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NUR417 / NUR 417 EXAM 2
Care of Adult II
Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
100% Guarantee Pass.
Expert Verified Explanation
Multiple choice (single best answer)
Select All That Apply (SATA)
Fill-in-the-blank
Case Studies/Scenario-Based Questions
, 1. A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD)
from mechanical ventilation. Which patient assessment finding indicates that the weaning
protocol should be stopped?
a. The patient's heart rate is 97 beats/min.
b. The patient's oxygen saturation is 93%.
c. The patient respiratory rate is 32 breaths/min.
d. The patient's spontaneous tidal volume is 450 mL.
ANSWER: C
Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The
patient's heart rate is within normal limits, but the nurse should continue to monitor it. An O2 saturation of
93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable
range.
2. The nurse educator is evaluating the performance of a new registered nurse (RN) who is
providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak
end-expiratory pressure (PEEP). Which action indicates that the new RN is safe?
a. The RN plans to suction the patient every 1 to 2 hours.
b. The RN uses a closed-suction technique to suction the patient.
c. The RN tapes the connection between the ventilator tubing and the ET.
d. The RN changes the ventilator circuit tubing routinely every 48 hours.
ANSWER: B
The closed-suction technique is used when patients require high levels of PEEP (>10 cm H2O) to prevent
the loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be
scheduled routinely, but it should be done only when patient assessment data indicate the need for
suctioning. Taping connections between the ET and ventilator tubing would restrict the ability of the tubing
to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for ventilator-
associated pneumonia and are not indicated routinely.
3. After change-of-shift report on a ventilator weaning unit, which patient should the nurse
assess first?
a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on
the ventilator
b. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2)
monitoring
c. Patient who was successfully weaned and extubated 4 hours ago and has no urine output
, for the last 6 hours
d. Patient with a central venous O2 saturation (ScvO2) of 69% while on bilevel positive
airway pressure (BiPAP)
ANSWER: C
The decreased urine output may indicate acute kidney injury or that the patient's cardiac output and
perfusion of vital organs have decreased. Any of these causes would require rapid action. The data about
the other patients indicate that their conditions are stable and do not require immediate assessment or
changes in their care. Continuous PETCO2 monitoring is frequently used when patients are intubated. The
rest mode should be used to allow patient recovery after a failed SBT, and an ScvO2 of 69% is within
normal limits.
4. DIF: Cognitive Level: Apply (application)
A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD)
from mechanical ventilation. Which patient assessment finding indicates that the weaning
protocol should be stopped?
a. The patient's heart rate is 97 beats/min.
b. The patient's oxygen saturation is 93%.
c. The patient respiratory rate is 32 breaths/min.
d. The patient's spontaneous tidal volume is 450 mL.
ANSWER: C
Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The
patient's heart rate is within normal limits, but the nurse should continue to monitor it. An O2 saturation of
93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable
range.
5. A patient who is receiving positive pressure ventilation is scheduled for a spontaneous
breathing trial (SBT). Which finding by the nurse is most likely to result in postponing the
SBT?
a. New ST segment elevation is noted on the cardiac monitor.
b. Enteral feedings are being given through an orogastric tube.
c. Scattered rhonchi are heard when auscultating breath sounds.
d. hydromorphone (Dilaudid) is being used to treat postoperative pain
Answer: A.
new st segment elevation
, Myocardial ischemia is a contraindication for ventilator weaning. The ST segment elevation is an indication
that weaning should be postponed until further investigation and/or treatment for myocardial ischemia can
be done. Ventilator weaning can proceed when opioids are used for pain management, abnormal lung
sounds are present, or enteral feedings are being used.
6. The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is
receiving mechanical ventilation. Which intervention will most directly treat this finding?
a. Reposition the patient every 1 to 2 hours.
b. Increase suctioning frequency to every hour.
c. Add additional water to the patient's enteral feedings.
d. Instill 5 mL of sterile saline into the ET before suctioning.
ANSWER: C
Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without any
specific evidence for the need will increase the incidence of mucosal trauma and would not address the
etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may
decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of
secretions.
7. The nurse notes premature ventricular contractions (PVCs) while suctioning a patient's
endotracheal tube. Which next action by the nurse is indicated?
a. Plan to suction the patient more frequently.
b. Decrease the suction pressure to 80 mm Hg.
c. Give antidysrhythmic medications per protocol.
d. Stop and ventilate the patient with 100% oxygen.
ANSWER: D
Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The
nurse should stop suctioning and ventilate the patient with 100% O2. There is no indication that more
frequent suctioning is needed. Lowering the suction pressure will decrease the effectiveness of suctioning
without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for
antidysrhythmic medications (which may have adverse effects) unless they recur when the suctioning is
stopped and patient is well oxygenated.
8. Which assessment finding obtained by the nurse when caring for a patient receiving
mechanical ventilation indicates the need for suctioning?
NUR417 / NUR 417 EXAM 2
Care of Adult II
Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
100% Guarantee Pass.
Expert Verified Explanation
Multiple choice (single best answer)
Select All That Apply (SATA)
Fill-in-the-blank
Case Studies/Scenario-Based Questions
, 1. A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD)
from mechanical ventilation. Which patient assessment finding indicates that the weaning
protocol should be stopped?
a. The patient's heart rate is 97 beats/min.
b. The patient's oxygen saturation is 93%.
c. The patient respiratory rate is 32 breaths/min.
d. The patient's spontaneous tidal volume is 450 mL.
ANSWER: C
Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The
patient's heart rate is within normal limits, but the nurse should continue to monitor it. An O2 saturation of
93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable
range.
2. The nurse educator is evaluating the performance of a new registered nurse (RN) who is
providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak
end-expiratory pressure (PEEP). Which action indicates that the new RN is safe?
a. The RN plans to suction the patient every 1 to 2 hours.
b. The RN uses a closed-suction technique to suction the patient.
c. The RN tapes the connection between the ventilator tubing and the ET.
d. The RN changes the ventilator circuit tubing routinely every 48 hours.
ANSWER: B
The closed-suction technique is used when patients require high levels of PEEP (>10 cm H2O) to prevent
the loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be
scheduled routinely, but it should be done only when patient assessment data indicate the need for
suctioning. Taping connections between the ET and ventilator tubing would restrict the ability of the tubing
to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for ventilator-
associated pneumonia and are not indicated routinely.
3. After change-of-shift report on a ventilator weaning unit, which patient should the nurse
assess first?
a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on
the ventilator
b. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2)
monitoring
c. Patient who was successfully weaned and extubated 4 hours ago and has no urine output
, for the last 6 hours
d. Patient with a central venous O2 saturation (ScvO2) of 69% while on bilevel positive
airway pressure (BiPAP)
ANSWER: C
The decreased urine output may indicate acute kidney injury or that the patient's cardiac output and
perfusion of vital organs have decreased. Any of these causes would require rapid action. The data about
the other patients indicate that their conditions are stable and do not require immediate assessment or
changes in their care. Continuous PETCO2 monitoring is frequently used when patients are intubated. The
rest mode should be used to allow patient recovery after a failed SBT, and an ScvO2 of 69% is within
normal limits.
4. DIF: Cognitive Level: Apply (application)
A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD)
from mechanical ventilation. Which patient assessment finding indicates that the weaning
protocol should be stopped?
a. The patient's heart rate is 97 beats/min.
b. The patient's oxygen saturation is 93%.
c. The patient respiratory rate is 32 breaths/min.
d. The patient's spontaneous tidal volume is 450 mL.
ANSWER: C
Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The
patient's heart rate is within normal limits, but the nurse should continue to monitor it. An O2 saturation of
93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable
range.
5. A patient who is receiving positive pressure ventilation is scheduled for a spontaneous
breathing trial (SBT). Which finding by the nurse is most likely to result in postponing the
SBT?
a. New ST segment elevation is noted on the cardiac monitor.
b. Enteral feedings are being given through an orogastric tube.
c. Scattered rhonchi are heard when auscultating breath sounds.
d. hydromorphone (Dilaudid) is being used to treat postoperative pain
Answer: A.
new st segment elevation
, Myocardial ischemia is a contraindication for ventilator weaning. The ST segment elevation is an indication
that weaning should be postponed until further investigation and/or treatment for myocardial ischemia can
be done. Ventilator weaning can proceed when opioids are used for pain management, abnormal lung
sounds are present, or enteral feedings are being used.
6. The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is
receiving mechanical ventilation. Which intervention will most directly treat this finding?
a. Reposition the patient every 1 to 2 hours.
b. Increase suctioning frequency to every hour.
c. Add additional water to the patient's enteral feedings.
d. Instill 5 mL of sterile saline into the ET before suctioning.
ANSWER: C
Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without any
specific evidence for the need will increase the incidence of mucosal trauma and would not address the
etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may
decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of
secretions.
7. The nurse notes premature ventricular contractions (PVCs) while suctioning a patient's
endotracheal tube. Which next action by the nurse is indicated?
a. Plan to suction the patient more frequently.
b. Decrease the suction pressure to 80 mm Hg.
c. Give antidysrhythmic medications per protocol.
d. Stop and ventilate the patient with 100% oxygen.
ANSWER: D
Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The
nurse should stop suctioning and ventilate the patient with 100% O2. There is no indication that more
frequent suctioning is needed. Lowering the suction pressure will decrease the effectiveness of suctioning
without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for
antidysrhythmic medications (which may have adverse effects) unless they recur when the suctioning is
stopped and patient is well oxygenated.
8. Which assessment finding obtained by the nurse when caring for a patient receiving
mechanical ventilation indicates the need for suctioning?
