Running Head: WRITING MULTIPLE CHOICE QUESTIONS AND 1

ALTERNATIVE FORMAT ITEMS

Writing Multiple Choice Questions and Alternative Format Items

Jean A. O’Connor

SUNY Polytechnic Institute

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Question 1: A nurse in the Post Anesthesia Care Unit (PACU) has received a patient

from Endoscopy status post bronchoscopy with biopsy. On arrival to the PACU, the

patient is coughing profusely, and placed on humidified oxygen @8LPM. SpO2 is 96%.

15 minutes into the recovery the patient becomes tachypneic with respirations 36, and O2

saturation drops to 86%. The patient is anxious and using accessory muscles. What

intervention must the nurse prepare for immediately?

A. Immediate intubation

B. Chest tube insertion

C. CT Scan of the Chest

D. Return to Endoscopy for repeat Bronchoscopy

Cognitive Instructional Objective: Infers severity of illness and interventions based on

signs and symptoms of respiratory distress in patients with altered states of respiratory

health.

Cognitive level: Analysis

Phase of the Nursing Process: Planning

Area of Client Needs: Physiological Integrity

Test Answer and Rationale: Answer is B Chest tube insertion. Patients undergoing

invasive procedures such as Bronchoscopy with biopsy are at risk for traumatic

pneumothorax due to accidental puncture of the pleura. Although it is normal for patients

to cough profusely after a bronchoscopy with biopsy, symptoms usually resolve with 15-

20 minutes. It is important to recognize the signs and symptoms of traumatic

pneumothorax through the deterioration of respiratory function, and understand that chest
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tube insertion is the medical management for this condition (Hinkle & Cheever, 2014, p.

614).

Question 2: A nurse is caring for a client in the emergency room who came in

complaining of chest pain, and shortness of breath. A 12 lead ECG shows sinus

tachycardia, and T wave inversion in leads I-IV. Chest X-Ray is within normal limits.

ABG shows a PaO2 of 88, SaO2 of 96%, and PaCO2 38. History and physical reveal a

healthy client, mid 30’s with a history of depression, and recent ankle injury from

running. The client denies any surgeries. Family history reveals Father deceased from

lung cancer, and mother with history of hypertension, Factor V Leiden, and

hyperlipidemia. Brother with juvenile diabetes, two sisters living no medical history. The

client is ordered for a pulmonary angiogram. The nurse understands that this test is being

performed because the patient’s diagnosis is highly suspicious for which of the following

conditions?

A. Lung Cancer

B. ARDS

C. Pulmonary Embolism

D. Pneumothorax

Cognitive Instructional Objective: Correlates common respiratory disorders with

critical alterations in respiratory status/functioning, and nursing interventions.

Cognitive Level: Analysis

Phase of the Nursing Process: Analysis

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Area of Client Needs: Physiological Integrity

Test Answer and Rationale: Answer is C Pulmonary Embolism. Pulmonary Embolism

(PE) is a life-threatening respiratory emergency. Nurses need to recognize the signs and

symptoms of PE, which may present differently for different patients. In this scenario the

client’s complaint of chest pain, shortness of breath and ECG changes are all signs and

symptoms of PE, but could be mistaken for myocardial infarction. Typically on a 12 lead

ECG tachycardia and T-wave inversion in leads I-IV are seen. ABG values, and chest x-

ray can be normal in patients with a PE, however hypoxemia and hypocapnia can be seen

on ABG as well due to obstruction and tachypnea (Hinkle & Cheever, 2014, p. 600-601).

The patient’s history of recent injury and a family history of Factor V Leiden, a clotting

disorder, put this patient at an increased risk for PE.

Question 3: The nurse has just received a patient in myasthenia gravis crisis to the

Intensive Care Unit for monitoring. The patient was diagnosed with pneumonia and has

been taking antibiotics at home for the past three days. According to the nurses care plan

for maintaining a patent airway, which of these symptoms would require immediate

intervention? Choose all that apply.

A. Snoring while sleeping

B. Inability of client to hold up their head

C. Drooling

D. Declining negative inspiratory force

E. Coughing

F. SpO2 93%
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G. Low forced vital capacity

H. Weak or absent gag reflex

Cognitive Instructional Objective: Determines treatment plan for acute alterations in

respiratory status.

Cognitive Level: Application

Phase of the Nursing Process: Implementation

Area of Client Needs: Physiological Integrity

Test Answer and Rationale: Answers are B, C, D, G, H. Myasthenia Gravis crisis is an

upper airway management emergency. Patients in crisis are at risk for respiratory failure.

Nurses caring for these patients must be aware of the signs of impending failure on these

patients that will ultimately lead to intubation, and have a plan set in place. MG is an

autoimmune disorder affecting myoneural junctions, and varying levels of deteriorating

muscle strength is seen with this disorder. It is critical to monitor the muscle strength of

the head and neck and accessory muscles as well as the gag reflex. Drooling indicates

inability to control secretions. A negative inspiratory force (NIF) and low forced vital

capacity (FVC) are the two most important indications for intubation, and should be

checked regularly by the nursing staff to determine trends. A patient who can cough

demonstrates good muscle control, and SpO2 of 93% is within normal limits. Snoring

while sleeping does not indicated respiratory failure (Hinkle & Cheever, 2014, p. 2040-

2043).
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Question 4: A nurse in the cardiac step down unit is caring for a client being managed

for heart failure after an acute myocardial infarction (MI). During the nurses morning

assessment the client is observed to be anxious, restless, coughing, and short of breath.

Pulmonary edema is suspected. In order of importance select from the choices below

what assessments the nurse should perform next to confirm this diagnosis.

A. Check vital signs

B. Listen to lung sounds

C. Observe for Jugular Venous Distention (JVD), and peripheral edema

D. Obtain blood work and a chest x-ray

E. Assess level of dyspnea

Psychomotor Instructional Objective: Differentiates changes in patient’s condition

requiring intervention for patients demonstrating alterations in respiratory

status/functioning.

Cognitive Level: Analysis

Phase of the Nursing Process: Assessment

Area of Client Needs: Physiological Integrity

Test Answer and Rationale: Answer in order of importance: E, B, A, C, D. Patients

with know history of heart failure, or acute MI are at risk for pulmonary edema due to left

ventricular (LV) failure. As the LV fails, blood backs up into the pulmonary circulation

causing pulmonary interstitial edema. Blood volume and pressure develop in the left

atrium as a result of the left ventricular failure. The increased left atrial pressure causes

an increase in pulmonary venous pressure, which causes an increase in hydrostatic

pressure, that forces fluid out of the pulmonary capillaries and into the interstitial spaces
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and alveoli (Hinkle & Cheever, 2014, p. 811). It is important for the nurse to understand

that patients with known heart failure (chronic), or acute MI (acute) can develop

pulmonary edema. Prevention is achieved through early recognition of the signs and

symptoms. The nurse must first recognize the level of dyspnea the client is experiencing.

Auscultation of lung sounds should be done next to determine level of adventitious

sounds. Clients are often tachycardic so vital signs should be checked, and client placed

on cardiac monitor, if not on one already. The nurse should observe for JVD and

peripheral edema as a sign of right heart failure from severe pulmonary congestion.

Blood work and Chest x-ray will confirm the extent of pulmonary edema (Hinkle &

Cheever, 2014, p. 811).

Question 5: The nurse is caring for an elderly client in the Post Anesthesia Care Unit

(PACU) who has undergone a right hemicolectomy. The patient is moaning in pain, and

restless, but is unable to scale the pain. A FLACC score of 7 is determined and the patient

is medicated with 50mcg of fentanyl. Shortly after the fentanyl administration the

cardiac monitor SpO2 alarms indicating a rapidly decreasing oxygen saturation, and

apneic respirations. The patient is not responsive. What is the nurse’s first intervention?

A. Put the patient on 100% non-rebreather mask

B. Provide positive pressure ventilation with Bag Mask Ventilation with oxygen at

15LPM and a rate of 10-12 breaths/minute

C. Auscultate breath sounds

D. Give Naloxone 40mg IV push

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Psychomotor Instructional Objective: Manages equipment to intervene in patients

demonstrating respiratory compromise.

Cognitive Level: Analysis

Phase of the Nursing Process: Intervention

Area of Client Needs: Physiological Integrity

Test Answer and Rationale: Fentanyl is an opioid analgesic often used on patients in

the PACU for pain management. Side effects from opioids include respiratory

depression, and elderly clients are at a higher risk for this. Immediate management of a

patient in respiratory arrest for the nurse at the bedside would be to begin positive

pressure ventilation with BMV, and oxygenation until an advanced airway could be

placed or an opioid antagonist such as naloxone can be given (Hinkle & Cheever, 2014,

p. 227-231). The proper dose for naloxone initially is 0.1-0.2mg IV at 2-3 minute

intervals not to exceed 10mg (PDR.net, 2017).

Question 6: The nurse is caring for a 63kg client with a diagnosis of pneumonia. Vital

signs are B.P. 80/50, HR 110 sinus tachycardia, RR 26; Temperature 102.2 F/39 C. Initial

ABG results are as follows (see chart 1):

pH 7.27

PaCO2 53 mm Hg

PaO2 50 mm Hg

SaO2 79%

HCO3- 24 mEq/L
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The patient is now intubated and placed on mechanical ventilation with the following

settings: assist control with a respiratory rate of 20, Tidal volume 650, FIO2 100%, and

PEEP 5. Repeat ABG is obtained with the following results (see chart 2):

pH 7.40

PaCO2 33 mm Hg

PaO2 93 mm Hg

SaO2 98%

HCO3- 28 mEq/L

Which of these orders would the nurse expect to follow in response to the repeat ABG

results?

A. Keep the FIO2 at 100% and increase the respiratory rate to 22; repeat ABG in 30

minutes

B. Increase the Tidal volume to 750, and decrease the respiratory rate to 12; repeat

ABG in 30 minutes

C. Decrease the FIO2 to 60% and decrease the respiratory rate to 12; repeat ABG in

30 minutes

D. Decrease the FIO2 to 80% and increase the PEEP to 10; repeat ABG in 30

minutes

Psychomotor Instructional Objective: Associates abnormal ABG lab values with the

need for change in treatment for patients with alteration in respiratory status

Cognitive Level: Analysis

Phase of the Nursing Process: Evaluation

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Area of Client Needs: Physiological Integrity

Test Answer and Rationale: Answer is C Decrease the FIO2 to 60% and decrease the

respiratory rate to 12. The client’s initial ABG evaluation showed a respiratory acidosis,

which, after intubation and mechanical ventilation, showed improved oxygenation, and

respiratory alkalosis. Once oxygenation improves, it is important to wean FIO2. The low

PaCo2 is probably due to the high respiratory rate setting on the ventilator, which can be

corrected by lowering the rate. Changes to ventilator settings should always be followed

with a repeat ABG (Hinkle & Cheever, 2014, p. 509-514).

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References

Hinkle, J.L., Cheever, K.H. (2014). Brunner & Suddarth’s textbook of medical-surgical

nursing. (13th ed.). Philadelphia: Wolters Kluwer.

PDR.net (2017). naloxone hydrochloride-drug summary. Retrieved from:

http://www.pdr.net/drug-summary/Narcan-naloxone-hydrochloride-3837