NUR 419 Quizzes for Exam 1 Questions With Complete
Solutions
A client being admitted to the medical intensive care unit
required endotracheal intubation soon after arriving on the unit
from the emergency department. The client received midazolam
and propofol for sedation for the procedure and is still drowsy.
Which action by the nurse will help prevent accidental
displacement of the endotracheal tube?
A. Ask a family member to stay at the client's bedside
continuously
B. Start a continuous intravenous infusion of propofol and a
neuromuscular blocker
C. Apply soft wrist restraints and secure with quick release tie
method
D. Hire a sitter to stay at the client's bedside Correct Answers C
-Apply soft wrist restraints and secure with quick release tie
method until the client is awake and able to follow commands.
Alternative methods to prevent displacement of medical devices
may be attempted at this point.
A client has experienced an acute lung injury. What factors in
the client's history will increase his risk for developing adult
respiratory distress syndrome (ARDS)?
A. Has a sedentary lifestyle
B. Has no known chronic diseases
C. Drinks one glass of wine on holidays
D. Smokes two packs a day Correct Answers D. Smokes two
packs a day
-The clients most at risk for development of ARDS after acute
lung injury are those older than 65 years, those with a severe
,acute illness on presentation such as sepsis or a preexisting
chronic disorder, those who smoke cigarettes, those with a
history of alcohol abuse, and those with gastric content
aspiration.
A client has recently arrived in the ICU following coronary
arterial bypass graft surgery and has not yet emerged from
anesthesia. He requires full ventilatory support. Which
ventilation mode is prescribed to care for this client?
A. Synchronized intermittent mandatory ventilation mode
B. Pressure-controlled ventilation mode
C. Pressure support ventilation mode
D. Assist-control mode Correct Answers D. Assist-control
mode
-In assist-control mode (or volume-control mode, as it is often
termed), a mandatory (or "control") rate is selected. If the client
wishes to breathe faster, he or she can trigger the ventilator and
receive a full-volume breath. This mode of ventilation is often
used to fully support a client, such as when the client is first
intubated or when the client is too weak to perform the work of
breathing (e.g., when emerging from anesthesia). Synchronized
intermittent mandatory ventilation mode is used more often for
weaning. Pressure support ventilation mode augments or assists
spontaneous breathing efforts by delivering a high flow of gas to
a selected pressure level early in inspiration and maintaining that
level throughout the inspiratory phase; it would not be the best
choice for a client who needs full ventilation support. Pressure-
controlled ventilation mode is used to control plateau pressures
in conditions, such as ARDS, in which compliance is decreased
and the risk for barotrauma is high.
, A client in a critical care unit has increased stress from the
constant noise and light levels. What nursing intervention best
attenuates these sources of stress?
A. Need for constant observation and evaluation
B. Use of tile floors for ease in cleaning
C. Frequent nursing group rounds for all clients
D. Dimming lights during the night Correct Answers D
-Although constant observation and evaluation of clients is
necessary in critical care, actions such as dimming lights when
possible during hours of sleep, reducing unnecessary noise at
night, and providing for the client's privacy can reduce some
stress.
A client in severe congestive heart failure is at risk for the
development of acute respiratory failure and is receiving
supplemental oxygen therapy. What nursing assessment
parameter is most indicative of acute respiratory failure?
A. New onset of systolic gallop
B. Increasing pitting leg edema
C. Arterial PaO2 45 mm Hg
D. Conversion to atrial fibrillation Correct Answers C. Arterial
PaO2 45 mm Hg
-Acute respiratory failure is defined as the inability to maintain
arterial blood gases with pH greater than 7.25, PaCO 2 less than
50 mm Hg, and PaO 2 greater than 50 mm Hg even with
supplemental oxygen. The other answers indicate worsening
congestive heart failure but are not specific to respiratory failure.
A client in the CCU is on a ventilator with oral intubation. The
nurse notices that a pressure sore is forming on the client's lip
Solutions
A client being admitted to the medical intensive care unit
required endotracheal intubation soon after arriving on the unit
from the emergency department. The client received midazolam
and propofol for sedation for the procedure and is still drowsy.
Which action by the nurse will help prevent accidental
displacement of the endotracheal tube?
A. Ask a family member to stay at the client's bedside
continuously
B. Start a continuous intravenous infusion of propofol and a
neuromuscular blocker
C. Apply soft wrist restraints and secure with quick release tie
method
D. Hire a sitter to stay at the client's bedside Correct Answers C
-Apply soft wrist restraints and secure with quick release tie
method until the client is awake and able to follow commands.
Alternative methods to prevent displacement of medical devices
may be attempted at this point.
A client has experienced an acute lung injury. What factors in
the client's history will increase his risk for developing adult
respiratory distress syndrome (ARDS)?
A. Has a sedentary lifestyle
B. Has no known chronic diseases
C. Drinks one glass of wine on holidays
D. Smokes two packs a day Correct Answers D. Smokes two
packs a day
-The clients most at risk for development of ARDS after acute
lung injury are those older than 65 years, those with a severe
,acute illness on presentation such as sepsis or a preexisting
chronic disorder, those who smoke cigarettes, those with a
history of alcohol abuse, and those with gastric content
aspiration.
A client has recently arrived in the ICU following coronary
arterial bypass graft surgery and has not yet emerged from
anesthesia. He requires full ventilatory support. Which
ventilation mode is prescribed to care for this client?
A. Synchronized intermittent mandatory ventilation mode
B. Pressure-controlled ventilation mode
C. Pressure support ventilation mode
D. Assist-control mode Correct Answers D. Assist-control
mode
-In assist-control mode (or volume-control mode, as it is often
termed), a mandatory (or "control") rate is selected. If the client
wishes to breathe faster, he or she can trigger the ventilator and
receive a full-volume breath. This mode of ventilation is often
used to fully support a client, such as when the client is first
intubated or when the client is too weak to perform the work of
breathing (e.g., when emerging from anesthesia). Synchronized
intermittent mandatory ventilation mode is used more often for
weaning. Pressure support ventilation mode augments or assists
spontaneous breathing efforts by delivering a high flow of gas to
a selected pressure level early in inspiration and maintaining that
level throughout the inspiratory phase; it would not be the best
choice for a client who needs full ventilation support. Pressure-
controlled ventilation mode is used to control plateau pressures
in conditions, such as ARDS, in which compliance is decreased
and the risk for barotrauma is high.
, A client in a critical care unit has increased stress from the
constant noise and light levels. What nursing intervention best
attenuates these sources of stress?
A. Need for constant observation and evaluation
B. Use of tile floors for ease in cleaning
C. Frequent nursing group rounds for all clients
D. Dimming lights during the night Correct Answers D
-Although constant observation and evaluation of clients is
necessary in critical care, actions such as dimming lights when
possible during hours of sleep, reducing unnecessary noise at
night, and providing for the client's privacy can reduce some
stress.
A client in severe congestive heart failure is at risk for the
development of acute respiratory failure and is receiving
supplemental oxygen therapy. What nursing assessment
parameter is most indicative of acute respiratory failure?
A. New onset of systolic gallop
B. Increasing pitting leg edema
C. Arterial PaO2 45 mm Hg
D. Conversion to atrial fibrillation Correct Answers C. Arterial
PaO2 45 mm Hg
-Acute respiratory failure is defined as the inability to maintain
arterial blood gases with pH greater than 7.25, PaCO 2 less than
50 mm Hg, and PaO 2 greater than 50 mm Hg even with
supplemental oxygen. The other answers indicate worsening
congestive heart failure but are not specific to respiratory failure.
A client in the CCU is on a ventilator with oral intubation. The
nurse notices that a pressure sore is forming on the client's lip
