N22 Test 3 Exam QUESTIONS AND
CORRECT ANSWERS
The medical nurse is creating the care plan of an adult patient requiring mechanical
ventilation. What nursing action is most appropriate?
A) Keep the patient in a low Fowler's position.
B) Perform tracheostomy care at least once per day.
C) Maintain continuous bedrest.
D) Monitor cuff pressure every 8 hours. - CORRECT ANSWER Ans: D
Feedback:
The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy
care at least every 8 hours because of the risk of infection. The patient should be encouraged
to ambulate, if possible, and a low Fowler's position is not indicated.
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a
patient who has a tracheostomy tube and is receiving mechanical ventilation. What action
should the critical care nurse recommend when caring for the cuff?
A) Deflate the cuff overnight to prevent tracheal tissue trauma.
B) Inflate the cuff to the highest possible pressure in order to prevent aspiration.
C) Monitor the pressure in the cuff at least every 8 hours
D) Keep the tracheostomy tube plugged at all times. - CORRECT ANSWER Ans: C
Feedback:
Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours
by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the
minimal leak volume or minimal occlusion volume technique. Plugging is only used when
weaning the patient from tracheal support. Deflating the cuff overnight would be unsafe and
inappropriate. High cuff pressure can cause tissue trauma.
The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment
parameter is most important for the nurse to assess?
A) Fluid intake for the last 24 hours
B) Baseline arterial blood gas (ABG) levels
,C) Prior outcomes of weaning
D) Electrocardiogram (ECG) results - CORRECT ANSWER Ans: B
Feedback:
Before weaning a patient from mechanical ventilation, it is most important to have baseline
ABG levels. During the weaning process, ABG levels will be checked to assess how the
patient is tolerating the procedure. Other assessment parameters are relevant, but less critical.
Measuring fluid volume intake and output is always important when a patient is being
mechanically ventilated. Prior attempts at weaning and ECG results are documented on the
patient's record, and the nurse can refer to them before the weaning process begins.
A patient recovering from thoracic surgery is on long-term mechanical ventilation and
becomes very frustrated when he tries to communicate. What intervention should the nurse
perform to assist the patient?
A) Assure the patient that everything will be all right and that remaining calm is the best
strategy.
B) Ask a family member to interpret what the patient is trying to communicate.
C) Ask the physician to wean the patient off the mechanical ventilator to allow the patient to
speak freely.
D) Express empathy and then encourage the patient to write, use a picture board, or spell
words with an alphabet board. - CORRECT ANSWER Ans: D
Feedback:
If the patient uses an alternative method of communication, he will feel in better control and
likely be less frustrated. Assuring the patient that everything will be all right offers false
reassurance, and telling him not to be upset minimizes his feelings. Neither of these methods
helps the patient to communicate. In a patient with an endotracheal or tracheostomy tube, the
family members are also likely to encounter difficulty interpreting the patient's wishes.
Making them responsible for interpreting the patient's gestures may frustrate the family. The
patient may be weaned off a mechanical ventilator only when the physiologic parameters for
weaning have been met.
The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a
patient's high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is.
What would be the nurse's best response?
A) CPAP allows a higher percentage of oxygen to be safely used.
B) CPAP allows a lower percentage of oxygen to be used with a similar effect.
,C) CPAP allows for greater humidification of the oxygen that is administered.
D) CPAP allows for the elimination of bacterial growth in oxygen delivery systems. -
CORRECT ANSWER Ans: B
Feedback:
Prevention of oxygen toxicity is achieved by using oxygen only as prescribed. Often, positive
end-expiratory pressure (PEEP) or CPAP is used with oxygen therapy to reverse or prevent
microatelectasis, thus allowing a lower percentage of oxygen to be used. Oxygen is
moistened by passing through a humidification system. Changing the tubing on the oxygen
therapy equipment is the best technique for controlling bacterial growth.
The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing
to assist in the collaborative process of weaning the patient from a ventilator, the nurse is
aware that the weaning of the patient will progress in what order?
A) Removal from the ventilator, tube, and then oxygen
B) Removal from oxygen, ventilator, and then tube
C) Removal of the tube, oxygen, and then ventilator
D) Removal from oxygen, tube, and then ventilator - CORRECT ANSWER Ans: A
Feedback:
The process of withdrawing the patient from dependence on the ventilator takes place in three
stages: the patient is gradually removed from the ventilator, then from the tube, and, finally,
oxygen.
The critical care nurse and the other members of the care team are assessing the patient to see
if he is ready to be weaned from the ventilator. What are the most important predictors of
successful weaning that the nurse should identify?
A) Stable vital signs and ABGs
B) Pulse oximetry above 80% and stable vital signs
C) Stable nutritional status and ABGs
D) Normal orientation and level of consciousness - CORRECT ANSWER Ans: A
Feedback:
Among many other predictors, stable vital signs and ABGs are important predictors of
successful weaning. Pulse oximetry must greatly exceed 80%. Nutritional status is important,
, but vital signs and ABGs are even more significant. Patients who are weaned may or may not
have full level of consciousness.
The nurse is caring for a client with an endotracheal tube who is on a ventilator. When
assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate
pressure on the tracheal wall?
A) Between 10 and 15 mm Hg
B) Between 15 and 20 mm Hg
C) Between 20 and 25 mm Hg
D) Between 25 and 30 mm Hg - CORRECT ANSWER Ans: B
Feedback:
Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff
pressures should be maintained between 15 and 20 mm Hg.
The decision has been made to discharge a ventilator-dependent patient home. The nurse is
developing a teaching plan for this patient and his family. What would be most important to
include in this teaching plan?
A) Administration of inhaled corticosteroids
B) Assessment of neurologic status
C) Turning and coughing
D) Signs of pulmonary infection - CORRECT ANSWER Ans: D
Feedback:
The nurse teaches the patient and family about the ventilator, suctioning, tracheostomy care,
signs of pulmonary infection, cuff inflation and deflation, and assessment of vital signs.
Neurologic assessment and turning and coughing are less important than signs and symptoms
of infection. Inhaled corticosteroids may or may not be prescribed.
A perioperative nurse is caring for a postoperative patient. The patient has a shallow
respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address
the patient's increased risk for what complication?
A) Acute respiratory distress syndrome (ARDS)
B) Atelectasis
CORRECT ANSWERS
The medical nurse is creating the care plan of an adult patient requiring mechanical
ventilation. What nursing action is most appropriate?
A) Keep the patient in a low Fowler's position.
B) Perform tracheostomy care at least once per day.
C) Maintain continuous bedrest.
D) Monitor cuff pressure every 8 hours. - CORRECT ANSWER Ans: D
Feedback:
The cuff pressure should be monitored every 8 hours. It is important to perform tracheostomy
care at least every 8 hours because of the risk of infection. The patient should be encouraged
to ambulate, if possible, and a low Fowler's position is not indicated.
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a
patient who has a tracheostomy tube and is receiving mechanical ventilation. What action
should the critical care nurse recommend when caring for the cuff?
A) Deflate the cuff overnight to prevent tracheal tissue trauma.
B) Inflate the cuff to the highest possible pressure in order to prevent aspiration.
C) Monitor the pressure in the cuff at least every 8 hours
D) Keep the tracheostomy tube plugged at all times. - CORRECT ANSWER Ans: C
Feedback:
Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours
by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the
minimal leak volume or minimal occlusion volume technique. Plugging is only used when
weaning the patient from tracheal support. Deflating the cuff overnight would be unsafe and
inappropriate. High cuff pressure can cause tissue trauma.
The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment
parameter is most important for the nurse to assess?
A) Fluid intake for the last 24 hours
B) Baseline arterial blood gas (ABG) levels
,C) Prior outcomes of weaning
D) Electrocardiogram (ECG) results - CORRECT ANSWER Ans: B
Feedback:
Before weaning a patient from mechanical ventilation, it is most important to have baseline
ABG levels. During the weaning process, ABG levels will be checked to assess how the
patient is tolerating the procedure. Other assessment parameters are relevant, but less critical.
Measuring fluid volume intake and output is always important when a patient is being
mechanically ventilated. Prior attempts at weaning and ECG results are documented on the
patient's record, and the nurse can refer to them before the weaning process begins.
A patient recovering from thoracic surgery is on long-term mechanical ventilation and
becomes very frustrated when he tries to communicate. What intervention should the nurse
perform to assist the patient?
A) Assure the patient that everything will be all right and that remaining calm is the best
strategy.
B) Ask a family member to interpret what the patient is trying to communicate.
C) Ask the physician to wean the patient off the mechanical ventilator to allow the patient to
speak freely.
D) Express empathy and then encourage the patient to write, use a picture board, or spell
words with an alphabet board. - CORRECT ANSWER Ans: D
Feedback:
If the patient uses an alternative method of communication, he will feel in better control and
likely be less frustrated. Assuring the patient that everything will be all right offers false
reassurance, and telling him not to be upset minimizes his feelings. Neither of these methods
helps the patient to communicate. In a patient with an endotracheal or tracheostomy tube, the
family members are also likely to encounter difficulty interpreting the patient's wishes.
Making them responsible for interpreting the patient's gestures may frustrate the family. The
patient may be weaned off a mechanical ventilator only when the physiologic parameters for
weaning have been met.
The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a
patient's high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is.
What would be the nurse's best response?
A) CPAP allows a higher percentage of oxygen to be safely used.
B) CPAP allows a lower percentage of oxygen to be used with a similar effect.
,C) CPAP allows for greater humidification of the oxygen that is administered.
D) CPAP allows for the elimination of bacterial growth in oxygen delivery systems. -
CORRECT ANSWER Ans: B
Feedback:
Prevention of oxygen toxicity is achieved by using oxygen only as prescribed. Often, positive
end-expiratory pressure (PEEP) or CPAP is used with oxygen therapy to reverse or prevent
microatelectasis, thus allowing a lower percentage of oxygen to be used. Oxygen is
moistened by passing through a humidification system. Changing the tubing on the oxygen
therapy equipment is the best technique for controlling bacterial growth.
The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing
to assist in the collaborative process of weaning the patient from a ventilator, the nurse is
aware that the weaning of the patient will progress in what order?
A) Removal from the ventilator, tube, and then oxygen
B) Removal from oxygen, ventilator, and then tube
C) Removal of the tube, oxygen, and then ventilator
D) Removal from oxygen, tube, and then ventilator - CORRECT ANSWER Ans: A
Feedback:
The process of withdrawing the patient from dependence on the ventilator takes place in three
stages: the patient is gradually removed from the ventilator, then from the tube, and, finally,
oxygen.
The critical care nurse and the other members of the care team are assessing the patient to see
if he is ready to be weaned from the ventilator. What are the most important predictors of
successful weaning that the nurse should identify?
A) Stable vital signs and ABGs
B) Pulse oximetry above 80% and stable vital signs
C) Stable nutritional status and ABGs
D) Normal orientation and level of consciousness - CORRECT ANSWER Ans: A
Feedback:
Among many other predictors, stable vital signs and ABGs are important predictors of
successful weaning. Pulse oximetry must greatly exceed 80%. Nutritional status is important,
, but vital signs and ABGs are even more significant. Patients who are weaned may or may not
have full level of consciousness.
The nurse is caring for a client with an endotracheal tube who is on a ventilator. When
assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate
pressure on the tracheal wall?
A) Between 10 and 15 mm Hg
B) Between 15 and 20 mm Hg
C) Between 20 and 25 mm Hg
D) Between 25 and 30 mm Hg - CORRECT ANSWER Ans: B
Feedback:
Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff
pressures should be maintained between 15 and 20 mm Hg.
The decision has been made to discharge a ventilator-dependent patient home. The nurse is
developing a teaching plan for this patient and his family. What would be most important to
include in this teaching plan?
A) Administration of inhaled corticosteroids
B) Assessment of neurologic status
C) Turning and coughing
D) Signs of pulmonary infection - CORRECT ANSWER Ans: D
Feedback:
The nurse teaches the patient and family about the ventilator, suctioning, tracheostomy care,
signs of pulmonary infection, cuff inflation and deflation, and assessment of vital signs.
Neurologic assessment and turning and coughing are less important than signs and symptoms
of infection. Inhaled corticosteroids may or may not be prescribed.
A perioperative nurse is caring for a postoperative patient. The patient has a shallow
respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address
the patient's increased risk for what complication?
A) Acute respiratory distress syndrome (ARDS)
B) Atelectasis
