1. Theb n nurseb n findsb n theb n patientb n inb n cardiopulmonaryb n arrestb n withb n nob n pulseb n or
b n respi-
bnrations. bnWhichbnoxygenbndeliverybndevice bnwillbnthebnnurse bnusebnforbnthisbnpatient?
a. Non-rebreather b n mask
b. Bag-valve-maskbnunit
c. Continuousb n positiveb n airwayb n pressureb n (CPAP)
d. High-flowbnnasalbncannula:bnb.bnBag-valve-maskbnunit
Thebnprioritybnofbnthebnnursebnisbntobnventilatebnthebnpatientbnmanuallybnusingbnabnbag-valve-
maskbn(BVM)bnunit.bnThisbnallowsbnairbntobnbebnforcedbnintobnthebnpatient'sbnlungsbnwhenbntherebnarebnnobnspontaneousbnrespirations.bn
Thebnnon-
rebreatherbnmaskbnandbnnasalbncannulabnrequirebnthebnpatientbntobnbreathebnonbnhisbnorbnherbnown.bnCPAPbnisbnusedbnforbnpatientsbn
whobnarebnawake,bnoriented,bnandbninbnrespiratorybnfailure.
2. Theb n nurseb n isb n caringb n forb n ab n patientb n whob n isb n slowb n tob n awakenb n followingb n gene
ral
anesthesia.b n Theb n patientb n isb n breathingb n spontaneouslyb n butb n isb n minimallyb n responsi
veb n andbnhavingbndifficultybnmaintainingbnabnpatentbnairway.bnWhichbninterventionbn
isbnthebnmostbnappropriatebnforbnthebnpatientbntobnimprovebnoxygenation?
a. Insertbnanbnoralbnairway.
b. Lowerb n theb n headb n ofb n theb n bed.
c. Turnb n theb n patient'sb n headb n tob n theb n side.
d. Monitorbnthebnpatient'sbnpulsebnoximetry.:bna.bnInsertbnanbnoralbnairway.
Anbnoralbn(oropharyngeal)bnairwaybnwillbnpreventbnthebnpatient'sbntonguebnfrombnfallingbnbackbnandbnoccludingbnthebnairway.bn
Loweringbnthebnheadbnofbnthebnbedbnwillbnonlybnincreasebnairwaybnocclusionbnandbnriskbnofbnaspiration.bnTurningbnthebnpatient'sbnh
eadbntobnthebnsidebnwillbnnotbnclearbnthebnbackbnofbnthebnpatient'sbntonguebnfrombnthebnairway.bnMonitoringbnthebnpatient'sbnpulsebno
ximetrybnwillbnnotbnimprovebnoxygenationbnorbnclearbnthebnairway.
3. Theb n nurseb n isb n caringb n forb n ab n patientb n withb n ab n historyb n ofb n left-
sidedb n congestiveb n heart
failurebnwhobnisbnacutelybnshortbnofbnbreath.bnThebnnursebnhearsbnfinebncracklesbnthrougho
utbnbothb n lungb n fieldsb n andb n notesb n thatb n theb n patient'sb n pulseb n oximetryb n isb n onlyb n 8
,8%b n onb n 4b n Lbnofbnoxygen.bnWhatbnisbnthebnprioritybninterventionbnofbnthebnnurse?
a. Administerb n theb n orderedb n intravenousb n diuretic.
b. Prepareb n forb n insertionb n ofb n ab n chestb n tube.
, c. Suctionb n secretionsb n fromb n theb n patient'sb n respiratoryb n tract.
d. Havebnthebnpatientbnusebnthebnorderedbnincentivebnspirometer.:bna.bnAdministerbnthebnorde
redbnintravenousbndiuretic.
Thebnpatient'sbnrespiratorybndistressbnisbnduebntobnpulmonarybnedemabnandbnfluidbnoverloadbnfrombnleft-
sidedbncongestivebnheartbnfailure.bnAbnpatientbnwithbnheartbnfailurebnmaybnbebnonbndiuretics.bnAbndiureticbnwillbnpullbnthebnexcessbnfluidb
noutbnofbnthebnbodybnthroughbnthebnurinebnandbnrelievebnthebnpatient'sbndistress.bnAbnchestbntubebnisbnnotbnneededbnasbnthebnfluidbnisbn
withinbnthebnalveolibnratherbnthanbnbetweenbnthebnlungbnandbnchestbnwall.bnSuctioningbnandbnusebnofbnanbnincentivebnspirometerbn
willbnnotbnaddressbnfluidbnoverloadbnorbnimprovebnthebnpatient'sbnsymptoms.
4. Thebnnursebn isbn caringbnforbn abnpatientbnwhobnhasbn beenbn intubatedbnwithbnanbnoralbn endo
tra-
chealb n tubeb n forb n severalb n weeks.b n Theb n physiciansb n predictb n thatb n theb n patientb n wil
lb n needbntob n remainb n onb n ab n ventilatorb n forb n atb n leastb n severalb n moreb n weeksb n beforeb
n heb n willb n beb n ablebntobnmaintainbnhisbnairwaybnandbnbreathebnonbnhisbnown.bnWhatbnproce
durebndoesbnthebnnursebnanticipatebnwillbnbebnplannedbnforbnthebnpatientbntobnfacilitatebnr
ecovery?
a. Placementb n ofb n ab n tracheostomyb n tube
b. Diagnosticb n thoracentesis
c. Pulmonaryb n angiogram
d. Lungbntransplantationbnsurgery:bna.bnPlacementbnofbnabntracheostomybntube
Placementbnofbnabntracheostomybntubebnwillbnsecurebnthebnpatient'sbnairwaybndirectlybnthroughbnthebntrachea,bneliminatingbnthebnn
eedbnforbnthebnendotrachealbntube.bnThisbnwillbnmakebnthebnpatientbnmorebncomfortablebnandbnmaybnallowbneatingbnwhilebnmini
mizingbndamagebntobnthebnoropharynxbnfrombnthebnendotrachealbntube.
5. Theb n nurseb n isb n caringb n forb n ab n patientb n withb n ab n chestb n tubeb n whob n wasb n transported
tobnradiologybnforbntesting.bnWhenbnthebnpatientbnreturnsbntobnthebnnursingbnunit,bnthe
bntransporter bnshowsbnthebnnurse bnthebnpatient's bnchestbntubebncollection bndevice, bnw
hichbnwasb n badlyb n damagedb n afterb n beingb n caughtb n inb n theb n elevatorb n door.b n Whatb n is
b n theb n prioritybnactionbnofbnthebnnurse?
a. Clampb n theb n chestb n tubeb n untilb n theb n collectionb n deviceb n isb n replaced.
b. Coverb n theb n insertionb n siteb n withb n ab n newb n occlusiveb n dressing.
b n respi-
bnrations. bnWhichbnoxygenbndeliverybndevice bnwillbnthebnnurse bnusebnforbnthisbnpatient?
a. Non-rebreather b n mask
b. Bag-valve-maskbnunit
c. Continuousb n positiveb n airwayb n pressureb n (CPAP)
d. High-flowbnnasalbncannula:bnb.bnBag-valve-maskbnunit
Thebnprioritybnofbnthebnnursebnisbntobnventilatebnthebnpatientbnmanuallybnusingbnabnbag-valve-
maskbn(BVM)bnunit.bnThisbnallowsbnairbntobnbebnforcedbnintobnthebnpatient'sbnlungsbnwhenbntherebnarebnnobnspontaneousbnrespirations.bn
Thebnnon-
rebreatherbnmaskbnandbnnasalbncannulabnrequirebnthebnpatientbntobnbreathebnonbnhisbnorbnherbnown.bnCPAPbnisbnusedbnforbnpatientsbn
whobnarebnawake,bnoriented,bnandbninbnrespiratorybnfailure.
2. Theb n nurseb n isb n caringb n forb n ab n patientb n whob n isb n slowb n tob n awakenb n followingb n gene
ral
anesthesia.b n Theb n patientb n isb n breathingb n spontaneouslyb n butb n isb n minimallyb n responsi
veb n andbnhavingbndifficultybnmaintainingbnabnpatentbnairway.bnWhichbninterventionbn
isbnthebnmostbnappropriatebnforbnthebnpatientbntobnimprovebnoxygenation?
a. Insertbnanbnoralbnairway.
b. Lowerb n theb n headb n ofb n theb n bed.
c. Turnb n theb n patient'sb n headb n tob n theb n side.
d. Monitorbnthebnpatient'sbnpulsebnoximetry.:bna.bnInsertbnanbnoralbnairway.
Anbnoralbn(oropharyngeal)bnairwaybnwillbnpreventbnthebnpatient'sbntonguebnfrombnfallingbnbackbnandbnoccludingbnthebnairway.bn
Loweringbnthebnheadbnofbnthebnbedbnwillbnonlybnincreasebnairwaybnocclusionbnandbnriskbnofbnaspiration.bnTurningbnthebnpatient'sbnh
eadbntobnthebnsidebnwillbnnotbnclearbnthebnbackbnofbnthebnpatient'sbntonguebnfrombnthebnairway.bnMonitoringbnthebnpatient'sbnpulsebno
ximetrybnwillbnnotbnimprovebnoxygenationbnorbnclearbnthebnairway.
3. Theb n nurseb n isb n caringb n forb n ab n patientb n withb n ab n historyb n ofb n left-
sidedb n congestiveb n heart
failurebnwhobnisbnacutelybnshortbnofbnbreath.bnThebnnursebnhearsbnfinebncracklesbnthrougho
utbnbothb n lungb n fieldsb n andb n notesb n thatb n theb n patient'sb n pulseb n oximetryb n isb n onlyb n 8
,8%b n onb n 4b n Lbnofbnoxygen.bnWhatbnisbnthebnprioritybninterventionbnofbnthebnnurse?
a. Administerb n theb n orderedb n intravenousb n diuretic.
b. Prepareb n forb n insertionb n ofb n ab n chestb n tube.
, c. Suctionb n secretionsb n fromb n theb n patient'sb n respiratoryb n tract.
d. Havebnthebnpatientbnusebnthebnorderedbnincentivebnspirometer.:bna.bnAdministerbnthebnorde
redbnintravenousbndiuretic.
Thebnpatient'sbnrespiratorybndistressbnisbnduebntobnpulmonarybnedemabnandbnfluidbnoverloadbnfrombnleft-
sidedbncongestivebnheartbnfailure.bnAbnpatientbnwithbnheartbnfailurebnmaybnbebnonbndiuretics.bnAbndiureticbnwillbnpullbnthebnexcessbnfluidb
noutbnofbnthebnbodybnthroughbnthebnurinebnandbnrelievebnthebnpatient'sbndistress.bnAbnchestbntubebnisbnnotbnneededbnasbnthebnfluidbnisbn
withinbnthebnalveolibnratherbnthanbnbetweenbnthebnlungbnandbnchestbnwall.bnSuctioningbnandbnusebnofbnanbnincentivebnspirometerbn
willbnnotbnaddressbnfluidbnoverloadbnorbnimprovebnthebnpatient'sbnsymptoms.
4. Thebnnursebn isbn caringbnforbn abnpatientbnwhobnhasbn beenbn intubatedbnwithbnanbnoralbn endo
tra-
chealb n tubeb n forb n severalb n weeks.b n Theb n physiciansb n predictb n thatb n theb n patientb n wil
lb n needbntob n remainb n onb n ab n ventilatorb n forb n atb n leastb n severalb n moreb n weeksb n beforeb
n heb n willb n beb n ablebntobnmaintainbnhisbnairwaybnandbnbreathebnonbnhisbnown.bnWhatbnproce
durebndoesbnthebnnursebnanticipatebnwillbnbebnplannedbnforbnthebnpatientbntobnfacilitatebnr
ecovery?
a. Placementb n ofb n ab n tracheostomyb n tube
b. Diagnosticb n thoracentesis
c. Pulmonaryb n angiogram
d. Lungbntransplantationbnsurgery:bna.bnPlacementbnofbnabntracheostomybntube
Placementbnofbnabntracheostomybntubebnwillbnsecurebnthebnpatient'sbnairwaybndirectlybnthroughbnthebntrachea,bneliminatingbnthebnn
eedbnforbnthebnendotrachealbntube.bnThisbnwillbnmakebnthebnpatientbnmorebncomfortablebnandbnmaybnallowbneatingbnwhilebnmini
mizingbndamagebntobnthebnoropharynxbnfrombnthebnendotrachealbntube.
5. Theb n nurseb n isb n caringb n forb n ab n patientb n withb n ab n chestb n tubeb n whob n wasb n transported
tobnradiologybnforbntesting.bnWhenbnthebnpatientbnreturnsbntobnthebnnursingbnunit,bnthe
bntransporter bnshowsbnthebnnurse bnthebnpatient's bnchestbntubebncollection bndevice, bnw
hichbnwasb n badlyb n damagedb n afterb n beingb n caughtb n inb n theb n elevatorb n door.b n Whatb n is
b n theb n prioritybnactionbnofbnthebnnurse?
a. Clampb n theb n chestb n tubeb n untilb n theb n collectionb n deviceb n isb n replaced.
b. Coverb n theb n insertionb n siteb n withb n ab n newb n occlusiveb n dressing.
