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NUR210 Exam 2- Respiratory Study Guide
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NUR210 Exam 2- RespiratoryStudy Guide
For the patient admitted to the intensive care unit (ICU) receiving assisted ventilation,
which indicator best reflects the patient's alveolar oxygenation status?
a. PETCO2
b. PaCO2
c. SpO2
d. SVO2 - Answer b. PaCO2
Which diagnostic test will provide the nurse with the most specific information to
evaluate the effectiveness of interventions for a patient with ventilatory failure?
a. Chest x-ray
b. O2 saturation
c. Arterial blood gases
d. Central venous pressure - Answer c. Arterial blood gases
The nurse provides care for a patient who sustained multiple injuries as a result of a
motor vehicle accident. Which assessment finding requires immediate intervention?
a. Bruising on the left flank
b. Tracheal deviation
c. Pain
d. Rapid, thready pulse - Answer b. Tracheal deviation
Which action would the nurse take to verify the correct placement of an oral
endotracheal tube (ET) immediately after insertion and before securing the tube?
a. Obtain a portable chest x-ray
b. Ascultate for bilateral breath sounds
c. Observe for symmetrical chest movement
d. Use an end-tidal CO2 monitor - Answer d. Use an end-tidal CO2 monitor
,A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action
should the nurse plan to promote airway clearance?
a. Restrict oral fluids during the day
b. Teach pursed-lip breathing technique
c. Help the patient to splint the chest when coughing
d. Encourage the patient to wear the nasal O2 cannula - Answer c. Help the patient to
splint the chest when coughing
A 70-year-old male patient with chronic renal failure due to a 15-year history of
uncontrolled hypertension arrived at the emergency department today with a new onset
of lethargy, confusion, diarrhea, and weakness. He has no other medical history. His
arterial blood gases were pH 7.30 (low), PaCO2 35 mmHg (normal), HCO3 16 mEq/L
(low), and PaO2 mmHg (normal). His vital signs are BP 148/90, pulse 72, and
respirations 32 with increased depth. He was admitted to the hospital this evening with
a diagnosis of metabolic acidosis and renal failure.
Which actions would the nurse include in the plan of care? (Select all that apply).
a. Oxygen supplementation
b. Blood sugar checks AC & HS
c. Intravenous access
d. Monitor serum CO2 level
e. Pain control
f. Safety precautions
g. High protein diet
h. Consult with physical therapy - Answer c, d, f
During a change-of-shift report on a medical unit, the nurse learns that a patient with
aspiration pneumonia who was admitted with respiratory distress has become
increasingly agitated. Which action should the nurse take first?
a. Give the prescribed PRN sedative drug
b. Offer reassurance and reorient the patient
c. Use pulse oximetry to check the oxygen saturation
d. Notify the healthcare provider about the patient's status - Answer c. Use pulse
oximetry to check the oxygen saturation
, 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?
a. No sedative is ordered for the patient
b. The patient does not respond to voice
c. The patient has no cough reflex when suctioned
d. The patient's oxygen saturation is 90%-93%. - Answer a. No sedative is ordered for
the patient
which serum bicarbonate ion level would indicate a compensatory response in the
patient experiencing respiratory acidosis?
a. 24 mEq/L
b. 25 mEq/L
c. 26 mEq/L
d. 27 mEq/L - Answer d. 27
The nurse monitors a patient in the emergency department after chest tube placement
for a hemopneumothorax. The nurse is most concerned with which assessment finding
is observed.
a. A large air leak in the water-seal chamber
b. 400 mL of blood in the collection chamber
c. Report of pain with each deep inspiration
d. Subcutaneous emphysema at the insertion site - Answer b. 400 mL of blood in the
collection chamber
A patient is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory
pressure (PEEP). Which action by the nurse promotes patient safety?
a. Using a closed-suction technique when suctioning is needed
b. Taping the connection between the ventilator tubing and the ET
c. Changing the ventilator circuit tubing routinely every 48 hours
d. Planning to suction the patient at least every 1 to 2 hours - Answer a. Using a
closed-suction technique when suctioning is needed
Which finding by the nurse should result in postponing the spontaneous breathing trial
for a patient receiving positive pressure ventilation?
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