NCLEX EXAM 2 MECHANICAL VENTILATION GRADED A 2023-2024, Exams of Nursing

Download NCLEX EXAM 2 MECHANICAL VENTILATION GRADED A 2023-2024 and more Exams Nursing in PDF only on Docsity! NCLEX EXAM 2 MECHANICAL VENTILATION GRADED A 2023-2024 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 - ANSWER A The client must always be assessed before attention is turned to equipment. 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 - ANSWER C High levels of oxygen delivery can result in collapsed alveoli and absorption atelectasis. PEEP can help alveoli remain properly inflated. The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate? A) Keep the patient in a low Fowlers position. B) Perform tracheostomy care at least once per day. C) Maintain continuous bedrest. D) Monitor cuff pressure every 8 hours. - ANSWER D The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess? A) Fluid intake for the last 24 hours B) Baseline arterial blood gas (ABG) levels C) Prior outcomes of weaning D) Electrocardiogram (ECG) results - ANSWER B A patient recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the patient? A)Assure the patient that everything will be all right and that remaining calm is the best strategy. B)Ask a family member to interpret what the patient is trying to communicate. C) Ask the physician to wean the patient off the mechanical ventilator to allow the patient to speak freely. D) Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board. - ANSWER D The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patients high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurses best response? A) CPAP allows a higher percentage of oxygen to be safely used. B) CPAP allows a lower percentage of oxygen to be used with a similar effect. C) CPAP allows for greater humidification of the oxygen that is administered. D) CPAP allows for the elimination of bacterial growth in oxygen delivery systems. - ANSWER B The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order? A) Removal from the ventilator, tube, and then oxygen B) Removal from oxygen, ventilator, and then tube C) Removal of the tube, oxygen, and then ventilator D) Removal from oxygen, tube, and then ventilator - ANSWER A 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 - ANSWER A The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall? A) Between 10 and 15 mm Hg B) Between 15 and 20 mm Hg e. volume delivered varies based on selected pressure and patient lung compliance - ANSWER ACE A patient in acute respiratory failure is receiving ACV 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 - ANSWER A What should the nurse recognize as a factor commonly responsible for sodium and fluid retention in the patient on mechanical ventilation? a. increased release of ADH b. increased release of atrial natriuretic factor c. increased insensible water loss via the airway d.decreased renal perfusion with release of renin - ANSWER D A patient receiving mechanical ventilation is very anxious and agitated, and neuromuscular blocking agents are used to promote vasodilation. What should the nurse recognize about the care of this patient? a. the patient will be too sedated to be aware of the details of care b. caregivers should be encouraged to provide stimulation and diversion c. the patient should always be addressed and explanations of care given d. communication will not be possible with the use of neuromuscular blocking agents - ANSWER C The nurse determines that alveolar hypoventilation is occurring in a patient on a ventilator when what happens? a. the patient develops cardiac dysrhythmias b.auscultation reveals an air leak around the ET tube cuff c.ABG results show a PaCO2 of 32 mm Hg and a pH of 7.47 d. the patient tries to breathe faster than the ventilator setting - ANSWER B 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 - ANSWER B 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. - ANSWER D 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 - ANSWER A 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 - ANSWER C 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. - ANSWER A 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 a. increase the FIO2. b.decrease the respiratory rate. c. increase the tidal volume (VT). d. leave the ventilator at the current settings. - ANSWER B When the nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation, which patient assessment indicates that the weaning protocol should be discontinued? a. The patient heart rate is 98 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 500 mL. - ANSWER C A patient who is receiving mechanical ventilation is anxious and is fighting the ventilator. Which action should the nurse take first? a. Ventilate the patient with a manual resuscitation bag. b.Verbally coach the patient to breathe with the ventilator. c. Sedate the patient with the ordered PRN lorazepam (Ativan). d. Increase the rate for the ordered propofol (Diprivan) infusion. - ANSWER B A patient with a subarachnoid hemorrhage is intubated and placed on a mechanical ventilator. When monitoring the patient, the nurse will need to notify the health care provider if the patient develops a. oxygen saturation of 94%. b. respirations of 18 breaths/min. c. green nasogastric tube drainage. d. increased jugular vein distention (JVD). - ANSWER D 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 - ANSWER BE 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 c. continuous positive airway pressure To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation? a.Avoid use of positive end-expiratory pressure (PEEP). b. Suction every 2 hours. c. Elevate head of bed to 30 to 45 degrees. d.Give enteral feedings at no more than 10 mL/hr. - ANSWER C 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. Sensitivity C. Flow rate D. Tidal volume (TV) - ANSWER A 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) - ANSWER D The nurse is caring for a client who is in the process of weaning off of mechanical ventilation. Which assessment finding should the nurse report to the healthcare provider?(Select all that apply.) A. Agitation B. Pallor C. Oxygen saturation level of 98% D. Respiratory rate of 18 beats/min E. Abdominal breathing - ANSWER ABE The nurse caring for a client who is mechanically ventilated is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up? 1. Muscle weakness in the arms and legs 2. A temperature of 98.6° F decreased from 99.0° F 3. A blood pressure of 90/60 mm Hg decreased from 112/78 mm Hg 4. A heart rate of 80 beats per minute decreased from 85 beats per minute - ANSWER 3 Complications of mechanical ventilation include the following: (1) hypotension caused by application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart; (2) pneumothorax or subcutaneous emphysema as a result of positive pressure; (3) gastrointestinal alterations such as stress ulcers; (4) malnutrition if nutrition is not maintained; (5) infections; (6) muscular deconditioning; and (7) ventilator- dependence or inability to wean. Some muscle weakness is expected. Options 1, 2, and 4 present normal assessment findings. The nurse is caring for a client who is mechanically ventilated, and the high- pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. 1. Water or a kink in the tubing 2. Biting on the endotracheal tube 3.Increased secretions in the airway 4.Disconnection or leak in the system 5. The client stops spontaneous breathing. - ANSWER 123 The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication? 1. Excessive secretions 2. Kinks in the ventilator tubing 3. The presence of a mucous plug 4. Displacement of the endotracheal tube - ANSWER 4 A health care provider writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The nurse determines that the process of weaning will occur by which mechanism? 1. Gradually decreasing the respiratory rate until the client can assume the work of breathing without ventilatory assistance 2. Attaching a T-piece to the ventilator and providing supplemental oxygen at a concentration that is 10% higher than the ventilator setting 3. Providing pressure support to decrease the workload of breathing and increase the client's ability to initiate spontaneous breathing efforts 4. Removing the ventilator from the client and closely monitoring the client's ability to breathe spontaneously for a predetermined amount of time - ANSWER 1 A client who is intubated and receiving mechanical ventilation has a problem of risk for infection. The nurse should include which measures in the care of this client? Select all that apply. 1. Monitor the client's temperature. C) Patients under the influence of neuromuscular blocking agents are fully aware of activity around them. D)The nurse must be alert for complications of immobility such as deep vein thrombosis, pressure ulcers, and atelectasis. - ANSWER A The nurse is caring for a patient who was just placed on mechanical ventilation and is observing the patient's vital signs because positive-pressure ventilation can lead to: (Select all that apply.) A) decreased cardiac output. B) decreased venous return. C) increased renal function. D) decreased intracranial pressure. E) increased hepatic function. - ANSWER ABD What is the advantage of using Volume Cycled Ventilation? (SATA) A. the ventilator pushes air into lungs until a preset airway pressure is reached B. the ventilator pushes air into the lungs until a preset volume is reached C. a constant tidal volume is delivered regardless of pressure needed to deliver the tidal volume D. limits excessive pressure being exerted on the lungs E. allows the health care team to determine if intubation is really neccessary - ANSWER BCD In what ventilation setting does the vent deliver tidal volume at a preset rate because the patient is not breathing spontaneously? A. Controlled Mandatory Ventilation B. Assisted Control C. Synchronized Intermittent Mandatory Ventilation D. Continuous Positive Airway Pressure - ANSWER A In the patient using Controlled Mandatory Ventilation, what drug are they on to suppress respiratory effort? A. Morphine, Fentanyl, or Hydromorphone B. Propofol C. Rocuronium, Pancuronium, or Nimbex D. Formoterol, Salmeterol, or Arformoterol - ANSWER C Rocuronium, Pancuronium, & Nimbex are all non-Depolarizing Neuromuscular Blocking Agents. But, be considerate that the patient recieving this type of ventilation will also require sedation and opioids. What ventilation setting delivers preset tidal volume whenever the patient exerts inspiration, and still ensures that the patient recieves a breath if they do not spontaneously trigger the ventilator? A. Controlled Mandatory Ventilation B. Assisted Control C. Synchronized Intermittent Mandatory Ventilation D. Continuous Positive Airway Pressure - ANSWER B Assisted Control Ventilation 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 - ANSWER D Synchronized Intermittent Mechanical Ventilation 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 - ANSWER B