CAI EXAM 2 practice questions

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?

Agitation

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?

Brush the client's teeth with a suction toothbrush every 12 hours.

A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect?

increasing dyspnea

What is the sequence of actions the nurse should take when preparing to suction a tracheostomy?

-adjust the suction -sterile gloves -check function of suction catheter -hyperoxygenate the pt -insert catheter w/o suction -apply suction while rotating catheter -assess for secretion clearance

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first?

Assess the client's airway

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?

Clear breath sounds

A nurse is caring for a pt who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

Continuous bubbling in the water-seal chamber

A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take?

Encourage the client to take deep breaths.

The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?

Fluctuation of the fluid level within the water seal chamber

A nurse is implementing the ventilator care bundle for a client who is receiving mechanical ventilation. Which of the following should the nurse expect to find in the bundle?

Instructions on mouth care

In caring for a client in acute respiratory failure, the nurse recognizes that noninvasive positive pressure ventilation (NIPPV) may be used for which client?

Is alert and cooperative but has increasing respiratory exhaustion

A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?

PaCO2 50 mm Hg

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?

Perform pre-oxygenation prior to suctioning.

A nurse is caring for a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicates the intervention was effective?

Pink mucous membranes

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition?

Severe dyspnea Decreased LOC Headache Hypotension

A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider?

Stridor

A UAP is taking care of a patient with a chest tube. The nurse should intervene when she observes the UAP

Stripping or milking the chest tube to promote drainage

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?

Suppress respiratory effort

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?

Tachycardia

A nurse is assessing a client 5 hr after the insertion of a chest tube that is attached to a water-seal drainage system. Which of the following observations about the drainage should the nurse report to the provider?

about 150mL/hr drainage over the past 2 hr

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

administer oxygen therapy

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent pulmonary embolism?

assess legs for redness, apply elastic compression stockings, perform passive range of motion exercises

A nurse is caring for a pt who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?

attach a humidifier bottle to the base of the flow meter

Which of the following clinical manifestations is often an early indicator of respiratory failure?

change in mental status

A nurse is caring for a client who has a three-chamber closed chest tube system. WHich of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?

continue to monitor the client

A nurse is caring for a client who is 6 hr post-op and has a chest tube in place that is attached to a closed-chest water-seal drainage system. The nurse should identify that which of the following is an indication of a problem in the drainage system?

continuous bubbling in the water-seal chamber

which of the following is a potential cause for a high alarm on a mechanical ventilator?

copious secretions

The nurse suspects that a pt with PEEP has negative effects of ventilatory maneuver when which finding is present?

decreasing blood pressure

which of the following is a potential cause for a low-pressure alarm on a ventilator

disconnected tubing

a nurse is caring for a client who requires a chest tube. The provider asks for the suction pressure of the closed-chest drainage system to be set at -40 cm of water. Which of the following closed-chest drainage systems should the nurse prepare for the client?

dry suction-control system

A nurse is providing discharge teaching for a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

eat foods that contain plenty of potassium

a nurse is caring for a pt who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications?

elevate HOB to at least 30 degrees, admin pantoprazole as prescribed, reposition the endotracheal tube to the opposite side of the mouth daily

How often should the client receive oral care when an oral endotracheal tube is in place?

every 2-4 hrs

A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

verify that the suction regulator is on and check the tubing for leaks

bubbling in which chamber of the chest tube unit signifies an air leak?

water seal chamber

The nurse determines that a low CO2 level on an ABG report may result from which of the following problems?

hyperventilation

Following a motor vehicle accident, the nurse assesses the driver for which distinctive sign if flail chest?

paradoxical chest movement

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Cheyne-Stokes respirations

A nurse is caring for a pt who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?

encourage the pt to increase fluid intake

The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

evaluate chest expansion

After endotracheal intubation and mechanical ventilation have been started, a pt in respiratory failure becomes very agitated and is breathing asynchronously with the ventilator. What is most important for the nurse to do first?

evaluate the pt's pain level, ABG's, and electrolyte values

A nurse is caring for a client who has a chest tube in place. Which of the following strategies should the nurse use to help promote comfort for the client?

have the client splint the affected side during coughing

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

heparin

A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition?

hypoxemia

A nurse is planning education for a client who has a chest tube in place that is attached to a closed-chest drainage system. Which of the following instructions should the nurse plan to provide when the client is ready to ambulate?

keep the collection device upright at all times

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

keep the drainage system below the level of the client's chest at all times

A nurse is preparing to transport a client who has a chest tube and a closed-chest wet-suction drainage system to radiology. Which of the following actions should the nurse take when detaching the suction source for transportation?

make sure the air vent is open

A nurse in the PACU is assessing a pt who has an endotracheal tube (ET) in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

movement of ET tubs into the right main bronchus

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

movement of the trachea toward the unaffected side

When preparing to perform sterile closed suctioning technique of the endotracheal tube for a client on a ventilator, what should the nurse do prior to suctioning?

preoxygenate with 100% oxygen

A nurse in the emergency department is caring for a client who has cardiogenic pulmonary edema. The client's assessment findings include anxiousness, dyspnea at rest, crackles, BP 110/79, and apical HR 112/min. Which of the following interventions is the nurse's priority?

provide the client with supplemental oxygen at 5L/min via facemask

a nurse is caring for a pt who has returned to the unit following a surgical procedure. The pt's O2 sat is 85%. Which of the following actions should the nurse take first?

raise the HOB

A nurse is caring for a pt who has a tracheostomy. Which of the following interventions should the nurse implement when performing tracheostomy care?

secure new tracheostomy ties before removing old ones

A male client has COPD and is a smoker. The nurse notices respiratory distress and no breath sounds over the left chest. Which type of pneumothorax should the nurse suspect is occuring?

spontaneous pneumothorax

A nurse is caring for a client who has a chest tube in place that is attached to a water-seal drainage system. Which of the following findings should the nurse recognize as an indication of subcutaneous emphysema?

a dry ,crackling sound at the insertion site when palpated

Which of the following would indicate that an intubated patient receiving positive pressure ventilation through a mechanical ventilator may be ready for extubation?

patient is awake, alert, and able to follow commands

Which of the following indicates the most appropriate method for providing nursing care to clients requiring mechanical ventilation?

perform daily spontaneous awakening trial

A nurse is planning care for a pt who has ARDS. Which of the following interventions should the nurse include in the plan?

place in a prone position

a nurse is caring for a client who has a chest tube in place that is attached to a closed-chest drainage system. Which of the following actions should the nurse take if the chest tube becomes dislodged from the closed-chest drainage system?

submerge the end of the chest tube in 1 inch of sterile water