NUR 419 Quizzes for Exam 1
Questions With Verified Answers
/.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
-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.
/.The nurse is caring for a client who is orally intubated and on a mechanical ventilator.
The nurse believes that the client is experiencing excess anxiety. For this client, what
behavior best indicates anxiety?
A. Restlessness
B. Glasgow Coma Scale score of 3
C. Increased respiratory rate
D. Verbalization
-According to many critical care nurses, the top five physiologic and behavioral
indicators of anxiety are agitated behavior, increased blood pressure, increased heart
rate, verbalization of anxiety, and restlessness. For this client, verbalization is not
possible due to oral intubation. Increased respiratory rate is not one of the most
common behaviors. A Glasgow Coma Scale score of 3 is deep coma.
/.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 where it comes into contact with the
endotracheal tube. Which nursing action would be most appropriate?
A. Repositioning the endotracheal tube from one side to the other
B. Retaping the endotracheal tube
C. Using twill tape
D. Placing an oral bite block in the client's mouth
-Patients should be monitored for pressure areas from the ETT and or ETT holder. If
pressure is noticed the offending object should be repositioned.
/.You are caring for a client immediately after removal of the endotracheal tube. Which
of the following signs would you report immediately if experienced by the client?
A. Respiratory rate of 24 per minute.
B. Stridor
, C. Occassional pink tinged sputum.
D. Basilar crackles on the right
/.Which of the following health care personnel are responsible for programming and
setup of the ventilator?
A. CRNA
B. Respiratory therapist
C. Physician
D. Registered Nurse
/.A critically ill client who is intubated and agitated is restrained with soft wrist restraints.
Based on research findings, what is the best nursing action?
A. Remove the restraints periodically for range of motion.
B. Maintain the restraints to protect client safety.
C. Remove the restraints periodically to check skin integrity.
D. Assess and intervene for causes of agitation.
-Restraints have been shown to increase the risk of injury and to increase agitation.
Physical restraints should be used as a last resort to protect the client when other
methods have failed. The nurse should attempt to identify and alleviate the cause of the
agitation so that restraint use can be discontinued. Removing restraints periodically to
check skin integrity and provide range of motion should also be done, although these do
not address the central problem. Client safety is jeopardized when restraints are used
unnecessarily.
/.A nurse is setting up an ambu bag to assist with ventilation of a client during a
respiratory arrest. Which of the following correctly describes the setup of an ambu bag?
A. connect the tubing to 15 L of Oxygen
B. connect the tubing to medical air only
C. leave the tubing of the ambu bag disconnected
D. connect the tubing of the ambu bag to wall suction
/.The use of positive pressure in Bipap support or Mechanical Ventilation (peep) may
lead to reduced venous return. Which of the following is a consequence of reduced
venous return?
A. Hypotension
B. Poor perfusion
C. Low systemic vascular resistance
D. Hypoxia
/.Which of the following observations corresponds with possible obstruction of the
endotracheal tube? Select all that apply.
A. The high-pressure alarm goes off on the ventilator
B. Thick secretions or mucous in the airways
C. The low-pressure alarm goes off on the ventilator.
D. Biting the endotracheal tube
Questions With Verified Answers
/.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
-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.
/.The nurse is caring for a client who is orally intubated and on a mechanical ventilator.
The nurse believes that the client is experiencing excess anxiety. For this client, what
behavior best indicates anxiety?
A. Restlessness
B. Glasgow Coma Scale score of 3
C. Increased respiratory rate
D. Verbalization
-According to many critical care nurses, the top five physiologic and behavioral
indicators of anxiety are agitated behavior, increased blood pressure, increased heart
rate, verbalization of anxiety, and restlessness. For this client, verbalization is not
possible due to oral intubation. Increased respiratory rate is not one of the most
common behaviors. A Glasgow Coma Scale score of 3 is deep coma.
/.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 where it comes into contact with the
endotracheal tube. Which nursing action would be most appropriate?
A. Repositioning the endotracheal tube from one side to the other
B. Retaping the endotracheal tube
C. Using twill tape
D. Placing an oral bite block in the client's mouth
-Patients should be monitored for pressure areas from the ETT and or ETT holder. If
pressure is noticed the offending object should be repositioned.
/.You are caring for a client immediately after removal of the endotracheal tube. Which
of the following signs would you report immediately if experienced by the client?
A. Respiratory rate of 24 per minute.
B. Stridor
, C. Occassional pink tinged sputum.
D. Basilar crackles on the right
/.Which of the following health care personnel are responsible for programming and
setup of the ventilator?
A. CRNA
B. Respiratory therapist
C. Physician
D. Registered Nurse
/.A critically ill client who is intubated and agitated is restrained with soft wrist restraints.
Based on research findings, what is the best nursing action?
A. Remove the restraints periodically for range of motion.
B. Maintain the restraints to protect client safety.
C. Remove the restraints periodically to check skin integrity.
D. Assess and intervene for causes of agitation.
-Restraints have been shown to increase the risk of injury and to increase agitation.
Physical restraints should be used as a last resort to protect the client when other
methods have failed. The nurse should attempt to identify and alleviate the cause of the
agitation so that restraint use can be discontinued. Removing restraints periodically to
check skin integrity and provide range of motion should also be done, although these do
not address the central problem. Client safety is jeopardized when restraints are used
unnecessarily.
/.A nurse is setting up an ambu bag to assist with ventilation of a client during a
respiratory arrest. Which of the following correctly describes the setup of an ambu bag?
A. connect the tubing to 15 L of Oxygen
B. connect the tubing to medical air only
C. leave the tubing of the ambu bag disconnected
D. connect the tubing of the ambu bag to wall suction
/.The use of positive pressure in Bipap support or Mechanical Ventilation (peep) may
lead to reduced venous return. Which of the following is a consequence of reduced
venous return?
A. Hypotension
B. Poor perfusion
C. Low systemic vascular resistance
D. Hypoxia
/.Which of the following observations corresponds with possible obstruction of the
endotracheal tube? Select all that apply.
A. The high-pressure alarm goes off on the ventilator
B. Thick secretions or mucous in the airways
C. The low-pressure alarm goes off on the ventilator.
D. Biting the endotracheal tube
