The nurse is caring for a 33-year-old 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/minute.
Question 2After receiving change-of-shift report on a medical unit, which patient should the nurse assess first?
a. A patient with cystic fibrosis who has thick, green-colored sputum
b. A patient with pneumonia who has crackles bilaterally in the lung bases
c. A patient with emphysema who has an oxygen saturation of 90 to 92
d. A patient with septicemia who has intercostal and suprasternal retractions
Question 3A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion.
Which assessment finding by the nurse is most important to report to the health care provider?
a. The patient has bibasilar lung crackles.
b. The patient is sitting in the tripod position.
c. The patient's respirations have decreased from 30 to 10 breaths/minute.
d. The patient's pulse oximetry indicates an O2 saturation of 91.
Question 4A patient admitted with acute respiratory failure has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action is a priority for the nurse to include in the plan of care?
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 >93.
Question 5A 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. Suction the endotracheal tube every 2 to 4 hours.
c. Limit the use of positive end-expiratory pressure.
d. Give enteral feedings at no more than 10 mL/hr.
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