NUR417 NUR 417 EXAM 2

NUR417 / NUR 417 EXAM 2

Care of Adult II Concordia, St. Paul Actual Questions and Answers

This Exam contains:

➢ 100% Guarantee Pass.➢ Expert Verified Explanation ➢ Multiple choice (single best answer) ➢ Select All That Apply (SATA) ➢ Fill-in-the-blank ➢ Case Studies/Scenario-Based Questions

• / 4

A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped?

• The patient's heart rate is 97 beats/min.
• The patient's oxygen saturation is 93%.
• The patient respiratory rate is 32 breaths/min.
• The patient's spontaneous tidal volume is 450 mL.

ANSWER

C

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.

The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action indicates that the new RN is safe?

• The RN plans to suction the patient every 1 to 2 hours.
• The RN uses a closed-suction technique to suction the patient.
• The RN tapes the connection between the ventilator tubing and the

ET.

• The RN changes the ventilator circuit tubing routinely every 48

hours.

ANSWER

B

The closed-suction technique is used when patients require high levels of 2 / 4

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.

After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first?

• Patient who failed a spontaneous breathing trial and has been

placed in a rest mode on the ventilator

• Patient who is intubated and has continuous partial pressure end-

tidal CO2 (PETCO2) monitoring

• Patient who was successfully weaned and extubated 4 hours ago

and has no urine output for the last 6 hours

• Patient with a central venous O2 saturation (ScvO2) of 69% while

on bilevel positive airway pressure (BiPAP)

ANSWER

C

The decreased urine output may indicate acute kidney injury or that the patient's cardiac output and perfusion of vital organs have decreased. Any of these causes would require rapid action. The data about the other patients indicate that their conditions are stable and do not require immediate assessment or changes in their care. Continuous PETCO2 monitoring is frequently used when patients are intubated. The rest mode should be used to allow patient recovery after a failed SBT, and an ScvO2 of 69% is within normal limits.

• / 4

DIF: Cognitive Level: Apply (application) A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped?

• The patient's heart rate is 97 beats/min.
• The patient's oxygen saturation is 93%.
• The patient respiratory rate is 32 breaths/min.
• The patient's spontaneous tidal volume is 450 mL.

ANSWER

C

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.

A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most likely to result in postponing the SBT?

• New ST segment elevation is noted on the cardiac monitor.
• Enteral feedings are being given through an orogastric tube.
• Scattered rhonchi are heard when auscultating breath sounds.
• hydromorphone (Dilaudid) is being used to treat postoperative pain

Answer

• ) new st segment elevation

Myocardial ischemia is a contraindication for ventilator weaning. The ST segment elevation is an indication that weaning should be postponed until further investigation and/or treatment for myocardial ischemia can be done.

• / 4