CAI Quiz 4 (Got 98) questions with
complete solutions 2025.
A nurse is caring for a client whom the respiratory therapist has just removed the
endotracheal tube. Which of the following actions should the nurse take first?
• Evaluate the client for stridor
• Administer oxygen via face mask
• Instruct the client to cough
• Keep the client in a semi-to high-Fowler's position - ANSWER: • Evaluate the client for
stridor
In caring for a client in acute respiratory failure, the nurse recognizes that noninvasive
positive pressure ventilation (NIPPV) may be used for which client?
• Responds to hourly bronchodilator neutralization treatments
• Has copious secretions that require frequent suctioning
• Is alert and cooperative but has increasing respiratory exhaustion
• Is comatose and has high oxygen requirements - ANSWER: • Is alert and cooperative
but has increasing respiratory exhaustion
A nurse in the PACU is assessing a client who has an endotracheal tube
(ET) tube in place and observes the absence of left-sided chest wall expansion upon
respiration. Which of the following complications should the nurse suspect?
• Passage of the ET tube into the esophagus
, • Infection of the vocal cords
Movement of the ET tube into the right main bronchus
• Blockage of the ET tube by the client's tongue - ANSWER: • Infection of the vocal
cords
Movement of the ET tube into the right main bronchus
A patient on a positive pressure ventilator is receiving a neuromuscular blocking agent
(NMBA) to prevent asynchronous breathing. Which situation requires action by the
nurse?
• The patient's oxygen saturation is 90% to 93%.
• The patient has no cough reflex when suctioned.
• The patient does not respond to voice.
• No sedative is ordered for the patient. - ANSWER: • No sedative is ordered for the
patient.
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?
• Reposition the patient every 1 to 2 hours.
• Instill 5 mL of sterile saline into the ET before suctioning.
• Add additional water to the patient's enteral feedings.
• Increase suctioning frequency to every hour. - ANSWER: • Add additional water to the
patient's enteral feedings.
A nurse on a medical-surgical unit is assessing a client who recently transferred from
the ICU following endotracheal extubation. Which of the following findings should the
nurse identify as a possible manifestation of tracheal stenosis and report to the
provider?
• Hemoptysis
• Kussmauls respirations
complete solutions 2025.
A nurse is caring for a client whom the respiratory therapist has just removed the
endotracheal tube. Which of the following actions should the nurse take first?
• Evaluate the client for stridor
• Administer oxygen via face mask
• Instruct the client to cough
• Keep the client in a semi-to high-Fowler's position - ANSWER: • Evaluate the client for
stridor
In caring for a client in acute respiratory failure, the nurse recognizes that noninvasive
positive pressure ventilation (NIPPV) may be used for which client?
• Responds to hourly bronchodilator neutralization treatments
• Has copious secretions that require frequent suctioning
• Is alert and cooperative but has increasing respiratory exhaustion
• Is comatose and has high oxygen requirements - ANSWER: • Is alert and cooperative
but has increasing respiratory exhaustion
A nurse in the PACU is assessing a client who has an endotracheal tube
(ET) tube in place and observes the absence of left-sided chest wall expansion upon
respiration. Which of the following complications should the nurse suspect?
• Passage of the ET tube into the esophagus
, • Infection of the vocal cords
Movement of the ET tube into the right main bronchus
• Blockage of the ET tube by the client's tongue - ANSWER: • Infection of the vocal
cords
Movement of the ET tube into the right main bronchus
A patient on a positive pressure ventilator is receiving a neuromuscular blocking agent
(NMBA) to prevent asynchronous breathing. Which situation requires action by the
nurse?
• The patient's oxygen saturation is 90% to 93%.
• The patient has no cough reflex when suctioned.
• The patient does not respond to voice.
• No sedative is ordered for the patient. - ANSWER: • No sedative is ordered for the
patient.
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?
• Reposition the patient every 1 to 2 hours.
• Instill 5 mL of sterile saline into the ET before suctioning.
• Add additional water to the patient's enteral feedings.
• Increase suctioning frequency to every hour. - ANSWER: • Add additional water to the
patient's enteral feedings.
A nurse on a medical-surgical unit is assessing a client who recently transferred from
the ICU following endotracheal extubation. Which of the following findings should the
nurse identify as a possible manifestation of tracheal stenosis and report to the
provider?
• Hemoptysis
• Kussmauls respirations
