Running Head: ASSEMBLING & ADMINISTERING A TEST 1

Assembling & Administering a Test

Jean A. O’Connor

SUNY Polytechnic Institute

ASSEMBLING & ADMINISTERING A TEST 2

TEST BLUEPRINT
Course Unit: Alterations in Respiratory Status and Functioning
________________________________________
CONTENT OBJ. COGNITIVE PHASE OF AREA OF
# LEVEL NSG. PROCESS CLIENT
NEEDS

Environment
Application
Comprehend

Physiological

Psychosocial
Understand

Assessment

Implement

Evaluation

Promotion
Safe Care
Analysis

Planning
Analysis

Health
Traumatic 1 X X X
Pneumothorax
Pulmonary 1 X X X
Embolus
Respiratory Failure 1 X X X
Pulmonary Edema 2 X X X
Respiratory Arrest 2 X X X
ABG 2 X X X

Totals 6 0 0 1 5 1 1 1 2 1 0 6 0 0
Percentages 0 0 17 83 17 17 17 33 17 0 100 0 0

Objectives Hours Formula Number of

Questions
1 Hours per each 3
objective
Over total hours of
all objectives X
number of questions
2 Hours per each 3
objective
Over total hours of
all objectives X
number of questions

TOTAL: 6
ASSEMBLING & ADMINISTERING A TEST 3

COVER SHEET

Exam 1

SUNY Polytechnic Institute

Alterations in Respiratory Function

Examination 1

November 2017

Please do not open this test until instructed to do so.

This is a 6 question, closed book test. Each question is worth 5 points. You have 30

minutes to complete the exam. You will need a #2 pencil only. No electronic devices are

permitted in the testing area. All books, and personal belongings must be put away.

This is a multiple-choice exam. Select the one option that best answers the question. If

you are unsure of an answer, skip it and return when you have completed the rest of the

exam. There are no penalties for guessing, but try not to guess. Your knowledge of the

material will help to guide your answer choices.

Good luck!
ASSEMBLING & ADMINISTERING A TEST 4

Directions:

 Check that you have 7 pages total: 1 cover page, 1 direction page , and 5 exam

pages.

 Ensure your test number on your exam pages matches the exam number on the

cover page.

 Fill in the information at the top of the exam page.

 Use only a #2 pencil.

 Circle the one correct answer to each question.

 If the question requires more than one answer, then circle all the correct choices

to the question

 If the question wants you to place your answers in order of importance, then place

the letter answers in the space provided in order of importance.

 If you have any questions during the exam please raise your hand.

 Mark any questions that you skip in order to easily return to the question.

 When the exam is finished, wait for the proctor to collect the exam.

 Do not leave your seat without permission.

 Sign and print your name and date below.

Signature: ________________________________________

Print Name: ______________________________________

Date: ____________________________________________
ASSEMBLING & ADMINISTERING A TEST 5

Exam 1

Name: _____________________

Date: ______________________

Test Questions

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

from Endoscopy status post bronchoscopy with biopsy. 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

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

complaining of chest pain, and shortness of breath. Chest X-Ray is within normal limits.

ABG shows a PaO2 of 88, SaO2 of 96%, and PaCO2 38. 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
ASSEMBLING & ADMINISTERING A TEST 6

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. The nurse is developing a plan of

care to maintain a patent airway. Which of these outcomes should receive priority in the

plan? Choose all that apply.

A. Ability of client to hold up their head

B. Absence of drooling

C. Negative inspiratory force >30cmH2O

D. Cough suppression

E. Forced vital capacity <20mL/Kg

F. Negative gag reflex

G. Absence of snoring

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. In

order of importance select from the choices below what assessments the nurse should

perform.

A. Check vital signs 1st___________

B. Listen to lung sounds 2nd___________

C. Observe for jugular venous distention 3rd___________

D. (JVD), and peripheral edema 4th___________

E. Obtain blood work and a chest x-ray 5th___________

F. Assess level of dyspnea 6th___________

ASSEMBLING & ADMINISTERING A TEST 7

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

(PACU) who has undergone a right hemicolectomy. 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

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- 20 mEq/L

The patient is now intubated and placed on mechanical ventilation with the following

settings: assist control with a respiratory rate of 16, Tidal volume 650, FIO2 100%, and

PEEP 5. Repeat ABG is obtained. Which one of these ABG values indicate the ventilator

settings are correct, and the patient is improving?

ASSEMBLING & ADMINISTERING A TEST 8

A.

pH 7.38

PaCO2 48 mm Hg

PaO2 88 mm Hg

SaO2 95%

HCO3- 22mEq/L

B.

pH 7.55

PaCO2 30 mmHg

PaO2 75 mmHg

SaO2 84%

HCO3- 28mEq/L

C.

pH 7.20

PaCO2 65 mmHg

PaO2 68 mmHg

SaO2 80%

HCO3- 18mEq/L

D.

pH 7.50

PaCO2 40 mmHg
ASSEMBLING & ADMINISTERING A TEST 9

PaO2 80 mmHg

SaO2 94%

HCO3- 31mEq/L
ASSEMBLING & ADMINISTERING A TEST 10

Test Question Answers and Rationales

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

from Endoscopy status post bronchoscopy with biopsy. 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: Implementation

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
ASSEMBLING & ADMINISTERING A TEST 11

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. Chest X-Ray is within normal limits.

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

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, and shortness of breath are signs and symptoms of PE,

but could be mistaken for myocardial infarction, or other respiratory illness. Typically on

a 12 lead ECG tachycardia and T-wave inversion in leads I-IV are seen. ABG values,
ASSEMBLING & ADMINISTERING A TEST 12

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). It is important to obtain a thorough history and physical.

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. The nurse is developing a plan of

care to maintain a patent airway. Which of these outcomes should receive priority in the

plan? Choose all that apply.

A. Ability of client to hold up their head

B. Absence of drooling

C. Negative inspiratory force >30cmH2O

D. Cough suppression

E. Forced vital capacity <20mL/Kg

F. Negative gag reflex

G. Absence of snoring

Cognitive Instructional Objective: Determines treatment plan for acute alterations in

respiratory status.

Cognitive Level: Application

Phase of the Nursing Process: Planning

Area of Client Needs: Physiological Integrity

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

upper airway management emergency. Patients in crisis are at risk for respiratory failure.
ASSEMBLING & ADMINISTERING A TEST 13

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 normal NIF is >30cmH2O

and a normal FVC is >20ml/kg. A patient who can cough demonstrates good muscle

control, and patients should have a positive gag reflex that indicates airway protection.

Snoring while sleeping does not indicate respiratory failure (Hinkle & Cheever, 2014, p.

2040-2043).

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. In

order of importance select from the choices below what assessments the nurse should

perform.

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

ASSEMBLING & ADMINISTERING A TEST 14

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

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).

ASSEMBLING & ADMINISTERING A TEST 15

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

(PACU) who has undergone a right hemicolectomy. 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

Psychomotor Instructional Objective: Manages equipment to intervene in patients

demonstrating respiratory compromise.

Cognitive Level: Analysis

Phase of the Nursing Process: Implementation

Area of Client Needs: Physiological Integrity

Test Answer and Rationale: Answer is B. 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,
ASSEMBLING & ADMINISTERING A TEST 16

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- 20 mEq/L

The patient is now intubated and placed on mechanical ventilation with the following

settings: assist control with a respiratory rate of 16, Tidal volume 650, FIO2 100%, and

PEEP 5. Repeat ABG is obtained. Which of one these ABG values indicate the ventilator

settings are correct, and the patient is improving?

A.

pH 7.38

PaCO2 48 mm Hg

PaO2 88 mm Hg

SaO2 95%

HCO3- 22mEq/L
ASSEMBLING & ADMINISTERING A TEST 17

B.

pH 7.55

PaCO2 30 mmHg

PaO2 75 mmHg

SaO2 84%

HCO3- 28mEq/L

C.

pH 7.20

PaCO2 65mmHg

PaO2 68 mmHg

SaO2 80%

HCO3- 18mEq/L

D.

pH 7.50

PaCO2 40 mmHg

PaO2 80 mmHg

SaO2 94%

HCO3- 31mEq/L
ASSEMBLING & ADMINISTERING A TEST 18

Psychomotor Instructional Objective: Associates abnormal ABG lab values with the

need for change in treatment for patients and the ability to evaluate improvement on

patients with alteration in respiratory status.

Cognitive Level: Analysis

Phase of the Nursing Process: Evaluation

Area of Client Needs: Physiological Integrity

Test Answer and Rationale: Answer is A. The client’s initial ABG evaluation shows a

respiratory acidosis. Choice A’s ABG value shows improvement from an acidotic state

with a normal pH of 7.38, an improving PaCO2, a PaO2, SaO2, and HCO3- all now

within normal limits. Choice B shows a respiratory alkalosis with a high pH of 7.55, a

low PaCO2 of 30, a low PaO2, and a borderline HCO3-. Choice C demonstrates a

worsening acidosis, and Choice D represents a metabolic alkalosis with an elevated pH, a

normal PaCO2, and an elevated HCO3- (Hinkle & Cheever, 2014, p. 271-272).
ASSEMBLING & ADMINISTERING A TEST 19

References

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

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

McDonald, M.E. (2018). The nurse educator’s guide to assessing learning outcomes (4th

ed.). Burlington, MA: Jones & Bartlett Learning.

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

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