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41. High pressure alarm still alarms after suctioning the client. What should the nurse do next?
a) disconnect the client from mechanical ventilation and do manual resuscitation
b) call the respiratory therapist
c) call another nurse to be with the client while the nurse calls for the physician
d) turn off the alarm
42. Which of the following community-acquired pneumonias demonstrates the highest occurrence during summer and fall?
a) pneumococcal pneumonia
b) legionaire's pneumonia
c) viral pneumonia
d) mycoplasma pneumonia
43. A client is admitted to an acute care facility with a tentative diagnosis of PCP (pneumocystis carinii pneumonia). She had lost 25 lbs. over the past 2 months and complains of anorexia. At this point, the highest priority goal is that the patient will
a) increase nutrient intake
b) have no further weight loss
c) be free from infection
d) maintain cardiopulmonary functioning
44. A patient underwent a pneumonectomy and developed tension pneumothorax. Which of the following is an early indication of tension pneumothorax
a) frothy, blood-tinged sputum
b) trachea shifts toward unaffected side of the chest
c) development of subcutaneous emphysema
d) open, sucking chest wound
45. The nurse is caring for a client on mechanical ventilator. The low-pressure alarm of the ventilator turns on. The most important nursing action is:
a) prepare to suction the client
b) check air leak from endotracheal tube
c) check if the tube is kinked
d) turn off the alarm
ANSWERS AND RATIONALE
41) A
- oxygenation and ventilation are the priority among clients on mechanical ventilation
42) B
- legionaire's pneumonia is the highest in incidence during summer. Whereas, pneumococcal pneumonia is most common during winter.
43) D
- cardiopulmonary functioning is a priority in the patient with pneumocystis carinii pneumonia.
44) B
- mediastinal shift indicates pneumothorax. This causes airway obstruction.
45) B
- when the low-pressure alarm turns on, this indicates disconnection of tubings. So, appropriate nursing action is to check for air leak. When the high pressure alarm turns on, this indicates obstruction. It may be due to accumulation of mucous secretions, kinks along the tubing, or the client is biting the endotracheal tube.
Related Topics:
- Online Nursing Practice Test about Respiratory Diseases (46-50)
- Go back to Online Nursing Practice Test about Respiratory Diseases (1-6) to start the test from the beginning.
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