NCLEX-PN Test #19 3 — Questions and Answers
Question 1: A client on a mechanical ventilator suddenly develops increasing peak airway pressures, decreased breath sounds on the left, tracheal deviation to the right, and hypotension. What complication does the nurse suspect?
- Right main stem intubation
- Left-sided tension pneumothorax (Correct answer)
- Ventilator-associated pneumonia
- Pulmonary embolism
Correct answer: Left-sided tension pneumothorax
Tension pneumothorax presents with: tracheal deviation AWAY from the affected side (to the right = left-sided tension pneumo), absent breath sounds on the affected side, hypotension (obstructive shock), rising peak airway pressures on the ventilator, and cyanosis. It requires immediate needle decompression (2nd intercostal space, midclavicular line) — it is rapidly fatal.
Question 2: The nurse is caring for a client with adult respiratory distress syndrome (ARDS). Which ventilator strategy is the standard of care?
- High tidal volume (12–15 mL/kg) to maximize oxygen delivery
- Lung-protective ventilation with low tidal volume (6 mL/kg of ideal body weight) and PEEP (Correct answer)
- Continuous positive airway pressure (CPAP) only without mechanical ventilation
- High FiO₂ (100%) maintained throughout the illness
Correct answer: Lung-protective ventilation with low tidal volume (6 mL/kg of ideal body weight) and PEEP
ARDSnet lung-protective ventilation uses low tidal volumes (6 mL/kg IBW) to prevent ventilator-induced lung injury (volutrauma, barotrauma), PEEP (positive end-expiratory pressure) to recruit collapsed alveoli, and titrating FiO₂ to maintain SpO₂ 88–95%. High tidal volumes worsen ARDS by overdistending injured lung units.
Question 3: A client is being weaned from mechanical ventilation and extubated. Within 30 minutes, the client develops inspiratory stridor. What does this indicate?
- Normal post-extubation sounds that will resolve within an hour
- Post-extubation laryngeal edema causing upper airway obstruction (Correct answer)
- Mucus plugging of the lower airways
- Pulmonary edema from fluid overload
Correct answer: Post-extubation laryngeal edema causing upper airway obstruction
Post-extubation stridor is inspiratory high-pitched sound caused by laryngeal or subglottic edema, which can progress to complete airway obstruction. It is an emergency: notify the provider immediately, administer racemic epinephrine nebulizer and/or IV dexamethasone as ordered, apply supplemental oxygen, and prepare for possible re-intubation.
Question 4: A client with a pulmonary embolism has been started on a heparin infusion. The nurse notes the aPTT is 28 seconds (sub-therapeutic). What is the appropriate action?
- The aPTT is within normal range — no action needed
- Notify the provider — the heparin dose likely needs to be increased per protocol (Correct answer)
- Stop the heparin infusion and switch to warfarin
- Administer protamine sulfate to reverse the heparin effect
Correct answer: Notify the provider — the heparin dose likely needs to be increased per protocol
Therapeutic aPTT for heparin therapy is 60–100 seconds (1.5–2.5× normal). An aPTT of 28 seconds is sub-therapeutic, meaning the client is not adequately anticoagulated and remains at risk for further clot extension. The provider must be notified to increase the heparin dose per protocol or weight-based heparin nomogram.
Question 5: A client with severe community-acquired pneumonia has a PaO₂/FiO₂ ratio of 150. What does this value indicate?
- Normal gas exchange — no supplemental oxygen required
- Mild hypoxemia — requires low-flow nasal cannula
- Moderate to severe ARDS — meets criteria for ARDS diagnosis (Correct answer)
- Hyperoxia — FiO₂ should be decreased
Correct answer: Moderate to severe ARDS — meets criteria for ARDS diagnosis
The P/F ratio (PaO₂/FiO₂) categorizes ARDS severity: Mild ARDS = 200–300 (with PEEP ≥5 cmH₂O); Moderate ARDS = 100–200; Severe ARDS = < 100. A P/F ratio of 150 indicates moderate ARDS. Normal P/F is > 400. This client requires lung-protective mechanical ventilation. (Berlin Definition 2012).
Question 6: The PN is caring for a client receiving continuous oxygen via nasal cannula at 4 L/min. The client's SpO₂ is 96%. Which assessment finding indicates the oxygen therapy is achieving its goal?
- The client is alert, oriented, and their lips and nailbeds are pink (Correct answer)
- The client is drowsy with a respiratory rate of 22 breaths per minute
- The client has a PaCO₂ of 58 mmHg
- The client's SpO₂ has decreased to 88% over the past hour
Correct answer: The client is alert, oriented, and their lips and nailbeds are pink
SpO₂ 96% with alert orientation, pink lips and nailbeds, and a comfortable respiratory rate indicates adequate oxygenation is being maintained. Drowsiness can indicate CO₂ retention (especially in COPD). Elevated PaCO₂ indicates CO₂ retention. Decreasing SpO₂ indicates oxygen therapy is insufficient. Clinical assessment of oxygenation combines SpO₂ with neurological and color assessment.
NCLEX-PN Test #19 3
A client on a mechanical ventilator suddenly develops increasing peak airway pressures, decreased breath sounds on the left, tracheal deviation to the right, and hypotension.
What complication does the nurse suspect?