QUICK ASSESSMENT 2

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QUICK ASSESSMENT 2

This Assessment Is Powered by ACHIEVERS NCLEX-RN CONSULT. Visit us at www.achieversnclexrn.com

Total Questions: 20

Passmark: 15

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Q1. A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a non-rebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient’s care, you would anticipate a physician order for what action?
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1 point

A. Perform endotracheal intubation and initiate mechanical ventilation.

B. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth.

C. Administer furosemide (Lasix) 100 mg IV push stat.

D. Call a code for respiratory arrest.

Q2. A nurse is caring for a client who has just been intubated for respiratory failure. The physician orders the ventilator to be set in SIMV mode. Which best describes SIMV?
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1 point

A. The fraction of inspired oxygen that is delivered to the client through the ventilator

B. The application of positive pressure at the end of each client exhalation

C. A preset number of breaths delivered to the client at a certain volume

D. The delivery of positive air pressure throughout the respiratory cycle

Q3. A client who developed acute respiratory distress syndrome (ARDS) after a motor vehicle crash (MVC) is being weaned from the ventilator. Which ventilator mode will the nurse utilize to wean the client?
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1 point

1. Synchronized intermittent mandatory ventilation (SIMV).

2. Controlled ventilation.

3. Assist-control ventilation.

4. Positive end expiratory pressure (PEEP).

Q4. The nurse is caring for a client on a ventilator that is set on intermittent
mandatory ventilation (IMV). Assessment on the ventilator is IMV mode of 8 breaths per minute. The nurse assesses the client’s respiratory rate of 13 per minute. These findings indicate that:

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1 point

❍ A. The client is “fighting” the ventilator.

❍ B. Pressure support ventilation is being used.

❍ C. Additional breaths are being delivered by the ventilator.

❍ D. The client is breathing five additional breaths on his own

Q5. A nurse is caring for a client who has been on a mechanical ventilator for 2 days. What is the best indicator of ventilator-associated pneumonia?
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1 point

A. Fever and positive blood cultures

B. Purulent sputum that grows a positive bacterial culture

C. Crackles and rhonchi on auscultation

D. Leukocytosis

Q6. You are 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?
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1 point

A. Administer ordered antibiotics as scheduled

B. Hyperoxygenate the patient before suctioning

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

D. Suction the airway when coarse crackles are audible

Q7. The nurse is caring for a client who has been receiving mechanical ventilation (MV) for 4 days. During multidisciplinary morning rounds, the health care provider questions the development of a ventilator-associated pneumonia (VAP). Which of the following manifestations does the nurse assess as the best indicator of VAP?
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1 point

1.Blood-tinged sputum

2.Positive blood cultures

3.Positive, purulent sputum culture

4.Rhonchi and crackles

Q8. The nurse cares for the client prescribed assist-control mechanical ventilation with positive end-expiratory pressure of 5 cm H2O. Which actions will the nurse include in the plan of care?

Select all that apply.
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1 point

1. Strict handwashing before suctioning.

2. Brush teeth every 12 hours.

3. Elevate head of bed 20 degrees.

4. Administer pantoprazole 40 mg intravenous daily.

5. Change client position every 2 hours.

Required

Q9. You are 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?
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1 point

A Administer ordered antibiotics as scheduled

B Hyperoxygenate the patient before suctioning

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

D Suction the airway when coarse crackles are audible

Q10. *

1 point

Option 1

Option 2

Option 3

Option 4

Option 5

Option 6

Required

Q11. The nurse is caring for a client who is on mechanical ventilation. What is the BEST evidence that the client needs endotracheal suctioning? *

1 point

1. Rhonchi throughout the lungs

2. Wheezes throughout lung fields

3. Friction rub with inspiration

4. Decreased breath sounds

Q12. The nurse is preparing to perform tracheal suctioning for a patient with an endotracheal tube. Which of the following personal protective equipment (PPE) will the nurse be wearing when applying suction? Select all that apply.

Select all that apply:

1 point

1. Goggles

2. N95 Respirator

3. Sterile gloves

4. Clean gloves

5. Facemask

Required

Q13. Following a motor vehicle accident, a client is brought to the emergency room with shallow, labored respirations. The client is intubated and placed on a ventilator. What is the nurse’s priority action immediately after the intubation?
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1 point

1. Suction to clear all secretions

2. Listen for bilateral breath sounds

3. Secure the endotracheal tube

4. Obtain x-ray to verify tube placement

Q14. A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?
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1 point

A. phenytoin (Dilantin)

B. mannitol (Osmitrol)

C. lidocaine (Xylocaine)

D. furosemide (Lasix)

Q15. An 87-year-old client requires long-term ventilator therapy. He has a tracheostomy in place and requires frequent suctioning. Which of the following techniques is correct?
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1 point

A. Using intermittent suction while advancing the catheter.

B. Using continuous suction while withdrawing the catheter.

C. Using intermittent suction while withdrawing the catheter.

D. Using continuous suction while advancing the catheter.

Q16. A client is admitted to the floor after having a tracheostomy placed 72 hours ago. Which of the following pieces of equipment is the priority to keep at the bedside at all times? *

1 point

1. Clamps

2. Wrench

3. Inner cannula

4. Obturator

Q17. The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's priority when caring for a client with a new tracheostomy?

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1 point

1. Changing the inner cannula within the first 8 hours to help prevent mucus plugs

2. Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these ties

3. Deflating and re-inflating the cuff every 4 hours to prevent mucosal tissue damage

4. Performing frequent mouth care every 2 hours to help prevent infection

Q18. The nurse is caring for a client receiving mechanical ventilation via tracheostomy 2 weeks following a tracheotomy. The nurse enters the client's room to address a ventilator alarm and notes the tracheostomy tube dislodged and lying on the client's chest. Which action by the nurse is appropriate?

Click on the exhibit button for additional information.

1 point

1. Apply a nonrebreather face mask with 100% oxygen

2. Apply dry, sterile gauze over the stoma and secure with tape

3. Insert a new tracheostomy tube using the bedside obturator

4. Insert a sterile catheter into the stoma and suction the airway

Q19. The nurse enters a client's room and discovers the client is having difficulty breathing because the tracheostomy tube has become dislodged. Which is the INITIAL action the nurse should take?
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1 point

1. Perform mouth-to-stoma breathing.

2. Extend the client's neck.

3. Place the client in high-Fowler's position.

4. Administer oxygen.

Q20. The nurse is reviewing ABG results on a client, and notes that the pH and the HCO3 are out of range, while the pCO2 is normal. This client is most likely experiencing a problem with which body system?
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1 point

1. The cardiovascular system

2. The neurological system

3. The respiratory system

4. The renal system

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