The nurse is caring for a 33-year-old patient who arrived in the emergency
department with acute respiratory distress. Which assessment finding by the nurse
requires the most rapid action?
a. The patients PaO2 is 45 mm Hg.
b. The patients PaCO2 is 33 mm Hg.
c. The patients respirations are shallow.
d. The patients respiratory rate is 32 breaths/minute.
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, ANS: A
The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action
is needed to prevent further deterioration of the patient. Although the
shallow breathing, rapid respiratory rate, and low PaCO2 also need to be
addressed, the most urgent problem is the patients poor oxygenation.
A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is
receiving mechanical ventilation using synchronized intermittent mandatory
ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) 80%, tidal
volume 450, rate 16/minute, and positive end-expiratory pressure (PEEP) 5 cm. Which
assessment finding is most important for the nurse to report to the health care
provider?
a. Oxygen saturation 99%
b. Respiratory rate 22 breaths/minute
c. Crackles audible at lung bases
d. Heart rate 106 beats/minute
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ANS: A
The FIO2 of 80% increases the risk for oxygen toxicity. Because the patients
O2 saturation is 99%, a decrease in FIO2 is indicated to avoid toxicity. The
other patient data would be typical for a patient with ARDS and would not
need to be urgently reported to the health care provider.
The nurse uses the Situation-Background-Assessment-Recommendation (SBAR)
format to communicate a change in patient status to a health care provider. In which
, order should the nurse make the following statements? (Put a comma and a space
between each answer choice [A, B, C, D].)
a. The patient needs to be evaluated immediately and may need intubation and
mechanical ventilation.
b. The patient was admitted yesterday with heart failure and has been receiving
furosemide (Lasix) for diuresis, but urine output has been low.
c. The patient has crackles audible throughout the posterior chest and the most
recent oxygen saturation is 89%. Her condition is very unstable.
d. This is the nurse on the surgical unit. After assessing the patient, I am very
concerned about increased shortness of breath over the past hour
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ANS: D, B, C, A
The order of the nurses statements follows the SBAR format
The nurse is caring for a patient who is intubated and receiving positive pressure
ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most
important to report to the health care provider?
a. Blood urea nitrogen (BUN) level 32 mg/dL
b. Red-brown drainage from orogastric tube
c. Scattered coarse crackles heard throughout lungs
d. Arterial blood gases: pH 7.31, PaCO2 50, PaO2 68
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department with acute respiratory distress. Which assessment finding by the nurse
requires the most rapid action?
a. The patients PaO2 is 45 mm Hg.
b. The patients PaCO2 is 33 mm Hg.
c. The patients respirations are shallow.
d. The patients respiratory rate is 32 breaths/minute.
Give this one a try later!
, ANS: A
The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action
is needed to prevent further deterioration of the patient. Although the
shallow breathing, rapid respiratory rate, and low PaCO2 also need to be
addressed, the most urgent problem is the patients poor oxygenation.
A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is
receiving mechanical ventilation using synchronized intermittent mandatory
ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) 80%, tidal
volume 450, rate 16/minute, and positive end-expiratory pressure (PEEP) 5 cm. Which
assessment finding is most important for the nurse to report to the health care
provider?
a. Oxygen saturation 99%
b. Respiratory rate 22 breaths/minute
c. Crackles audible at lung bases
d. Heart rate 106 beats/minute
Give this one a try later!
ANS: A
The FIO2 of 80% increases the risk for oxygen toxicity. Because the patients
O2 saturation is 99%, a decrease in FIO2 is indicated to avoid toxicity. The
other patient data would be typical for a patient with ARDS and would not
need to be urgently reported to the health care provider.
The nurse uses the Situation-Background-Assessment-Recommendation (SBAR)
format to communicate a change in patient status to a health care provider. In which
, order should the nurse make the following statements? (Put a comma and a space
between each answer choice [A, B, C, D].)
a. The patient needs to be evaluated immediately and may need intubation and
mechanical ventilation.
b. The patient was admitted yesterday with heart failure and has been receiving
furosemide (Lasix) for diuresis, but urine output has been low.
c. The patient has crackles audible throughout the posterior chest and the most
recent oxygen saturation is 89%. Her condition is very unstable.
d. This is the nurse on the surgical unit. After assessing the patient, I am very
concerned about increased shortness of breath over the past hour
Give this one a try later!
ANS: D, B, C, A
The order of the nurses statements follows the SBAR format
The nurse is caring for a patient who is intubated and receiving positive pressure
ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most
important to report to the health care provider?
a. Blood urea nitrogen (BUN) level 32 mg/dL
b. Red-brown drainage from orogastric tube
c. Scattered coarse crackles heard throughout lungs
d. Arterial blood gases: pH 7.31, PaCO2 50, PaO2 68
Give this one a try later!
