Critical care Exam 1

What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply. 1 Crackles 2 Atelectasis 3 Hypoxemia 4 Severe dyspnea 5 Increased pulmonary wedge pressure

Crackles, Atelectasis, Hypoxemia, & Severe dyspnea

It is determined that a client with heart block will require implantation of a permanent pacemaker to assist heart function. The client expresses concern about having an increased risk of accidental electrocution. How should the nurse respond? 1 "No one has been electrocuted yet by a pacemaker." 2 "New technology prevents electrocution from occurring." 3 "The pacemaker is pretested for safety before it is inserted." 4 "The voltage emitted is not strong enough to electrocute."

"The voltage emitted is not strong enough to electrocute."

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, the nurse expects to identify: 1 Hypertension 2 Tenacious sputum 3 Altered mental status 4 Slow rate of breathing

Altered mental status

A nurse is caring for several clients in the intensive care unit. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome (ARDS)? 1 Aspirating gastric contents 2 Getting an opioid overdose 3 Experiencing an anaphylactic reaction 4 Receiving multiple blood transfusions

Aspirating gastric contents

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? 1 Regulate the positive end-expiratory pressure (PEEP) according to the rate and depth of the client's respirations. 2 Deflate the cuff on the endotracheal tube for a few minutes every one to two hours. 3 Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. 4 Adjust the temperature of fluid in the humidification chamber depending on the volume of gas delivered.

Assess the need for suctioning when the high-pressure alarm of the ventilator is activated.

A client is on mechanical ventilation. When condensation collects in the ventilator tubing, the nurse should: 1 Notify a respiratory therapist 2 Drain the fluid from the tubing 3 Decrease the amount of humidity 4 Record the amount of fluid removed from the tubing

Drain the fluid from the tubing

A client with late-stage dementia of the Alzheimer type aspirates gastric contents and develops acute respiratory distress syndrome (ARDS). The pathophysiologic changes associated with ARDS progress through expected phases. What phase is characterized by signs of pulmonary edema and atelectasis? 1 Fibrotic 2 Exudative 3 Reparative 4 Proliferative

Exudative

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is important when suctioning the endotracheal tube? 1 Apply negative pressure while inserting the suction catheter. 2 Hyperoxygenate with 100% oxygen before and after suctioning. 3 Suction two to three times in succession to effectively clear the airway. 4 Use rapid movements of the suction catheter to loosen secretions.

Hyperoxygenate with 100% oxygen before and after suctioning.

A client with a suspected dysrhythmia is to wear a Holter monitor for 24 hours at home. What should the nurse instruct the client to do? 1 Keep a record of the day's activities 2 Avoid going through laser-activated doors 3 Record the pulse and blood pressure every four hours 4 Delay taking prescribed medications until the monitor is removed

Keep a record of the days activities

After an anterior fossa craniotomy, a client is placed on controlled mechanical ventilation. To ensure adequate cerebral blood flow the nurse should: 1 Clear the ear of draining fluid 2 Discontinue anticonvulsant therapy 3 Elevate the head of the bed 30 degrees 4 Monitor serum carbon dioxide levels routinely

Monitor serum carbon dioxide levels routinely

A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube with a high-volume, low-pressure cuff. What problem is prevented when the nurse uses a high-volume, low-pressure cuff? 1 Air leakage 2 Lung infection 3 Mucosal necrosis 4 Tracheal secretion

Mucosal necrosis

A postoperative client is being weaned from mechanical ventilation. What is the most important factor for the nurse to consider when organizing activities? 1 Remain with the client to assess responses. 2 Allow family members to participate in the process. 3 Permit the client more extended times alone for independence. 4 Observe monitoring devices at the control panel of the ventilator

Remain with the client to assess responses.

When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate? 1 Remove secretions by suctioning. 2 Lower the setting of the tidal volume. 3 Check that tubing connections are secure. 4 Obtain a specimen for arterial blood gases (ABGs)

Remove secretions by suctioning.

When caring for a client on mechanical ventilation, the nurse should monitor for which signs of hyperventilation? 1 Hypoxia 2 Hypercapnia 3 Metabolic acidosis 4 Respiratory alkalosis

Respiratory alkalosis

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? 1 Administer sedatives around the clock 2 Turn client every four hours 3 Increase ventilator settings as needed 4 Suction as needed

Suction as needed

What nursing action should be included in the plan of care for a client who had a permanent fixed (asynchronous) pacemaker inserted? 1 Instruct the client that it is better to sleep on two pillows. 2 Encourage the client to reduce activity from former levels. 3 Teach the client to keep daily accurate records of the pulse. 4 Inform the client that the pacemaker functions when the heart rate drops below a preset rate

Teach the client to keep daily accurate records of the pulse

A client has an endotracheal tube and is receiving mechanical ventilation. Periodic suctioning is necessary and the nurse follows a specific protocol when performing this procedure. Select in order of priority the nursing actions that should be taken when suctioning. 1. Assess client's vital signs and lung sounds 2. Insert the catheter without applying suction 3. Rotate the catheter while suction is applied 4. Administer oxygen via a ventilation bag

Vital signs, oxygenate the patient, Insert the catheter without applying suction, and then rotate the catheter while suction is applied.

A client with a pulmonary embolus is intubated, and mechanical ventilation is instituted. What should the nurse do when suctioning the endotracheal tube? 1 Apply suction while inserting the catheter. 2 Hyperoxygenate with 100% oxygen before and after suctioning. 3 Use short, jabbing movements of the catheter to loosen secretions. 4 Suction two to three times in quick succession to remove most of the secretions.

Hyperoxygenate with 100% oxygen before and after suctioning.

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? 1 Chest tube insertion 2 Aggressive diuretic therapy 3 Administration of beta blockers 4 Positive end-expiratory pressure (PEEP)

PEEP