Week 2 EAQ/HESIs

Question 1

To which part of the respiratory system would the client’s radiology report refer when identifying the angle of Louis?

Hilum

Carina

Alveoli

Epiglottis

Answer 1

Carina

Question 2

Which amount would the nurse recognize as the normal value of a client’s inspiratory reserve volume?

0.5 L

1.0 L

1.5 L

3.0 L

Answer 2

3.0 L

Question 3

Which explanation would the nurse provide to the parents of a child with spasmodic croup who ask why their child is receiving humidified oxygen?

It helps prevent drying of membranes.

It provides a mode of giving inhalant medications.

It increases the surface tension of the respiratory tract.

It provides an environment free of pathogenic organisms.

Answer 3

It helps prevent drying of membranes.

Question 4

A child with cystic fibrosis (CF) has recurrent episodes of bronchitis, and the parents ask why this happens. Which reason would the nurse include in the reply?

Associated heart defects cause heart failure and respiratory depression.

Neuromuscular irritability causes spasm and constriction of the bronchi.

Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria.

The increased salt content in saliva irritates the mucous membranes, resulting in inflammation of the nasopharynx.

Answer 4

Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria.

Question 5

Which of these assessments would be the highest priority for the nurse to complete on a client who arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and bilateral lower extremities?

Level of consciousness

Characteristics of pain

Quality of respirations

Observation of abdominal contusions

Answer 5

Quality of respirations

Question 6

Which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema?

Prevents bronchial spasm

Decreases air trapping in lung

Improves alveolar surface area

Strengthens diaphragmatic contraction

Answer 6

Decreases air trapping in lung

Question 6

Which is the priority nursing intervention to prevent thrombus formation in a child with sickle cell anemia?

Encouraging fluids

Encouraging bed rest

Administering oxygen (O 2)

Administering prescribed anticoagulants

Answer 6

Encouraging fluids

Question 7

The nurse notes that a child with cystic fibrosis (CF) who was admitted with a respiratory infection is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. Which action would the nurse take?

Encourage increased physical activities

Perform postural drainage

Maintenance of dietary restrictions

Monitor intake and output

Answer 7

Perform postural drainage

Question 8

Parents whose child has cystic fibrosis (CF) have no history of CF in their family and ask how their child inherited this disorder. How would the nurse clarify the way in which the disease was inherited?

It is a mutated gene.

It involves an X-linked gene.

The inheritance is autosomal recessive.

The inheritance is autosomal dominant.

Answer 8

The inheritance is autosomal recessive.

Question 9

Which type of breathing pattern would a client experiencing hypercarbia exhibit ?

Eupnea

Tachypnea

Hypoventilation

Kussmaul respiration

Answer 9

Hypoventilation

Question 10

The nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. Which term would the nurse use to document these sounds?

Vesicular

Bronchial

Crackles

Rhonchi

Answer 10

Crackles

Question 11

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 gas analysis
D. Central venous pressure monitoring

Answer 11

C. Arterial blood gas analysis

Arterial blood gas (ABG) analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs give information about the
PaCO2 and pH. The other tests may also be done to help in assessing oxygenation or determining the cause of the patient’s ventilatory failure.

Question 12

A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 78%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?

A. Administration of 100% O2 by non-rebreather mask
B. Endotracheal intubation and positive pressure ventilation
C. Insertion of a mini-tracheostomy with frequent suctioning
D. Initiation of continuous positive pressure ventilation (CPAP)

Answer 12

B. Endotracheal intubation and positive pressure ventilation

The patient’s lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Giving high-flow O2 will not be helpful because the patient’s respiratory rate is so low. Insertion of a
mini-tracheostomy will promote removal of secretions, but it will not improve the patient’s respiratory rate or oxygenation. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange

Question 13

The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes and a weak cough effort. Which action should nurse take?

A. Position the patient on the left side.
B. Assist the patient with staged coughing.
C. Place a humidifier in the patient’s room.
D. Schedule a 4-hour rest period for the patient.

Answer 13

B. Assist the patient with staged coughing.

The patient’s assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 4-hour rest period at this time may allow the O2 saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the left side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.

Question 14

A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced?

A) The patient’s PaO2 is 50 mm Hg and the SaO2 is 88%.
B) The patient has subcutaneous emphysema on the upper thorax.
C) The patient has bronchial breath sounds in both the lung fields.
D) The patient has a first-degree atrioventricular heart block with a rate of 58 beats/min.

Answer 14

B) The patient has subcutaneous emphysema on the upper thorax.

The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not specific indications
that PEEP should be reduced

Question 15

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient’s caregiver is accurate?

A) “PEEP will push more air into the lungs during inhalation.”
B) “PEEP prevents the lung air sacs from collapsing during exhalation.”
C) “PEEP will prevent lung damage while the patient is on the ventilator.”
D) “PEEP allows the breathing machine to deliver 100% O2 to the lungs.”

Answer 15

B) “PEEP prevents the lung air sacs from collapsing during exhalation.”

By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage (e.g., fibrotic changes that occur with ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.

Question 16

A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?

A) Elevate head of bed to 30 to 45 degrees.
B) Give enteral feedings at no more than 10 mL/hr.
C) Suction the endotracheal tube every 2 to 4 hours.
D) Limit the use of positive end-expiratory pressure.

Answer 16

A) Elevate head of bed to 30 to 45 degrees.

Elevation of the head decreases the risk for aspiration. Positive end -expiratory pressure is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient’s high energy needs

Question 17

A patient admitted with acute respiratory failure has ineffective airway clearance from thick secretions. Which nursing intervention would specifically address this patient problem?

A) Encourage use of the incentive spirometer.
B) Offer the patient fluids at frequent intervals.
C) Teach the patient the importance of ambulation.
D) Titrate oxygen level to keep O2 saturation above 93%.

Answer 17

B) Offer the patient fluids at frequent intervals.

Because the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. Patients should be instructed to use the incentive spirometer on a regular basis (e.g., every hour) to facilitate the clearance of the secretions. The other actions may be helpful in improving the patient’s gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.

Question 18

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 next?

A.Increase the tidal volume and respiratory rate.
B. Decrease the fraction of inspired oxygen (FIO2).
C. Perform endotracheal suctioning more frequently.
D. Lower the positive end-expiratory pressure (PEEP).

Answer 18

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

Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for another pneumothorax.

Question 19

The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid
action?

A. The patient’s PaO2 is 45 mm Hg.
B. The patient’s PaCO2 is 33 mm Hg.
C. The patient’s respirations are shallow.
D. The patient’s respiratory rate is 32 breaths/min

Answer 19

A. The patient’s PaO2 is 45 mm Hg.

The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient’s poor oxygenation

Question 20

A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal
volume of 450, rate of 16/minute, and positive end expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider?

A. O2 saturation of 99%
B. Heart rate 106 beats/min
C. Crackles audible at lung bases
D. Respiratory rate 22 breaths/min

Answer 20

A. O2 saturation of 99%

As the FIO2 of 80% increases, the patient’s O2 saturation is 99%. A decrease in FIO2 is needed to avoid toxicity. The other patient data would be typical for a patient with ARDS and would not be the most important data to report to the health care provider.

Question 21

Which actions should the nurse start to reduce the risk for ventilatorassociated pneumonia (VAP)? (Select allthat apply.)

A. Obtain arterial blood gases daily.
B. Provide a “sedation holiday” daily.
C. Give prescribed pantoprazole (Protonix).
D. Elevate the head of the bed to at least 30 degrees.
E. Provide oral care daily with chlorhexidine (0.12%) solution.

Answer 21

B. Provide a “sedation holiday” daily.
C. Give prescribed pantoprazole (Protonix).
D. Elevate the head of the bed to at least 30 degrees.
E. Provide oral care daily with chlorhexidine (0.12%) solution.

All these interventions are part of the ventilator bundle that is recommended to
prevent VAP. Arterial blood gases may be done daily but are not always necessary and
do not help prevent VAP.

VAP
Hygiene, Wean assessment, HOB 30-45%, Turn patient, Suction, mobilization, decrease sedation

Question 22

The nurse observes a new onset of agitation and confusion in a patient with chronic
obstructive pulmonary disease (COPD). Which action should the nurse take first?

A. Observe for facial symmetry.
B. Notify the health care provider.
C. Attempt to calm and reorient the patient.
D.Assess oxygenation using pulse oximetry.

Answer 22

D.Assess oxygenation using pulse oximetry.

Because agitation and confusion are often the initial indicators of hypoxemia, the nurse’s initial action should be to assess O2 saturation. The other actions are appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider.

Question 23

When caring for a patient with pulmonary hypertension, which parameter will the nurse use to directly evaluate the effectiveness of the treatment?

A. Central venous pressure (CVP)
B. Systemic vascular resistance (SVR)
C. Pulmonary vascular resistance (PVR)
D. Pulmonary artery wedge pressure (PAWP)

Answer 23

C. Pulmonary vascular resistance (PVR)

PVR is a major contributor to pulmonary hypertension, and a decrease would
indicate that pulmonary hypertension was improving. The other parameters
may also be monitored but do not directly assess for pulmonary hypertension

Question 24

What action by a new intensive care unit staff nurse would indicate that the nurse educator’s teaching about arterial pressure monitoring has been effective? A. Balances and calibrates the monitoring equipment every 2 hours. B. Positions the zero-reference stopcock line level with the phlebostatic axis. C. Ensures that the patient is supine with the head of the bed flat for all readings. D. Rechecks the location of the phlebostatic axis with changes in the patient’s position.

Answer 24

B. Positions the zero-reference stopcock line level with the phlebostatic axis. For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment every 2 hours. Accurate hemodynamic readings are possible with the patient’s head raised to 45 degrees or in the prone position. The anatomic position of the phlebostatic axis does not change when patients are repositioned.

Question 25

What is the best initial action by the nurse to verify the correct placement of an oral endotracheal tube (ET) after insertion? A. Obtain a portable chest x-ray. B. Use an end-tidal CO2 monitor. C. Auscultate for bilateral breath sounds. D. Observe for symmetrical chest movement.

Answer 25

B. Use an end-tidal CO2 monitor. 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 CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured.

Question 26

Which assessment finding by the nurse caring for a patient receiving mechanical ventilation indicates the need for suctioning? A. The patient was last suctioned 6 hours ago. B. The patient’s oxygen saturation drops to 93%. C. The patient’s respiratory rate is 32 breaths/min. D. The patient has occasional audible expiratory wheezes.

Answer 26

C. The patient’s respiratory rate is 32 breaths/min. 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 and not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance. Suctioning the patient may induce bronchospasm and increase wheezing. An O2 saturation of 93% is acceptable and does not suggest that immediate suctioning is needed.

Question 27

The nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which 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 27

C. The patient respiratory rate is 32 breaths/min. 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

Question 28

The nurse responding to a ventilator alarm finds the patient lying in bed gasping and the endotracheal tube on the floor. Which action should the nurse take next? A. Activate the rapid response team. B. Provide reassurance to the patient. C. Call the health care provider to reinsert the tube. D. Manually ventilate the patient with 100% oxygen.

Answer 28

D. Manually ventilate the patient with 100% oxygen. The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team are also appropriate after the nurse has stabilized the patient’s oxygenation.

Question 29

The nurse notes that a patient’s endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark, and the patient is anxious and restless. Which action should the nurse take next? A. Check the O2 saturation. B. Offer reassurance to the patient. C. Listen to the patient’s breath sounds. D.Notify the patient’s health care provider.

Answer 29

C. Listen to the patient’s breath sounds. The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions are also appropriate, but detection and correction of tube malposition are the most critical actions.

Question 30

A patient who is orally intubated and receiving mechanical ventilation is anxious and is “fighting” the ventilator. Which action should the nurse take next? A. Verbally coach the patient to breathe with the ventilator. B. Sedate the patient with the ordered PRN lorazepam (Ativan). C. Manually ventilate the patient with a bagvalve-mask device. D.Increase the rate for the ordered propofol (Diprivan) infusion.

Answer 30

A. Verbally coach the patient to breathe with the ventilator. The initial response by the nurse should be to try to decrease the patient’s anxiety by coaching the patient about how to coordinate respirations with the ventilator. The other actions may also be helpful if the verbal coaching is ineffective in reducing the patient’s anxiety.

Question 31

The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient 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 changes the ventilator circuit tubing routinely every 48 hours. D. The RN tapes the connection between the ventilator tubing and the ET

Answer 31

B. The RN uses a closed-suction technique to suction the patient. 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.

Question 32

Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway? A. Weak cough effort B. Profuse green sputum C. Respiratory rate of 28 breaths/min D. Resting pulse oximetry (SpO2) of 85%

Answer 32

A. Weak cough effort The weak cough effort indicates that the patient is unable to clear the airway effectively. The other data suggest problems with gas exchange and breathing pattern.

Question 33

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax.Which assessment finding is of most concern? A. A large air leak in the water-seal chamber B. Report of pain with each deep inspiration C. 400 mL of blood in the collection chamber D. Subcutaneous emphysema at the insertion site

Answer 33

C. 400 mL of blood in the collection chamber The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.

Question 34

The emergency department nurse notes tachycardia and absent breath sounds over the right thorax of a patient who has just arrived after an automobile accident. For which intervention will the nurse prepare the patient? A. Emergency pericardiocentesis B. Stabilization of the chest wall C. Bronchodilator administration D. Chest tube connected to suction

Answer 34

D. Chest tube connected to suction The patient’s history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient’s clinical manifestations are not consistent with these problems.

Question 35

A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suctioncontrol chamber of the collection device. Which action by the nurse is appropriate? A. Adjust the dial on the wall regulator. B. Continue to monitor the collection device. C. Document the presence of a large air leak. D.Notify the surgeon of a possible pneumothorax.

Answer 35

B. Continue to monitor the collection device. Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.

Question 36

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next? A. Palpate extremities for bilateral pulses. B. Observe the patient’s respiratory effort. C. Check the patient’s level of consciousness. D. Examine the patient for any external bleeding.

Answer 36

B. Observe the patient’s respiratory effort. Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient’s breathing. The other actions are also part of the initial survey, but assessment of breathing should be done immediately after assessing for airway patency

Question 37

The emergency department (ED) triage nurse is assessing four victims involved in a motor vehicle collision. Which patient has the highest priority for treatment? A. A patient with no pedal pulses B. A patient with an open femur fracture C. A patient with paradoxical chest motion D.A patient with bleeding facial lacerations

Answer 37

C. A patient with paradoxical chest motion Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxical chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems.