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1. Which clinical manifestation indicates to the nurse that a patient is experiencing intermediate
respiratory failure?
a. Lethargy
b. Tachycardia
c. Dyspnea
d. Restlessness - ANSWER a. Lethargy
2. The nurse is caring for a patient on the following ventilator settings: FIO2 70%, TV 550, RR 16,
PEEP 15. Upon assessment, the nurse recognizes absent breath sounds on the right side. What
is the nurse most concerned about?
A. Pneumonia
B. Tension pneumothorax
C. Need for emergency tracheostomy
D. Need for higher FIO2 through ventilator settings - ANSWER B. Tension pneumothorax
,3. A patient has arrived in the emergency room complaining of chest pain. The patient is
confused and does not remember when the chest pain started. What laboratory test results in
the highest priority in assisting the nurse in planning care for this patient?
A. Troponin 3.6 ng/mL
B. Creatinine 1.7 ng/mL
C. Creatine kinase (CK) 50 units/L
D. Potassium 3.1 mEq/L - ANSWER A. Troponin 3.6 ng/mL
4. Which patient statement indicates to the nurse a need for additional teaching regarding the
prevention of pulmonary embolism (PE)?
a. "I will decrease my intake of saturated fats."
b. "I will continue to try to quit smoking by using a nicotine gum."
c. "I won't need any blood work since I am being discharged with warfarin."
d. "I joined a gym so that I can take an aerobic exercise class." - ANSWER c. "I won't need
any blood work since I am being discharged with warfarin."
5. A Registered Nurse is caring for a patient with an endotracheal tube on a mechanical
ventilator. What task can the RN delegate to the LPN
A. Suction endotracheal tube for stable patients
B. Reposition and secure endotracheal tube
C. Administer sedatives, analgesics and paralytic medications as needed
D. Monitor ventilator settings and alarms - ANSWER A. Suction endotracheal tube for stable
patients
6. The nurse provides care to a patient admitted for a traumatic brain injury. The patient's
arterial blood gas (ABG) analysis indicates respiratory acidosis. Which action by the nurse is best
when providing care to this patient?
a. Assessing respiratory rate and depth closely
,b. Administering sodium bicarbonate, per prescription
c. Monitoring peripheral vascular status
d. Reassuring the patient to decrease anxiety - ANSWER a. Assessing respiratory rate and
depth closely
7. The nurse assists the health-care provider with a patient intubation. Which is the priority
action by the nurse?
A. Ensure suction is available, if needed.
B. Place the intubation tray at the bedside for the procedure.
C. Explain each step of the procedure to the patient and family.
D. Administer manual breaths to the patient using a resuscitation bag and mask. - ANSWER
D. Administer manual breaths to the patient using a resuscitation bag and mask
8. The nurse suctions a patient's tracheostomy tube. During the procedure, the patient's heart
rate drops to the low 50s and oxygen saturation falls to 85%. Which is the priority action by the
nurse?
a. Tell the patient to relax and continue the procedure.
b. Stop the suctioning procedure and administer oxygen.
c. Notify the health-care provider at the end of the procedure.
d. Document the patient's reaction to the procedure in the medical record. - ANSWER b.
Stop the suctioning procedure and administer oxygen.
9. The nursing student is assisting with a patient receiving mechanical ventilation and
recognizes the need to reduce incidence of ventilator associated pneumonia (VAP). Which
intervention would the nurse question?
A. Elevate head of bed at 10 degrees
B. PUD prophylaxis
C. Daily sedation vacations
, D. Oral care per policy of hospital - ANSWER A. Elevate head of bed at 10 degrees
10. Your patient that was extubated 2 hours ago starts complaining of trouble breathing and
swallowing. You assess your patient recognizing stridor. What is the nurse's priority action?
A. Notify MD of possible airway obstruction
B. Obtain arterial blood gas
C. Auscultate patient's lung sounds
D. Lay your patient flat to reduce stridor - ANSWER C. Auscultate patient's lung sounds
11. A patient arrives to the ER complaining of shortness of breath, tightness of chest and had
audible wheezes. Patient's vitals are BP 168/78, HR 128, Resp 36 and O2 Sat of 78%. Which
order would the nurse do first?
A. Administer PRN nitroglycerin to reduce chest pain
B. Administer 6 liter high flow nasal cannula per protocol
C. Wait for chest x-ray to be obtained
D. Page respiratory therapy to come and put patient on oxygen - ANSWER B. Administer 6
liter high flow nasal cannula per protocol
12. An intubated patient receiving mechanical ventilation requires all of the following should be
readily available but which piece of equipment absolutely has to be with the patient at all times,
even during transport?
A. Self-inflating bag-valve mask (e.g Ambu bag)
B. IV pump
C. Suctioning equipment
D. Patent IV access - ANSWER A. Self-inflating bag-valve mask (e.g Ambu bag)
13. When assisting the physician with intubation, which order would the nurse question?
A. To administer paralytic without adequate sedation