NUR417 / NUR 417 EXAM 2 Care of Adult II | Actual
Questions and Answers | Latest Update 2026/2027 |
Graded A+ (100% Correct) Concordia
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.
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.
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.
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.
,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.
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.
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.
Which assessment finding obtained by the nurse when caring for a patient receiving
mechanical ventilation indicates the need for suctioning?
a. The patient was last suctioned 6 hours ago.
b. The patient's oxygen saturation drops to 93%.
c. The patient's respiratory rate is 32 breaths/min.
d. The patient has occasional audible expiratory wheezes.
ANSWER
C
The increase in respiratory rate indicates that the patient may have decreased airway
clearance and requires suctioning. Suctioning is done when patient assessment data
indicate that it is needed and not on a scheduled basis. Occasional expiratory wheezes
do not indicate poor airway clearance, and suctioning the patient may induce
bronchospasm and increase wheezing. An O2 saturation of 93% is acceptable and does
not suggest that immediate suctioning is needed.
Questions and Answers | Latest Update 2026/2027 |
Graded A+ (100% Correct) Concordia
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.
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.
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.
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.
,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.
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.
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.
Which assessment finding obtained by the nurse when caring for a patient receiving
mechanical ventilation indicates the need for suctioning?
a. The patient was last suctioned 6 hours ago.
b. The patient's oxygen saturation drops to 93%.
c. The patient's respiratory rate is 32 breaths/min.
d. The patient has occasional audible expiratory wheezes.
ANSWER
C
The increase in respiratory rate indicates that the patient may have decreased airway
clearance and requires suctioning. Suctioning is done when patient assessment data
indicate that it is needed and not on a scheduled basis. Occasional expiratory wheezes
do not indicate poor airway clearance, and suctioning the patient may induce
bronchospasm and increase wheezing. An O2 saturation of 93% is acceptable and does
not suggest that immediate suctioning is needed.
