RNSG 2432 level 4 - Review 2 Exam with
145 questions and well Elaborated
Answers.
RNSG 2432 level 4 - Review 2 Exam with
145 questions and well Elaborated
Answers.
The nurse is caring for a patient who has an intraaortic balloon pump in place. Which
action should be included in the plan of care?
a. Position the patient supine at all times.
b. Avoid the use of anticoagulant medications.
c. Measure the patients urinary output every hour.
d. Provide passive range of motion for all extremities. - ANSWER- C
Monitoring urine output will help determine whether the patients cardiac output has
improved and also help monitor for balloon displacement.
The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent
thrombus formation. Limited movement is allowed for the extremity with the balloon
insertion site to prevent displacement of the balloon.
While waiting for cardiac transplantation, a patient with severe cardiomyopathy has a
ventricular assist device (VAD) implanted. When planning care for this patient, the nurse
should anticipate
a. giving immunosuppressive medications.
b. preparing the patient for a permanent VAD.
c. teaching the patient the reason for complete bed rest.
d. monitoring the surgical incision for signs of infection. - ANSWER- D
The insertion site for the VAD provides a source for transmission of infection to the
circulatory system and requires frequent monitoring.
Patients with VADs are able to have some mobility and may not be on bed rest. The
VAD is a bridge to transplantation, not a permanent device. Immunosuppression is not
necessary for nonbiologic devices like the VAD.
To verify the correct placement of an oral endotracheal tube (ET) after insertion, the
best initial action by the nurse is to
a. auscultate for the presence of bilateral breath sounds.
,RNSG 2432 level 4 - Review 2 Exam with
145 questions and well Elaborated
Answers.
b. obtain a portable chest x-ray to check tube placement.
c. observe the chest for symmetric chest movement with ventilation.
d. use an end-tidal CO2 monitor to check for placement in the trachea. - ANSWER- D
End-tidal CO2 monitors are currently recommended for rapid verification of ET
placement.
Auscultation for bilateral breath sounds and checking chest expansion are also used,
but they are not as accurate as end-tidal CO2monitoring. A chest x-ray confirms the
placement but is done after the tube is secured.
To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on
mechanical ventilation, the nurse should
a. inflate the cuff with a minimum of 10 mL of air.
b. inflate the cuff until the pilot balloon is firm on palpation.
c. inject air into the cuff until a manometer shows 15 mm Hg pressure.
d. inject air into the cuff until a slight leak is heard only at peak inflation. - ANSWER- D
The minimal occluding volume technique involves injecting air into the cuff until an air
leak is present only at peak inflation.
The volume to inflate the cuff varies with the ET and the patients size. Cuff pressure
should be maintained at 20 to 25 mmHg. An accurate assessment of cuff pressure
cannot be obtained by palpating the pilot balloon.
The nurse notes premature ventricular contractions (PVCs) while suctioning a patients
endotracheal tube. Which action by the nurse is a priority?
a. Decrease the suction pressure to 80 mm Hg.
b. Document the dysrhythmia in the patients chart.
c. Stop and ventilate the patient with 100% oxygen.
d. Give antidysrhythmic medications per protocol. - ANSWER- C
Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system
stimulation. The nurse should stop suctioning and ventilate the patient with 100%
oxygen.
Lowering the suction pressure will decrease the effectiveness of suctioning without
improving the hypoxemia. Because the PVCs occurred during suctioning, there is no
need for antidysrhythmic medications (which may have adverse effects) unless they
recur when the suctioning is stopped and patient is well oxygenated.
,RNSG 2432 level 4 - Review 2 Exam with
145 questions and well Elaborated
Answers.
Which assessment finding obtained by the nurse when caring for a patient receiving
mechanical ventilation indicates the need for suctioning?
a. The patients oxygen saturation is 93%.
b. The patient was last suctioned 6 hours ago.
c. The patients respiratory rate is 32 breaths/minute.
d. The patient has occasional audible expiratory wheezes. - ANSWER- C
The increase in respiratory rate indicates that the patient may have decreased airway
clearance and requires suctioning.
Suctioning is done when patient assessment data indicate that it is needed, not on a
scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance,
and suctioning the patient may induce bronchospasm and increase wheezing. An
oxygen saturation of 93% is acceptable and does not suggest that immediate suctioning
is needed.
The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is
receiving mechanical ventilation. Which intervention will be most effective in addressing
this problem?
a. Increase suctioning to every hour.
b. Reposition the patient every 1 to 2 hours.
c. Add additional water to the patients enteral feedings.
d. Instill 5 mL of sterile saline into the ET before suctioning. - ANSWER- C
Because the patients secretions are thick, better hydration is indicated.
Suctioning every hour without any specific evidence for the need will increase the
incidence of mucosal trauma and would not address the etiology of the ineffective
airway clearance. Instillation of saline does not liquefy secretions and may decrease the
SpO2. Repositioning the patient is appropriate but will not decrease the thickness of
secretions.
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 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3 of 23 mEq/L (23 mmol/L).
The nurse will anticipate the need to
a. increase the FIO2.
b. increase the tidal volume.
, RNSG 2432 level 4 - Review 2 Exam with
145 questions and well Elaborated
Answers.
c. increase the respiratory rate.
d. decrease the respiratory rate. - ANSWER- D
The patients PaCO2 and pH indicate respiratory alkalosis caused by too high a
respiratory rate.
The PaO2 is appropriate for a patient with COPD and increasing the respiratory rate
and tidal volume would further lower the PaCO2.
A patient with respiratory failure has arterial pressure based cardiac output (APCO)
monitoring and is receiving mechanical ventilation with peak end-expiratory pressure
(PEEP) of 12 cm H2O. Which information indicates that a change in the ventilator
settings may be required?
a. The arterial pressure is 90/46.
b. The heart rate is 58 beats/minute.
c. The stroke volume is increased.
d. The stroke volume variation is 12%. - ANSWER- A
The hypotension suggests that the high intrathoracic pressure caused by the PEEP may
be decreasing venous return and (potentially) cardiac output.
The other assessment data would not be a direct result of PEEP and mechanical
ventilation.
A nurse is weaning a 68-kg male 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 patients heart rate is 97 beats/min.
b. The patients oxygen saturation is 93%.
c. The patient respiratory rate is 32 breaths/min.
d. The patients spontaneous tidal volume is 450 mL. - ANSWER- C
Tachypnea is a sign that the patients work of breathing is too high to allow weaning to
proceed.
The patients heart rate is within normal limits, although the nurse should continue to
monitor it. An oxygen saturation of 93% is acceptable for a patient with COPD. A
spontaneous tidal volume of 450 mL is within the acceptable range.
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