Respiratory

A mechanically ventilated patient has an arterial blood gas result as follows: pH = 7.50 PaCO2 = 34 mmHg PaO2 = 70 mmHg HCO3 = 30 mEq/L The nurse anticipates which changes will be made to the patient’s ventilator settings?

The nurse is preparing to obtain an arterial blood gas sample from a patient. Which intervention does the nurse perform first?

A patient is brought to the emergency department unresponsive following an opioid overdose. The nurse anticipates the patient’s arterial blood gas results will reflect which condition?

A 3-day-old premature neonate was born at 24-weeks estimated gestational age. The patient is mechanically ventilated with a fraction of inspired oxygen (FiO2) of 30%, rate of 40 breaths per minute, positive end expiratory pressure of 5, and peak inspiratory pressure of 20. The arterial blood gas results are as follows: pH = 7.34, PaCO2 = 48 mmHg, PaO2 = 70 mmHg, and HCO3 = 25 mEq/L. The nurse anticipates which changes will be made to the patient’s ventilator settings?

A patient who is recovering from diabetic ketoacidosis (DKA) has bacterial pneumonia with a positive sputum culture. Which organism is most likely responsible for this patient’s DKA?

A child with type 1 diabetes is undergoing treatment for diabetic ketoacidosis. For which life-threatening complications of treatment should the nurse be vigilant? Select all that apply.

A patient who is immobilized following surgery to repair a pelvic fracture is at risk for which life-threatening condition?

The nurse is a first responder at a mass casualty event. According to the Simple Triage and Rapid Treatment (START) protocol, which patient will receive medical care first?

The nurse is a first responder following a mass casualty incident and performs triage on these victims while waiting for assistance. List the patients in order they must be treated according to the Simple Triage and Rapid Treatment (START) protocol.

A patient is admitted with concern for heart failure. Which symptom is a major criterion of heart failure according to the Modified Framingham clinical criteria for the diagnosis of heart failure?

A patient with heart failure is unable to walk from the kitchen to the bedroom without becoming dyspneic. However, the dyspnea resolves with rest. The nurse recognizes this patient has which class of heart failure according to the New York Heart Association classification system?

A patient presents to the emergency department complaining of weakness, fatigue, and nausea. The nurse observes distended neck veins and auscultates rales. The patient states, “I’ve had such trouble sleeping lately, but sleeping in my recliner seems to help.” The nurse anticipates the patient will be diagnosed with which condition?

A patient has been admitted with acute decompensated heart failure (ADHF) and has gained 5 kg in the last week. Which medication does the nurse anticipate administering to address the patient’s fluid volume status?

A 10-year-old patient presents to the school nurse following a class party complaining of pain, arm swelling, and a swollen mouth after a bee sting. Lungs are clear with good air movement. Which action does the nurse take first?

The nurse begins an intravenous infusion of ampicillin. Ten minutes later, the patient states she has itching and swollen lips. What is the nurse’s first action?

An individual experiencing anaphylaxis due to ingestion of peanuts has received epinephrine via autoinjector. Following the injection, the individual’s respirations have become less labored. In which position should the individual be placed while waiting for emergency medical personnel to arrive?

A fetus is diagnosed in utero with autosomal recessive polycystic kidney disease. The mother is noted to have severe oligohydramnios. Which statement is most accurate for the prognosis of the fetus?

The nurse is attending the delivery of a full-term neonate whose mother received poor prenatal care. The neonate has cyanosis, increased work of breathing, a barrel chest, and a scaphoid abdomen. The nurse auscultates the patient’s lung fields and notes bowel sounds over the left side of the chest. The nurse suspects which condition in this neonate?

A patient admitted with influenza A requires which isolation precautions?

A 17-year-old patient is declared brain dead after a motor vehicle accident in which he sustained a liver laceration, severe subdural hematoma, and high cervical spinal cord injury. The parents have decided to donate their son’s organs. Which statement by the nurse is appropriate?

The terminally-ill patient with chronic obstructive pulmonary disease (COPD) is in a hospice. He says to the nurse, “I know I will die soon. I would feel at peace knowing my organs and tissues will be able to help other people after I’m gone. Which response by the nurse is most appropriate?

Which assessment indicates the patient with chronic pain is meditating effectively?

Which patients may benefit from exogenous surfactant administration? Select all that apply.

Which blood pressure is an indication the 34-year-old patient requires an increase in norepinephrine infusion dosage?

The nurse understands which is an indicator that norepinephrine is having its desired effect?

Which vital sign reported by the unlicensed assistive personnel (UAP) does the nurse investigate first?

The patient with which assessment is to be treated first in the emergency department?

Which assessment requires the most immediate intervention?

Which order does the nurse complete first in the patient with acute respiratory failure?

The nurse is reviewing the arterial blood gas results of a healthy 12-year-old patient in the emergency department in acute respiratory distress due to smoke inhalation during a house fire. Which lab value does the nurse anticipate from this patient?

The nurse has counseled the patient who has been admitted for an exacerbation of chronic obstructive pulmonary disease about the dangers of smoking tobacco. Which statement by the patient indicates a need for further teaching? 

Upon arrival of the patient to the post-anesthesia recovery unit (PACU), which assessment does the nurse perform first?

Which assessment at the beginning of the shift of the patient with a recent head injury requires the most immediate action?

Which statement by the family member of a patient who has Guillain-Barré Syndrome indicates that they understand the nurse’s teaching on the disease process?

The nurse in the neonatal intensive care unit receives report from the Labor and Delivery nurse about a full-term neonate and learns the patient’s Apgar scores were 0-0-1-5 at 1, 5, 10, and 15 minutes of life, respectively. How does the nurse interpret this information?

The full-term neonate is born via normal spontaneous vaginal delivery (NSVD). The neonate cries at the perineum and maintained flexion against gravity but is noted to be bluish gray. Which intervention is appropriate?

The neonate born at 41 weeks gestation is diagnosed with persistent pulmonary hypertension of the newborn (PPHN). Which information does the nurse give the mother about this condition?

Place the nursing interventions for a 16-year-old patient in the hospital for severe malnutrition and depression with a history of falls in order from highest priority to lowest priority.

Which nursing intervention is the highest priority for the patient admitted with a chronic obstructive pulmonary disease (COPD) exacerbation?

The patient is brought to the emergency department following a serious motor vehicular accident (MVA). List the assessments the nurse performs in order from highest to lowest priority.

The emergency department nurse is assessing the unconscious patient following a fall from the ladder while he was doing home improvement work. Which assessment is performed first?

The nurse is the first responder to a motor vehicular accident involving the injury of a 40-year-old male. Which action is the highest priority?

Which patient is triaged as first to be treated following a hurricane?

The nurse is caring for a patient receiving total parenteral nutrition (TPN). The nurse most closely assesses for which complication in this patient? 

The nurse is most vigilant for signs of which complication in a patient receiving total parenteral nutrition (TPN)?

Which patient must be triaged for emergency department care first?

A 41-year-old male complains of sudden onset of severe chest pain and describes it as a constant tearing sensation that radiates to his lower back. The nurse is most suspicious of which condition?

The nurse suspects that a patient has Ludwig’s angina. Which action does the nurse take first?

An 84-year-old patient being treated for a chronic obstructive pulmonary disorder (COPD) exacerbation starts to become disoriented after the evening meal and will not stay in bed. Which intervention does the nurse take first?

A patient with severe chronic obstructive pulmonary disorder (COPD) is receiving 3 liters per minute of oxygen via nasal canal. Which oxygen saturation indicates respiratory support is adequate?