is the removal of entire lung with or without resection of the mediastinal lymph nodes. Indications include malignant lesions, unilateral tuberculosis, extensive unilateral bronchiectasis, multiple lung abscesses, massive hemoptysis, and bronchopleural fistula.

What does an intrapulmonary shunting value of 35% indicate? a. Normal gas exchange of venous blood b. An abnormal finding indicative of a shunt-producing disorder c. A serious and potentially life-threatening condition d. Metabolic alkalosis

ANS: C A shunt greater than 10% is considered abnormal and indicative of a shunt-producing disorder. A shunt greater than 30% is a serious and potentially life-threatening condition that requires pulmonary intervention.

Which airway would be the most appropriate for a patient requiring intubation longer than 21 days? a. Oropharyngeal airway b. Esophageal obturator airway c. Tracheostomy tube d. Endotracheal intubation

ANS: C Although no ideal time to perform the procedure has been identified, it is commonly accepted that if a patient has been intubated or is anticipated to be intubated for longer than 7 to 10 days, a tracheostomy should be performed.

Which oxygen therapy device should is used in a patient requiring the delivery of a precise low FiO2? a. Simple mask b. Nasal cannula c. Air-entrainment mask d. Partial rebreathing mask

ANS: C An air-entrainment mask is used in patients requiring the delivery of a precise low FiO2. A simple mask, partial rebreathing mask, and nasal cannula are not able to provide as precise level of oxygen as an air-entrainment mask.

The nurse is performing a pulmonary assessment on a patient with pulmonary fibrosis. Which finding is unexpected? a. Diminished thoracic expansion b. Tracheal deviation to the most affected side c. Hyperresonant percussion tones d. Decreased breath sounds

ANS: C Assessment findings associated with pulmonary fibrosis include diminished thoracic expansion, tracheal deviation to the most affected side, decreased or absent breath sounds, and resonance or dullness on percussion. Hyperresonance is not an expected finding in pulmonary fibrosis.

The nurse is observing a new graduate listen to a patient's lungs. Which action by the new graduate indicates a need to review auscultation skills? a. The nurse starts at the apices and moves to the bases. b. The nurse compares breath sounds from side to side. c. The nurse listens during inspiration. d. The nurse listens posteriorly, laterally, and anteriorly.

ANS: C Breath sounds are assessed during both inspiration and expiration. Auscultation is done in a systematic sequence: side-to-side, top-to-bottom, posteriorly, laterally, and anteriorly

Use of oxygen therapy in the patient who is hypercapnic may result in which situation? a. Oxygen toxicity b. Absorption atelectasis c. Carbon dioxide retention d. Pneumothorax

ANS: C Deoxygenated hemoglobin carries more CO2 compared with oxygenated hemoglobin. Administration of oxygen increases the proportion of oxygenated hemoglobin, which causes increased release of CO2 at the lung level. Because of the risk of CO2 accumulation, all patients who are chronically hypercapnic require careful low-flow oxygen administration.

What nursing intervention can minimize the complications of suctioning? a. Inserting the suction catheter no more than 5 inches b. Premedicating the patient with atropine c. Hyperoxygenating the patient with 100% oxygen d. Increasing the suction to 150 mm Hg

ANS: C Hypoxemia can be minimized by giving the patient three hyperoxygenation breaths (breaths at 100% FiO2) with the ventilator before the procedure and again after each pass of the suction catheter.

The nurse is caring for a patient with respiratory failure. The nurse notes the patient's diaphragmatic excursing is 8 cm. What coexisting conditions could account for this finding? a. Asthma and emphysema b. Hepatomegaly and ascites c. Atelectasis and pleural effusion d. Pneumonia and pneumothorax

ANS: C Normal diaphragmatic excursion is 3 to 5 cm and is part of the percussion component of the physical examination. Diaphragmatic excursion is increased in pleural effusion, and disorders that elevate the diaphragm, such as atelectasis or paralysis. Diaphragmatic excursion is decreased in disorders such as ascites, pregnancy, hepatomegaly, and emphysema.

What assessment technique uses the creation of sound waves across the body surface to determine abnormal densities? a. Inspection b. Palpation c. Percussion d. Auscultation

ANS: C Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

What medication may be included in the preprocedural medications for a diagnostic bronchoscopy? a. Aspirin for anticoagulation b. Vecuronium to inhibit breathing c. Codeine to decrease the cough reflex d. Cimetidine to decrease hydrochloric acid secretion

ANS: C Preprocedural medications for a diagnostic bronchoscopy may include atropine and intramuscular codeine. Whereas atropine lessens the vasovagal response and reduces the secretions, codeine decreases the cough reflex. When a bronchoscopy is performed therapeutically to remove secretions, decreased cough and gag reflexes are present, which may impair secretion clearance.

The Passy-Muir valve is contraindicated in which patient? a. A patient who is trying to relearn normal breathing patterns b. A patient who has minimal secretions c. A patient with laryngeal or pharyngeal dysfunction d. A patient who wants to speak while on the ventilator

ANS: C The Passy-Muir valve is contraindicated in patients with laryngeal or pharyngeal dysfunction, excessive secretions, or poor lung compliance.

A patient is intubated, and sputum for culture and sensitivity is ordered. Which of the following is important for obtaining the best specimen? a. After the specimen is in the container, dilute thick secretions with sterile water. b. Apply suction when the catheter is advanced to obtain secretions from within the endotracheal tube. c. Do not apply suction while the catheter is being withdrawn because this can contaminate the sample with sputum left in the endotracheal tube. d. Do not clear the endotracheal tube of all local secretions before obtaining the specimen.

ANS: C To prevent contamination of secretions in the upper portion of the endotracheal tube, do not apply suction while the catheter is being withdrawn. Clear the endotracheal or tracheostomy tube for all local secretions, avoiding deep airway penetration. This will prevent contamination with upper airway flora. Do not dilute thick secretions with sterile water. This will compromise the specimen.

A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. Which criteria would indicate that the patient is not tolerating weaning? a. A decrease in heart rate from 92 to 80 beats/min b. An SpO2 of 92% c. An increase in respiratory rate from 22 to 38 breaths/min d. Spontaneous tidal volumes of 300 to 350 mL

ANS: C Weaning intolerance indicators include (1) a decrease in level of consciousness; (2) a systolic blood pressure increased or decreased by 20 mm Hg; (3) a diastolic blood pressure greater than 100 mm Hg; (4) a heart rate increased by 20 beats/min; (5) premature ventricular contractions greater than 6/min, couplets, or runs of ventricular tachycardia; (6) changes in ST segment (usually elevation); (7) a respiratory rate greater than 30 breaths/min or less than 10 breaths/min; (8) a respiratory rate increased by 10 breaths/min; (9) a spontaneous tidal volume less than 250 mL; (10) a PaCO2 increased by 5 to 8 mm Hg or pH less than 7.30; (11) an SpO2 less than 90%; (12) use of accessory muscles of ventilation; (13) complaints of dyspnea, fatigue, or pain; (14) paradoxical chest wall motion or chest abdominal asynchrony; (15) diaphoresis; and (16) severe agitation or anxiety unrelieved with reassurance.

A patient is admitted with acute respiratory failure secondary to pneumonia. Upon auscultation, the nurse hears creaking, leathery, coarse breath sounds in the lower anterolateral chest area during inspiration and expiration. This finding is indicative of what condition? a. Emphysema b. Atelectasis c. Pulmonary fibrosis d. Pleural effusion

ANS: D A pleural friction rub is the result of irritated pleural surfaces rubbing together and is characterized by a leathery, dry, loud, coarse sound. A pleural friction rub is seen with pleural effusions or pleurisy and is not indicative of emphysema, atelectasis, or pulmonary fibrosis.

In a patient who is hemodynamically stable, which procedure can be used to estimate the PaCO2 levels? a. PaO2/FiO2 ratio b. A-a gradient c. Residual volume (RV) d. End-tidal CO2

ANS: D Capnography is the measurement of exhaled carbon dioxide (CO2) gas; it is also known as end-tidal CO2 monitoring. Normally, alveolar and arterial CO2 concentrations are equal in the presence of normal ventilation-perfusion (V/Q) relationships. In a patient who is hemodynamically stable, the end-tidal CO2 (PetCO2) can be used to estimate the PaCO2. Normally, the PaO2/FiO2 ratio is greater than 286; the lower the value, the worse the lung function. The A-a gradient is normally less than 20 mm Hg on room air for patients younger than 61 years. This estimate of intrapulmonary shunting is the least reliable clinically, but it is used often in clinical decision making. Residual volume is the amount of air left in the lung after maximal exhalation. A normal value is 1200 to 1300 mL.

What assessment technique involves having the patient breathe in and out slowly with an open mouth? a. Inspection b. Palpation c. Percussion d. Auscultation

ANS: D Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

Which statement best describes the effects of positive-pressure ventilation on cardiac output? a. Positive-pressure ventilation increases intrathoracic pressure, which increases venous return and cardiac output. b. Positive-pressure ventilation decreases venous return, which increases preload and cardiac output. c. Positive-pressure ventilation increases venous return, which decreases preload and cardiac output. d. Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return and cardiac output.

ANS: D Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return to the right side of the heart. Impaired venous return decreases preload, which results in a decrease in cardiac output.

What is the preset positive pressure used to augment the patient's inspiratory effort known as? a. Positive end-expiratory pressure (PEEP) b. Continuous positive airway pressure (CPAP) c. Pressure control ventilation (PCV) d. Pressure support ventilation (PSV)

ANS: D Preset positive pressure used to augment the patient's inspiratory efforts is known as pressure support ventilation. With continuous positive airway pressure, positive pressure is applied during spontaneous breaths; the patient controls rate, inspiratory flow, and tidal volume. Positive end-expiratory pressure is positive pressure applied at the end of expiration of ventilator breaths.

Determination of oxygenation status by oxygen saturation alone is inadequate. What other value must be known? a. pH b. PaCO2 c. d. Hemoglobin (Hgb)

ANS: D Proper evaluation of the oxygen saturation level is vital. For example, an SaO2 of 97% means that 97% of the available hemoglobin is bound with oxygen. The word available is essential to evaluating the SaO2 level because the hemoglobin level is not always within normal limits and oxygen can bind only with what is available.

Which arterial blood gas (ABG) values would indicate a need for oxygen therapy? a. PaO2 of 80 mm Hg b. PaCO2 of 35 mm Hg c. HCO of 24 mEq d. SaO2 of 87%

ANS: D The amount of oxygen administered depends on the pathophysiologic mechanisms affecting the patient's oxygenation status. In most cases, the amount required should provide an arterial partial pressure of oxygen (PaO2) of greater than 60 mm Hg or an arterial hemoglobin saturation (SaO2) of greater than 90% during both rest and exercise.

Which blood gas parameter is the acid-base component that reflects kidney function? a. pH b. PaO2 c. PaCO2 d. HCO3¯

ANS: D The bicarbonate () is the acid-base component that reflects kidney function. The bicarbonate is reduced or increased in the plasma by renal mechanisms. The normal range is 22 to 26 mEq/L. pH measures the hydrogen ion concentration of plasma. PaO2 measures partial pressure of oxygen dissolved in arterial blood plasma. PaCO2 measures the partial pressure of carbon dioxide dissolved in arterial blood plasma.

On admission, a patient presents with a respiratory rate of 24 breaths/min, pursed-lip breathing, heart rate of 96 beats/min in sinus tachycardia, and a blood pressure of 110/68 mm Hg. The patient's arterial blood gas (ABG) values on room air are PaO2, 70 mm Hg; pH, 7.38; PaCO2, 52 mm Hg; and , 34 mEq/L. What diagnoses would be most consistent with the above arterial blood gas values? a. Acute pulmonary embolism b. Acute myocardial infarction c. Congestive heart failure d. Chronic obstructive pulmonary disease

ANS: D The fact that the level has increased enough to compensate for the increased pCO2 level indicates that this is not an acute condition because the kidneys can take several days to adjust. The other choices would present with a lower level. The values indicate respiratory acidosis, and one of the potential causes is chronic obstructive pulmonary disease. Potential causes for respiratory alkalosis are pulmonary embolism, acute myocardial infarction, and congestive heart failure.

Which ABG values reflect compensation? a. pH, 7.26; PaCO2, 55 mm Hg; , 24 mEq/L b. pH, 7.30; PaCO2, 32 mm Hg; , 18 mEq/L c. pH, 7.48; PaCO2, 30 mm Hg; , 22 mEq/L d. pH, 7.38; PaCO2, 58 mm Hg; , 30 mEq/L

ANS: D The pH is within normal limits, and both the PaCO2 and the values are abnormal. Compensated respiratory acidosis values include a pH of 7.35 to 7.39, PaCO2 above 45 mm Hg, and above 26 mEq/L.

A 75-kg patient is on a ventilator and may be ready for extubation. A respiratory therapist assesses the patient's rapid shallow breathing index (RSBI). Which result best suggests that the patient is ready for a spontaneous breathing trial? a. RSBI = 150 b. RSBI = 125 c. RSBI = 110 d. RSBI = 90

ANS: D The rapid, shallow breathing index (RSBI) can predict weaning success. An RSBI of less than 105 is considered predictive of weaning success. If the patient is receiving sedation, the medication is discontinued at least 1 hour before the RSBI is measured. If the patient meets criteria for weaning readiness and has an RSBI of less than 105, a spontaneous breathing trial can be performed.

A patient has a permanent pacemaker implanted with the identification code beginning with VVI, which indicates: A) Ventricular paced, ventricular sensed, inhibited B) Atrial paced, ventricular sensed, inhibited C) Ventricular sensed, ventricular paced, inhibited D) Atrial sensed, atrial paced, inhibited

ANS: A The identification of VVI indicates ventricular paced, ventricular sensed, inhibited.

A patient would be considered for cardiac conduction surgery if which of the following are present? A) Sinus bradycardia not responsive to other treatments B) Functional rhythms not responsive to other treatments C) Atrial and ventricular tachycardias not responsive to other treatments D) Ventricular fibrillation not responsive to other treatments

ANS: C Cardiac conduction surgery is considered in patients who do not respond to medications and antitachycardia pacing.

An unstable patient exhibiting atrioventricular nodal reentry tachycardia (AVNRT) has not responded to vagal maneuvers or drug therapy. What will the nurse anticipate as the next step in the management of this patient's dysrhythmia? A) Cardioversion B) Carotid sinus massage C) Defibrillation D) Cardiac bypass surgery

ANS: A A patient with AVNRT who is unstable or does not respond to vagal maneuvers will require cardioversion. Carotid sinus massage is an example of a vagal maneuver. Defibrillation should never be attempted on a patient with a pulse. Cardiac bypass surgery is indicated for a patient with blocked coronary arteries.

What condition develops when air enters the pleural space from the lung on inhalation and cannot exit on exhalation? a. Tension pneumothorax b. Sucking chest wound c. Open pneumothorax d. Pulmonary interstitial empyema

ANS: A A tension pneumothorax develops when air enters the pleural space from either the lung or the chest wall on inhalation and cannot escape on exhalation. Open pneumothorax is a laceration in the parietal pleura that allows atmospheric air to enter the pleural space; it occurs as a result of penetrating chest trauma. Pulmonary interstitial emphysema is air in the pulmonary interstitial space.

A stable patient with atrial flutter is symptomatic from the arrhythmia. The physician administers amiodarone IV in an attempt to: A) Convert the arrhythmia to a sinus rhythm B) Slow the ventricular rate C) Block the conduction of the AV node D) Slow the conduction through the AV node

ANS: A Amiodarone is used to promote conversion to sinus rhythm, while medications such as diltiazem, verapamil, and digitalis are used to slow the ventricular rate.

The nurse is caring for a patient in the critical care unit who experiences ventricular tachycardia (VT). What is the drug of choice for this dysrhythmia? A) Amiodarone B) Lidocaine C) Adenosine D) Clonidine

ANS: A Amiodarone-administered IV is the antidysrhythmic medication of choice for a stable patient with VT. Other medications that may be used are procainamide and sotalol. Although lidocaine has been the medication most commonly used for immediate, short-term therapy, it has no proven short- or long-term efficacy in cardiac arrest.

A patient is exhibiting ventricular tachycardia with an irregular rhythm. The nurse should expect which dysrhythmia as the cause of the ventricular tachycardia? A) Atrial fibrillation B) Atrial flutter C) Premature ventricular complex D) Sinus bradycardia

ANS: A Atrial fibrillation should be suspected as the cause of a ventricular tachycardia with an irregular rhythm and it should be treated appropriately.

The nurse caring for a patient on the telemetry floor who is experiencing symptomatic sinus bradycardia is aware the medication of choice for treatment of this dysrhythmia is atropine. What guidelines will the nurse following when administering atropine? A) Administer atropine 0.5 mg rapidly as an IV bolus every 3 to 5 minutes to a maximum total dose of 3 mg. B) Administer atropine 0.5 mg slowly as an IV bolus every minute to a maximum total dose of 3 mg. C) Administer atropine 1.0 mg rapidly as an IV bolus every 3 to 5 minutes to a maximum total dose of 3 mg. D) Administer atropine 1.0 mg slowly as an IV bolus every minute to a maximum total dose of 3 mg.

ANS: A Atropine 0.5 mg given rapidly as an intravenous (IV) bolus every 3 to 5 minutes to a maximum total dose of 3 mg is the medication of choice in treating symptomatic sinus bradycardia.

The nurse caring for a patient with a tachydysrhythmia would teach and prepare him for which of the following procedures: A) Catheter ablation therapy B) Transubcutaneous pacemaker C) Cardioversion D) Implantable cardiac device

ANS: A Catheter ablation therapy uses radiofrequency energy to ablate or burn accessory pathways or ectopic sites in the atria, AV node, or ventricles that cause tachyarrhythmias.

A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The patient suddenly becomes confused, seeing nonexistent animals in the room and pulling at the bedding. The nurse suspects the patient may be experiencing what issue? a. Delirium b. Hypoxemia c. Hypocalcemia d. Sedation withdrawal

ANS: A Delirium is represented by a global impairment of cognitive processes, usually of sudden onset, coupled with disorientation, impaired short-term memory, altered sensory perceptions (hallucinations), abnormal thought processes, and inappropriate behavior. There is no evidence provided that would indicate the patient is hypoxemic, hypocalcemic, or going through sedation withdrawal.

A patient is admitted with diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetric chest movement. These findings are indicative of which disorder? a. Tension pneumothorax b. Pneumonia c. Pulmonary fibrosis d. Atelectasis

ANS: A Diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetric chest movement are indicative of tension pneumothorax.

The nurse is caring for a patient who develops pulseless electrical activity. Upon confirmation, the nurse would immediately: A) Start CPR B) Administer epinephrine C) Notify the physician STAT D) Start an IV of NSS wide-open rate

ANS: A During asystole or pulseless electrical activity, CPR must be initiated immediately to maintain minimal cardiac output and oxygenation, followed by intubation, and then administration of epinephrine.

The nurse is caring for a patient who converted to ventricular fibrillation (VF) and was defibrillated at 200 joules, 300 joules, and 360 joules respectively. The patient remains in VF. According to national standards, the nurse is aware that the following medication should be used: A) Epinephrine 1 mg IV push B) Lidocaine 100 mg IV push C) Amiodarone 300 mg IV push D) Sodium bicarbonate 1 amp IV push

ANS: A Epinephrine is administered after three consecutive defibrillations to make it easier to convert the dysrhythmia to a normal sinus rhythm with defibrillation. Epinephrine may also increase cerebral and coronary artery blood flow. Antiarrythmic medications such as amiodarone and lidocaine are given if ventricular dysrhythmia persists.

The nurse is caring for a patient 1 hour postoperative pacemaker implantation. Upon assessing the patient's ECG, spikes appear within the QRS complex and ST segment. This is described as: A) Failure to sense B) Failure to capture C) Pacemaker failure D) Demand pacing

ANS: A Failure to sense is when the pacemaker is unable to detect an electrically conducted signal produced by the heart such as a P wave or QRS complex. It is seen as spikes on the QRS complex and ST segment. Failure to capture is no response of the ventricle of the heart to the electrical conducting system.

A patient was admitted following an aspiration event on the medical-surgical floor. The patient is receiving 40% oxygen via a simple facemask. The patient has become increasingly agitated and confused. The patient's oxygen saturation has dropped from 92% to 84%. The nurse notifies the practitioner about the change in the patient's condition. What interventions should the nurse anticipate? a. Intubation and mechanical ventilation b. Change in antibiotics orders c. Suction and reposition the patient d. Orders for a sedative

ANS: A Given the significant drop in oxygen saturation, increasing agitation and confusion, the nurse should anticipate the patient will need to be intubated and mechanically ventilated. Administering antibiotics, suctioning and repositioning, and administering a sedative would not address the development of severe hypoxemia.

A patient presenting to the emergency room is experiencing atrial flutter. The initial management of atrial flutter in a stable patient with a narrow QRS and regular R-R interval is: A) Rapid IV administration of adenosine 6 mg, followed by a 20-mL saline flush and elevation of the arm B) IV administration of a beta-blocker C) Rapid IV administration of adenosine 12 mg, repeating the drug administration if needed D) IV administration of magnesium

ANS: A If the patient with atrial flutter is stable, the QRS is narrow, and the R-R interval is regular, 6 mg of adenosine may be rapidly administered followed by a 20-mL saline flush and elevation of the arm. If the rhythm does not convert to sinus rhythm within 1 to 2 minutes, a 12-mg bolus may be administered and repeated, if needed, within 1 to 2 minutes. If the adenosine fails to convert the rhythm or if the R-R interval is irregular, then magnesium, diltiazem, or beta-blockers may be administered.

A nurse is assessing an ECG rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second. The overall heart rate is 60 beats/min. The nurse assesses the cardiac rhythm as: A) Normal sinus rhythm B) Sinus bradycardia C) Sick sinus syndrome D) Heart Block

ANS: A Normal sinus rhythm appears as a regular rhythm with a rate of 60 to 100 beats per minute. The PR and QRS measurements are normal according to normal sinus rhythm.

What two pathogens are most frequently associated with ventilator-associated pneumonia? a. Staphylococcus aureus and Pseudomonas aeruginosa b. Escherichia coli and Haemophilus influenzae c. Acinetobacter baumannii and Haemophilus influenzae d. Klebsiella spp. and Enterobacter spp.

ANS: A Pathogens that can cause hospital-associated pneumonia (HAP) include Escherichia coli, H. influenzae, methicillin-sensitive S. aureus, S. pneumoniae, P. aeruginosa, Acinetobacter baumannii, methicillin-resistant S. aureus (MRSA), Klebsiella spp., and Enterobacter spp. Two of the pathogens most frequently associated with ventilator-associated pneumonia (VAP) are S. aureus and P. aeruginosa.

When administering propofol over an extended period, what laboratory value should the nurse routinely monitor? a. Serum triglyceride level b. Sodium and potassium levels c. Platelet count d. Acid-base balance

ANS: A Prolonged use of propofol may cause an elevated triglyceride level because of its high lipid content.

Which nursing intervention should be used to optimize oxygenation and ventilation in the patient with acute lung failure? a. Provide adequate rest and recovery time between procedures. b. Position the patient with the good lung up. c. Suction the patient every hour. d. Avoid hyperventilating the patient.

ANS: A Providing adequate rest and recovery time between various procedures prevents desaturation and optimizes oxygenation. In acute lung failure, the goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Hyperventilate the patient before suctioning; suction patients as needed.

What are the risk factors for delirium? a. Hypertension, alcohol abuse, and benzodiazepine administration b. Coma, hypoxemia, and trauma c. Dementia, hypertension, and pneumonia d. Coma, alcohol abuse, hyperglycemia

ANS: A Risk factors for delirium risk include dementia, hypertension, alcohol abuse, high severity of illness, coma, and benzodiazepine administration.

The nurse performs inspection of the oral cavity as part of a focused pulmonary assessment to check for evidence of what condition? a. Hypoxia b. Dyspnea c. Dehydration d. Malnutrition

ANS: A Severe hypoxia will be manifested by central cyanosis, which is evident in the oral and circumoral areas. Although dehydration and nutritional status can both be partially assessed by oral cavity inspection, this information is not as vital as determining hypoxia. Dyspnea means difficulty breathing.

A patient reports feeling palpitations, light-headedness, and weakness. The nurse finds a pulse deficit when doing the assessment. This may be an indicator of: A) Atrial fibrillation B) Sinus tachycardia C) Premature atrial complex D) Junctional rhythm

ANS: A Signs and symptoms of atrial fibrillation include palpitations, light-headedness, weakness, and a pulse deficit.

An adult patient who has undergone an implantable cardioverter defibrillator (ICD) procedure asks about the purpose of this device. The nurse's best response would be: A) "To detect and treat ventricular fibrillation and ventricular tachycardia" B) "To detect and treat bradycardia" C) "To detect and treat atrial fibrillation" D) "To shock your heart if you have a heart attack at home"

ANS: A The ICD is a device that detects and terminates life-threatening episodes of ventricular tachycardia and ventricular fibrillation.

A 12-lead EKG performed on a patient 4 hours after onset of chest pain reveals ST segment elevation. The nurse recognizes that this finding indicates: A) Transient ischemia typical of unstable angina B) Lack of permanent damage to myocardial cells C) Myocardial infarction associated with prolonged and complete coronary thrombosis D) Myocardial infarction associated with transient or incomplete artery occlusion

ANS: A The ST segment represents early ventricular repolarization. It is analyzed to identify whether it is above or below the isoelectric line, which may be a sign of cardiac ischemia.

5. To find the heart rate from an ECG strip of a patient with a normal sinus rhythm, the nurse counts 20 small boxes between two R waves. The heart rate would be: A) 75 beats/min B) 80 beats/min C) 60 beats/min D) 140 beats/min

ANS: A The calculation to determine the heart rate on an ECG strip counting the number of small boxes between R waves is 1500 divided by the number of R waves (1500 divided by 20 equals 75).

What are the most common presenting signs and symptoms associated with a pulmonary embolism (PE)? a. Tachycardia and tachypnea b. Hemoptysis and evidence of deep vein thromboses c. Apprehension and dyspnea d. Right ventricular failure and fever

ANS: A The patient with a pulmonary embolism may have any number of presenting signs and symptoms, with the most common being tachycardia and tachypnea. Additional signs and symptoms that may be present include dyspnea, apprehension, increased pulmonic component of the second heart sound (P1), fever, crackles, pleuritic chest pain, cough, evidence of deep vein thrombosis, and hemoptysis. Syncope and hemodynamic instability can occur as a result of right ventricular failure.

In what condition are bronchophony, egophony, and whispering pectoriloquy increased? a. Pneumonia with consolidation b. Pneumothorax c. Asthma d. Bronchiectasis

ANS: A Voice sounds are increased in pneumonia with consolidation because there is increased vibration through material. Bronchophony and whispering pectoriloquy are heard as clear transmission of sounds on auscultation; egophony is heard as an "a" sound when the patient is saying "e."

An adult patient is in ventricular fibrillation; when defibrillating the patient, the nurse must: A) Maintain good contact between paddles and patient skin. B) Use ultrasound gel as a conducting agent. C) Call "all clear" once before discharging the defibrillator. D) Ensure the defibrillator is in the sync mode.

ANS: A When defibrillating an adult patient, the nurse should maintain good contact between the paddles and the patient's skin to prevent arcing, apply an appropriate conducting agent between the skin and the paddles, and ensure the defibrillator is in the non-sync mode. "All clear" should be called 3 times before discharging the paddles.

Which oxygen administration device can deliver oxygen concentrations of 90%? a. Nonrebreathing mask b. Nasal cannula c. Partial rebreathing mask d. Simple mask

ANS: A With an FiO2 of 55% to 70%, a nonrebreathing mask with a tight seal over the face can deliver 90% to 100% oxygen. It is used in emergencies and short-term therapy requiring moderate to high FiO2.

What psychologic factors contribute to long-term mechanical ventilation dependence? (Select all that apply.) a. Fear b. Delirium c. Lack of confidence d. Depression e. Trust in the stuff

ANS: A, B, C, D Psychologic factors contributing to long-term mechanical ventilation dependence include a loss of breathing pattern control (anxiety, fear, dyspnea, pain, ventilator asynchrony, lack of confidence in ability to breathe), lack of motivation and confidence (inadequate trust in staff, depersonalization, hopelessness, powerlessness, depression, inadequate communication), and delirium (sensory overload, sensory deprivation, sleep deprivation, pain medications).

Medical management of a patient with status asthmaticus includes which treatments? (Select all that apply.) a. Oxygen therapy b. Bronchodilators c. Corticosteroids d. Antibiotics e. Intubation and mechanical ventilation

ANS: A, B, C, E Medical management of a patient with status asthmaticus is directed toward supporting oxygenation and ventilation. Bronchodilators, corticosteroids, oxygen therapy, and intubation and mechanical ventilation are the mainstays of therapy.

What risk factors need to be considered when preparing a patient for a thoracentesis? (Select all that apply.) a. Coagulation defects b. Unstable hemodynamics c. Pleural effusion d. Uncooperative patient e. Empyema

ANS: A, B, D No absolute contraindications to thoracentesis exist, although some risks may contraindicate the procedure in all but emergency situations. These risk factors include unstable hemodynamics, coagulation defects, mechanical ventilation, the presence of an intraaortic balloon pump, and patients who are uncooperative. It is used most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema.

Which conditions will commonly reveal breath sounds with inspiration greater than expiration on assessment? (Select all that apply.) a. Normal lung b. Bronchiectasis c. Emphysema d. Acute bronchitis e. Diffuse pulmonary fibrosis

ANS: A, B, D The normal lung, bronchiectasis, and acute bronchitis will commonly present with an inspiration greater than expiration ratio. Acute bronchitis can also have inspiration that equals expiration ratio as also seen with emphysema, diffuse pulmonary fibrosis, and consolidating pneumonia. Noting that many conditions present with the same findings affirms the need for further assessment and evaluation.

Which complications can result from prolonged deep sedation? (Select all that apply.) a. Pressure ulcers b. Thromboembolism c. Diarrhea d. Nosocomial pneumonia e. Delayed weaning from mechanical ventilation f. Hypertension

ANS: A, B, D, E Oversedation can result in a multitude of complications. Prolonged deep sedation is associated with significant complications of immobility, including pressure ulcers, thromboembolism, gastric ileus, nosocomial pneumonia, and delayed weaning from mechanical ventilation.

A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The patient suddenly becomes confused, seeing nonexistent animals in the room and pulling at the bedding. What is the medication of choice for treating this patient? a. Diazepam b. Haloperidol c. Lorazepam d. Propofol

ANS: B Haloperidol is the drug of choice when treating delirium. Lorazepam has been associated with an increased incidence of delirium. Propofol is indicated for sedation use. Diazepam is not an appropriate choice for this patient.

Nursing management of the patient with acute lung failure includes which interventions? (Select all that apply.) a. Positioning the patient with the least affected side up b. Providing adequate rest between treatments c. Performing percussion and postural drainage every 4 hours d. Controlling fever e. Pharmaceutical medications to control anxiety

ANS: A, B, D, E The goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Patients with diffuse lung disease may benefit from being positioned with the right lung down because it is larger and more vascular than the left lung. For patients with alveolar hypoventilation, the goal of positioning is to facilitate ventilation. These patients benefit from nonrecumbent positions such as sitting or a semierect position. In addition, semirecumbency has been shown to decrease the risk of aspiration and inhibit the development of hospital-associated pneumonia. Frequent repositioning (at least every 2 hours) is beneficial in optimizing the patient's ventilatory pattern and ventilation/perfusion matching. These include performing procedures only as needed, hyperoxygenating the patient before suctioning, providing adequate rest and recovery time between various procedures, and minimizing oxygen consumption. Interventions to minimize oxygen consumption include limiting the patient's physical activity, administering sedation to control anxiety, and providing measures to control fever.

Place the steps for analyzing arterial blood gases in the proper order. 1. Assess level for metabolic abnormalities 2. Assess PaO2 for hypoxemia 3. Examine PaCO2 for acidosis or alkalosis 4. Re-examine pH to determine level of compensation 5. Examine pH for acidemia or alkalemia a. 5, 1, 2, 4, 3 b. 2, 5, 3, 1, 4 c. 1, 2, 4, 3, 5 d. 1, 3, 4, 5, 2

ANS: B A methodic approach when assessing arterial blood gases allows the nurse to detect subtle changes. A methodic approach includes look at the PaO2 level, look at the pH level, look at the PaCO2 level, look at the , and look again at the pH level.

The critical care nurse has responded to a cardiac arrest on a medical-surgical unit. The continuous electrocardiogram monitoring indicates that the patient is experiencing ventricular fibrillation. After the initial defibrillations, the next step in the management of this patient is: A) Administration of medications until an electrical rhythm is obtained B) 5 cycles of CPR alternating with a rhythm check and defibrillation C) Continuous defibrillation until an electrical rhythm is obtained D) Continuous CPR until an electrical rhythm is obtained

ANS: B After the initial defibrillation, 5 cycles of CPR alternating with a rhythm check and defibrillation are the treatments used to convert ventricular fibrillation (VF) to an electrical rhythm that produces a pulse.

An adult patient being assessed in the emergency room is anxious about his health status. The ECG rhythm strip shows a heart rate of 120 beats/min. Characteristics of a sinus tachycardia rhythm are: A) P:QRS ratio of 2:1 B) P:QRS ratio of 1:1 C) Ventricular and atrial rhythm are irregular D) Atrial rhythm regular, ventricular rhythm irregular

ANS: B Anxiety can cause a patient to experience sinus tachycardia. The characteristics of this rhythm are a P:QRS ratio of 1:1, with regular atrial and ventricular rhythm.

A nurse is caring for a patient on a cardiac monitor and whose rhythm suddenly changes. There are no P waves; instead she observes wavy lines. The QRS complexes measure 0.08 second and are irregular. The patient's heart rate is 120 beats/minute. The nurse interprets that this rhythm is: A) Sinus tachycardia B) Atrial fibrillation C) Ventricular tachycardia D) Ventricular fibrillation

ANS: B Atrial fibrillation is seen as a loss of P waves with a wavy baseline. QRS can be normal, but the heart rate ranges from 100 to 160 beats/min.

The nurse should assess for which of the following potential complications in a postoperative patient with permanent pacemaker implantation? A) Decreased urinary output B) Bleeding at the generator implantation site C) Decreased respiratory rate D) Decreased pulse rate

ANS: B Bleeding, hematomas, local infections, perforation of the myocardium, and tachycardia are complications of pacemaker implantations.

For which situation does a patient with acute lung failure require a bronchodilator? a. Excessive secretions b. Bronchospasms c. Thick secretions d. Fighting the ventilator

ANS: B Bronchodilators aid in smooth muscle relaxation and are of particular benefit to patients with airflow limitations. Mucolytics and expectorants are no longer used because they have been found to be of no benefit in this patient population.

When auscultating a patient's lungs, the nurse notes breath sounds that sound like popping in the small airways. What should the nurse document in the patient's record? a. Sonorous wheezes b. Crackles c. Sibilant wheezes d. Pleural friction rub

ANS: B Crackles or rales are short, discrete, popping or crackling sounds produced by fluid in the small airways or alveoli.

A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The patient suddenly becomes confused, seeing nonexistent animals in the room and pulling at the bedding. What parameter should be monitored while the patient is haloperidol? a. Sedation level b. QTc-interval c. Oxygen saturation level d. Brain waves

ANS: B Electrocardiogram (ECG) monitoring is recommended because haloperidol use can produce dose-dependent QTc-interval prolongation, with an increased incidence of ventricular dysrhythmias. BIS monitoring is indicated for deep sedation use.

3. While analyzing a rhythm strip, the nurse identifies the resting state of the heart by looking at the: A) P wave B) T wave C) U wave D) QRS complex

ANS: B Feedback: The T wave represents ventricular muscle depolarization, also referred to as the resting state.

The nurse is performing external defibrillation. Which of the following is a vital step in the procedure? A) Gel pads are placed anterior over the apex and posterior for better conduction. B) No one is to be touching the patient at the time shock is delivered. C) Continue to ventilate the patient via endotracheal tube during the procedure. D) Second shock cannot be administered for 1 minute to allow recharging.

ANS: B In external defibrillation, both paddles may be placed on the front of the chest, which is the standard paddle placement. Whether using pads or paddles, the nurse must observe two safety measures. First, maintain good contact between the pads or paddles and the patient's skin to prevent leaking. Second, ensure that no one is in contact with the patient or with anything that is touching the patient when the defibrillator is discharged, to minimize the chance that electrical current will be conducted to anyone other than the patient. Ventilation should be stopped during defibrillation.

A patient was admitted with acute lung failure secondary to pneumonia. What is the single most important measure to prevent the spread of infection between staff and patients? a. Place the patient in respiratory isolation. b. Ensure everyone is using proper hand hygiene. c. Use personal protective equipment. d. Initiate prompt administration of antibiotics.

ANS: B Proper hand hygiene is the single most important measure available to prevent the spread of bacteria from person to person.

While conducting a physical assessment on a patient with chronic obstructive pulmonary disease (COPD), the nurse notes that the patient's breathing is rapid and shallow. What is this type of breathing pattern called? a. Hyperventilation b. Tachypnea c. Obstructive breathing d. Bradypnea

ANS: B Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation. Hyperventilation is manifested by an increase in both the rate and depth of ventilation. Obstructive breathing is characterized by progressively shallower breathing until the patient actively and forcefully exhales. Bradypnea is a slow respiratory rate characterized as less than 12 breaths/min in an adult.

Which diagnostic criteria is indicative of mild adult respiratory distress syndrome (ARDS)? a. Radiologic evidence of bibasilar atelectasis b. PaO2/FiO2 ratio less than or equal to 200 mm Hg c. Pulmonary artery wedge pressure greater than 18 mm Hg d. Increase in static and dynamic compliance

ANS: B The Berlin Definition of ARDS is as follows: timing—within 1 week of known clinical insult or new or worsening respiratory symptoms; chest imaging—bilateral opacities not fully explained by effusions, lobar or lung collapse, or nodules; origin of edema—respiratory failure not fully explained by cardiac failure or fluid overload; need objective assessment to exclude hydrostatic edema if no risk factor present; oxygenation—mild (200 mg Hg less than PaO2/FiO2 less than or equal to 300 mm Hg with positive end-respiratory airway pressure (PEEP) or constant positive airway pressure greater than or equal to 5 cm H2O), moderate (100 mg Hg less than PaO2/FiO2 less than or equal to 200 mm Hg with PEEP greater than or equal to 5 cm H2O), or severe (PaO2/FiO2 less than or equal to 100 mm Hg with PEEP greater than or equal to 5 cm H2O). The mortality rate for ARDS is estimated to be 34% to 58%.

What is the major hemodynamic consequence of a massive pulmonary embolus? a. Increased systemic vascular resistance leading to left heart failure b. Pulmonary hypertension leading to right heart failure c. Portal vein blockage leading to ascites d. Embolism to the internal carotids leading to a stroke

ANS: B The major hemodynamic consequence of a pulmonary embolus is the development of pulmonary hypertension, which is part of the effect of a mechanical obstruction when more than 50% of the vascular bed is occluded. In addition, the mediators released at the injury site and the development of hypoxia cause pulmonary vasoconstriction, which further exacerbates pulmonary hypertension.

What is a major side effect of benzodiazepines? a. Hypertension b. Respiratory depression c. Renal failure d. Phlebitis

ANS: B The major side effects of benzodiazepines include hypotension and respiratory depression. These side effects are dose related.

A trauma victim has sustained right rib fractures and pulmonary contusions. Auscultation reveals decreased breath sounds on the right side. Bulging intercostal muscles are noted on the right side. Heart rate (HR) is 130 beats/min, respiratory rate (RR) is 32 breaths/min, and breathing is labored. In addition to oxygen administration, what procedure should the nurse anticipate? a. Thoracentesis b. Chest tube insertion c. Pericardiocentesis d. Emergent intubation

ANS: B The patient is experiencing a pneumothorax and will need immediate chest tube insertion. Chest tubes are inserted into the pleural space to remove fluid or air, reinstate the negative intrapleural pressure, and re-expand a collapsed lung.

A patient is admitted with acute lung failure secondary to emphysema. Percussion of the lung fields will predictably exhibit which tone? a. Resonance b. Hyperresonance c. Tympany d. Dullness

ANS: B The percussion tone of hyperresonance is heard with emphysema related to overinflation of the lung. Resonance can be found in normal lungs or with the diagnosis of bronchitis. Tympany occurs with the diagnosis of large pneumothorax and emphysematous blebs. Dullness occurs with the diagnosis of atelectasis, pleural effusion, pulmonary edema, pneumonia, and a lung mass.

The nurse is caring for a patient who converts from normal sinus rhythm at 72/min to atrial fibrillation with a ventricular response at 164/min. Blood pressure is 160/76. Respiratory rate is 20/min with normal chest expansion and clear lungs bilaterally. IV heparin and cardizem are given. The nurse understands that the goal is to: A) Decrease SA node conduction B) Control ventricular rate C) Improve oxygenation D) Maintain anticoagulation

ANS: B Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. A rapid ventricular response reduces the time for ventricular filling, resulting in a smaller stroke volume. Control of rhythm is the initial treatment of choice followed by anticoagulation with heparin and then coumadin.

A patient who has been transported to the emergency room after a motor vehicle accident is experiencing ventricular asystole. Management of ventricular asystole focuses on : A) Continuous defibrillation until an electrical rhythm is obtained B) High-quality CPR with minimal interruptions C) Cessation at resuscitation attempts after 2 minutes D) Administration of medications until an electrical rhythm is obtained

ANS: B Ventricular asystole is treated the same as pulseless electrical activity (PEA), focusing on high-quality CPR with minimal interruptions and identifying the underlying and/or contributing factors.

What are the causes of delirium in critically ill patients? (Select all that apply.) a. Hyperglycemia b. Meningitis c. Cardiomegaly d. Pulmonary embolism e. Alcohol withdrawal syndrome f. Hyperthyroidism

ANS: B, E, F The causes of delirium in critically ill patients include metabolic causes (acid-base disturbance, electrolyte imbalance, hypoglycemia), intracranial causes (epidural or subdural hematoma, intracranial hemorrhage, meningitis, encephalitis, cerebral abscess, tumor), endocrine causes (hyperthyroidism or hypothyroidism, Addison disease, hyperparathyroidism, Cushing syndrome), organ failure (liver encephalopathy, kidney encephalopathy, septic shock), respiratory causes (hypoxemia, hypercarbia), and medication-related causes (alcohol withdrawal syndrome, benzodiazepines, heavy metal poisoning).

Which finding confirms the diagnosis of a pulmonary embolism (PE)? a. Low-probability ventilation-perfusion (V/Q) scan b. Negative pulmonary angiogram c. High-probability V/Q scan d. Absence of vascular markings on the chest radiograph

ANS: C A definitive diagnosis of a pulmonary embolism requires confirmation by a high-probability ventilation-perfusion (V/Q) scan, an abnormal pulmonary angiogram or computed tomography scan, or strong clinical suspicion coupled with abnormal findings on lower extremity deep venous thrombosis studies.

What is the medical treatment for a pneumothorax greater than 15%? a. Systemic antibiotics to treat the inflammatory response b. An occlusive dressing to equalize lung pressures c. Interventions to evacuate the air from the pleural space d. Mechanical ventilation to assist with re-expansion of the collapsed lung

ANS: C A pneumothorax greater than 15% requires intervention to evacuate the air from the pleural space and facilitate re-expansion of the collapsed lung. Interventions include aspiration of the air with a needle and placement of a small-bore (12 to 20 Fr) or large-bore (24 to 40 Fr) chest tube.

A patient was admitted in acute lung failure. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. Which test would the nurse expect the practitioner to order to identify the infectious pathogen? a. CBC with differential b. Wound culture of surgical site c. Sputum Gram stain and culture d. Urine specimen

ANS: C A sputum Gram stain and culture are done to facilitate the identification of the infectious pathogen. In 50% of cases, though, a causative agent is not identified. A diagnostic bronchoscopy may be needed, particularly if the diagnosis is unclear or current therapy is not working. In addition, a complete blood count (CBC) with differential, chemistry panel, blood cultures, and arterial blood gas analysis is obtained.

Which intervention is an effective nursing strategy to decrease the incidence of delirium? a. Restriction of visitors b. Early nutritional support c. Clustering of nursing care activities d. Bedrest

ANS: C As lack of sleep is a major contributor to the development of delirium, interventions to promote sleep should help decrease the incidence of delirium. Some critical care units have initiated sleep protocols to increase the opportunity for patients to sleep at night, dimming lights at night, ensuring there are periods of time when tubes are not manipulated, and clustering nursing care interventions to provide some uninterrupted rest periods. Early ambulation is also appropriate.

8. Which statement is correct concerning endotracheal tube cuff management? a. The cuff should be deflated every hour to minimize pressure on the trachea. b. A small leak should be heard on inspiration if the cuff has been inflated using the minimal leak technique. c. Cuff pressures should be kept between 20 to 30 mm Hg to ensure an adequate seal. d. Cuff pressure monitoring should be done once every 24 hours.

ANS: C Cuff pressures are monitored at a minimum of every shift and are maintained within 20 to 30 mm Hg because greater pressures decrease blood flow to the capillaries in the tracheal wall and lesser pressures increase the risk of aspiration. Pressures greater than 30 mm Hg (41 cm H2O) should be reported to the physician. Cuffs are not routinely deflated because this increases the risk of aspiration. The minimal leak technique is no longer recommended.

4. An adult patient has damage to the electrical conduction of the ventricles of the heart. The nurse would expect to see changes in the: A) P wave B) T wave C) QRS complex D) U wave

ANS: C Feedback: The QRS complex represents the depolarization of the ventricles, and as such, the electrical activity of that ventricle.

When caring for a patient with a cardiac dysrhythmia, the most appropriate goal for the patient is to maintain: A) Nutritional intake B) Fluid intake C) Cardiac output D) Social contacts

ANS: C For patient safety, the most appropriate goal is to maintain cardiac output to prevent worsening complications as a result of decreased cardiac output.

While palpating a patient's lungs the nurse notes fremitus over the patient's trachea but not the lung periphery. What do these findings indicate? a. Bilateral pleural effusion b. Bronchial obstruction c. A normal finding d. Apical pneumothorax

ANS: C Fremitus is described as normal, decreased, or increased. With normal fremitus, vibrations can be felt over the trachea but are barely palpable over the periphery. With decreased fremitus, there is interference with the transmission of vibrations. Examples of disorders that decrease fremitus include pleural effusion, pneumothorax, bronchial obstruction, pleural thickening, and emphysema.

The nurse doing discharge teaching on a patient with a newly inserted permanent pacemaker teaches the patient to: A) Start lifting the arm above the shoulder right away to prevent shoulder restriction B) Avoid cooking with a microwave oven C) Avoid exposure to high-voltage electrical generators D) Avoid walking through store and library antitheft devices

ANS: C High-output electrical generators can reprogram pacemakers and should be avoided. Recent pacemaker technology allows patients to safely use most household electronic appliances and devices (eg, microwave ovens). The affected arm should not be raised above the shoulder for one week following placement of the pacemaker. Antitheft alarms may be triggered, so patients should be taught to walk through them quickly and avoid standing in or near these devices. These alarms generally do not interfere with pacemaker function.

Which cause of hypoxemia is the result of blood passing through unventilated portions of the lungs? a. Alveolar hypoventilation b. Dead space ventilation c. Intrapulmonary shunting d. Physiologic shunting

ANS: C Hypoxemia is the result of impaired gas exchange and is the hallmark of acute respiratory failure. Hypercapnia may be present, depending on the underlying cause of the problem. The main causes of hypoxemia are alveolar hypoventilation, ventilation-perfusion (V/Q) mismatching, and intrapulmonary shunting. Intrapulmonary shunting occurs when blood passes through a portion of a lung that is not ventilated. Physiologic shunting is normal and not a cause of hypoxemia.

The nurse is caring for a patient who suddenly develops bradycardia. The patient is breathing but with a decreased level of consciousness and decreased blood pressure. Which of the following treatments would be done by the nurse first? A) Begin CPR B) Administer atropine IV C) Application of a transcutaneous pacemaker D) Discontinue cardioversion

ANS: C If a patient suddenly develops bradycardia, emergency pacing may be started with a transcutaneous pacemaker, which most defibrillators are now able to perform. If the patient is alert, sedation and analgesia should be used. CPR would not be initiated because the patient has a pulse and is breathing.

An adult patient with third-degree AV block is on continuous cardiac monitoring. The EKG will show which of the following rhythm characteristics? A) PP interval and RR intervals are irregular B) PP interval equal to RR interval C) Fewer QRS complexes than P waves D) PR interval constant

ANS: C In third-degree AV block, no atrial impulse is conducted through the AV node into the ventricles. As a result, there are impulses stimulating the atria and impulses stimulating the ventricles. Therefore, there are more P waves than QRS complexes due to the difference in the natural pacemaker (nodes) rates of the heart.

The nurse is caring for a patient receiving lidocaine IV. Which factor is most relevant to administration of this medication? A) Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter B) Increase in systemic blood pressure C) Presence of premature ventricular contractions (PVCs) on cardiac monitor D) Increase in intracranial pressure (ICP)

ANS: C Lidocaine drips are commonly used to treat patients whose arrhythmias haven't been controlled with oral medication and who are having PVCs that are visible on the cardiac monitor. SaO2, blood pressure, and ICP are important factors but aren't as significant as PVCs in this situation.

Which chest wall deformity is characterized by an increase in anteroposterior (AP) diameter with displacement of the sternum forward and the ribs outward? a. Funnel chest b. Pigeon breast c. Barrel chest d. Harrison's groove

ANS: C Normal ratio of anteroposterior diameter to lateral diameter ranges from 1:2 to 5:7. A barrel chest is characterized by displacement of the sternum forward and the ribs outward and is suggestive of chronic obstructive pulmonary disease. Funnel chest, pectus excavatum, creates a pit-shaped depression. Pigeon chest, pectus carinatum, causes an increase in anteroposterior diameter. Both are related to restrictive pulmonary disease. Harrison's groove, a rib deformity, is a result of rickets.

What is the major advantage of using propofol as opposed to another sedative for short-term sedation? a. Fewer side effects b. Slower to cross the blood-brain barrier c. Shorter half-life and rapid elimination rate d. Better amnesiac properties

ANS: C Propofol is an effective short-term anesthetic agent, useful for rapid "wake-up" of patients for assessment; if continuous infusion is used for many days, emergence from sedation can take hours or days; sedative effect depends on the dose administered, depth of sedation, and length of time sedated.

The nurse caring for a patient with an arrhythmia who develops a sudden drop in blood pressure, chest pain, and decreased mentation identifies which of the following conditions related to the arrhythmia: A) Hepatomegaly B) Right-sided heart failure C) Decreased cardiac output D) Left-sided heart failure

ANS: C Symptoms of decreased cardiac output related to cardiac arrhythmias include a sudden drop in blood pressure and symptoms of hypoxemia, such as decreased mentation, chest pain and dyspnea. Right-sided heart failure include jugular vein distention, edema, and hepatomegaly. Left-sided failure symptoms include dyspnea pulmonary crackles and decreased blood pressure and S3, S4 heart sounds.

The nurse is caring for a patient who requires transcutaneous pacing. She sets the rate to 80/min. She knows that the milliamperage setting is adequate when: A) She sees the pacemaker spike at a rate of 80/min. B) The milliamperage reaches 40. C) There is evidence of a paced QRS. D) Oxygenation has improved.

ANS: C The appropriate ECG complex should immediately follow the pacing spike; therefore, a QRS complex should follow a ventricular pacing spike.

A patient presents with chest trauma from a motor vehicle accident. Upon assessment, the nurse documents that the patient is complaining of dyspnea, shortness of breath, tachypnea, and tracheal deviation to the right. In addition, the patient's tongue is blue-gray. Based on this assessment data, what additional assessment findings would the nurse expect to find? a. Kussmaul breathing pattern b. Absent breath sounds in the right lower lung fields c. Absent breath sounds in the left lung fields d. Diminished breath sounds in the right upper lung fields

ANS: C The clinical picture described is most consistent with left pneumothorax. This would cause the trachea to deviate to the right, away from the increasing pressure of the left. A pneumothorax this severe would completely collapse the left lung, thus causing absent breath sounds in that lung. The right lung fields would not be affected. Kussmaul breathing pattern is rapid, deep and labored.

A patient is admitted in respiratory distress secondary to pneumonia. The nurse knows that obtaining a history is very important. What is the appropriate intervention at this time for obtaining this data? a. Collect an overview of past medical history, present history, and current health status. b. Do not obtain any history at this time. c. Curtail the history to just a few questions about the patient's chief complaint and precipitating events. d. Complete the history and then provide measures to assist the patient to breathe easier.

ANS: C The initial presentation of the patient determines the rapidity and direction for the interview. For a patient in acute distress, the history should be curtailed to just a few questions about the patient's chief complaint and the precipitating events.

An adult patient experiences premature atrial complex (PAC) on occasion (once every couple of hours) but remains hemodynamically stable. The patient expresses concern over the arrhythmia developing into a more fatal arrhythmia in the future. The most appropriate nursing diagnosis for this patient is: A) Decreased cardiac output B) Alteration in comfort C) Anxiety related to fear of unknown D) Potential for injury

ANS: C The patient is stable, and PAC is not uncommon; therefore, it does not require treatment. The patient is fearful of the possibility of worsening arrhythmias.

Depending on the patient's risk for the recurrence of pulmonary embolism (PE), how long may a patient remain on warfarin once they are discharged from the hospital? a. 1 to 3 months b. 3 to 6 months c. 3 to 12 months d. 12 to 36 months

ANS: C The patient should remain on warfarin for 3 to 12 months depending on his or her risk for thromboembolic disease.

Which therapeutic measure would be the most effective in treating hypoxemia in the presence of intrapulmonary shunting associated with acute respiratory distress syndrome (ARDS)? a. Sedating the patient to blunt noxious stimuli b. Increasing the FiO2 on the ventilator c. Administering positive-end expiratory pressure (PEEP) d. Restricting fluids to 500 mL per shift

ANS: C The purpose of using positive-end expiratory pressure (PEEP) in a patient with acute respiratory distress syndrome is to improve oxygenation while reducing FiO2 to less toxic levels. PEEP has several positive effects on the lungs, including opening collapsed alveoli, stabilizing flooded alveoli, and increasing functional residual capacity. Thus, PEEP decreases intrapulmonary shunting and increases compliance.

What are the two scales that are recommended for assessment of agitation and sedation in adult critically ill patients? a. Ramsay Scale and Riker Sedation-Agitation Scale (SAS) b. Ramsay Scale and Motor Activity Assessment Scale (MAAS) c. Riker Sedation-Agitation Scale (SAS) and the Richmond Agitation-Sedation Scale (RASS) d. Richmond Agitation-Sedation Scale (RASS) and Motor Activity Assessment Scale (MAAS)

ANS: C The two scales that are recommended for assessment of agitation and sedation in adult critically ill patients are the SAS and the RASS.

A patient is admitted with signs and symptoms of a pulmonary embolus (PE). What diagnostic test most conclusive to determine this diagnosis? a. ABG b. Bronchoscopy c. Pulmonary function test d. V/Q scan

ANS: D A ventilation-perfusion (V/Q) scan is the most conclusive test for a pulmonary embolus. Arterial blood gas (ABG) analysis tests oxygen levels in the blood, bronchoscopy is to used view the bronchi, and pulmonary function tests are used to measure lung volume.

The nurse is preparing a patient for an ECG. Which of the following should be done prior to electrode placement? A) Cleaning the skin with povidone-iodine solution prior to applying the electrodes B) Ensuring that the area for electrode placement is dry C) Applying tincture of benzoin to the electrode sites and waiting for it to become "tacky" D) Abrading the skin by rubbing the electrode sites briskly with a rough surface such as a clean, dry gauze or washcloth

ANS: D An ECG is obtained by slightly abrading the skin with a clean, dry gauze pad and placing electrodes on the body at specific areas. The abrading of skin will enhance signal transmission.

To select the correct size of an oropharyngeal airway, the nurse should ensure the airway extends from which area to which area? a. Tip of the nose to the ear lobe b. Middle of the mouth to the ear lobe c. Tip of the nose to the middle of the trachea d. Corner of the mouth to the angle of the jaw

ANS: D An oropharyngeal airway's proper size is selected by holding the airway against the side of the patient's face and ensuring that it extends from the corner of the mouth to the angle of the jaw. If the airway is improperly sized, it will occlude the airway. Nasopharyngeal airways are measured by holding the tube against the side of the patient's face and ensuring that it extends from the tip of the nose to the ear lobe.

A patient has been admitted with the diagnosis of acute respiratory distress syndrome (ARDS). Arterial blood gasses (ABGs) revealed an elevated pH and decreased PaCO2. The patient is becoming fatigued, and the practitioner orders a repeat ABG. Which set of results would be indicative of the patient's current condition? a. Elevated pH and decreased PaCO2 b. Elevated pH and elevated PaCO2 c. Decreased pH and decreased PaCO2 d. Decreased pH and elevated PaCO2

ANS: D Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen administration (refractory hypoxemia). Initially, the PaCO2 is low as a result of hyperventilation, but eventually the PaCO2 increases as the patient fatigues. The pH is high initially but decreases as respiratory acidosis develops.

What is the sequence for auscultation of the anterior chest? a. Right side, top to bottom, then left side, top to bottom b. Left side, top to bottom, then right side, top to bottom c. Side to side, bottom to top d. Side to side, top to bottom

ANS: D Auscultation should be done in a systematic sequence: side to side, top to bottom, posteriorly, laterally, and anteriorly.

A nursing intervention to assess the hemodynamic effects of a dysrhythmia on a patient would be to: A) Obtain an ECG rhythm strip B) Obtain a blood level of drugs administered C) Assess the patient's level of anxiety D) Assess the patient's BP and pulse rate

ANS: D BP and pulse rate are indicators of the hemodynamic effect of dysrhythmias on a patient and are nursing measures that do not require a physician's order. Obtaining an ECG or drug levels requires a physician's order.

Which of the following medications is used for sedation in patients experiencing withdrawal syndrome? a. Dexmedetomidine b. Hydromorphone c. Diazepam d. Clonidine

ANS: D Clonidine (often prescribed as a Catapres patch) is a central α-agonist and is recommended for sedation during withdrawal syndrome.

The nurse is aware that cryoablation therapy involves: A) Peeling away the area of endocardium responsible for the dysrhythmia B) Using electrical shocks directly to endocardium to eliminate the source of dysrhythmia C) Using high-frequency sound waves to eliminate the source of dysrhythmia D) Using a probe cooled to a temperature of -60°C (-76° F) to eliminate the source of dysrhythmia

ANS: D Cryoablation therapy involves using the cooled probe to create a small scar on the endocardium to eliminate the source of the dysrhythmias. Endocardium resection involves peeling away a specified area of the endocardium. Electrical ablation involves using shocks to eliminate the area causing the dysrhythmias. Radio frequency ablation uses high-frequency sound waves to destroy the area causing the dysrhythmias.

What is the most common contributing factor to the development of delirium in critically ill patients? a. Sensory overload b. Hypoxemia c. Electrolyte disturbances d. Sleep deprivation

ANS: D Delirium is frequently associated with critical illness. Provision of adequate sleep and early mobilization are recommended to reduce the incidence of delirium.

Which condition is an example of a disorder with increased tactile fremitus? a. Emphysema b. Pleural effusion c. Pneumothorax d. Pneumonia

ANS: D Examples of disorders that increase tactile fremitus include pneumonia, lung cancer, and pulmonary fibrosis. Emphysema, pleural effusion, and pneumothorax are disorders that decrease fremitus.

Which medication has a greater advantage for treatment of alcohol withdrawal syndrome (AWS) because of its longer half-life and high lipid solubility? a. Lorazepam b. Midazolam c. Propofol d. Diazepam

ANS: D Management of alcohol withdrawal involves close monitoring of AWS-related agitation and administration of IV benzodiazepines, generally diazepam (Valium) or lorazepam (Ativan). Diazepam has the advantage of a longer half-life and high lipid solubility. Lipid-soluble medications quickly cross the blood-brain barrier and enter the central nervous system to rapidly produce a sedative effect. Midazolam is the recommended drug for use in alleviating acute agitation but is known to cause seizures with AWS because of rapid withdrawal. Propofol is indicated for sedation use.

Patients with left-sided pneumonia may benefit from placing them in which position? a. Reverse Trendelenburg b. Supine c. On the left side d. On the right side

ANS: D Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Because gravity normally facilitates preferential ventilation and perfusion to the dependent areas of the lungs, the best gas exchange would take place in the dependent areas of the lungs. Thus, the goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position.

What nursing intervention can facilitate the prevention of aspiration? a. Observing the amount given in the tube feeding b. Assessing the patient's level of consciousness c. Encouraging the patient to cough and to breathe deeply d. Positioning a patient in a semirecumbent position

ANS: D Semirecumbency has been shown to decrease the risk of aspiration and inhibit the development of hospital-associated pneumonia.

Supplemental oxygen administration is usually effective in treating hypoxemia related which situation? a. Physiologic shunting b. Dead space ventilation c. Alveolar hyperventilation d. Ventilation-perfusion mismatching

ANS: D Supplemental oxygen administration is effective in treating hypoxemia related to alveolar hypoventilation and ventilation-perfusion mismatching. When intrapulmonary shunting exists, supplemental oxygen alone is ineffective. In this situation, positive pressure is necessary to open collapsed alveoli and facilitate their participation in gas exchange. Positive pressure is delivered via invasive and noninvasive mechanical ventilation.

Which statement describes the major difference between tachypnea and hyperventilation? a. Tachypnea has increased rate; hyperventilation has decreased rate. b. Tachypnea has decreased rate; hyperventilation has increased rate. c. Tachypnea has increased depth; hyperventilation has decreased depth. d. Tachypnea has decreased depth; hyperventilation has increased depth.

ANS: D Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation. Hyperventilation is manifested by an increase in both the rate and depth of ventilation.

The nurse notes that the ECG strip of a patient who has had a temporary pacemaker inserted indicates loss of capture. The priority nursing intervention upon identification of this problem is to: A) Change the generator B) Increase sensitivity C) Change the battery D) Turn the patient to the left side

ANS: D The most appropriate action to take initially when there is loss of capture is to turn the patient to the left side before changing the battery or generator or adjusting the sensitivity.

The nurse who is caring for a patient in ICU on a ventilator assesses a need for suctioning and is aware that the most common cardiac arrhythmia occurring during endotracheal suctioning is: A) Sinus tachycardia B) Ventricular tachycardia C) Paroxysmal supraventricular tachycardia D) Sinus bradycardia

ANS: D Vagal stimulation such as vomiting, suctioning, severe pain, and extreme emotions may cause sinus bradycardia when the sinus node creates an impulse at a slower-than-normal rate. Sinus bradycardia has a ventricular and atrial rate less than 60. The treatment of choice is to block vagal stimulation, thus allowing a normal rate to occur. Sinus tachycardia occurs when the sinus node creates an impulse at a faster-than-normal rate resulting from physiologic or psychological stress. Ventricular tachycardia is associated with coronary artery disease

Which lung sounds would be most likely heard in a patient experiencing an asthma attack? a. Coarse rales b. Pleural friction rub c. Fine crackles d. Expiratory wheezes

ANS: D Wheezes are high-pitched, squeaking, whistling sounds produced by airflow through narrowed small airways. They are heard mainly on expiration but may also be heard throughout the ventilatory cycle. Depending on their severity, wheezes can be further classified as mild, moderate, or severe. Rales are crackling sounds produced by fluid in the small airways or alveoli or by the snapping open of collapsed airways during inspiration. A pleural friction rub is a dry, coarse sound produced by irritated pleural surfaces rubbing together and is caused by inflammation of the pleura.

A patient was admitted after a left pneumonectomy. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. What action should the nurse take next? a. Lavage the airway with normal saline. b. Place the patient supine in a semi-Fowler position. c. Manually ventilate the patient. d. Suction the airway.

ANS: D When aspiration is witnessed, emergency treatment should be instituted to secure the airway and minimize pulmonary damage. The patient's head should be turned to the side, and the oral cavity and upper airway should be suctioned immediately to remove the gastric contents.

The nurse notes that leads I, II, and III differ from one another on the cardiac rhythm strip because: A) The view of the electrical current changes in relation to the lead placement. B) Conduction of the heart differs with lead placement. C) Electrocardiogram (ECG) equipment has malfunctioned. D) The circadian rhythm has changed.

Ans: A Each lead offers a different reference point to view the electrical activity of the heart. The lead displays the configuration of electrical activity of the heart.

The nurse evaluating a rhythm strip notes that the wave forms that move to the top of the strip indicate: A) The heart rate B) A negative deflection C) An isoelectric wave D) A positive deflection

Ans: D Feedback: When an ECG wave form moves to the top of the strip, it is referred to as a positive deflection; when it moves to the bottom of the strip, it is then referred to as a negative deflection.

To achieve ventilator synchrony in a mechanically ventilated patient with acute respiratory distress syndrome (ARDS), which level of sedation might be most effective? a. Light b. Moderate c. Conscious d. Deep

D. Deep Deep sedation is used when the patient must be unresponsive to deliver necessary care safely

A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. Despite the nurse's actions, the patient continues to be agitated, triggering the high-pressure alarm on the ventilator. Which medication would be appropriate to sedate the patient this time? a. Midazolam 2 to 5 mg intravenous push (IVP) every 5 to 15 minutes until the patient is no longer triggering the alarm b. Haloperidol 5 mg IVP stat c. Propofol 5 mcg/kg/min by IV infusion d. Fentanyl 25 mcg IVP over a 15-minute period

a. Midazolam 2 to 5 mg intravenous push (IVP) every 5 to 15 minutes until the patient is no longer triggering the alarm Midazolam is the recommended drug for use in alleviating acute agitation. Propofol can be used for short- and intermediate-term sedation. Haloperidol is indicated for dementia. Fentanyl is a narcotic and is not appropriate for use as a sedative.

A patient is admitted unit with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. What action should be the nurse take first? a. Administer midazolam 5 mg by intravenous push immediately. b. Assess the patient to see if a physiologic reason exists for his agitation. c. Obtain an arterial blood gas level to ensure the patient is not hypoxemic. d. Apply soft wrist restraints to keep him from pulling out the endotracheal tube.

b. Assess the patient to see if a physiologic reason exists for his agitation. The first step in determining the need for sedation is to assess the patient quickly for any physiologic causes that can be quickly reversed. In this case, endotracheal suctioning may solve the high-pressure alarm problem.

A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. The patient continues to be very agitated, and the nurse can find nothing physiologic to account for the high-pressure alarm. What action should the nurse take next? a. Administer midazolam 5 mg by intravenous push immediately. b. Eliminate noise and other stimuli in the room and speak softly and reassuringly to the patient. c. Obtain an arterial blood gas to ensure the patient is not becoming more hypoxemic. d. Call the respiratory care practitioner to replace the malfunctioning ventilator.

b. Eliminate noise and other stimuli in the room and speak softly and reassuringly to the patient. Optimizing the environment, speaking calmly, explaining things to the patient, and providing distractions are all nonpharmacologic means to decrease anxiety.

A patient has been taking benzodiazepines and suddenly develops respiratory depression and hypotension. After careful assessment, the nurse determines that the patient is experiencing benzodiazepine overdose. What is the nurse's next action? a. Decrease benzodiazepines to half the prescribed dose. b. Increase IV fluids to 500 cc/h for 2 hours. c. Administer flumazenil (Romazicon). d. Discontinue benzodiazepine and start propofol.

c. Administer flumazenil (Romazicon). The major unwanted side effects associated with benzodiazepines are dose-related respiratory depression and hypotension. If needed, flumazenil (Romazicon) is the antidote used to reverse benzodiazepine overdose in symptomatic patients.

A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient had become very agitated and required some sedation. After the patient's agitation is controlled, which medications would be most appropriate for long-term sedation? a. Morphine 2 mg/h continuous IV drip b. Haloperidol 15 mcg/kg/min continuous IV infusion c. Propofol 5 mcg/kg/min by IV infusion d. Lorazepam 0.01 to 0.1 mg/kg/h by IV infusion

d. Lorazepam 0.01 to 0.1 mg/kg/h by IV infusion Propofol may be used for ongoing sedation for short- and intermediate-term sedation (1-3 days) and should be coupled with a short-acting opioid analgesic. Morphine is an opioid analgesic and is not sedation. Lorazepam infusion (0.01-0.1 mg/kg/h) is recommended for long-term sedation.