CCRN Respiratory Exam with Questions and Answers, Exams of Medicine

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What is indicative of a massive pulmonary embolism? (A) fever, purulent sputum, hypoxemia (B) hypoxemia, hypotension, increased alveolar dead space (C) hypoxemia, shunt, decreased surfactant production (D) hypoventilation, wheezing, air trapping ANSWERV ¥ (B) A pulmonary embolism results in increased alveolar dead space; hypoxemia and hypotension are present when the pulmonary embolism is massive. Choice (A) is indicative of pneumonia. Choice (C) is indicative of ALI/ARDS. Choice (D) is indicative of asthma. The patient develops agitation with respiratory distress, distended neck veins, hypotension, and diminished breath sounds on the right with tracheal deviation to the left. Which treatment is a priority for this patient? (A) fluid bolus (B) needle aspiration of the chest (C) chest tube insertion (D) intubation ANS WERV ¥ (B) The patient has signs of tension pneumothorax (right side), which is a life-threatening problem that requires immediate chest decompression. Fluids will not resolve the primary problem, so choice (A) is incorrect. A chest tube will be needed, but it is not the priority intervention, so choice (C) is incorrect. An artificial airway will not address the problem, so choice (D) is incorrect. A 75 kg patient with ARDS is receiving mechanical ventilation with the following settings: assist-control mode, a breath rate of 16 breaths/minute; Fiz 80%; Vt 350 mL; PEEP 10 cm 1120. ABGs are obtained and reveal the following: pI 7.32, pC 55, Or 45, IICO 25. Which intervention should the nurse anticipate’? (A) Increase the Vt. (B) Increase the breath rate. (C) Increase the FiOz. (D) Increase the PEEP. ANSWERV ¥ (D) The PEEP setting of 10 cm H20 is often not high enough to correct the hypoxemia for a patient with ARDS: higher PEEP is required. The patient has an elevated pCQ2, but this is expected and generally well-tolerated for a patient with ARDS who receives the needed low Vt settings. Choices (A). (B), and (C) are not appropriate interventions for this situation. What would indicate a worsening condition and the possible need for intubation for a patient with status asthmaticus? (A) anxiety (B) bilateral wheezing (C) pulsus paradoxus (D) Sa02 92% ANSWERY ¥ (C) Pulsus paradoxus, a variation of systolic pressure > 15 mmg with inspiration and expiration, is a sign of significant air trapping that may decrease venous return and BP. Choice (A) is incorrect because anxicly is expected. Rather, lethargy and decreased responsiveness would be danger signs. Choice (B) is incorrect because bilateral wheezing is expected due to narrowed airways; a silent chest is an indication of a worsening condition. Mild hypoxemia (choice (D)) may be treated with an increase in FiO2. The patient is receiving mechanical ventilation and enteral tube feeding. There is a sudden increase in the peak inspiratory pressure. The ventilator high-pressure alarm is sounding. There is development of a right lung infiltrate on the chest film. What most likely caused these findings? (D) Prepare for intubation. ANSWERV ¥ (C) The patient has pneumonia of the right lung. Keeping the good lung down allows the effects of gravity on perfusion to address hypoxemia. (Note that gravitational effects on lung perfusion is also the rationale for PRONING a patient with ARDS.) The head of the bed should be kept greater than 30 degrees to optimize oxygenation. Thus, rule out choice (A). Hydration, not fluid restriction, is needed for pneumonia to help mobilize secretions. Rule out choice (B). There are no indications in the question that intubation is required. so choice (D) is not the correct answer. Which of the following is true about lung compliance? (A) A patient with ARDS has increased lung compliance. (B) A decrease in lung compliance decreases the work of breathing. (C) A patient with asthma has decreased lung compliance. (D) Surfactant increases lung compliance. ANSWERV ¥ (D) Surfactant is produced by Type Il alveolar cells. As a result of the destruction of these cells caused by ARDS, lung compliance is decreased, not increased, making choice (A) incorrect. A decrease in lung compliance increases the work of breathing, so choice (B) is not the answer. A patient with asthma has decreased airway compliance, but the patient's lung compliance is normal. Therefore, choice (C) is incorrect as well. Which patient finding represents a deficiency of oxygen at the cellular level (hypoxia) due to decreased oxygen consumption? (A) hemoglobin 8.8 mg/ dL (B) Pad? 61 mmHg (C) diagnosis of septic shock (D) fever ANSWERV ¥ (C) A patient with septic shock has low 02 consumption (VOz) aue to the cells' inability to utilize oxygen, which results in anaerobic metabolism (elevated lactate). Ilypoxia will not occur with either mild anemia (choice (A)) or mild hypoxemia (choice (B)). Fever shifts the oxyhemoglobin-dissociation curve to the right, resulting in hemoglobin more readily releasing oxygen to tissues. Therefore, choice (D) is not correct, cither. Match each ABG below with the letter of the correct interpretation on the right. ___ pH 7. 51, PaCO2 28, HCO3 22 ___ pH 7. 22, PaC02 68, HCO3 39 ___ pH 7. 49, PaCO2 32, HCO3 34 ___ pH 7. 25, PaCO2 28, HCO3 12 ___ pH 7. 31, PaCO2 48, HCO3 24 pH 7. 24, PaCO2 35, HCO3 15 pH 7. 44, PaCO2 12, HCO3 18 A. Metabolic acidosis, no compensation B. Respiratory acidosis, partial compensation C. Respiratory acidosis, no compensation D. Metabolic alkalosis, no compensation E. Respiratory alkalosis, no compensation F. Metabolic acidosis, partial compensation G. Mixed disorder, respiratory alkalosis and metabolic acidosis ANSWERVV __E.__pH7. 51, PaCO2 28, HCO3 22 B.__ pH 7. 22, PaCO2 68, HCO3 39 __D._ pH 7. 49, PaCO2 32, HCO3 34 __F._ pH 7. 25, PaCO2 28, HCO3 12 _C._ pl 7. 31, PaCO2 48, NCO3 24 (A) right lung pneumonia (B) right pneumothorax (C) right pulmonary edema (D) right atelectasis ANSWERV V (A) These signs are found over an arca of lung consolidation, usually secondary to pneumonia. A pneumothorax (choice (B)) results in decreased or absent breath sounds. A pulmonary edema (choice (C)) results in crackles. Atelectasis (choice (D)) results in crackles or diminished breath sounds. The patient has been receiving enteral feeding and is now tachypneic. The SpO2 is 89% on 2 L/ nasal cannula oxygen. Auscultation of the lungs reveals crackles over the right middle lobe. What is the priority intervention? (A) Call for a chest X-ray. (B) Call Anesthesia for insertion of an endotracheal tube (ETT). (C) Turn the patient to the right side. (D) Increase the Fi02. ANSWERY ¥ (D) The patient has most likely aspirated based on a history of enteral feeding and right lung examination. The immediate priority is to improve oxygenation. A chest X-ray will be needed, but improving oxygenation is more important. Therefore, choice (A) is incorrect. The patient does not have signs of an immediate need for an ETT, so rule out choice (B). There is no benefit to turning the patient to the right side, so choice (C) is incorrect as well. The patient, who has been receiving mechanical ventilation, is receiving a spontaneous breathing trial (SBT). The ventilator Settings include CPAP 10 cm H20, pressure support 5 cm H20, and Fi2 0.30. The patient is experiencing inereased work of breathing, and SpO2 is 0.95. What intervention will most likely decrease the patient's work of breathing? (A) increasing the tidal volume (B) increasing the CPAP (C) increasing the FiO2 (D) increasing the pressure support ANSWERV ¥ (D) Pressure support senses when the patient begins inspiration and provides a "boost" or support to decrease the work of breathing. The tidal volume cannot be increased because CAP is a spontaneous ventilatory mode with no set breaths or tidal volume. Therefore, rule out choice (A). An increase in CAP is not indicated since this patient has no signs of hypoxemia. Therefore, tule out choice (B). The patient does not need an increase in FiOz, so rule out choice (C) as well. A patient, who is receiving mechanical ventilation, is scheduled for a spontaneous breathing trial (SBT). The patient's chest x-ray is improving. The level of consciousness has decreased, and he now responds to shaking rather than voice. The FiO2 is 40%, the resting minute ventilation is 8 L/min, and the rapid shallow breathing index (RSBI) is 108 breaths/min/L. What intervention is indicated at this time’? (A) Continue with the SBT as planned. (B) Hold the SBT because of the patient's minute ventilation. (C) [fold the SBT because of the FiO2 requirements. (D) Hold the SBT because of the change in the level of consciousness and because of the RSBI. ANSWERV ¥ (D) The RSBI should ideally be less than 105 breaths/min/L, and the patient's change in level of consciousness needs to be discussed with the physician before beginning an SBT. The SBT should not continue as originally planned. so rule out choice (A). The minute ventilation described in choice (B) and the FiO, requirements described in choice (C) are not a problem. The patient was admitted with acute pancreatitis and has developed tachypnea, bilateral crackles, and SpO2 of 84% despite an increase of FiO2 to 1.00 per non-rebreather mask. A chest X-ray shows bilateral "ground glass" appearance. The nurse anticipates which priority intervention? (D) PEEP ANSWERV ¥ (A) The breath rate needs to be lowered to allow for a longer expiratory time. A patient with asthma requires a longer expiratory time to prevent air trapping. Lowering the breath rate will allow for the needed longer expiratory time and will prevent air trapping. The remaining ventilator settings listed in choices (B), (C), and (D) are appropriate for a patient with status asthmaticus and would not need to be questioned. The arterial blood gas (ABG) results of a post-op patient with diabetes are reported as follows: pH 7.30, PaCO2 51, Pa02 61, HCO 25. Which intervention would address this patient's acid-base status? (A) Assess the clectrolytes. (B) Increase the FiO2. (C) Administer naloxone (Narcan). (D) Check the patient's blood sugar. ANSWERV ¥ (C) The patient has uncompensated respiratory acidosis, and opioid reversal is the only action that would address this problem. Electrolyte assessment is indicated for metabolic alkalosis. It is not needed in this situation, so eliminate choice (A). An increase in FiO may be indicated, but it would not address the primary problem of hypoventilation; the hypoxemia may be a result of the high PaCO2. Therefore, eliminate choice (B). There is no indication for an immediate assessment of the patient's blood sugar, so eliminate choice (D). The post-op patient who is receiving mechanical ventilation has a right-sided chest tube. Which assessment would necessitate notifying the provider? (A) peak airway pressure of 20 em H20 (B) development of bubbling in the water seal chamber (C) drainage of 40 mL over eight hours (D) tidaling with deep inspiration in the water seal chamber ANSWERV ¥ (B) Bubbling in the water seal chamber that was not previously present is a sign of a new air leak, and the provider should be notified. An airway pressure of 20 cm H20 is normal, so choice (A) is incorrect. Note that persistent pressures greater than 30 cm H20 may lead to an air leak. Choices (C) and (D) are normal assessment findings. The patient who is receiving mechanical ventilation developed agitation, tachypnea, unequal chest excursion, and diminished breath sounds on the right. The ventilator high-pressure alarm is frequently sounding. The blood pressure is elevated. What is the priority treatment for this patient? (A) right lung chest tube insertion (B) increase in FiOz (C) right lung needle aspiration (D) sedation ANSWERV ¥ (A) The patient has signs of a right-sided pneumothorax, and emergent placement of a chest tube is needed. This scenario does not indicate the need for an increase in FiQz, so rule out choice (B). Needle aspiration would be indicated for a tension pneumothorax, but this patient does not have hypotension or other signs of a tension pneumothorax. Therefore, rule out choice (C). This patient is agitated due to lung collapse, and sedation, while needed, is not the priority. Choice (D) can therefore be ruled out as well. PEFP therapy is essential for a patient with ARDS. Which nursing intervention is appropriate for a patient receiving PEEP therapy for the treatment of ARDS? (A) Monitor for possible barotrauma. (B) Decrease PEEP if hypotension develops. (C) Titrate PEEP down when hypoxemia is corrected, and then decrease the Fi02. V1 and V2. The patient's blood pressure is 98/58. In addition to increasing the FiOz, what intervention does the nurse anticipate for the patient? (A) non-invasive ventilation (B) anticoagulation (C) vasopressors (D) PEEP therapy ANSWERV ¥ (B) This patient has signs of a pulmonary embolism that is most likely massive as evidenced by the hypoxemia, hypotension, and ECG changes. Anticoagulation is a priority. Non-invasive ventilation (choice (A)) would not provide any benefit for this problem. Vasopressors (choice (C)) are not indicated. Instead, fluid boluses should be administered to increase right heart preload. A patient with a PE has increased dead space ventilation. The patient does not have a pathologic shunt, which would require PEEP therapy as described in choice (D). The patient admitted with asthma was anxious and had bilateral inspiratory and expiratory wheezing throughout all lung fields. Continuous inhalation of albuterol was initiated, steroids were administered, and IV fluids were given to provide hydration (in order to prevent mucus plugging). The patient is now lethargic with diminished breath sounds and a respiratory rate of 24 breaths’ minute with retractions. A repeat ABG demonstrates the following: pH 7.31, PaC02 47 mmHg, and Pa02 63 mmHg. What priority intervention is indicated at this time for this patient? (A) Increase the FiO2. (B) Decrease the albuterol treatments to every 2 hours and PRN. (C) Get a repeat chest X-ray. (D) Intubate, and provide ventilation. ANSWERV ¥ (D) This patient has signs of deterioration with PaCO, elevation despite an increased respiratory rate. which is a sign of worsening ventilation. Diminished breath sounds indicate decreased air flow, and lethargy may be a sign of tiring. Thus, the proper actions in this case are to intubate and provide ventilation. The FiO, can be increased, but doing so will not improve the patient's air flow and ventilation. Therefore, choice (A) is not the answer. A decrease in albuterol is not indicated, so choice (B) is incorrect. A repeat chest X-ray is also not indicated, so choice (C) is incorrect as well. The patient is receiving a spontaneous breathing trial (SBT) and develops atrial fibrillation with a rapid ventricular response (140 beats/minute). There is no change in the patient's blood pressure or level of consciousness. What is the priority nursing intervention’? (A) Contact the provider about the rhythm change. (B) Discontinue the SBT, and return the patient to a ventilator. (C) Order an ECG. (D) Continue the SBT, and monitor the patient. ANSWERV ¥ (B) The onset of a sustained rhythm change is an indication to discontinue the SBT. Choices (A) and (C) are not priorities. Choice (D) is contraindicated. The patient has left lower lobe pneumonia and has been receiving 40% oxygen via a mask. The patient has developed an increased respiratory rate with a decrease in the SpO2. An ABG is obtained with the following results: pH 7. 29, PaCO2 51, PaQ2 57, SaQ2 0.87, and HCO3 27. The patient is alert and denies any discomfort other than dyspnea. What intervention would be beneficial to the patient? (A) Insert an endotracheal tube (ETT), and initiate mechanical ventilation. (B) Increase the FiO2 per face mask. (C) Initiate non-invasive ventilation (NIV). (D) Re-evaluate antibiotic therapy. ANS WERV ¥ (C) The patient has both oxygenation and ventilation abnormalitics as evidenced by the ABG. NIV can address both issucs without the associated complications of invasive mechanical ventilation. The ABG and the patient's clinical status do not warrant the need for mechanical ventilation, so choice (A) is not correct. hypertension. Pedal edema may be present due to right heart failure, but it is not due to dilator therapy. There are complications that result from the pulmonary stabilization strategies that are needed to treat a patient with ARDS. Which of the following is an example of a complication that the nurse might encounter when caring for a patient who requires pulmonary stabilization strategies? (A) barotrauma (B) hypertension (C) hypocapnia (D) cardiac arrhythmia ANSWERV ¥ (A) The high PEEP requirement may result in barotrauma. Hypotension, not hypertension, is a result of high PEEP. Eliminate choicc (B). Hypercapnia, not hypocapnia, will result from low tidal volumes, but is generally well- tolerated. Eliminate choice (C). Cardiac arrhythmias are not a direct complication of high PEEP and low tidal volumes. Eliminate choice (D). The patient is receiving non-invasive ventilation for acute respiratory failure secondary to pneumonia and has a history of COPD. The patient has increased secretions, is agitated, and keeps removing the face mask, resulting in oxygen desaturation below 90%. Which intervention is now indicated for this patient? (A) Provide sedation. (B) Initiate intubation and mechanical ventilation. (C) Increase the FiO2. (D) Apply restraints. ANSWER ¥ ¥ (B) Non-invasive ventilation is contraindicated for a patient with copious secretions or a patient who is unable to cooperate by leaving the mask in place. Securement of the airway and the provision of adequate oxygen are priorities. The interventions described in choices (A), (C), and (D) are not indicated for this patient. A 90 kg patient was admitted with upper Gl bleeding secondary to esophageal varices. The patient required fluid resuscitation and developed ARDS, which necessitated mechanical ventilation. The current ventilator settings include: breath rate 12 breaths/minute, tidal volume 900 mL, FiO2 1.00, and PEEP 20. The SpO is 0.91, the plateau pressure is 38 cm H20, and the vital signs are stable. What intervention is needed for this patient's treatment plan? (A) Decrease the tidal volume. (B) Increase the breath rate. (C) Decrease PEEP. (D) Decrease the Fio2?. ANSWERV ¥ (A) The patient's plateau pressure is elevated, and the patient requires a decrease in the tidal volume to prevent volutrauma. There is no evidence presented that the breath rate needs to be increased, so rule out choice (B). The PEEP is not titrated down until the FiO, is lower, so choice (C) is incorrect. The FiO should not be decreased until the tidal volume is addressed. Therefore, choice (D) is incorrect. The patient was admitted with a crush injury to the left leg and developed dyspnea, tachypnea, a fever, and a cough. The lungs are clear, and a petechial rash is noted on the back and chest. SpO on room air is decreased to 0.91. The patient is at risk for which complication? (A) air trapping (B) hypercapnia (C) septic shock