Comprehensive Care III Exam 1 Practice Questions with Definitions and Key Concepts

a. valvular heart disease

When teaching a patient about the long-term consequences of rheumatic fever, the nurse should discuss the possibility of which of the following?

a. valvular heart disease

b. pulmonary hypertension

c. superior vena cava syndrome

d. hypertrophy of the right ventricle

a. Giving IV antibiotics as prescribed

Which is a priority nursing intervention for a patient during the acute phase of rheumatic fever?

a. Giving IV antibiotics as prescribed

b. Managing pain with opioid analgesics

c. Encouraging fluid intake for hydration

d. Performing frequent active range-of-motion exercises

a. Obtain and record daily weight

c. Observe for overt signs of bleeding

e. Obtain and record vital signs, including pulse oximetry

A patient is diagnosed with mitral stenosis and new-onset atrial fibrillation. Which interventions could the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply)

a. Obtain and record daily weight

b. Determine apical-radial pulse rate

c. Observe for overt signs of bleeding

d. Teach the patient how to get a Medic Alert device

e. Obtain and record vital signs, including pulse oximetry

a. dyspnea and tachypnea

The most common early clinical manifestations of ARDS that the nurse may see are which of the following?

a. dyspnea and tachypnea

b. cyanosis and apprehension

c. respiratory distress and frothy sputum

d. bradycardia and increased work of breathing

c. Giving adequate analgesia and sedation

d. Elevating the head of bed 30 to 45 degrees when supine

e. Monitoring hemodynamic parameters and daily weights

Interventions used in managing the patient with ARDS include which of the following? (Select all that apply)

a. IV injection of surfactant

b. Aggressive IV fluid resuscitation

c. Giving adequate analgesia and sedation

d. Elevating the head of bed 30 to 45 degrees when supine

e. Monitoring hemodynamic parameters and daily weights

c. Sepsis

The most common indirect predisposing disorder of ARDS is which of the following?

a. Gastric aspiration

b. Severe trauma

c. Sepsis

d. Pneumonia

c. Suction control chamber

When caring for a patient with a chest tube, where can the nurse expect continuous, gentle bubbling in the collection device?

a. Collection container

b. Water seal

c. Suction control chamber

d. Tubing

c. Pressure monitoring system to the level of the atrium, or the phlebostatic axis

To establish hemodynamic monitoring for a patient, the nurse zeros what?

a. Cardiac output monitoring system to the level of the left ventricle

b. Pressure monitoring system to the level of the catheter tip in the patient

c. Pressure monitoring system to the level of the atrium, or the phlebostatic axis

d. Pressure monitoring system to the level of the atrium, or the midclavicular line

a. Increase functional residual capacity and improve oxygenation

The purpose of adding PEEP to positive pressure ventilation is which of the following?

a. Increase functional residual capacity and improve oxygenation

b. Increase FIO2 to try to help wean the patient and avoid O2 toxicity

c. Determine if the patient can be weaned and avoid pneumomediastinum

d. Determine if the patient is in synchrony with the ventilator or needs to be paralyzed

c. Observing for cardiac dysrhythmias during suctioning

The nursing management of a patient with an artificial airway includes...

a. Maintaining ET tube cuff pressure at 35 cm H2O

b. Routine suctioning of the tube at least every 2 hours

c. Observing for cardiac dysrhythmias during suctioning

d. Preventing tube dislodgment by limiting mouth care to lubrication of the lips

b. Chest pain and palpitations

In the patient with supraventricular tachycardia, which assessment indicates decreased cardiac output?

a. Hypertension and dyspnea

b. Chest pain and palpitations

c. Abdominal distention and tachypnea

d. Bounding pulses and a systolic murmur

b. Assess for bilateral breath sounds

**The first action by the nurse is to assess for bilateral breath sounds as an initial indication of correct tube placement. After this is done, the tube should be securely taped in place to prevent dislodgement, a chest x-ray is needed to confirm tube placement, and then the nurse can assure the client about alternative communication means

The client has just had emergency intubation for respiratory distress. Immediately following insertion of the endotracheal tube, what action by the nurse is most appropriate?

a. Tape the tube securely in place

b. Assess for bilateral breath sounds

c. Call for a chest x-ray to determine placement

d. Provide the client an alternative method of communication

d. A harsh or crowing sound with inspiration

**A harsh or crowing sound with inspiration indicates stridor, which is consistent with airway narrowing and edema following endotracheal tube removal

Which respiratory assessment finding is of greatest concern to the nurse following endotracheal tube extubation?

a. Increased respiratory rate from 16 to 20 bpm

b. Scattered bilateral rhonchi

c. Expectoration of whitish yellow secretions

d. A harsh or crowing sound with inspiration

a. Submerge the tube in sterile water or saline

**The priority (first) action of the nurse is to submerge the tube in sterile water or saline to reestablish the underwater seal. This will prevent the client from sucking air through the chest tube into the pleural space during inspiration

A client with a closed chest drainage system tries to get out of bed alone and disconnects the chest tube from the drainage system, which falls on the floor. What should the nurse do FIRST?

a. Submerge the tube in sterile water or saline

b. Set up and attach a new closed chest drainage system

c. Assess the client's respiratory status

d. Check the client's pulse and blood pressure

a. Document and continue to monitor the bubbling

**The nurse should document this normal finding and continue to monitor. Fluid addition and removal are based on fluid level, not on bubbling action of suction. The nurse should not turn up suction because the gentle bubbling indicates proper function

Following chest tube insertion, the nurse notes continuous bubbling in the suction control chamber of the closed chest drainage system. What action should the nurse plan to take at this time?

a. Document and continue to monitor the bubbling

b. Add water to the suction control chamber

c. Remove water from the suction control chamber

d. Turn up the suction on the wall suction unit

b. There is an air leak in the system

**Continuous bubbling in the water seal chamber most often indicates a leak or loose connection in the system, and air is being sucked continuously into the closed chest drainage system

During routine chest tube assessment, the nurse notes the presence of continuous bubbling in the water seal chamber of the closed chest drainage system. Which conclusion should the nurse draw from this data?

a. A new pneumothorax has developed

b. There is an air leak in the system

c. The wall suction unit is set on intermediate or high level

d. The drainage tube connections are taped too tightly

b. Administer a dose of a PRN analgesic to the client

The client is scheduled for removal of a chest tube at 0900. At approximately 0830, what action should the nurse take?

a. Obtain a telephone report of the chest x-ray findings from radiology

b. Administer a dose of a PRN analgesic to the client

c. Ensure that a suture-removal set and dressing materials are available

d. Explain to the client the upcoming removal procedure

a. Blood is shunted past alveoli with no ventilation

**One of the primary alterations occurring with ARDS is the collapse of alveoli and therefore loss of ventilation in those areas. Air does not become trapped in hyperinflated alveoli in ARDS; instead, alveoli collapse

A client who develops acute respiratory distress syndrome (ARDS) is exhibiting hypoxemia unresponsive to oxygen therapy. In explaining the client's condition to the family, the nurse would incorporate which concept?

a. Blood is shunted past alveoli with no ventilation

b. The individual has difficulty expelling air trapped in the alveoli

c. There is excess surfactant production by the alveoli

d. Thick secretions block the airways

c. Enoxaparin

**Administration of anticoagulants is an effective intervention to prevent pulmonary embolism

What pharmacologic treatment would the nurse administer aimed at prevention of pulmonary embolism?

a. Streptokinase

b. Vitamin K

c. Enoxaparin

d. Protamine sulfate

c. Shunting of blood around nonventilated alveoli

**A primary physiological alteration occurring with ARDS is shunting of blood around nonventilated alveoli. Alveoli collapse in ARDS, preventing air from entering the alveoli, and ventilation decreases

The nurse caring for a client diagnosed with acute respiratory distress syndrome (ARDS) should consider that, in this client, impaired gas exchange is mostly likely related to which factor?

a. Air trapping in the alveoli

b. Accumulation of exudative fluid into the alveoli

c. Shunting of blood around nonventilated alveoli

d. Excessive alpha-1-antitrypsin

d. Client's ECG monitor shows paced beats at the rate of 72 per minute

**Paced beats indicate that the pacemaker is functioning

The nurse is caring for a client who had a permanent pacemaker inserted because of a complete heart block. The nurse determines that which client outcome indicates a successful procedure?

a. Client ambulating in the hall within 4 hours of the procedure without dyspnea or chest pain

b. Client's ECG monitor demonstrates normal sinus rhythm

c. Heart rate of 80 beats per minute, BP 112/74 mmHg

d. Client's ECG monitor shows paced beats at the rate of 72 per minute

a. "It is best to avoid strenuous exercise, stairs, and lifting before your surgery."

**Symptomatic aortic stenosis has a poor prognosis without surgery. Restricting activity limits myocardial oxygen consumption

The nurse is caring for a client with a diagnosis of aortic stenosis who has surgery scheduled in 2 weeks. The client reports episodes of angina and passing out recently at home. What would be the nurse's best explanation about recommended activity at this time?

a. "It is best to avoid strenuous exercise, stairs, and lifting before your surgery."

b. "Take short walks three times daily to prepare for postoperative rehabilitation."

c. "There are no activity restrictions unless the angina reoccurs; then please call the office."

d. "Gradually increase activity before surgery to build stamina for the postoperative period."

b. Assess for early signs of endocarditis

**The main complication of rheumatic fever is carditis

During the acute phase of rheumatic fever, what is a priority action of the nurse?

a. Encourage ambulation at least four times per day

b. Assess for early signs of endocarditis

c. Maintain hydration by encouraging sips of water

d. Manage pain with routine opioid analgesics

a. Lower the positive end-expiratory pressure (PEEP)

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate?

a. Lower the positive end-expiratory pressure (PEEP)

b. Decrease the fraction of inspired oxygen (FiO2)

c. Increase the tidal volume and respiratory rate

d. Perform endotracheal suctioning more frequently

c. Tracheal deviation

Which of the following is a LATE sign of the development of a tension pneumothorax?

a. Hypotension

b. Tachycardia

c. Tracheal deviation

d. Dyspnea

c. Agitation or confusion

A patient with severe chronic lung disease is hospitalized with respiratory distress. Which finding would suggest to the nurse that the patient has developed rapid decompensation?

a. An SpO2 of 86%

b. A blood pH of 7.33

c. Agitation or confusion

d. PaCO2 increases from 48 to 55 mm Hg

a. Oxygen

b. Sterile water

c. Enclosed hemostat clamps

e. Occlusive dressing

**a hemostat clamp helps check for air leaks in the chest tube

A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (Select all that apply)

a. Oxygen

b. Sterile water

c. Enclosed hemostat clamps

d. Indwelling urinary catheter

e. Occlusive dressing

b. Apply sterile gauze to the insertion site

**using ABCs, this is the priority because the sterile gauze allows air to escape and reduces the risk for development of a tension pneumothorax

A nurse is caring for a patient who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first?

a. Obtain a chest x-ray

b. Apply sterile gauze to the insertion site

c. Place tape around the insertion site

d. Assess respiratory status

b. Gentle, constant bubbling in the suction control chamber

c. Rise and fall in the level of water in the water seal chamber with inspiration and expiration

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply)

a. Continuous bubbling in the water seal chamber

b. Gentle, constant bubbling in the suction control chamber

c. Rise and fall in the level of water in the water seal chamber with inspiration and expiration

d. Exposed sutures without dressing

e. Drainage system upright at chest level

d. Place an occlusive dressing over the site once the tube is removed

A nurse is assisting a provider with the removal of a chest tube. Which of the following actions should the nurse take?

a. Instruct the client to lie prone with arms by the sides

b. Complete a surgical checklist on the client

c. Remind the client that there is minimal discomfort during the removal process

d. Place an occlusive dressing over the site once the tube is removed

a. Encourage the client to cough and deep breathe

b. Check for continuous bubbling in the suction chamber

e. Obtain a chest x-ray

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply)

a. Encourage the client to cough and deep breathe

b. Check for continuous bubbling in the suction chamber

c. Strip the drainage tubing every 4 hr

d. Clamp the tube once a day

e. Obtain a chest x-ray

b. "It allows preset pressure delivered during spontaneous ventilation"

**delivers preset pressure to decrease the patient's work of breathing

A nurse is caring for a client who is receiving mechanical ventilation and is on pressure support mode. Which of the following statements by the nurse indicates an understanding of pressure support mode?

a. "It keeps the alveoli open and prevents atelectasis"

b. "It allows preset pressure delivered during spontaneous ventilation"

c. "It guarantees minimal minute ventilator"

d. "It delivers a preset ventilatory rate and tidal volume to the client"

b. Pale skin

e. Elevated blood pressure

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply)

a. Confusion

b. Pale skin

c. Bradycardia

d. Hypotension

e. Elevated blood pressure

d. Assess breath sounds every 4 hr

**not A bc you should try a less invasive restraint first, not B bc ventilator setting should be constantly monitored (hourly), and not C bc tube placement is measured at the patient's lips/teeth

A nurse is caring for a client who is receiving mechanical ventilation via an ET tube. Which of the following actions should the nurse take?

a. Apply a vent restraint if self-extubation is attempted

b. Monitor ventilator settings every 8 hr

c. Document tube placement in centimeters at the angle of jaw

d. Assess breath sounds every 4 hr

b. Venturi mask

**can deliver high flow oxygen in a precise amount

A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client?

a. Nonrebreather mask

b. Venturi mask

c. Nasal cannula

d. Simple face mask

a. Fluid volume overload

Aortic valve regurgitation often has clinical manifestations that result from what?

a. Fluid volume overload

b. Hypovolemia

c. Decreased arterial pressure

d. Increased cardiac output

b. Synchronized intermittent mandatory ventilation (SIMV)

c. Continuous positive airway pressure

d. Pressure support ventilation

**all these require the client to generate force to take spontaneous breaths

A nurse is reviewing the plan of care for a client who is receiving mechanical ventilation. Which of the following ventilator modes will increase the client's work of breathing? (Select all that apply)

a. Assist-control

b. Synchronized intermittent mandatory ventilation (SIMV)

c. Continuous positive airway pressure

d. Pressure support ventilation

e. Independent lung ventilation

a. Obtain baseline vitals and oxygen saturation

A nurse is caring for a client who, upon awakening, was disoriented to person, place, and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority?

a. Obtain baseline vitals and oxygen saturation

b. Obtain a sputum culture

c. Obtain a complete history from the client

d. Provide a pneumococcal vaccine

a. Tachypnea

b. Deviation of the trachea

A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply)

a. Tachypnea

b. Deviation of the trachea

c. Bradycardia

d. Decreased use of accessory muscles

b. Obtain a large-bore IV needle for decompression

A nurse is assisting the provider to care for a patient who has developed a spontaneous pneumothorax. Which of the following actions should the nurse perform first?

a. Assess the client's pain

b. Obtain a large-bore IV needle for decompression

c. Administer lorazepam

d. Prepare for chest tube insertion

c. Administer oxygen via a high-flow mask

A nurse in the ED is assessing a client who was in a motor vehicle crash. Findings include absent breath sound in the left lower lobe with dyspnea, blood pressure 118/68, HR 124/min, respirations 38/min, temperature 101.4, and SaO2 92% on room air. Which of the following actions should the nurse take?

a. Obtain a chest x-ray

b. Prepare for chest tube insertion

c. Administer oxygen via a high-flow mask

d. Initiate IV access

b. "This medication is given to facilitate ventilation"

**vecuronium is a neuromuscular blocking agent --> can help w/ patients on ventilators

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a patient who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

a. "This medication is given to treat infection"

b. "This medication is given to facilitate ventilation"

c. "This medication is given to decrease inflammation"

d. "This medication is given to reduce anxiety"

a. A client who experienced a near-drowning incident

b. A client following coronary artery bypass graft surgery

d. A client who has dysphagia

e. A client who experienced acute drug toxicity

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome (ARDS)? (Select all that apply)

a. A client who experienced a near-drowning incident

b. A client following coronary artery bypass graft surgery

c. A client who has a hemoglobin of 15.1 mg/dL

d. A client who has dysphagia

e. A client who experienced acute drug toxicity

d. "A chest x-ray is needed to verify placement after the procedure"

A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

a. "Air should be instilled into the monitoring system prior to the procedure"

b. "The client should be positioned on the left side during the procedure"

c. "The transducer should be level with the second intercostal space after the line is placed"

d. "A chest x-ray is needed to verify placement after the procedure"

b. A client who has COPD

d. A client who underwent stent placement in a coronary artery

A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? (Select all that apply)

a. A client who has an SaO2 of 92%

b. A client who has COPD

c. A client who has a blood potassium level of 4.3 mEq/L

d. A client who underwent stent placement in a coronary artery

a. Follow-up ECG

b. Energy settings used

e. Skin condition under the electrodes

A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? (Select all that apply)

a. Follow-up ECG

b. Energy settings used

c. IV fluid intake

d. Urinary output

e. Skin condition under the electrodes

b. Pacemaker insertion

A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/min and notifies the provider. Which of the following prescriptions might be appropriate for this client?

a. Defibrillation

b. Pacemaker insertion

c. Synchronized cardioversion

d. Administration of IV lidocaine

a. "This means the pacemaker fires in an asynchronous pattern"

**asynchronous means the pacemaker fires w/o regard for electrical activity within the heart

A cardiac nurse educator is reviewing the use of the fixed rate mode pacemaker with a group of newly hired nurses. Which of the following statements by a newly hired nurse indicates understanding of the review?

a. "This means the pacemaker fires in an asynchronous pattern"

b. "This means the pacemaker fires only when the HR is below a certain rate"

c. "The pacemaker can automatically adjust to a client's increased activity level"

d. "The pacemaker activity is triggered by heart muscle activity"

c. Neck vein distension

**mitral valve insufficiency can lead to pulmonary congestion --> fluid buildup can cause distension

A nurse is completing an admission physical assessment of a client who has mitral valve insufficiency. Which of the following findings should the nurse expect?

a. S4 heart sound

b. Petechiae

c. Neck vein distension

d. Splenomegaly

a. Dyspnea

b. Client report of fatigue

e. Peripheral edema

A nurse educator is reviewing expected findings in a client who has right-sided valvular heart disease with a group of nurses. Which of the following findings should the nurse include in the discussion? (Select all that apply)

a. Dyspnea

b. Client report of fatigue

c. Bradycardia

d. Pleural friction rub

e. Peripheral edema

d. Check the drainage system for an air leak

You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the correct nursing intervention for this type of finding?

a. Reposition the patient because the tubing is kinked

b. Continue to monitor the drainage system

c. Increase the suction to the drainage system until the bubbling stops

d. Check the drainage system for an air leak

c. The water in the chamber will decrease during inspiration and increase during expiration

A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber, what do you expect to find?

a. The water in the chamber will increase during inspiration and decrease during expiration

b. There will be continuous bubbling noted in the chamber

c. The water in the chamber will decrease during inspiration and increase during expiration

d. The water in the chamber will not move

b. Dry suction chest tube system

This chest drainage system has no water column to control suction but uses a suction monitor bellow that balances the wall suction and you can adjust water suction pressure using the rotary suction dial on the side of the system. It allows for higher suction pressure levels, has no bubbling sounds, and water does not evaporate from it as with other systems. What type of chest tube system does this statement describe?

a. Mediastinal chest tube system

b. Dry suction chest tube system

c. Wet suction chest tube system

d. Dry-Wet suction chest tube system

a. Document your findings as normal

You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention?

a. Document your findings as normal

b. Assess for an air leak due to bubbling noted in the suction chamber

c. Notify the physician about the drainage

d. Milk the tubing to ensure patency of the tubes

b. Place a sterile dressing over the site and tape it on three sides and notify the physician

While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention?

a. Stay with the patient and monitor their vital signs while another nurse notifies the physician

b. Place a sterile dressing over the site and tape it on three sides and notify the physician

c. Attempt to re-insert the tube

d. Keep the site open to air and notify the physician

c. "Take a deep breath, hold it in, and bear down."

**By requesting that the client take a deep breath, hold it in and bear down, this action increases the pressure inside the chest while also not allowing additional air in the chest; therefore, this is the priority instruction to provide to the client prior to the removal of a chest tube.

The nurse prepares to assist the health care provider (HCP) with the removal of a client's chest tube. Which priority instruction should the nurse provide to the client immediately before removal?

a. "Lie flat and breathe deeply so you won't feel pain"

b. "Breathe in twice, then breathe out slowly with pursed lips."

c. "Take a deep breath, hold it in, and bear down."

d. "Inhale and exhale very rapidly until the tube is out."

d. Submerge the distal portion of the chest tube below the surface of sterile water

Which is the priority nursing action in the provision of care for a client with a chest tube whose family member accidentally kicks the drainage unit causing it to crack?

a. Immediately place the client in Trendelenburg position

b. Notify the charge nurse and file an incident report

c. Place a clamp on the tube that is close to the client until a new drainage unit is available

d. Submerge the distal portion of the chest tube below the surface of sterile water

a. Continue to monitor the client and document chest tube drainage

Which action should the nurse implement when bubbling is observed in the suction control chamber for a client with a mediastinal chest tube?

a. Continue to monitor the client and document chest tube drainage

b. Disconnect the chest tube from suction for one hour and restart suction

c. Notify the healthcare provider (HCP) of the presence of an air leak

d. Palpate around the chest tube dressing to assess for crepitus

b. Drainage collection chamber

The nurse provides care for a client who has a chest tube drainage system in place. Which is the location the nurse should use to assess the client's chest tube output?

a. Air leak gauge

b. Drainage collection chamber

c. Suction control chamber

d. Water-seal chamber

d. Removing excess air and fluid

A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for?

a. Maintaining positive chest-wall pressure

b. Monitoring pleural fluid osmolarity

c. Providing positive intrathoracic pressure

d. Removing excess air and fluid

d. Document that the chest drainage system is operating as it is intended

The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patients respirations. How should the nurse best respond to this assessment finding?

a. Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes

b. Inform the physician promptly that there is in imminent leak in the drainage system

c. Encourage the patient to do deep breathing and coughing exercises

d. Document that the chest drainage system is operating as it is intended

c. Check the level of the suction on the wall

The student nurse assesses her patient with a chest tube. She notices that the suction control chamber of the chest tube is not bubbling. What is the first thing this student should do?

a. Document this normal finding

b. Encourage the patient to cough and deep breathe

c. Check the level of the suction on the wall

d. Clamp the chest tube and call for help

c. The injury allows air into the pleural space but prevents it from escaping from the pleural space

The nurse is presenting a class on chest tubes. Which statement describes a tension pneumothorax?

a. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures

b. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere

c. The injury allows air into the pleural space but prevents it from escaping from the pleural space

d. A tension pneumothorax results from a puncture of the pleura during a central line placement.

a. When ordered by a physician to simulate tube removal and assess the patient's response

When is it beneficial to clamp a patient's chest tube?

a. When ordered by a physician to simulate tube removal and assess the patient's response

b. Whenever a patient leaves the nursing unit and cannot be monitored

c. When ambulating a postoperative patient with a chest tube

d. It is never beneficial to clamp a patient's chest tube

d. Perform the Valsalva maneuver

**Valsalva maneuver = take a deep breath, exhale, and bear down

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action?

a. Exhale slowly

b. Stay very still

c. Inhale and exhale quickly

d. Perform the Valsalva maneuver

b. A downward trend in blood pressure

The healthcare provider is caring for a patient who has a pneumothorax. When assessing the patient and the chest tube drainage system, a large fibrin clot is noted in the tubing. Which additional assessment finding requires immediate action by the healthcare provider?

a. Increasing pain at the insertion site

b. A downward trend in blood pressure

c. Decreased water in the suction control

d. Fluctuations in the water seal

c. Encourage the patient to breathe deeply and cough regularly

When caring for a patient who has a pneumothorax, which of these actions should the healthcare provider include in the patient's plan of care?

a. Empty the drainage chamber every shift and record the amount

b. Vigorously massage the tube every 2 hours to promote drainage

c. Encourage the patient to breathe deeply and cough regularly

d. Change the insertion site dressing daily using aseptic technique

b. A 6 foot, 135 lb male who smokes

**A primary spontaneous pneumothorax occurs most commonly in young males who are tall and thin

Which of these individuals is at risk for a primary spontaneous pneumothorax?

a. A patient in the intensive care unit receiving mechanical ventilation

b. A 6 foot, 135 lb male who smokes

c. A patient with an 18-year history of emphysema

d. A patient with a penetrating chest wound that makes a sucking sound

c. The patient with a respiratory rate of 28 and asymmetric chest wall movement

The healthcare provider is caring for four patients. Which patient should be assessed first?

a. The patient who is in a tripod position and breathing through pursed lips

b. The patient with a pain rating of 7 on a 0 to 10 pain scale whose oxygen saturation is 91%

c. The patient with a respiratory rate of 28 and asymmetric chest wall movement

d. The patient with bilateral crackles, fever, and mucopurulent sputum

a. Prepare for replacement of the tube

b. Keep the tubing below the level of the insertion site

d. Notify the provider to evaluate the level of suction

A nurse is caring for a client with a chest tube. He notes that the dressing around the client's tube insertion site is wet and there is some crepitus with mild palpation. Which actions by the nurse are most appropriate in this situation? (Select all that apply)

a. Prepare for replacement of the tube

b. Keep the tubing below the level of the insertion site

c. Remove the tube and place an occlusive dressing over the site

d. Notify the provider to evaluate the level of suction

e. Gently milk the tubing to remove clots, if present

a. The client's respiratory rate

A nurse is caring for a client who has a chest tube because of a pneumothorax. The nurse can tell the certified nursing assistant to check which of the following?

a. The client's respiratory rate

b. Whether there is increased drainage in the last four hours

c. Whether the chest tube is tidaling

d. The level of the water seal on the chest tube

c. The client with continuous bubbling in the drainage chamber

**Continuous bubbling in the chamber reflects an air leak, meaning there could be a hole in the tubing or it could be dislodged

A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first?

a. The client with tidaling in the drainage tubing

b. The client with suction pressure set at 20 cm H2O

c. The client with continuous bubbling in the drainage chamber

d. The client whose drainage system is standing on the floor

b. Tension pneumothorax

The nurse is caring for a client with a chest tube. The nurse will refrain from clamping the chest tube because which of the following could happen?

a. Barrel chest

b. Tension pneumothorax

c. Airway constriction

d. Pneumonia

b. Intermittent

**Intermittent bubbling is noted when a pneumothorax occurs --> as long as there is air in the pleural space, there will be intermittent bubbling in the chamber

If a pneumothorax is present and the client has a chest tube, what type of bubbling would be expected in the water chamber?

a. Tiny bubbles

b. Intermittent

c. Constant

d. No bubbling

a. Continue to monitor the patient

The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with closed chest tube drainage. The nurse should do which of the following?

a. Continue to monitor the patient

b. Check all connections for a leak in the system

c. Lower the drainage collector further from the chest

d. Clamp the tubing at progressively distal points away from the patient until the tidaling stops

c. Stripping or milking the chest tube to promote drainage

An unlicensed assistive personnel is taking care of a patient with a chest tube. The nurse should intervene when she observes the unlicensed assistive personnel doing which of the following?

a. Looping the drainage tubing on the bed

b. Securing the drainage container in an upright position

c. Stripping or milking the chest tube to promote drainage

d. Reminding the patient to cough and deep breathe every 2 hours

a. Assess the client's respiratory status

**client must always be assessed before attention is turned to equipment

The peak pressure alarm is sounding on the ventilator of the client with a recent tracheostomy. What intervention should be done first?

a. Assess the client's respiratory status

b. Decrease the sensitivity of the alarm

c. Ensure that the connecting tubing is not kinked

d. Suction the client

c. Lung sounds may indicate absorption atelectasis

**High levels of oxygen delivery can result in collapsed alveoli and absorption atelectasis --> PEEP can help alveoli remain properly inflated

The client with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds, and the most recent ABGs show a PaO2 level of 95 mm Hg. The ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is the nurse concerned?

a. The low PaO2 level may result in oxygen toxicity

b. The 100% oxygen delivery requirement indicates immediate extubation

c. Lung sounds may indicate absorption atelectasis

d. The level of oxygen delivery may indicate absorption atelectasis

a. Stable vital signs and ABGs

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

c. Signs of cardiovascular insufficiency because pressure in the chest impedes venous return

The nurses monitors the patient with positive pressure mechanical ventilation for...

a. Paralytic ileus because pressure on the abdominal contents affects bowel motility

b. Diuresis and sodium depletion because of increased release of atrial natriuretic peptide

c. Signs of cardiovascular insufficiency because pressure in the chest impedes venous return

d. Respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO2 levels

a. decreased BP

A patient in acute respiratory failure is receiving assist-control ventilation with a positive end-expiratory pressure (PEEP) of 10 cm H20. What sign alerts the nurse to undesirable effects of increased airway and thoracic pressure?

a. decreased BP

b. decreased PaO2

c. increased crackles

d. decreased spontaneous respirations

d. Elevate the head of the bed 30 degrees

A 68-yr-old male patient diagnosed with sepsis is orally intubated on mechanical ventilation. Which nursing action is most important?

a. Use the open-suctioning technique

b. Administer morphine for discomfort

c. Limit noise and cluster care activities

d. Elevate the head of the bed 30 degrees

a. PaO2 of 60 mm Hg

The nurse is caring for a 65-yr-old man with acute respiratory distress syndrome (ARDS) who is on pressure support ventilation (PSV), fraction of inspired oxygen (FIO2) at 80%, and positive end-expiratory pressure (PEEP) at 15 cm H2O. The patient weighs 72 kg. What finding would indicate that treatment is effective?

a. PaO2 of 60 mm Hg

b. Tidal volume of 700 mL

c. Cardiac output of 2.7 L/min

d. Inspiration to expiration ratio of 1:2

c. Prevention of alveolar collapse during expiration

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?

a. Increased inflation of the lungs

b. Prevention of barotrauma to the lung tissue

c. Prevention of alveolar collapse during expiration

d. Increased fraction of inspired oxygen concentration (FIO2) administration

a. The respiratory rate is 32 breaths/min

Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?

a. The respiratory rate is 32 breaths/min

b. The pulse oximeter shows a SpO2 of 93%

c. The patient has not been suctioned for the last 6 hours

d. The lungs have occasional audible expiratory wheezes

b. Decrease the respiratory rate

Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patients arterial blood gas (ABG) results include a pH of 7.50, PaO2 of 80 mm Hg, PaCO2 of 29 mm Hg, and HCO3 of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to do which of the following actions?

a. Increase the FIO2

b. Decrease the respiratory rate

c. Increase the tidal volume (VT)

d. Leave the ventilator at the current settings

b. Intermittent trials of spontaneous ventilation followed by ventilatory support to provide rest

What plan should the nurse use when weaning a patient from a ventilator?

a. Decrease the delivered FIO2 concentration

b. Intermittent trials of spontaneous ventilation followed by ventilatory support to provide rest

c. Substitute ventilator support with manual resuscitation bag if the patient becomes hypoxic

d. Implement weaning procedures around the clock until the patient does not experience ventilator fatigue

c. Maintain the head of bed at a 30- to 45-degree angle

The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care?

a. Administer ordered antibiotics as scheduled

b. Hyperoxygenate the patient before suctioning

c. Maintain the head of bed at a 30- to 45-degree angle

d. Suction the airway when coarse crackles are audible

a. Positive​ end-expiratory pressure​ (PEEP)

A client who is diagnosed with acute respiratory distress syndrome​ (ARDS) requires mechanical ventilation. Which ventilator mode should the nurse expect to implement to promote pressure throughout the respiratory​ cycle?

a. Positive​ end-expiratory pressure​ (PEEP)

b. Respiratory rate

c. Flow rate

d. Tidal volume​ (TV)

d. Synchronized intermittent mandatory ventilation​ (SIMV)

The nurse is caring for a client who has been using mechanical ventilation for several months after an episode of sepsis and acute respiratory distress syndrome​ (ARDS). Which ventilator setting should the nurse anticipate the healthcare provider ordering for​ weaning?

a. Positive​ end-expiratory pressure​ (PEEP)

b. Bilevel ventilation​ (BIPAP)

c. Assist-control mode ventilation​ (ACMV)

d. Synchronized intermittent mandatory ventilation​ (SIMV)

c. Accumulation of respiratory secretions

A nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which finding?

a. A disconnection of the ventilator tubing

b. An exaggerated client inspiratory effort

c. Accumulation of respiratory secretions

d. Generation of extreme negative pressure by the client

c. Peptic ulcer disease prophylaxis

Strategies to prevent ventilator associated pneumonia include which of the following?

a. Rotating the patient's position every 2 hours with HOB at 10 degrees

b. Daily oral care with peroxide

c. Peptic ulcer disease prophylaxis

d. Biweekly assessment of readiness to extubate

b. Assist control

What ventilation setting delivers preset tidal volume whenever the patient exerts inspiration, and still ensures that the patient receives a breath if they do not spontaneously trigger the ventilator?

a. Pressure support

b. Assist control

c. Synchronized intermittent mandatory ventilation

d. Continuous positive airway pressure

b. The patient trying to wean from mechanical ventilation

Synchronized Intermittent Mechanical Ventilation (SIMV) is best for which patient?

a. The patient with sleep apnea

b. The patient trying to wean from mechanical ventilation

c. The patient who is receiving neuromuscular blocking agents

d. The patient who has respiratory drive but cannot sustain normal tidal volume

a. Increased respiratory rate

The nurse is assessing a client with multiple trauma who is risk for developing acute respiratory distress syndrome (ARDS). The nurse should assess for which earliest sign of ARDS?

a. Increased respiratory rate

b. Bilateral wheezing

c. Inspiratory crackles

d. Intercostal retractions

c. Partial pressure of arterial oxygen (PaO2)

A female client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

a. pH

b. Bicarbonate (HCO3-)

c. Partial pressure of arterial oxygen (PaO2)

d. Partial pressure of arterial carbon dioxide (PaCO2)

c. Tidal volume

The amount of air inspired and expired with each breath is called what?

a. Stroke volume

b. Vital capacity

c. Tidal volume

d. Residual volume

a. 7.35 to 7.45

What is the normal pH range for arterial blood?

a. 7.35 to 7.45

b. 7 to 7.49

c. 7.50 to 7.60

d. 7.55 to 7.65

b. Baseline arterial blood gas (ABG) levels

Before weaning a male client from a ventilator, which assessment parameter is most important for the nurse to review?

a. Prior outcomes of weaning

b. Baseline arterial blood gas (ABG) levels

c. Electrocardiogram (ECG) results

d. Fluid intake for the last 24 hours

a. Vasoconstriction

b. Aortic stenosis

e. Pulmonary hypertension

What conditions below can result in an increased cardiac afterload? (Select all that apply)

a. Vasoconstriction

b. Aortic stenosis

c. Vasodilation

d. Dehydration

e. Pulmonary hypertension