Final NS4P1

The client admitted with full-thickness burns may be developing DIC. Which signs/symptoms would support the diagnosis of DIC? 1. Oozing blood from the IV catheter site. 2. Sudden onset of chest pain and frothy sputum. 3. Foul-smelling, concentrated urine. 4. A reddened, inflamed central line catheter site.

1. Oozing blood from the IV catheter site.

The nurse develops a care plan for a critically ill client with acute respiratory distress syndrome (ARDS) who is on a mechanical ventilator. What is the priority nursing diagnosis (ND)? 1. Imbalanced nutrition 2. Impaired gas exchange 3. Impaired tissue integrity 4. Risk for infection

2. Impaired gas exchange

A patient is admitted with metabolic acidosis. Which system is not functioning normally? A. Renal system B. Buffer system C. Endocrine system D. Respiratory system

Renal system

The client with a mechanical valve replacement asks the nurse, "Why do I have to take antibiotics before getting my teeth cleaned?" Which response by the nurse is most appropriate? 1. "You are at risk of developing an infection in your heart." 2. "Your teeth will not bleed as much if you have antibiotics." 3. "This procedure may cause your valve to malfunction." 4. "Antibiotics will prevent vegetative growth on your valves."

1. "You are at risk of developing an infection in your heart."

The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response? 1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal." 2. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias." 3. "Your doctor has ordered bedrest. Therefore, you must stay in the bed." 4. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger."

1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal."

The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply. 1. Assess the client's level of consciousness. 2. Monitor urine output every shift. 3. Turn the client every two (2) hours. 4. Maintain intravenous fluids as ordered. 5. Place the client in the Fowler's position.

1. Assess the client's level of consciousness. 3. Turn the client every two (2) hours. 4. Maintain intravenous fluids as ordered. 5. Place the client in the Fowler's position.

A client with suspected moderate to large pericardial effusion is admitted for monitoring. The nurse performs a head-to-toe assessment. Which of these findings indicates likely cardiac tamponade and require immediate intervention? Select all that apply 1. Blood pressure of 90/70 2. Bounding peripheral pulses 3. Decreased breath sounds on left side 4. Distant heart tones 5. Jugular venous distention

1. Blood pressure of 90/70 4. Distant heart tones 5. Jugular venous distention

The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first? 1. Check the tubing for any kinks. 2. Suction the airway for secretions. 3. Assess the lip line of the ET tube. 4. Sedate the client with a muscle relaxant.

1. Check the tubing for any kinks.

A client with chronic kidney disease has a large pleural effusion. What findings characteristic of a pleural effusion does the nurse expect? Select all that apply 1. Chest pain during inhalation 2. Diminished breath sounds 3. Dyspnea 4. Hyperresonance on percussion 5. Wheezing

1. Chest pain during inhalation 2. Diminished breath sounds 3. Dyspnea

The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, PaO2 92, PaCO2 38, HCO3 24. Which action should the nurse implement? 1. Continue to monitor the client without taking any action. 2. Encourage the client to take deep breaths and cough. 3. Administer one (1) ampule of sodium bicarbonate IVP. 4. Notify the respiratory therapist of the ABG results.

1. Continue to monitor the client without taking any action.

A client is hospitalized with worsening chronic heart failure. Which clinical manifestations does the admitting nurse most likely assess in this client? Select all that apply 1. Crackles on auscultation 2. Dry mucous membranes 3. Increased jugular venous distention 4. Rhonchi on auscultation 5. Skin "tenting" 6. 3+ pitting edema of the lower extremities

1. Crackles on auscultation 3. Increased jugular venous distention 6. 3+ pitting edema of the lower extremities Other manifestations include: anasarca and ascites

Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. 1. Encourage a low-fat, low-cholesterol diet. 2. Instruct client to walk 30 minutes a day. 3. Decrease the salt intake to two (2) g a day. 4. Refer to counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet.

1. Encourage a low-fat, low-cholesterol diet. 2. Instruct client to walk 30 minutes a day. 4. Refer to counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet.

Which signs/symptoms make the nurse suspect the most common opportunistic infection in the female client diagnosed with acquired immunodeficiency syndrome (AIDS)? 1. Fever, cough, and shortness of breath. 2. Oral thrush, esophagitis, and vaginal candidiasis. 3. Abdominal pain, diarrhea, and weight loss. 4. Painless violet lesions on the face and tip of nose.

1. Fever, cough, and shortness of breath. (Pneumocystis pneumonia is a serious infection that causes inflammation and fluid buildup in your lungs. Its brought on by a fungus called pneumocystis jirovecii that spreads through the air)

The nurse caring for a client who is HIV positive is stuck with the stylet used to start an IV. Which intervention should the nurse implement first? 1. Flush the skin with water and try to get the area to bleed. 2. Notify the charge nurse and complete an incident report. 3. Report to the employee health nurse for prophylactic medication. 4. Follow up with the infection control nurse to have lab work done.

1. Flush the skin with water and try to get the area to bleed.

The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement? 1. Instruct client to keep a diary of activity, especially when having chest pain. 2. Discuss the need to remove the Holter monitor during a.m. care and showering. 3. Explain that all medications should be withheld while wearing a Holter monitor. 4. Teach the client the importance of decreasing activity while wearing the monitor.

1. Instruct client to keep a diary of activity, especially when having chest pain.

The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? 1. Instruct the client to use a soft-bristle toothbrush. 2. Discuss the importance of getting a monthly partial thromboplastin time (PTT). 3. Teach the client about signs of pacemaker malfunction. 4. Explain to the client the procedure for synchronized cardioversion

1. Instruct the client to use a soft-bristle toothbrush.

The ED nurse is caring for a client who had a severe allergic reaction to a bee sting. Which discharge instructions should the nurse discuss with the client? 1. Instruct the client to wear a medical identification bracelet. 2. Apply corticosteroid cream to the site to prevent anaphylaxis. 3. Administer epinephrine 1:10,000 intravenously every three (3) minutes. 4. Teach the client to avoid attracting insects by wearing bright colors.

1. Instruct the client to wear a medical identification bracelet.

The client is experiencing multifocal premature ventricular contractions. Which antidysrhythmic medication would the nurse expect the health-care provider to order for this client? 1. Lidocaine. 2. Atropine. 3. Digoxin. 4. Adenosine.

1. Lidocaine. Other medications include B-blockers, procainamide, or amiodarone

The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS? 1. Low arterial oxygen when administering high concentration of oxygen. 2. The client has dyspnea and tachycardia and is feeling anxious. 3. Bilateral breath sounds clear and pulse oximeter reading is 95%. 4. The client has jugular vein distention and frothy sputum

1. Low arterial oxygen when administering high

The client has just had a pericardiocentesis. Which interventions should the nurse implement? Select all that apply. 1. Monitor vital signs every 15 minutes for the first hour. 2. Assess the client's heart and lung sounds. 3. Record the amount of fluid removed as output. 4. Evaluate the client's cardiac rhythm. 5. Keep the client in the supine position

1. Monitor vital signs every 15 minutes for the first hour. 2. Assess the client's heart and lung sounds. 3. Record the amount of fluid removed as output. 4. Evaluate the client's cardiac rhythm.

The client is diagnosed with acute pericarditis. Which sign/symptom warrants immediate attention by the nurse? 1. Muffled heart sounds. 2. Nondistended jugular veins. 3. Bounding peripheral pulses. 4. Pericardial friction rub.

1. Muffled heart sounds.

The nurse is admitting a patient with a diagnosis of pulmonary embolism. What risk factors is a priority for the nurse to assess (select all that apply.)? 1. Obesity 2. Pneumonia 3. Malignancy 4. Cigarette smoking 5. Prolonged air travel

1. Obesity 3. Malignancy 4. Cigarette smoking 5. Prolonged air travel

The client has a hematocrit of 22.3% and a hemoglobin of 7.7 g/dL. The HCP has ordered two (2) units of packed red blood cells to be transfused. Which interventions should the nurse implement? Select all that apply. 1. Obtain a signed consent. 2. Initiate a 22-gauge IV. 3. Assess the client's lungs. 4. Check for allergies. 5. Hang a keep-open IV of D5W

1. Obtain a signed consent 3. Assess the client's lungs. 4. Check for allergies.

Which signs/symptoms should the nurse assess in any client who has a long-term valvular heart disease? Select all that apply. 1. Paroxysmal nocturnal dyspnea. 2. Orthopnea. 3. Cough. 4. Pericardial friction rub. 5. Pulsus paradoxus.

1. Paroxysmal nocturnal dyspnea. 2. Orthopnea. 3. Cough.

The client diagnosed with pericarditis is experiencing cardiac tamponade. Which collaborative intervention should the nurse anticipate for this client? 1. Prepare for a pericardiocentesis. 2. Request STAT cardiac enzymes. 3. Perform a 12-lead electrocardiogram. 4. Assess the client's heart and lung sounds.

1. Prepare for a pericardiocentesis.

Which interventions should the nurse discuss with the female client who is positive for human immunodeficiency virus (HIV)? Select all that apply. 1. Recommend the client not to engage in unprotected sexual activity. 2. Instruct the client not to inform past sexual partners of HIV status. 3. Tell the client to not donate blood, organs, or tissues. 4. Suggest the client not get pregnant. 5. Explain the client does not have to tell health-care personnel of HIV status.

1. Recommend the client not to engage in unprotected sexual activity. 3. Tell the client to not donate blood, organs, or tissues. 4. Suggest the client not get pregnant. 5. Explain the client does not have to tell health-care personnel of HIV status.

The client is in ventricular fibrillation. Which interventions should the nurse implement? Select all that apply. 1. Start cardiopulmonary resuscitation. 2. Prepare to administer the antidysrhythmic adenosine IVP. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP

1. Start cardiopulmonary resuscitation. 3. Prepare to defibrillate the client. 4. Bring the crash cart to the bedside. 5. Prepare to administer the antidysrhythmic amiodarone IVP (Textbook states use either epinephrine or vasopressin)

Which medical treatment would be prescribed for the client with an AAA less than 3 cm? 1. Ultrasound every six (6) months. 2. Intravenous pyelogram yearly. 3. Assessment of abdominal girth monthly. 4. Repair of abdominal aortic aneurysm.

1. Ultrasound every six (6) months.

The client is in complete heart block. Which intervention should the nurse implement first? 1. Prepare to insert a pacemaker. 2. Administer atropine, an antidysrhythmic. 3. Obtain a STAT electrocardiogram (ECG). 4. Notify the health-care provider.

2. Administer atropine, an antidysrhythmic. (Textbook states atropine is not effective for third degree-heart block)

A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective? 1. "Im not worried about the device firing now because I know it wont hurt" 2. " I will let my daughter fix my hair until my healthcare provider says I can do it" 3. "I will look into public transportation because I wont be able to drive again" 4. "I will notify my travel agent that I can no longer travel by plane"

2. " I will let my daughter fix my hair until my healthcare Firing of the ICD may be painful -Driving may be approved by the -HCP once healed -Travel is not restricted

The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment? 1. "I have stomach pain every time I eat a big, heavy meal." 2. "I don't have any abdominal pain or any type of problems." 3. "I have periodic episodes of constipation and then diarrhea." 4. "I belch a lot, especially when I lay down after eating."

2. "I don't have any abdominal pain or any type of problems."

Which client would the nurse suspect of having a mitral valve prolapse? 1. A 60-year-old female with congestive heart failure. 2. A 23-year-old male with Marfan's syndrome. 3. An 80-year-old male with atrial fibrillation. 4. A 33-year-old female with Down syndrome.

2. A 23-year-old male with Marfan's syndrome.

Which laboratory result would the nurse expect in the client diagnosed with DIC? 1. A decreased prothrombin time (PT). 2. A low fibrinogen level. 3. An increased platelet count. 4. An increased white blood cell count

2. A low fibrinogen level.

Which assessment data would the nurse recognize to support the diagnosis of abdominal aortic aneurysm (AAA)? 1. Shortness of breath. 2. Abdominal bruit. 3. Ripping abdominal pain. 4. Decreased urinary output.

2. Abdominal bruit.

The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer morphine intramuscularly. 2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. 4. Place the client in a supine position. 5. Administer nitroglycerin subcutaneously

2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula.

The client diagnosed with Pneumocystis pneumonia (PCP) is being admitted to the intensive care unit. Which HCP's order should the nurse implement first? 1. Draw a serum for CD4 and complete blood count STAT. 2. Administer oxygen to the client via nasal cannula. 3. Administer trimethoprim-sulfamethoxazole, a sulfa antibiotic, IVPB. 4. Obtain a sputum specimen for culture and sensitivity.

2. Administer oxygen to the client via nasal cannula. (Oxygen is a priority, especially with a client diagnosed with a respiratory illness)

The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? 1. Medicate the client with intravenous morphine. 2. Assess the client's chest dressing and vital signs. 3. Encourage the client to turn from side to side. 4. Check the client's telemetry monitor

2. Assess the client's chest dressing and vital signs.

Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? 1. Assess the client's radial pulse. 2. Assess the client's serum potassium level. 3. Assess the client's glucometer reading. 4. Assess the client's pulse oximeter reading.

2. Assess the client's serum potassium level.

A client comes to the emergency department with severe dyspnea and a cough. Vital signs are a temperature 99.2 F (37.3 C), blood pressure 108/70 mm Hg, heart rate 88/min, and respirations 24/min. The client has a history of chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure? 1. Arterial blood gas (ABG) 2. B-type natriuretic peptide (BNP) 3. Cardiac enzyme (CK-MB) 4. Chest x-ray

2. B-type natriuretic peptide (BNP) BNP > 100pg/mL

The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment would require immediate follow-up? 1. Abdomen is soft, nondistended, and tender to touch 2. Blood pressure is 96/66 mm Hg and apical pulse is 112/min 3. Client rates as 4 on a scale of 0-10 4. Green bile is draining from the nasogastric tube

2. Blood pressure is 96/66 mm Hg and apical pulse is 112/min (Client's should be monitored postop for graft leakage and hemodynamic stability. Adequate blood pressure is necessary to maintain graft patency)

Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve? 1. Pulmonary embolus. 2. Cerebrovascular accident. 3. Hemoptysis. 4. Deep vein thrombosis.

2. Cerebrovascular accident.

Which client problem has priority for the client with a cardiac dysrhythmia? 1. Alteration in comfort. 2. Decreased cardiac output. 3. Impaired gas exchange. 4. Activity intolerance.

2. Decreased cardiac output.

The nurse is admitting a client with a diagnosis of right-sided heart failure resulting from pulmonary hypertension. What clinical manifestations are most likely to be assessed? 1. Crackles in lung bases 2. Increased abdominal girth 3. Jugular venous distention 4. Lower extremity edema 5. Orthopnea

2. Increased abdominal girth 3. Jugular venous distention 4. Lower extremity edema

The client with infective endocarditis is admitted to the medical department. Which health-care provider's order should be implemented first? 1. Administer intravenous antibiotic. 2. Obtain blood cultures times two (2). 3. Schedule an echocardiogram. 4. Encourage bedrest with bathroom privileges.

2. Obtain blood cultures times two (2).

The client diagnosed with an anaphylactic reaction is admitted to the emergency room. Which assessment data indicate the client is not responding to the treatment? 1. The client has a urinary output of 120 mL in two (2) hours. 2. The client has an AP of 110 and a BP of 90/60. 3. The client has clear breath sounds and an RR of 26. 4. The client has hyperactive bowel sounds

2. The client has an AP of 110 and a BP of 90/60. (These vital signs indicate shock, which is a medical emergency and requires immediate intervention)

The HCP prescribes an HMG-CoA reductase inhibitor (statin) medication to a client with CAD. Which should the nurse teach the client about this medication? 1. Take this medication on an empty stomach. 2. This medication should be taken in the evening. 3. Do not be concerned if muscle pain occurs. 4. Check your cholesterol level daily

2. This medication should be taken in the evening.

The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Ventilate with a manual resuscitation bag. 3. Request STAT arterial blood gases. 4. Auscultate the client's lung sounds.

2. Ventilate with a manual resuscitation bag.

The female client is diagnosed with rheumatic fever and prescribed penicillin, an antibiotic. Which statement indicates the client needs more teaching concerning the discharge teaching? 1. "I must take all the prescribed antibiotics." 2. "I may get a vaginal yeast infection with penicillin." 3. "I will have no problems as long as I take my medication." 4. "My throat culture was positive for a streptococcal infection."

3. "I will have no problems as long as I take my medication."

The client who smokes two (2) packs of cigarettes a day develops ARDS after a near-drowning. The client asks the nurse, "What is happening to me? Why did I get this?" Which statement by the nurse is most appropriate? 1. "Most people who almost drown end up developing ARDS." 2. "Platelets and fluid enter the alveoli due to permeability instability." 3. "Your lungs are filling up with fluid, causing breathing problems." 4. "Smoking has caused your lungs to become weakened, so you got ARDS."

3. "Your lungs are filling up with fluid, causing breathing problems."

Which collaborative treatment would the nurse anticipate for the client diagnosed with DIC? 1. Administer oral anticoagulants. 2. Prepare for plasmapheresis. 3. Administer frozen plasma. 4. Calculate the intake and output.

3. Administer frozen plasma.

The nurse knows the client understands the teaching concerning a low-fat, lowcholesterol diet when the client selects which meal? 1. Fried fish, garlic mashed potatoes, and iced tea. 2. Ham and cheese on white bread and whole milk. 3. Baked chicken, baked potato, and skim milk. 4. A hamburger, French fries, and carbonated beverage.

3. Baked chicken, baked potato, and skim milk.

The nurse receives handoff of care report on four clients. Which client should the nurse see first? 1. Client with atrial fibrillation who reports feeling palpitations and has an irregular pulse 2. Client with liver cirrhosis who reports bleeding from an IV insertion site and has a platelet count of 48,000 3. Client with pericarditis whose blood pressure has decreased from 122/70 mm Hg to 98/68 mm Hg over the past hour 4. Client with pneumonia whose white blood cell count has increased from 14,000 8 hours ago to 30,000

3. Client with pericarditis whose blood pressure has decreased from 122/70 mm Hg to 98/68 mm Hg over the past hour (May be an indication of cardiac tamponade)

The nurse is caring for a client with advanced heart failure on an inpatient hospice unit. The client is having trouble breathing. Which comfort intervention should the nurse implement first? 1. Administer as-needed (prn) albuterol by nebulizer 2. Administer prn intravenous (IV) furosemide 3. Elevate the head of the bed 4. Give prn sublingual morphine

3. Elevate the head of the bed

The client with acquired immunodeficiency syndrome (AIDS) dementia is referred to hospice. Which intervention has highest priority when caring for the client in the home? 1. Assess the client's social support network. 2. Identify the client's usual coping methods. 3. Have consistent uninterrupted time with the client. 4. Discuss and complete an advance directive.

3. Have consistent uninterrupted time with the client.

The client with pericarditis is prescribed a nonsteroidal anti-inflammatory drug (NSAID). Which teaching instruction should the nurse discuss with the client? 1. Explain the importance of tapering off the medication. 2. Discuss that the medication will make the client drowsy. 3. Instruct the client to take the medication with food. 4. Tell the client to take the medication when the pain level is around "8."

3. Instruct the client to take the medication with food.

A client admitted to the cardiac care unit with markedly elevated blood pressure and heart failure is receiving a continuous infusion of nitroprusside. Thirty minutes later, the client appears pale with cold, clammy sin and reports being lightheaded. Which is the priority nursing action? 1. Auscultate the client's lungs 2. Check the client's capillary refill 3. Measure the client's blood pressure 4. Review the client's electrocardiogram (ECG)

3. Measure the client's blood pressure

The nurse is caring for a client after percutaneous placement of a coronary stent for a myocardial infarction. The client rates lower back pain as 5 on a scale of 0-10 and has a blood pressure of 140/92 mm Hg. The cardiac monitor shows normal sinus rhythm with occasional premature ventricular contractions. Which prescription should the nurse administer? Lab results Potassium 3.3 Sodium 149 Glucose 157 1. Captopril PO every 8 hours 2. Morphine IV PRN for pain 3. Potassium chloride IVPB once 4. Regular insulin subq with meals

3. Potassium chloride IVPB once

Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator? 1. The client's urine output is 100 mL in four (4) hours. 2. The pulse oximeter reading is greater than 95%. 3. The client has asymmetrical chest expansion. 4. The telemetry reading shows sinus tachycardia.

3. The client has asymmetrical chest expansion. Signs of a pneumothorax

The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse? 1. The client's BP is 110/70 and pulse is 90. 2. The client's groin dressing is dry and intact. 3. The client refuses to keep the leg straight. 4. The client denies any numbness and tingling.

3. The client refuses to keep the leg straight. (Keep the extremity extended for 4 to 6 hours, as prescribed, keeping the leg straight to prevent arterial occlusion)

The client has just received a mechanical valve replacement. Which behavior by the client indicates the client needs more teaching? 1. The client takes prophylactic antibiotics. 2. The client uses a soft-bristle toothbrush. 3. The client takes an enteric-coated aspirin daily. 4. The client alternates rest with activity.

3. The client takes an enteric-coated aspirin daily.

The nurse is caring for clients on a medical floor. After the shift report, which client should be assessed first? 1. The client who is two thirds of the way through a blood transfusion and has had no complaints of dyspnea or hives. 2. The client diagnosed with leukemia who has a hematocrit of 18% and petechiae covering the body. 3. The client with peptic ulcer disease who called over the intercom to say that he is vomiting blood. 4. The client diagnosed with Crohn's disease who is complaining of perineal discomfort.

3. The client with peptic ulcer disease who called over the intercom to say that he is vomiting blood.

Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction? 1. Creatine kinase (CK-MB). 2. Lactate dehydrogenase (LDH). 3. Troponin. 4. White blood cells (WBCs).

3. Troponin.

A client is seen following a motor vehicle collision. An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital. The IV is now infusing at 200 mL/hr. Which assessment findings alerts the nurse to the development of hypovolemic shock? 1. Jugular venous distention 2. Mean arterial pressure 65 mm Hg 3. Urine output <0.5 mL/kg/hr 4. Warm, flush skin

3. Urine output <0.5 mL/kg/hr Other manifestations include: Change in mental status Tachycardia Cool, clammy skin Oliguria Tachypnea

A client is 48 hours post abdominal aneurysm repair. Which assessment by the nurse is cause for greatest concern? 1. Diminished breath sounds in bilateral lung bases 2. Hypoactive bowel sounds in all 4 quadrants 3. Urine output of 90 mL in the past 4 hours 4. Warm extremities with 1 + bilateral pedal pulses

3. Urine output of 90 mL in the past 4 hours

The nurse is teaching a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required? 1. " I need to avoid caffeinated products" 2. "I need to get my blood drug levels checked periodically 3. "I need to report anorexia and sleeplessness" 4. " I take cimetidine rather than omeprazole for heartburn"

4. " I take cimetidine rather than omeprazole for heartburn" (Cimetidine and ciprofloxacin can dramatically increase serum theophylline levels)

The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching? 1. "I should keep the tablets in the dark-colored bottle they came in." 2. "If the tablets do not burn under my tongue, they are not effective." 3. "I should keep the bottle with me in my pocket at all times." 4. "If my chest pain is not gone with one tablet, I will go to the ER."

4. "If my chest pain is not gone with one tablet, I will go to the ER."

A nurse is discussing discharge education with a client after his fifth hospitalization for pulmonary edema caused by his congestive heart failure. Which of the following statements indicates that further teaching is required? 1. "I should supplement my potassium intake." 2. " I should weigh myself daily." 3. "Moderate exercise may be helpful in my condition." 4. "Potato chips are an acceptable snack in moderation."

4. "Potato chips are an acceptable snack in moderation."

Which client would be most likely to develop an abdominal aortic aneurysm? 1. A 45-year-old female with a history of osteoporosis. 2. An 80-year-old female with congestive heart failure. 3. A 69-year-old male with peripheral vascular disease. 4. A 30-year-old male with a genetic predisposition to AAA.

4. A 30-year-old male with a genetic predisposition to AAA.

The client is diagnosed with pericarditis. Which are the most common signs/symptoms the nurse would expect to find when assessing the client? 1. Pulsus paradoxus. 2. Complaints of fatigue and arthralgias. 3. Petechiae and splinter hemorrhages. 4. Increased chest pain with inspiration.

4. Increased chest pain with inspiration.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate

4. Increased respiratory rate

The nurse is assessing a client an hour after a left lung lobectomy. The client is awake, alert, and oriented, and reports pain of 6 on a 0-10 scale. Pulse oximetry is 92% on 4 L oxygen via nasal canula. The chest tube is set to continuous water seal suction at -20 cm H2O. The collection chamber has accumulated 320 mL of frank red drainage in the last hour. What is the priority nursing action? 1. Clamp the chest tube immediately 2. Increase oxygen to 6 L via nasal cannula 3. Medicate client for pain and document the findings 4. Notify the health care provider immediately

4. Notify the health care provider immediately (Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately. Excessive drainage is defined as >100 mL/hr)

An elderly client with a history of stable chronic obstructive pulmonary disease, alcohol abuse, and cirrhosis has a serum theophylline level of 25.8 mcg/mL. Which clinical manifestations associated with theophylline toxicity should worry the nurse most? 1. Alterations in color vision 2. Gum (gingival) hypertrophy 3. Hyperthermia 4. Seizure activity

4. Seizure activity Theophylline has a narrow therapeutic index and plasma concentrations >20 mcg/mL Conditions associated with chronic toxicity include advanced age (>60), drug interactions (eg, alcohol, macrolide, and quinolone antibiotics), and liver disease

The client receiving a unit of PRBCs begins to chill and develops hives. Which action should be the nurse's first response? 1. Notify the laboratory and health-care provider. 2. Administer the histamine-1 blocker, Benadryl, IV. 3. Assess the client for further complications. 4. Stop the transfusion and change the tubing at the hub.

4. Stop the transfusion and change the tubing at the hub. Prior to attaching new tubing, aspirate, flush then attach new tubing along with new NS

Fifteen minutes after the nurse has initiated a transfusion of packed red blood cells, the client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first? 1. Collect urine for analysis. 2. Notify the laboratory of the reaction. 3. Administer diphenhydramine, an antihistamine. 4. Stop the transfusion at the hub.

4. Stop the transfusion at the hub.

The nurse writes a diagnosis of "potential for fluid volume deficit related to bleeding" for a client diagnosed with disseminated intravascular coagulation (DIC). Which would be an appropriate goal for this client? 1. The client's clot formations will resolve in two (2) days. 2. The saturation of the client's dressings will be documented. 3. The client will use lemon-glycerin swabs for oral care. 4. The client's urine output will be >30 mL per hour.

4. The client's urine output will be >30 mL per hour.

The nurse is teaching a class on valve replacements. Which statement identifies a disadvantage of having a biological tissue valve replacement? 1. The client must take lifetime anticoagulant therapy. 2. The client's infections are easier to treat. 3. There is a low incidence of thromboembolism. 4. The valve has to be replaced frequently

4. The valve has to be replaced frequently

A client in the emergency department is admitted with a diagnosis of rule out myocardial infarction (MI). Which laboratory test should the nurse monitor to determine if the client has had an MI? 1. D-dimer 2. Low density lipoprotein 3. Myoglobulin 4. Troponin

4. Troponin Lab values D-dimer <250ng/mL LDL <100mg/dL Troponin - Troponin T :<0.1ng/dL Troponin I :<0.5ng/dL

The nurse reviews laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires the most immediate action by the nurse? 1. Glucose 200 mg/dL 2. Hematocrit 38% 3. Potassium 3.4 mEq/L 4. Troponin 0.7 ng/mL

4. Troponin 0.7 ng/mL Troponin T <0.1 Troponin I <0.5

The client diagnosed with atrial fibrillation is admitted with warfarin (Coumadin) toxicity. Which HCP order would the nurse anticipate? 1. Protamine sulfate, an anticoagulant antidote. 2. Heparin sodium, an anticoagulant. 3. Lovenox, a low molecular weight anticoagulant. 4. Vitamin K, an anticoagulant agonist.

4. Vitamin K, an anticoagulant agonist.

A nurse is caring for an older adult client who had an acute myocardial infarction (MI). When assessing the client, the nurse should identify that older adults are prone to complications of MI from poor tissue perfusion because of which of the following age-related factors? A. Peripheral vascular resistance increase B. The sensitivity of blood pressure-adjusting baroreceptors increases C. Blood is hypercoagulable and clots quickly D. Cardiac medications are less effective

A. Peripheral vascular resistance increase This results from calcification and loss of elasticity of the blood vessels

A nurse is caring for a client with heart failure whose telemetry reading displays a flattening of the T wave. Which of the following laboratory results should the nurse anticipate as the cause of this ECG change? A. Potassium 2.8 mEq/L B. Digoxin level 0.7 ng/mL C. Hemoglobin 9.8 g/dL D. Calcium 8.0 mg

A. Potassium 2.8 mEq/L -therapeutic range for digoxin is 0.5 to 0.8 ng/mL (AV block, V-Fib, V-tach are a few of the dysrhythmias with toxic digoxin level) -low hemoglobin will manifest tachycardia

A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial infarction (MI). Which of the following indicators should the nurse identify to confirm reperfusion? A. Ventricular dysrhythmias B. Appearance of Q waves C. Elevated ST segment D. Recurrence of chest pain

A. Ventricular dysrhythmias

A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following findings should the nurse expect? A. Weight gain of 1kg (2.2 lb) in 1 day B. Pitting edema +1 C. client report of a nocturnal dyspnea D. B-type natriuretic peptide (BNP) level of 100 pg/dL

A. Weight gain of 1kg (2.2 lb) in 1 day This indicates the client is retaining fluid and is at risk for fluid volume overload

A nurse is preparing a client for cardiac catheterization. Which of the following pieces of information should the nurse give the client before the procedure? Select all that apply A. You'll have to lie flat for several hours after the procedure B. You'll receive medication to relax you before the procedure C. You'll feel a cool sensation after the injection of the dye D. You'll have to keep your leg straight after the procedure E. You'll have to limit the amount of fluid you drink for the first 24 hr.

A. You'll have to lie flat for several hours after the procedure B. You'll receive medication to relax you before the procedure D. You'll have to keep your leg straight after the procedure

A nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which of the following findings should the nurse expect? Select all that apply A bradycardia B. Bleeding at the venipuncture site C. Petechiae on the chest D. Flushed, dry skin E. Abdominal distention

B. Bleeding at the venipuncture site C. Petechiae on the chest E. Abdominal distention

A nurse is preparing an in-service presentation about the management of myocardial infarction (MI). Death following MI is often a result of which of the following complications? A. Cardiogenic shock B. Dysrhythmias C. Heart failure D. Pulmonary edema

B. Dysrhythmias Specifically ventricular dysrhythmias (ventricular fibrillation)

A nurse is completing dietary teaching with a client who has heart failure and is prescribed a 2g sodium diet. Which of the following statements by the client indicates understanding of the teaching? A. I should use salt sparingly while cooking B. I can have yogurt as a dessert C. I should use baking soda when I bake D. I should use canned vegetables instead of frozen

B. I can have yogurt as a dessert

A nurse is providing discharge teaching to an adult female client who has infective endocarditis about how to prevent recurrence. Which of the following statements by the client indicates an understanding of the teaching? A. I will ask my provider to change my contraception to an intrauterine device B. I will notify my doctor before I have dental procedures C. I will avoid using antiseptic mouthwash for oral care D. I will wear a mask when I go out in public

B. I will notify my doctor before I have dental procedures

A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? A. Increased cardiac output B. Increased pulmonary congestion C. Decreased left atrial pressure D. Decreased pulmonary artery pressure

B. Increased pulmonary congestion

A nurse is checking paradoxical blood pressure of a client who has a possible cardiac tamponade. In what order should the nurse complete the following steps? A. Deflate the cuff slowly and listen for the first audible sounds B. Palpate the blood pressure and inflate the cuff above the systolic pressure C. Identify the first BP sounds audible on expiration and then on inspiration D. Subtract the inspiratory pressure from the expiratory pressure E. Inspect for jugular venous distention and notify the provider

B. Palpate the blood pressure and inflate the cuff above the systolic pressure A. Deflate the cuff slowly and listen for the first audible sounds C. Identify the first BP sounds audible on expiration and then on inspiration D. Subtract the inspiratory pressure from the expiratory pressure E. Inspect for jugular venous distention and notify the provider

A nurse is transfusing a unit of B-positive fresh frozen plasma to a client whose blood type is O-negative. Which of the following actions should the nurse take? A. Continue to monitor for manifestations of a transfusion reaction B. Remove the unit of plasma immediately and start an IV infusion of normal saline solution C. Continue the transfusion and repeat the type and crossmatch D. Prepare to administer a dose f diphenhydramine IV

B. Remove the unit of plasma immediately and start an IV infusion of normal saline solution

A nurse is assessing a client who has pericarditis. Which of the following manifestations should the nurse expect? A. Bradycardia with ST- segment depression B. Relief of chest pain with deep inspiration C. Dyspnea with hiccups D. Chest pain when sitting upright

C. Dyspnea with hiccups The patient will also display a nonproductive cough. Manifestations can indicate heart failure from pericardial compression due to constrictive pericarditis or cardiac tamponade

A nurse is assessing a client who had coronary artery bypass graft for cardiac tamponade. Which of the following actions should the nurse take? A. Check for hypertension B. Auscultate for loud, bounding heart sounds C. Auscultate blood pressure for pulsus paradoxus D. Check for a pulse deficit

C. Auscultate blood pressure for pulsus paradoxus The client who has a cardiac tamponade will have pulsus paradoxus when the systolic blood pressure is at least 10 mm Hg or higher on expiration than on inspiration

A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalance should the nurse expect? A. Hypokalemia B. Hypernatremia C. Elevated Hct D. Decreased Hgb

C. Elevated Hct There will be hyperkalemia from cells bursting and hyponatremia from sodium leaking into the interstitial space

A nurse is providing discharge teaching for a client who has a newly inserted permanent pacemaker. Which of the following instructions should the nurse include in the teaching? A. Request provider's prescription when traveling to alert airport security B. Stand at least 3 feet away while using a microwave C. Keep your cell phone 6 inches away from your pacemaker when making a call D. Avoid showering for the first 2 weeks following surgery

C. Keep your cell phone 6 inches away from your pacemaker when making a call

Which interventions should the nurse perform before using an open-suctioning technique for a patient with an endotracheal (ET) tube (select all that apply.)? A. Put on clean gloves. B. Administer a bronchodilator. C. Perform a cardiopulmonary assessment. D. Hyperoxygenate the patient for 30 seconds. E. Perform hand hygiene before performing the procedure. F. Insert a few drops of normal saline into the ET to break up secretions.

C. Perform a cardiopulmonary assessment. D. Hyperoxygenate the patient for 30 seconds.

A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings indicates that the AAA is expanding? A. Increased BP and decreased pulse rate B. Jugular vein distention and peripheral edema C. Report of sudden, severe back pain D. Report of retrosternal chest pain radiating to the left arm

C. Report of sudden, severe back pain

A nurse is preparing an in-service presentation about assessing clients who are having an acute myocardial infarction (MI). What is the most common assessment findings with acute MI? A. Dyspnea B. Pain in the shoulder and left arm C. Substernal chest pain D. Palpitations

C. Substernal chest pain The nurse should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation

A nurse is assessing a client who is receiving a transfusion of packed red blood cells (RBC). Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? A. Severe hypertension B. Low body temperature C. Sudden oliguria D. Decreased respirations

C. Sudden oliguria This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This reaction results from the client's antibodies reacting to the transfused RBCs

A client who just learned that he has variant (Prizmental's) angina asks the nurse how this type of angina compares with stable angina. Which of the following replies should the nurse make? A. Exertion often brings on pain B. Variant angina occurs randomly at various times C. Variant angina can cause changes on your ECG D. Reducing your cholesterol can help you experience less pain

C. Variant angina can cause changes on your ECG -Attacks may be associated with ST-segment elevation on the ECG

A nurse is monitoring a client who had a myocardial infarction. For which complications should the nurse monitor in the first 24 hr? A. Infective endocarditis B. Pericarditis C. Ventricular dysrhythmias D. Pulmonary emboli

C. Ventricular dysrhythmias

A nurse is preparing to transfuse a unit of packed red blood cells (RBCs) for a client who has anemia. Which of the following actions should the nurse take first? A. Hang an IV infusion of 0.9%sodium chloride with the blood B. Compare the client's identification number with the number on the blood C. Witness the informed consent document D. Obtain pretransfusion vital signs

C. Witness the informed consent document

A nurse is caring for a client who is in hypovolemic shock. While awaiting for a unit of blood, the nurse should administer which of the following IV solutions? A. 0.45% sodium chloride B. Dextrose 5% in 0.9% sodium chloride C. Dextrose 10% in water D. 0.9% sodium chloride

D. 0.9% sodium chloride

A charge nurse is observing a newly licensed nurse administering an IV medication to a client who has an implanted venous access port. Which of the following observations requires intervention by the charge nurse? A. A dressing is not applied to the port site B. A 22-gauge non-coring needle is used to access the port C. Blood return is noted prior to administering the medication D. A solution of 5 mL heparin 1000 units/mL has been prepared

D. A solution of 5 mL heparin 1000 units/mL has been prepared

A nurse is assessing a client who is 85 years old. Which of the following findings should the nurse identify as a manifestation of myocardial infarction? A. Sudden hemoptysis B. Acute diarrhea C. Frontal headache D. Acute confusion

D. Acute confusion Other manifestations include nausea, vomiting, dyspnea, diaphoresis, anxiety, dizziness, palpitations, and fatigue

A nurse is preparing an automated external defibrillator (AED) for a client receiving CPR after a cardiac arrest. Which of the following actions should the nurse perform first? A. Press the analyze button on the machine B. Stop CPR and move away from the client C. Push the charge button to prepare to shock D. Apply the defibrillator pads to the client's chest

D. Apply the defibrillator pads to the client's chest After obtaining the AED, the nurse should first apply the 2 large adhesive defibrillator pads on the client's anterior chest wall to enable the machine to analyze the rhythm and deliver the shock appropriately

A nurse is completing an assessment for client who has a history of unstable angina. Which of the following findings should the nurse expect.? A. Chest pain is relieved soon after resting B. Nitroglycerin relieves chest pain C. Physical exertion does not precipitate chest pain D. Chest pain lasts for longer than 15 min

D. Chest pain lasts for longer than 15 min This is due to reduced blood flow in a coronary artery from atherosclerotic plaque and thrombus formation causing partial arterial obstruction or from an artery spasm

A nurse is assessing a client who is receiving a unit of whole blood. Which of the following findings should the nurse nurse identify as a manifestation of a hemolytic transfusion reaction? A. Bradycardia B. Paresthesia C. Hypertension D. Low back pain

D. Low back pain

A nurse is assessing a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect? A. Midsternal chest pain B. Thrill C. Pitting edema in lower extremities D. Lower back pain

D. Lower back pain

1. When assisting with oral intubation of a patient who is having respiratory distress, in which order will the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Obtain a portable chest-x-ray. b. Position the patient in the supine position. c. Inflate the cuff of the endotracheal tube after insertion. d. Attach an end-tidal CO2 detector to the endotracheal tube. e. Oxygenate the patient with a bag-valve-mask device for several minutes.

E,B,C,D,A

You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as A. metabolic acidosis. B. respiratory acidosis. C. respiratory alkalosis. D. within normal limits.

Within normal limits

1. When planning care for a patient hospitalized with a streptococcal infective endocarditis (IE), which intervention is most appropriate for the nurse to include? a. Arrange for placement of a long-term IV catheter. b. Monitor labs for levels of streptococcal antibodies. c. Teach the importance of completing all oral antibiotics. d. Encourage the patient to begin regular aerobic exercise.

a. Arrange for placement of a long-term IV catheter. (Patient will need a PICC line)

1. When admitting a patient with a non-ST-segment-elevation myocardial infarction (NSTEMI) to the intensive care unit, which action should the nurse perform first? a. Attach the heart monitor. b. Obtain the blood pressure. c. Assess the peripheral pulses. Auscultate the breath sounds

a. Attach the heart monitor.

1. A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Digoxin (Lanoxin) 0.25 mg/day b. Metoprolol (Lopressor) 12.5 mg/day c. Ibuprofen (Motrin) 400 mg every 6 hours d. Lantus insulin 24 U subcutaneously every evening

a. Digoxin (Lanoxin) 0.25 mg/day

1. Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse? a. No sedative has been ordered for the patient. b. The patient does not respond to verbal stimulation. c. There is no cough or gag reflex when the patient is suctioned. d. The patient's oxygen saturation remains between 90% to 93%.

a. No sedative has been ordered for the patient

1. A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider? a. O2 saturation of 99% b. Heart rate 106 beats/minute c. Crackles audible at lung bases d. Respiratory rate 22 breaths/minute

a. O2 saturation of 99% (FiO2 of 80% increases the risk for O2 toxicity. Because the patient's O2 saturation is 99%, a decrease in FiO2 is indicated to avoid toxicity)

1. The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies? a. Observe for distended neck veins. b. Auscultate for crackles in the lungs. c. Palpate for heaves or thrills over the heart. d. Monitor for elevated white blood cell count.

a. Observe for distended neck veins.

1. A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to improve gas exchange? a. On the left side b. On the right side c. In the tripod position d. In the high-Fowler's position

a. On the left side

1. The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider? a. Red-brown drainage from nasogastric tube b. Blood urea nitrogen (BUN) level 32 mg/dL c. Scattered coarse crackles heard throughout lungs d. Arterial blood gases: pH of 7.31, PaCO2 of 50, and PaO2 of 68

a. Red-brown drainage from nasogastric tube (nasogastric drainage indicates possible GI bleeding or stress ulcers and should be reported)

1. A patient with respiratory failure has arterial pressure-based cardiac output (APCO) monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12 cm H2O. Which information indicates that a change in the ventilator settings may be required? a. The arterial pressure is 90/46. b. The stroke volume is increased. c. The heart rate is 58 beats/minute. d. The stroke volume variation is 12%.

a. The arterial pressure is 90/46. (Hypotension suggests high intrathoracic pressure due to PEEP)

1. The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? a. The patient's PaO2 is 45 mm Hg. b. The patient's PaCO2 is 33 mm Hg. c. The patient's respirations are shallow. d. The patient's respiratory rate is 32 breaths/min.

a. The patient's PaO2 is 45 mm Hg.

1. A patient who is orally intubated and receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take next? a. Verbally coach the patient to breathe with the ventilator. b. Sedate the patient with the ordered PRN lorazepam (Ativan). c. Manually ventilate the patient with a bag-valve-mask device. d. Increase the rate for the ordered propofol (Diprivan) infusion

a. Verbally coach the patient to breathe with the ventilator.

1. A patient has a recent tracheostomy. What necessary equipment does the nurse ensure is kept at the bedside? Select all that apply. a. ambu bag b. pair of wire cutters c. oxygen tubing d. suction equipment e. tracheostomy tube with obturator

a. ambu bag c. oxygen tubing d. suction equipment e. tracheostomy tube with obturator

1. A patient was intubated for acute respiratory failure, and there is an endotracheal tube in place. Which nursing interventions are appropriate for this patient? Select all that apply. a. ensure that the oxygen is warmed and humidified b. suction the airway, then the mouth, and give oral care c. Suction the airway with the oral suction equipment d. Position the tubing so it does not pull on the airway e. apply suction only when withdrawing the suction catheter

a. ensure that the oxygen is warmed and humidified b. suction the airway, then the mouth, and give oral care d. Position the tubing so it does not pull on the airway e. apply suction only when withdrawing the suction catheter

1. The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes, a weak cough effort, and complains of fatigue. Which action should the nurse take next? a. Position the patient on the left side. b. Assist the patient with staged coughing. c. Place a humidifier in the patient's room. d. Schedule a 4-hour rest period for the patient.

b. Assist the patient with staged coughing.

1. A family member has been taught to provide oral care to a client with a tracheostomy. Which statement by the family member indicates an accurate understanding of the correct way to provide mouth care? a. "I can use glycerin swabs." b. "I'll use water and a toothette." c. "I can use hydrogen peroxide." d. "It is okay to use mouthwash."

b. "I'll use water and a toothette."

1. The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site

b. 400 mL of blood in the collection chamber

1. The nursing student is performing tracheostomy care on a client. Which action by the student leads the supervising nurse to intervene? a. Using folded gauze dressings on both sides of the stoma b. Cutting a slit in a gauze 4 x 4 pad to fit around the stoma c. Applying new tracheostomy ties before removing old ones d. Tying the twill tape in a square knot on the side of the neck

b. Cutting a slit in a gauze 4 x 4 pad to fit around the stoma

1. A patient has ST segment changes that suggest an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient? a. I b. II c. V2 d. V6

b. II

1. While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take? a. Suction the patient's oropharynx. b. Increase the prescribed O2 flow rate. c. Instruct the patient to cough and deep breathe. d. Help the patient to sit in a more upright position.

b. Increase the prescribed O2 flow rate.

1. Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)? a. Obtain arterial blood gases daily. b. Provide a "sedation holiday" daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30°. e. Provide oral care with chlorhexidine (0.12%) solution daily.

b. Provide a "sedation holiday" daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30°. e. Provide oral care with chlorhexidine (0.12%) solution daily.

1. The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action indicates that the new RN is safe? a. The RN plans to suction the patient every 1 to 2 hours. b. The RN uses a closed-suction technique to suction the patient. c. The RN tapes the connection between the ventilator tubing and the ET. d. The RN changes the ventilator circuit tubing routinely every 48 hours

b. The RN uses a closed-suction technique to suction the patient.

1. A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? a. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. b. The patient has subcutaneous emphysema on the upper thorax. c. The patient has bronchial breath sounds in both the lung fields. d. The patient has a first-degree atrioventricular heart block with a rate of 58 beats/min.

b. The patient has subcutaneous emphysema on the upper thorax. (Subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation)

1. To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to a. obtain a portable chest x-ray. b. use an end-tidal CO2 monitor. c. auscultate for bilateral breath sounds. d. observe for symmetrical chest movement.

b. use an end-tidal CO2 monitor. (Most accurate for rapid verification. ETCO2 should be at least 10 otherwise it is not placed correctly)

1. A patient with ST-segment elevation in three contiguous electrocardiographic leads is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction. Which question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy? a. "Do you have any allergies?" b. "Do you take aspirin on a daily basis?" c. "What time did your chest pain begin?" d. "Can you rate your chest pain using a 0 to 10 scale?"

c. "What time did your chest pain begin?" (Thrombolytic therapy should be started within 6 hours of the onset of the myocardial infarction)

1. Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter? a. Notify the health care provider. b. Offer reassurance to the patient. c. Auscultate the patient's breath sounds. Give prescribed PRN morphine sulfate IV

c. Auscultate the patient's breath sounds. Complications of central line insertion, include embolism and pneumothorax

1. The nurse notes that a patient's endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark, and the patient is anxious and restless. Which action should the nurse take next? a. Check the O2 saturation. b. Offer reassurance to the patient. c. Listen to the patient's breath sounds. d. Notify the patient's health care provider.

c. Listen to the patient's breath sounds.

1. The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider? a. Persistent cough of blood-tinged sputum. b. Scattered crackles in the posterior lung bases. c. Oxygen saturation 90% on 100% O2 by nonrebreather mask. d. Temperature 101.5° F (38.6° C) after 2 days of IV antibiotics.

c. Oxygen saturation 90% on 100% O2 by nonrebreather mask (indication of refractory hypoxemia)

A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped? a. The patient's heart rate is 97 beats/min. b. The patient's oxygen saturation is 93%. c. The patient respiratory rate is 32 breaths/min. d. The patient's spontaneous tidal volume is 450 mL.

c. The patient respiratory rate is 32 breaths/min. Also monitor for for tachycardia, dysrhythmia (PVC's), HTN, low oxygen, sustained Vt <5mL/kg, altered LOC, and agitation

1. Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The patient was last suctioned 6 hours ago. b. The patient's oxygen saturation drops to 93%. c. The patient's respiratory rate is 32 breaths/min. d. The patient has occasional audible expiratory wheezes

c. The patient's respiratory rate is 32 breaths/min.

1. The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. Appropriate instructions for the patient include a. limit dietary sources of potassium. b. take the hydrochlorothiazide before bedtime. c. notify the health care provider if nausea develops. d. take the digoxin if the pulse is below 60 beats/min.

c. notify the health care provider if nausea develops.

1. A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next? a. Increase the tidal volume and respiratory rate. b. Decrease the fraction of inspired oxygen (FIO2). c. Perform endotracheal suctioning more frequently. d. Lower the positive end-expiratory pressure (PEEP).

d. Lower the positive end-expiratory pressure (PEEP).

The nurse responds to a ventilator alarm and finds the patient lying in bed gasping and holding the endotracheal tube (ET) in her hand. Which action should the nurse take next? a. Activate the rapid response team. b. Provide reassurance to the patient. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen.

d. Manually ventilate the patient with 100% oxygen.

1. A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider? a. The Mantoux test had an induration of 7 mm. b. The chest-x-ray showed infiltrates in the lower lobes. c. The patient has a cough that is productive of blood-tinged mucus. d. The patient is being treated with antiretrovirals for HIV infection.

d. The patient is being treated with antiretrovirals for HIV infection.

1. Four hours after mechanical ventilation is initiated, a patient's arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to a. increase the FIO2. b. increase the tidal volume. c. increase the respiratory rate. d. decrease the respiratory rate

d. decrease the respiratory rate

1. The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops a. O2 saturation of 93%. b. green nasogastric tube drainage. c. respirations of 20 breaths/minute. d. increased jugular venous distention.

d. increased jugular venous distention.

1. To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should a. inflate the cuff with a minimum of 10 mL of air. b. inflate the cuff until the pilot balloon is firm on palpation. c. inject air into the cuff until a manometer shows 15 mm Hg pressure. d. inject air into the cuff until a slight leak is heard only at peak inflation.

d. inject air into the cuff until a slight leak is heard only at peak inflation. (MOV technique)

1. A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with a. obtaining a ventilation-perfusion scan. b. drawing blood for arterial blood gases. c. positioning the patient for a chest x-ray. d. insertion of a pulmonary artery catheter.

d. insertion of a pulmonary artery catheter. PAWP <18mmHg

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

4. Positive end-expiratory pressure

The nurse is caring for a 27-yr-old man with multiple fractured ribs from a motor vehicle crash. Which clinical manifestation, if experienced by the patient, is an early indication that the patient is developing respiratory failure? 1. Tachycardia and pursed lip breathing 2. Kussmaul respirations and hypotension 3. Frequent position changes and agitation 4. Cyanosis and increased capillary refill time

3. Frequent position changes and agitation

A client is diagnosed with a spontaneous pneumothorax. Which physiologic effect of a spontaneous pneumothorax should the nurse include in a teaching plan for the client? 1. Air will move from the lung into the pleural space. 2. The heart and great vessels shift toward the affected side. 3. There is greater negative pressure within the chest cavity. 4. Collapse of the other lung will occur if not treated immediately

1. Air will move from the lung into the pleural space.

What nursing action will limit hypoxia when suctioning a client's airway? 1. Apply suction only after catheter is inserted. 2. Limit suctioning with catheter to half a minute. 3. Lubricate the catheter with saline before insertion. 4. Use a sterile suction catheter for each suctioning episode.

1. Apply suction only after catheter is inserted.

Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment? 1. Assess the client's bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. 3. Notify the health-care provider as soon as possible. 4. Document the findings in the client's chart.

1. Assess the client's bilateral lung sounds.

The client with malignant left pleural effusion undergoes a thoracentesis and 900 mL of excess pleural fluid is removed. Which of these manifestations, if noted on the post-procedure assessment, should the nurse report to the health care provider immediately? 1. Asymmetrical chest expansion and decreased breath sounds on the left side 2. Blood pressure 100/65 mm Hg (mean arterial pressure 77 mm Hg) 3. Client complains of 6/10 pain at the needle insertion site 4. Respiratory rate 24/min, pulse oximetry 94% on oxygen 2L/min

1. Asymmetrical chest expansion and decreased breath sounds on the left side (Complications from insertion of the needle and removal of large amounts of fluid include iatrogenic pneumothorax, hemothorax, pulmonary edema, and infection)

The nurse is caring for a client with a chest tube to evacuate a hemopneumothorax after a motor vehicle accident. The drainage has been consistently 25-50 mL/hr for the majority of the shift. However, over the past 2 hours there has been no drainage. Which actions should the nurse take? Select all that apply 1. Auscultate breath sounds 2. Increase amount of suction 3. Instruct the client to cough and deep breathe 4. Milk the chest tube 5. Reposition the client

1. Auscultate breath sounds 3. Instruct the client to cough and deep breathe 5. Reposition the client

The client had a total laryngectomy with tracheostomy placement. The nurse obtains two sets of vital signs that are within normal limits. Which is the nurse's priority now? 1. Check the stoma for the amount of mucus secretions 2. Reposition so that the client is in a flat supine position 3. Measure the amount of blood on the wound dressing 4. Change the vital sign frequency to every 2 hours

1. Check the stoma for the amount of mucus secretions (Can obstruct the airway)

The charge nurse of the emergency department (ED) is mentoring a new registered nurse (RN). They are caring for a client who has a chest tube connected to wall suction for a pneumothorax. The client is being transferred from the ED to the telemetry unit. Which action by the new RN would cause the charge nurse to intervene? 1. Clamping the chest tube at the insertion site during the transfer 2. Disconnecting the suction tubing from the wall suction unit 3. hanging the chest tubing collection unit to the underside of the stretcher 4. Taping connections between the chest tube and suction tubing

1. Clamping the chest tube at the insertion site during the transfer

A chest tube is inserted into a client who was stabbed in the chest and is attached to a closed drainage system. Which is an important nursing intervention when caring for this client? 1. Observe for fluid fluctuations in the water-seal chamber. 2. Obtain a prescription for morphine to minimize agitation. 3. Apply a thoracic binder to prevent excessive tension on the tube. 4. Clamp the tubing securely to prevent a rapid decline in pressure.

1. Observe for fluid fluctuations in the water-seal chamber.

A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless. He has been given intravenous morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas (ABG) results best indicate that the client is in acute respiratory failure (ARF) and needs immediate intervention? 1. PaO2 49 mmHg (6.5kPa), PaCO2 60 mm Hg (8.0 k Pa) 2. PaO2 64 mm Hg (8.5 kPa), PaCO2 45 mm Hg (6.0 kPa) 3. PaO2 70 mm Hg (9.3k kPa), PaCO2 30mm Hg (4.0 kPa) 4. PaO2 86 mm Hg (11.5 kPa), PaCO2 25 mm Hg (3.33 kPa)

1. PaO2 49 mmHg (6.5kPa), PaCO2 60 mm Hg (8.0 k Pa)

The nurse is caring for a 65-yr-old man with acute respiratory distress syndrome (ARDS) who is on pressure support ventilation (PSV), fraction of inspired oxygen (FIO2) at 80%, and positive end-expiratory pressure (PEEP) at 15 cm H2O. The patient weighs 72 kg. What finding would indicate that treatment is effective? 1. PaO2 of 60 mm Hg 2. Tidal volume of 700 mL 3. Cardiac output of 2.7 L/min 4. Inspiration to expiration ratio of 1:2

1. PaO2 of 60 mm Hg

How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes? 1. Palpate around the tube insertion sites for crepitus. 2. Auscultate the breath sounds for crackles and rhonchi. 3. Observe the client for the presence of a barrel-shaped chest. 4. Compare the length of inspiration with the length of expiration.

1. Palpate around the tube insertion sites for crepitus.

The client is suspected of having a pulmonary embolus. Which diagnostic test confirms the diagnosis? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray. 4. Magnetic resonance imaging.

1. Plasma D-dimer test. (Spiral CT is the most used)

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.

1. Remove secretions by suctioning.

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? 1. Remove the air that is present in the intrapleural space 2. Drain serosanguineous fluid from the intrapleural compartment 3. Permit the development of positive pressure between the layers of the pleura 4. Provide access for the instillation of medication into the pleural space

1. Remove the air that is present in the intrapleural space

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1. Right pneumothorax 2. Pulmonary embolism 3. Displaced endotracheal tube 4. Acute respiratory distress syndrome

1. Right pneumothorax

The nurse is caring for the client requiring positive pressure mechanical ventilation. The client has been resisting the ventilator-assisted breaths, and the client's BP has been steadily decreasing. Which intervention should the nurse implement? 1. Place the client in the prone position to help aerate posterior alveoli 2. Ask the respiratory therapist to adjust the machine's RR's 3. Give the prescribed sedative-hypnotic medication if it is due now 4. Prepare to administer an IV bronchodilator such as aminophyline

3. Give the prescribed sedative-hypnotic medication if it is due now

A nurse in the emergency department is assessing a client for closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi

A. Absence of breath sounds

A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus? A. A client who has a chest tube following a pneumothorax B. A client who is postoperative following a laparoscopic appendectomy C. A client who has an acute exacerbation of Crohn's disease D. A client who is recovering from thyroid storm

A. A client who has a chest tube following a pneumothorax

The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. 1. Place the client in the low Fowler's position. 2. Assess chest tube drainage system frequently. 3. Maintain strict bedrest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.

2. Assess chest tube drainage system frequently. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.

When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, what potential effect is a cause for concern? 1. Rupture of the pericardium 2. Infection of the subpleural lining 3. Decreased filling of the right heart 4. Increased volume of the unaffected lung

3. Decreased filling of the right heart

The nurse is caring for the client with a left-sided chest tube attached to wet suction chest tube system. Which observation by the nurse would require immediate intervention? 1. Bubbling is occurring in the suction chamber 2. A loop of tubing is hanging off the bed 3. Tubing connections have bands on them 4. Chest tube insertion site dressing is occlusive

2. A loop of tubing is hanging off the bed

The charge nurse evaluates the care provided by a new registered nurse (RN) for a client receiving mechanical ventilation (MV). Which action by the new RN indicates the need for further education? 1. Administer morphine to relieve anxiety and restlessness 2. Applies suction when inserting the catheter into the airway 3. Increases the oxygen concentration on the MV before suctioning 4. Suctions when MV high pressure alarm continues to sound and rhonchi are present

2. Applies suction when inserting the catheter into the airway

The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's priority when caring for a client with a new tracheostomy? 1. Change the inner cannula within the first 8 hours to help prevent mucus plugs 2. Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these ties 3. Deflating and re-inflating the cuff every 4 hours to prevent mucosal tissue damage 4. Performing frequent mouth care every 2 hours to help prevent infection

2. Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these ties (Inner cannula is typically not changed until 24 hours after insertion; the cuff is kept inflated to prevent aspiration; mouth care is important but a priority following tracheostomy)

The nurse cares for a client with a pulmonary embolism. Which of the following clinical manifestations would the nurse anticipate? Select all that apply? 1. Bradycardia 2. Chest pain 3. Dyspnea 4. Hypoxemia 5. Tachypnea 6. Tracheal deviation

2. Chest pain 3. Dyspnea 4. Hypoxemia 5. Tachypnea

. The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of a pneumothorax in this client? 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a barrel chest 4. A sucking sound at the site of injury

2. Diminished breath sounds

A client just had a thoracentesis. For which response is it most important for the nurse to observe the client? 1. Signs of infection 2. Expectoration of blood 3. Increased breath sounds 4. Decreased respiratory rate

2. Expectoration of blood

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 2 to 3 times in succession to effectively clear the airway. 4. Use rapid movements of the suction catheter to loosen secretions.

2. Hyperoxygenate with 100% oxygen before and after suctioning

Which nursing action is important when suctioning the secretions of a client with a tracheostomy? 1. Use a new sterile catheter with each insertion. 2. Initiate suction as the catheter is being withdrawn. 3. Insert the catheter until the cough reflex is stimulated. 4. Remove the inner cannula before inserting the suction catheter

2. Initiate suction as the catheter is being withdrawn.

Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax? 1. Gentle bubbling in the suction compartment. 2. No fluctuation (tidaling) in the water-seal compartment. 3. The drainage compartment has 250 mL of blood 4. The client is able to deep breathe without any pain

2. No fluctuation (tidaling) in the water-seal compartment.

The nurse is caring for the client whose condition has prolonged from an acute lung injury from near-drowning to ARDS. Which intervention should the nurse question with the HCP? 1. Place in prone position if tolerated 2. Normal saline 1000-mL bolus, then at 250 mL/hour 3. Ventilatory support with positive end-expiratory pressure (PEEP) 4. Methylprednisolone 175 mg IV now and q4h

2. Normal saline 1000-mL bolus, then at 250 mL/hour

A client who has acquired immunodeficiency syndrome develops bacterial pneumonia. On admission to the emergency department, the client's PaO2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is determined to be 65 mm Hg. What should the nurse do first? 1. Increase the oxygen flow rate. 2. Notify the health care provider. 3. Decrease the tension of oxygen in the plasma. 4. Have the arterial blood gases redone to verify accuracy

2. Notify the health care provider (Indication of respiratory failure)

The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the health care provider is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? 1. Gather the needed supplies for the procedure. 2. Obtain a signed informed consent form. 3. Assist the client into a side-lying position. 4. Discuss the procedure with the client

2. Obtain a signed informed consent form.

A client with a severe asthma exacerbation following influenza infection is transferred to the intensive care unit due to rapidly deteriorating respiratory status. Which clinical manifestation supports the nurse's assessment of impending respiratory failure? Select all that apply 1. Arterial pH 7.50 2. PaCO2 55 mm Hg 3. PaO2 58 mm Hg 4. Paradoxical breathing 5. Restlessness and drowsiness

2. PaCO2 55 mm Hg 3. PaO2 58 mm Hg 4. Paradoxical breathing 5. Restlessness and drowsiness

The nurse assesses the client brought to the ED via ambulance after a motorcycle crash. The client has paradoxical chest movement with respirations, multiple bruises across the chest and torso, crepitus and tachypnea. What should the nurse do next? 1. Remove and reapply the cervical collar 2. Prepare for the client's imminent intubation 3. Insert another IV catheter to give medications 4. Tape the client's chest rib for protection

2. Prepare for the client's imminent intubation

What clinical indicators should the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? Select all that apply. 1. Hematemesis 2. Shortness of breath 3. Unilateral chest pain 4. Increased thoracic motion 5. Mediastinal shift toward the involved side

2. Shortness of breath 3. Unilateral chest pain

The nurse is caring for a client with a chest tube that was placed 2 hours ago for a pneumothorax. Where would the nurse expect gentle, continuous bubbling? 1. Air leak monitor 2. Collection chamber 3. Suction control chamber 4. Water seal chamber

2. Suction control chamber

. Which nursing assessment data support that the client has experienced a pulmonary embolism? 1. Calf pain with dorsiflexion of the foot. 2. Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade fever.

2. Sudden onset of chest pain and dyspnea.

The nurse assesses the client being treated for smoke inhalation. Which early signs indicate the possible onset ARDS in this client? 1. Cough with blood-tinged sputum and respiratory alkalosis 2. Decreased in white blood cell and red blood cell count 3. Diaphoresis and low saO2 despite oxygen administration 4. Steadily increasing BP and elevated PaO2

3. Diaphoresis and low saO2 despite oxygen administration

The nurse is assisting the health care provider (HCP) with a client's chest tube removal. Just as the HCP prepares to pull the chest tube, what instructions should the nurse give the client? 1. "Breathe as you normally would" 2. "Inhale and exhale slowly" 3. "Take a breath in, hold it, and bear down" 4. "Take rapid shallow breaths, similar to panting"

3. "Take a breath in, hold it, and bear down" (A post-procedure x-ray must be performed to ensure there is no reaccumulation of air or fluid in the pleural space)

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? 1. 1 minute 2. 5 seconds 3. 10 seconds 4. 30 seconds

3. 10 seconds

The nurse is admitting a 45-yr-old patient with asthma in acute respiratory distress. The nurse auscultates the patient's lungs and notes cessation of the inspiratory wheezing. The patient has not yet received any medication. What should this finding suggest to the nurse? 1. Spontaneous resolution of the acute asthma attack 2. An acute development of bilateral pleural effusions 3. Airway constriction requiring immediate interventions 4. Overworked intercostal muscles resulting in poor air exchange

3. Airway constriction requiring immediate interventions

The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? 1. Confirm that the ventilator settings are correct. 2. Verify that the ventilator alarms are functioning properly. 3. Assess the respiratory status and pulse oximeter reading. 4. Monitor the client's arterial blood gas results.

3. Assess the respiratory status and pulse oximeter reading.

The nurse is caring for a 37-yr-old female patient with multiple musculoskeletal injuries who has developed acute respiratory distress syndrome (ARDS). Which intervention should the nurse initiate to prevent stress ulcers? 1. Observe stools for frank bleeding and occult blood. 2. Maintain head of the bed elevation at 30 to 45 degrees. 3. Begin enteral feedings as soon as bowel sounds are present. 4. Administer prescribed lorazepam (Ativan) to reduce anxiety.

3. Begin enteral feedings as soon as bowel sounds are present.

The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse implement if there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a STAT chest x-ray. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client's pulse oximeter reading

3. Check the tubing for kinks or clots.

The nurse is caring for a patient who is admitted with a barbiturate overdose. The patient is comatose with a blood pressure of 90/60 mm Hg, apical pulse of 110 beats/min, and respiratory rate of 8 breaths/min. Based on the initial assessment findings, the nurse recognizes that the patient is at risk for which type of respiratory failure? 1. Hypoxemic respiratory failure related to shunting of blood 2. Hypoxemic respiratory failure related to diffusion limitation 3. Hypercapnic respiratory failure related to alveolar hypoventilation 4. Hypercapnic respiratory failure related to increased airway resistance

3. Hypercapnic respiratory failure related to alveolar hypoventilation

Arterial blood gas results are reported to the nurse for a 68-yr-old patient admitted with pneumonia: pH 7.31, PaCO2 49 mm Hg, HCO3 26 mEq/L, and PaO2 52 mm Hg. What order should the nurse complete first? 1. Administer albuterol inhaler prn. 2. Increase fluid intake to 2500 mL per 24 hours. 3. Initiate oxygen at 2 liters/minute by nasal cannula. 4. Perform chest physical therapy four times per day.

3. Initiate oxygen at 2 liters/minute by nasal cannula.

The nurse is caring for a client receiving mechanical ventilation via tracheostomy 2 weeks ago following a tracheotomy. The nurse enters the client's room to address a ventilator alarm and notes the tracheostomy tube dislodged and lying on the client's chest. Which action by the nurse is appropriate? 1. Apply a nonrebreather face mask with 100% oxygen 2. Apply dry, sterile gauze over the stoma and secure with tape 3. Insert a new tracheostomy tube using the bedside obturator 4. Insert a sterile catheter into the stoma and suction the airway

3. Insert a new tracheostomy tube using the bedside obturator

The nurse is caring for a patient with pneumonia unresponsive to two different antibiotics. Which action is most important for the nurse to complete before administering a newly prescribed antibiotic? 1. Teach the patient to cough and deep breathe. 2. Take the temperature, pulse, and respiratory rate. 3. Obtain a sputum specimen for culture and Gram stain. 4. Check the patient's oxygen saturation by pulse oximetry.

3. Obtain a sputum specimen for culture and Gram stain.

When an unlicensed assistive personnel (UAP) assists a client with a chest tube back to bed from the beside commode, the plastic drainage unit accidently falls over and cracks. The UAP immediately reports this incident to the nurse. What is the nurse's immediate action? 1. Clamp the tube close to the client's chest until a new chest drainage unit is set up 2. Notify the health care provider (HCP) 3. Place the distal end of the chest tube into a bottle of sterile saline 4. Position the client on the left side

3. Place the distal end of the chest tube into a bottle of sterile saline

The nurse is caring for a client who has been receiving mechanical ventilation (MV) for 4 days. During multidisciplinary morning rounds, the health care provider questions the development of a ventilator-associated pneumonia (VAP). Which of the following manifestations does the nurse assess as the best indicator of VAP? 1. Blood-tinged sputum 2. Positive blood cultures 3. Positive, purulent sputum cultures 4. Rhonchi and crackles

3. Positive, purulent sputum cultures (Other characteristics include leukocytosis (12,000mm3), elevated temperature (>100.4F[38 C], and new or progressive pulmonary infiltrates suggestive of pneumonia on chest x-ray)

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect? 1. Increased inflation of the lungs 2. Prevention of barotrauma to the lung tissue 3. Prevention of alveolar collapse during expiration 4. Increased fraction of inspired oxygen concentration (FIO2) administration

3. Prevention of alveolar collapse during expiration

A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" What likely cause of the spontaneous pneumothorax should the nurse's response take into consideration? 1. Pleural friction rub 2. Tracheoesophageal fistula 3. Rupture of a subpleural bleb 4. Puncture wound of the chest wall

3. Rupture of a subpleural bleb

The nurse in collaboration with respiratory therapy is determining a patient's readiness to wean from the ventilator. Which finding indicates the patient is not a candidate for weaning (select all that apply.)? 1. Minute volume of 8 L/min 2. Patient follow commands 3. Serum hemoglobin of 6 g/dL 4. Respirations of 28 breaths/min 5. Mean arterial pressure (MAP) of 45 mm Hg 6. Negative inspiratory force (NIF) of -15 cm H2O

3. Serum hemoglobin of 6 g/dL 5. Mean arterial pressure (MAP) of 45 mm Hg 6. Negative inspiratory force (NIF) of -15 cm H2O

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is most appropriate? 1. Continue to suction. 2. Notify the health care provider immediately. 3. Stop the procedure and reoxygenate the client. 4. Ensure that the suction is limited to 15 seconds

3. Stop the procedure and reoxygenate the client.

The client diagnosed with a pulmonary embolus is in the intensive care unit. Which assessment data warrant immediate intervention from the nurse? 1. The client's ABGs are pH 7.36, PaO2 95, PaCO2 38, HCO3 24. 2. The client's telemetry exhibits occasional premature ventricular contractions. 3. The client's pulse oximeter reading is 90%. 4. The client's urinary output for the 12-hour shift is 800 mL.

3. The client's pulse oximeter reading is 90%.

The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? 1. Administer oxygen 2. Check the client's vital signs 3. Ventilate the client manually 4. Start cardiopulmonary resuscitation

3. Ventilate the client manually

The home health nurse visits a 72-year-old client with pneumonia who was discharged from the hospital 3 days ago. The client has less of a productive cough at night but now reports sharp chest pain with inspiration. Which finding is most important for the nurse to report to the health care provider? 1. Bronchial breath sounds 2. Increased tactile fremitus 3. Low-pitched wheezing (rhonchi) 4. Pleural friction rub

4. Pleural friction rub (Caused by inflammation of the visceral pleura (over the lung) and the partial pleura (over the chest cavity) When inflamed, they rub together, causing pleuritic pain).

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take? 1. Take the client's vital signs. 2. Inform the health care provider. 3. Turn the client to the unaffected side. 4. Check the tube to ensure that it is not kinked

4. Check the tube to ensure that it is not kinked

A client presents to the emergency department with a stab wound to the chest. The nurse assesses tachycardia, tachypnea, and a sucking sound coming from the wound. Which of the following actions is priority? 1. Administer prescribed IV fluids 2. Apply supplemental oxygen via nonrebreather mask 3. Assist the health care provider for chest tube insertion 4. Cover the wound with petroleum gauze taped on three sides

4. Cover the wound with petroleum gauze taped on three sides

A 56-yr-old man with acute respiratory distress syndrome (ARDS) is on positive pressure ventilation (PPV). The patient's cardiac index is 1.4 L/min and pulmonary artery wedge pressure is 8 mm Hg. What order by the physician is important for the nurse to question? 1. Initiate a dobutamine infusion at 3 mcg/kg/min. 2. Administer 1 unit of packed red blood cells over the next 2 hours. 3. Change the maintenance intravenous (IV) rate from 75 to 125 mL/hr. 4. Increase positive end-expiratory pressure (PEEP) from 10 to 15 cm H2O.

4. Increase positive end-expiratory pressure (PEEP) from 10 to 15 cm H2O.

The client is admitted with possible PE. In consulting with the HCP, the nurse learns that the V/Q scan shows a ventilatory/perfusion quotient mismatch. Which intervention is appropriate? 1. Explain to the client that airborne precautions will be necessary 2. Tell the client the scan did not show a pulmonary embolus 3. Explain to the client that further diagnostic testing will be needed 4. Inform the client that further diagnostic testing will be needed

4. Inform the client that further diagnostic testing will be needed

The nurse is caring for a patient intubated and on a mechanical ventilator for several days. Which weaning parameter would tell the nurse if the patient has enough muscle strength to breathe without assistance? 1. Tidal volume 2. Minute ventilation 3. Forced vital capacity 4. Negative inspiratory force

4. Negative inspiratory force (The negative inspiratory force measures inspiratory muscle strength).

The nurse is caring for a client with a right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site.

A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment? 1. Color of sputum 2. Lung sounds 3. Saturation level 4. White blood cell count (WBC)

4. White blood cell count (WBC)

A patient with a gunshot wound to the right side of the chest arrives in the emergency department exhibiting severe shortness of breath with decreased breath sounds on the right side of the chest. Which action should the nurse take immediately? A. Cover the chest wound with a nonporous dressing taped on three sides. B. Pack the chest wound with sterile saline soaked gauze and tape securely. C. Stabilize the chest wall with tape and initiate positive pressure ventilation. D. Apply a pressure dressing over the wound to prevent excessive loss of blood.

A. Cover the chest wound with a nonporous dressing taped on three sides.

A nurse on a medical-surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the healthcare provider? A. Increased coughing B. Diaphragmatic breathing C. Hemoptysis D. Kussmaul respirations

A. Increased coughing (Other manifestations talking difficulties and breathing)

A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? A. Initiate bag-valve-mask ventilation B. Provide the client with a communication board C. obtain blood sample for ABG analysis D. Document the ventilator settings

A. Initiate bag-valve-mask ventilation

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A. Stabbing chest pain B. Calf tenderness C. Elevated temperature D. Bradycardia

A. Stabbing chest pain (Other manifestations include dyspnea, coughing, hemoptysis, tachycardia, diaphoresis, and a feeling of impending doom)

A nurse is caring for a client immediately following extubation. Which of the following manifestations indicates that the nurse should call the rapid response team? A. Stridor B. Coughing C. Hoarseness D. Extensive oral secretions

A. Stridor

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? A. Sudden onset of dyspnea B. Tracheal deviation C. Bradycardia D. Difficulty swallowing

A. Sudden onset of dyspnea

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? Select all that apply A. Tracheal deviation to the left B. Temperature of 38.8 C (102F) C. Absent breath sounds on the right side D. Neck vein distention E. Bradypnea

A. Tracheal deviation to the left C. Absent breath sounds on the right side D. Neck vein distention

A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? A. Excessive airway secretions B. A leak within the ventilator's circuitry C. Decreased lung compliance D. The client coughing or attempting to talk

B. A leak within the ventilator's circuitry

A patient whose tracheostomy was inserted 30 minutes ago is recovering in the postanesthesia recovery unit when the tracheostomy tube is expelled by coughing. What is the priority action by the nurse? A. Suction the tracheostomy opening. B. Maintain the airway with a sterile hemostat. C. Use an Ambu bag and mask to ventilate the patient. D. Insert the tracheostomy tube obturator into the stoma.

B. Maintain the airway with a sterile hemostat.

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? A. Tympanic temperature 38 C (100.4 F) B. PaO2 50 mmHg C. Rhonchi D. Hypopnea

B. PaO2 50 mmHg (Refractory hypoxemia)

A patient has a tracheostomy tube after reconstructive surgery for invasive head and neck cancer. What is most important for the nurse to assess before performing tracheostomy cannula care? A. Level of consciousness B. Quality of breath sounds C. Presence of the gag reflex D. Tracheostomy cuff pressure

B. Quality of breath sounds

A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make? A "Two tubes were necessary due to excessive bleeding from the area of the surgery" B. " The tubes drain blood from 2 different lung areas" C. " The lower tube will drain blood, and the higher tube will remove air" D. "The second tube will take over if blood clots block the first tube"

C. " The lower tube will drain blood, and the higher tube will remove air"

A nurse is providing discharge teaching to a client who had a pulmonary embolism. Which of the following statements indicate that the client understands the information? A. "I'll expect a little leg swelling since I won't be that active for a while" B. "I'll see the doctor every week to change my vena cava filter" C. "I'll call the doctor if I see any blood in my urine or stool" D. "I'll have to take the blood thinner for a few more days"

C. "I'll call the doctor if I see any blood in my urine or stool"

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing actions? A. Water-seal chamber has 5 cm of water. B. No new drainage in collection chamber C. Chest tube with a loose-fitting dressing D. Small pneumothorax at CT insertion site

C. Chest tube with a loose-fitting dressing

A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? A. Instruct the client to cough B. Administer oxygen via face mask C. Evaluate the client for stridor D. Keep the client in a semi-to-high fowler's position

C. Evaluate the client for stridor (may indicate laryngospasm or swelling around the glottis)

A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take? A. Cover the insertion site with a hydrocolloid dressing after removal B. Provide pain medication immediately after removal C. Instruct the client to perform the valsalva maneuver during removal D. Delegate removal of the chest tube to a LPN

C. Instruct the client to perform the valsalva maneuver during removal

A nurse is preparing to assist a provider with an arterial blood withdrawal from a client's radial artery for ABG measurement. Which of the following actions should the nurse plan to take? A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen B. Apply ice to the site after obtaining the specimen C. Perform an Allen's test prior to obtaining the specimen D. Release the pressure applied to the puncture site 1 min after the needle is withdrawn

C. Perform an Allen's test prior to obtaining the specimen

The nurse is caring for a patient with a tracheostomy. What is the priority nursing assessment for this patient? A. Electrolyte levels and daily weights B. Assessment of speech and swallowing C. Respiratory rate and oxygen saturation D. Pain assessment and assessment of mobility

C. Respiratory rate and oxygen saturation

A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? A. Wheezing B. Bradypnea C. Tachycardia D. Diaphoresis

C. Tachycardia (Other signs include dyspnea, restlessness, headache, and increased blood pressure)

A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? A. Clamp the chest tube if there is continuous bubbling in the water seal chamber B. Keep the chest tube drainage system at the level of the right atrium C. Tape all connections between the chest tube and drainage system D. Empty the collection chamber and record the amount of drainage every 8 hr

C. Tape all connections between the chest tube and drainage system

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? A. "I will seek immediate medical treatment for any upper respiratory infections." B. "I should continue to do deep breathing and coughing exercises for at least 12 weeks." C. "I will increase my food intake to 2400 calories a day to keep my immune system well." D. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

D. "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? A. Tracheostomy placement B. Thoracentesis C. CT scan of the chest D. Chest tube insertion

D. Chest tube insertion (connect to water-seal drainage system)

A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? A. Removing air from the pleural space B. Creating access for irrigating the chest cavity C. Evacuating secretions from the bronchioles and alveoli D. Draining blood and fluid from the pleural space

D. Draining blood and fluid from the pleural space

A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected form the chest drainage system. Which of the following actions should the nurse take? A. Place the drainage system at the head of the client's bed B. Increase the suction to the chest drainage system C. Place the client on low-flow oxygen via nasal cannula D. Immerse the end of the chest tube in a bottle of sterile water

D. Immerse the end of the chest tube in a bottle of sterile water

A nurse is preparing a client for thoracentesis. In which of the following positions should the nurse place the client? A. Lying flat on the affected side B. Prone with arms raised over the head C. Supine with the head of the bed elevated D. Sitting while leaning forward over the bedside table

D. Sitting while leaning forward over the bedside table

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. WHich of the following findings indicates that the nurse should suction the client's airway secretions? A. The client is unable to speak B. The client's airway secretions were last suctioned 2 hr ago C. The client coughs and expectorates a large mucous plug D. The nurse auscultates coarse crackles in the lung fields

D. The nurse auscultates coarse crackles in the lung fields

You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A proximal bowel obstruction is suspected. Which acid-base imbalance do you anticipate in this patient? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

Metabolic alkalosis

You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results? A. Partially compensated respiratory acidosis B. respiratory acidosis C. Normal acid-base balance with hypoxemia D. Normal acid-base balance with hypercapnia

Partially compensated respiratory acidosis