NUR 340 Exam 2 Review-questions Solved 100%
Correct
A nurse is monitoring a patient receiving moderate sedation for a colonoscopy. The
patient's oxygen saturation drops to 85%, and they develop snoring respirations. The
patient does not fully wake up when called but withdraws from a sternal rub. What is the
nurse’s next best action?
A. Administer naloxone as prescribed.
B. Apply a non-rebreather mask at 15 L/min.
C. Perform a head tilt–chin lift maneuver.
D. Prepare for endotracheal intubation.
The best answer is C – Perform a head tilt–chin lift maneuver.
Rationale:
The snoring respirations suggest partial airway obstruction, likely due to the tongue relaxing
and blocking the airway.
The first step is to reposition the airway using the head tilt–chin lift (or jaw thrust if a cervical
spine injury is suspected).
If repositioning improves oxygenation, the patient may not need further intervention
A 59-year-old male presents to the ED with right-sided weakness, facial droop, and slurred
speech that started 1 hour ago. His history includes type II diabetes, hypertension, atrial
,fibrillation, and a prior DVT. His INR is 1.1, head CT is negative, and creatinine is 1.9
mg/dL. Based on this information, what is the next best nursing action?
A. Administer IV alteplase (tPA) immediately.
B. Hold tPA and request a CT angiogram to evaluate for large vessel occlusion.
C. Assess for active bleeding risks and confirm AFib with ECG before tPA administration.
D. Start full-dose heparin for suspected cardioembolic stroke instead of giving tPA.
✅ Correct Answer: C
🔹 Rationale: While the patient is likely experiencing an ischemic stroke due to AFib or a
paradoxical embolism (DVT history), a thorough assessment for active bleeding risks and
confirmation of AFib via ECG should be performed before proceeding with tPA.
Define retracting in the context of respiration
Respiratory retractions are a medical term that describes when the muscles between the ribs
pull inward during inhalation. This can occur when someone is having difficulty breathing.
Normal ABG values
pH: 7.35 - 7.45
PCO2: 35 - 45
PaO2: 80 - 100
Bicarb: 22-26
O2 Sat: 95-100%
,Patient is a 25 year old male who is status post exposure to a toxic chemical. His respiratory
rate is 45 bpm. He is retracting and is deeply cyanotic. His SpO2 on a nonrebreather mask
(NRM) is 82%. On auscultation, you hear crackles bilaterally in his lungs. Considering his
ABG values, what should your next action be?
pH: 7.423
PaCO2: 38
HCO3: 24
PaO2: 42
Since the patient is cyanotic and retaining CO2 while retracting, the next step should
be intubation. The patient is on the highest supplemental oxygen source - a non rebreather
mask. The patient is unable to breathe properly on his own, and even though most ABG values
are normal, there is evidence that without assistance breathing he will enter acute respiratory
failure.
While on intubation, the healthcare team can diagnose the source of the problem.
You listen to the lung sounds of an intubated patient and discover normal lung sounds on
the right and diminished lung sounds on the left. What could be occurring?
The endotracheal tube likely entered the right bronchus too far. This is a common complication
of intubation since the right bronchus is larger and less angled so it's easier for the tube to slip in
this side. The tube will need to be pulled slightly back.
, If the tube enters the right main bronchus, it can result in uneven lung ventilation, potentially
causing lung collapse on the left side if left untreated.
After the provider orders a decrease in oxygen for an intubated patient from 100 to 80, RT
comes to change the ventilator and plans to draw ABG labs in 30 minutes. Why is it
important that nothing be done in these 30 minutes that could alter the lab values? (Suction
the patient, etc.)
It is important to evaluate how the patient is responding to the singular change of O2 decrease to
see if this change is safe to maintain. The 80% change will not be reflected correctly in the lab
values.
What are some important nursing interventions for an intubated patient?
- Early mobilization
- Immobility precautions
- Pressure injury prevention measures
- Suctioning
- Monitor vent settings
- check placement of endotracheal tube
- Sedation
- Establish a method of communication (communication board)
- Precautions to prevent ventilator-associated pneumonia
- Weaning process
Nursing measures to prevent ventilator-associated pneumonia
1. Elevate the Head of the Bed
Correct
A nurse is monitoring a patient receiving moderate sedation for a colonoscopy. The
patient's oxygen saturation drops to 85%, and they develop snoring respirations. The
patient does not fully wake up when called but withdraws from a sternal rub. What is the
nurse’s next best action?
A. Administer naloxone as prescribed.
B. Apply a non-rebreather mask at 15 L/min.
C. Perform a head tilt–chin lift maneuver.
D. Prepare for endotracheal intubation.
The best answer is C – Perform a head tilt–chin lift maneuver.
Rationale:
The snoring respirations suggest partial airway obstruction, likely due to the tongue relaxing
and blocking the airway.
The first step is to reposition the airway using the head tilt–chin lift (or jaw thrust if a cervical
spine injury is suspected).
If repositioning improves oxygenation, the patient may not need further intervention
A 59-year-old male presents to the ED with right-sided weakness, facial droop, and slurred
speech that started 1 hour ago. His history includes type II diabetes, hypertension, atrial
,fibrillation, and a prior DVT. His INR is 1.1, head CT is negative, and creatinine is 1.9
mg/dL. Based on this information, what is the next best nursing action?
A. Administer IV alteplase (tPA) immediately.
B. Hold tPA and request a CT angiogram to evaluate for large vessel occlusion.
C. Assess for active bleeding risks and confirm AFib with ECG before tPA administration.
D. Start full-dose heparin for suspected cardioembolic stroke instead of giving tPA.
✅ Correct Answer: C
🔹 Rationale: While the patient is likely experiencing an ischemic stroke due to AFib or a
paradoxical embolism (DVT history), a thorough assessment for active bleeding risks and
confirmation of AFib via ECG should be performed before proceeding with tPA.
Define retracting in the context of respiration
Respiratory retractions are a medical term that describes when the muscles between the ribs
pull inward during inhalation. This can occur when someone is having difficulty breathing.
Normal ABG values
pH: 7.35 - 7.45
PCO2: 35 - 45
PaO2: 80 - 100
Bicarb: 22-26
O2 Sat: 95-100%
,Patient is a 25 year old male who is status post exposure to a toxic chemical. His respiratory
rate is 45 bpm. He is retracting and is deeply cyanotic. His SpO2 on a nonrebreather mask
(NRM) is 82%. On auscultation, you hear crackles bilaterally in his lungs. Considering his
ABG values, what should your next action be?
pH: 7.423
PaCO2: 38
HCO3: 24
PaO2: 42
Since the patient is cyanotic and retaining CO2 while retracting, the next step should
be intubation. The patient is on the highest supplemental oxygen source - a non rebreather
mask. The patient is unable to breathe properly on his own, and even though most ABG values
are normal, there is evidence that without assistance breathing he will enter acute respiratory
failure.
While on intubation, the healthcare team can diagnose the source of the problem.
You listen to the lung sounds of an intubated patient and discover normal lung sounds on
the right and diminished lung sounds on the left. What could be occurring?
The endotracheal tube likely entered the right bronchus too far. This is a common complication
of intubation since the right bronchus is larger and less angled so it's easier for the tube to slip in
this side. The tube will need to be pulled slightly back.
, If the tube enters the right main bronchus, it can result in uneven lung ventilation, potentially
causing lung collapse on the left side if left untreated.
After the provider orders a decrease in oxygen for an intubated patient from 100 to 80, RT
comes to change the ventilator and plans to draw ABG labs in 30 minutes. Why is it
important that nothing be done in these 30 minutes that could alter the lab values? (Suction
the patient, etc.)
It is important to evaluate how the patient is responding to the singular change of O2 decrease to
see if this change is safe to maintain. The 80% change will not be reflected correctly in the lab
values.
What are some important nursing interventions for an intubated patient?
- Early mobilization
- Immobility precautions
- Pressure injury prevention measures
- Suctioning
- Monitor vent settings
- check placement of endotracheal tube
- Sedation
- Establish a method of communication (communication board)
- Precautions to prevent ventilator-associated pneumonia
- Weaning process
Nursing measures to prevent ventilator-associated pneumonia
1. Elevate the Head of the Bed
