NUR417 / NUR 417 EXAM 2
Care of Adult II
Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
➢ 100% Guarantee Pass.
➢ Expert Verified Explanation
➢ Multiple choice (single best answer)
➢ Select All That Apply (SATA)
➢ Fill-in-the-blank
➢ Case Studies/Scenario-Based Questions
,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.
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.
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.
Care of Adult II
Concordia, St. Paul
Actual Questions and Answers
This Exam contains:
➢ 100% Guarantee Pass.
➢ Expert Verified Explanation
➢ Multiple choice (single best answer)
➢ Select All That Apply (SATA)
➢ Fill-in-the-blank
➢ Case Studies/Scenario-Based Questions
,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.
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.
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.
