MSN 377 Exam 3 - Ch 27, 65, 67

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? "I should continue to do deep breathing and coughing exercises for at least 12 weeks." "I will seek immediate medical treatment for any upper respiratory infections." "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." "I will increase my food intake to 2400 calories a day to keep my immune system well."

"I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." The follow-up chest x-ray examination will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.

The nurse is teaching the patient with human immunodeficiency virus (HIV) about the diagnosis of Candida albicans. What statement made by the patient indicates to the nurse that further teaching is required? "I got this fungus because I am immunocompromised." "I need to be isolated from my family and friends so they won't get it." "The effectiveness of my therapy can be monitored with fungal serology titers." "I will be given amphotericin B to treat the fungus."

"I need to be isolated from my family and friends so they won't get it." The patient with an opportunistic fungal infection does not need to be isolated because it is not transmitted from person to person. This immunocompromised patient will be likely to have a serious infection so it will be treated with IV amphotericin B. The effectiveness of the therapy can be monitored with fungal serology titers.

The nurse instructs a patient with a pulmonary embolism about administering enoxaparin after discharge. Which statement by the patient indicates understanding about the instructions? "I will inject this medicine into my upper arm." "I need to take this medicine with meals." "The medicine will dissolve the clot in my lung." "The medicine will be prescribed for 10 days."

"The medicine will be prescribed for 10 days." Enoxaparin is a low-molecular-weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots. Fibrinolytic agents (e.g., tissue plasminogen activator or alteplase) dissolve an existing clot. Enoxaparin is administered subcutaneously by injection into the abdomen.

631. 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 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. During suctioning, the nurse should monitor the client closely for adverse effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.

628. The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply. 1. Activities should be resumed gradually. 2. Avoid contact with other individuals, except family members, for at least 6 months. 3. A sputum culture is needed every 2 to 4weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members already have been exposed. 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. 6. When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

1. Activities should be resumed gradually. 3. A sputum culture is needed every 2 to 4weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members already have been exposed. 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client needs to follow the medication regimen exactly as prescribed and always have a supply of the medication on hand. Side and adverse effects of the medication and ways of minimizing them to ensure compliance should be explained. After 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activities should be resumed gradually and a well balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection should be consumed. Respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to put used tissues into plastic bags. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated . When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.

641. A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding? 1. Dyspnea 2. Headache 3.Weight gain 4. Hypothermia

1. Dyspnea Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the client's lymph nodes, liver, and spleen may occur as well.

646. The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply. 1. Dyspnea 2. Headache 3. Night sweats 4. A bloody, productive cough 5. A cough with the expectoration of mucoid sputum

1. Dyspnea 3. Night sweats 4. A bloody, productive cough 5. A cough with the expectoration of mucoid sputum Tuberculosis should be considered for any clients with a persistent cough, weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever, or chills. The client's previous exposure to tuberculosis should also be assessed and correlated with the clinical manifestations.

643. The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles? 1. Mask 2. Gown 3. Gloves 4. Eye protection

1. Mask Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. Options 2, 3, and 4 are not necessary.

640. A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? 1. Positive 2. Negative 3. Inconclusive 4. Need for repeat testing

1. Positive The client with HIV infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5 mm. The client without HIV is positive with an induration larger than 10 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect interpretations.

634. Aclient 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 Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi.

630. 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? 1.5seconds 2. 10 seconds 3. 30 seconds 4. 60 seconds

2. 10 seconds Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must pre-oxygenate the client before suctioning and limit the suctioning pass to 10 seconds.

626. The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. 1. A low arterial PCo2 level 2. A hyper-inflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise 4. A widened diaphragm noted on the chest x-ray 5. Pulmonary function tests that demonstrate increased vital capacity

2. A hyper-inflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

625. The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates 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 This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are short- ness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

638. The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care? 1. Surgical mask and gloves 2. Particulate respirator, gown, and gloves 3. Particulate respirator and protective eyewear 4. Surgical mask, gown, and protective eyewear

2. Particulate respirator, gown, and gloves The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath.

636. The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? 1. Palpation and clubbing 2. Percussion and vibration 3. Hyperoxygenation and suctioning 4. Administer a bronchodilator and monitor peak flow

2. Percussion and vibration Chest physiotherapy of percussion and vibration helps to loosen secretions in the smaller lower airways. Postural drainage positions the client so that gravity can help mucus move from smaller airways to larger ones to support expectoration of the mucus. Options 1, 3, and 4 are not actions that will loosen secretions.

644. An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? 1.Facetent 2. Venturi mask 3. Aerosol mask 4. Tracheostomy collar

2. Venturi mask The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation such as chronic obstructive pulmonary disease, because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.

629. The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? 1. Drycough 2. Hematuria 3. Bronchospasm 4. Blood-streaked sputum

3. Bronchospasm If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

639. A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1. Hot, flushed feeling 2. Sudden chills and fever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken

3. Chest pain that occurs suddenly The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restless- ness, tachycardia, cough, and cyanosis.

633. A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1. Cyanosis 2. Hypotension 3. Paradoxical chest movement 4. Dyspnea, especially on exhalation

3. Paradoxical chest movement Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.

647. The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis? 1. Chestx-ray 2. Bronchoscopy 3. Sputum culture 4. Tuberculin skin test

3. Sputum culture Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.

648. 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 If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin cardiopulmonary resuscitation. Checking vital signs is not the initial action. Although oxygen is helpful, it will not provide ventilation to the client.

A patients vital signs are pulse 80, respirations 24, and BP of 124/60 mm Hg and cardiac output is 4.8 L/min. What is the patients stroke volume?

60 mL Stroke volume = cardiac output/heart rate

637. The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement? 1. "I need to continue medication therapy for 1 month." 2. "I can't shop at the mall for the next 6 months." 3. "I can return to work if a sputum culture comes back negative." 4. "I should not be contagious after 2 to 3 weeks of medication therapy."

4. "I should not be contagious after 2 to 3 weeks of medication therapy." The client is continued on medication therapy for up to 12 months, depending on the situation. The client generally is considered noncontagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of 3 sputum cultures are negative.

635. 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 earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

632. The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? 1. Slow, deep respirations 2. Rapid, deep respirations 3. Paradoxical respirations 4. Pain, especially with inspiration

4. Pain, especially with inspiration Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.

627. The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? 1. Promote oxygen intake 2. Strengthen the diaphragm 3. Strengthen the intercostal muscles 4. Promote carbon dioxide elimination

4. Promote carbon dioxide elimination Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.

642. The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation? 1. Fever 2. Fatigue 3. Weight loss 4. Shortness of breath

4. Shortness of breath Dry cough and dyspnea are typical early manifestations of pulmonary sarcoidosis. Later manifestations include night sweats, fever, weight loss, and skin nodules.

645. The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? 1.Sitting up in bed 2. Side-lying in bed 3. Sitting in a recliner chair 4. Sitting up and leaning on an overbed table

4. Sitting up and leaning on an overbed table Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.

The nurse is caring for a group of patients. Which patient is at risk of aspiration? A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields

A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration.

Which factor indicates that tracheostomy placement would be preferable to endotracheal intubation? The patient is unable to clear secretions. A long-term airway is probably necessary. The patient is at high risk for aspiration. An upper airway obstruction is impairing the patient's ventilation.

A long-term airway is probably necessary. A tracheostomy is indicated when the need for an artificial airway is expected to be long term. Aspiration risk, an inability to clear secretions, and upper airway obstruction are indications for an artificial airway, but these are not specific indications for tracheostomy.

Which patient would most benefit from noninvasive positive pressure ventilation (NIPPV) to promote oxygenation? A patient whose respiratory failure is due to a head injury with loss of consciousness A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis A patient whose cardiac output and blood pressure are unstable A patient with a diagnosis of cystic fibrosis and who is currently producing copious secretions

A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis NIPPV such as continuous positive airway pressure (CPAP) is most effective in treating patients with respiratory failure resulting from chest wall and neuromuscular disease. It is not recommended in patients who are experiencing hemodynamic instability, decreased level of consciousness, or excessive secretions.

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)? A. Age B. Blood pressure C. Respiratory rate D. O2 saturation E. Presence of confusion F.Blood urea nitrogen (BUN) level

A+B+C+E+F Explanation/Rationale:Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 years and older). The other information is also essential to assess, but are not used for CURB-65 scoring.

The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Obtain the O2 saturation. b. Check the patient's pulse rate. c. Document the change in status. d. Notify the health care provider.

A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done

The nurse notes new onset confusion in an 89-year-old patient in a long-term care facility. The patient is normally alert and oriented. In which order should the nurse take the following actions? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain the oxygen saturation. b. Check the patients pulse rate. c. Document the change in status. d. Notify the health care provider

A, B, D, C Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done.

The nurse is caring for a patient who has an intraaortic balloon pump (IABP) after a massive heart attack. When assessing the patient, the nurse notices blood backing up into the IABP catheter. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].) a. Confirm that the IABP console has turned off. b. Assess the patient's vital signs and orientation. c. Obtain supplies for insertion of a new IABP catheter. d. Notify the health care provider of the IABP malfunction.

A, B, D, C Blood in the IABP catheter indicates a possible tear in the balloon. The console should shut off automatically to prevent complications such as air embolism. Next, the nurse will assess the patient and communicate with the health care provider about the patient's assessment and the IABP problem. Finally, supplies for insertion of a new IABP catheter may be needed based on the patient assessment and the decision of the health care provider.

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next? A. Auscultate for breath sounds. B. Administer the PRN morphine. C. Have the patient cough forcefully. D.Notify the patient's health care provider.

A. Auscultate for breath sounds. Explanation/Rationale:The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.

When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient's temperature is 101.8° F. What should the nurse plan to do? A. Discontinue the catheter and culture the tip. B. Use the catheter only for fluid administration. C. Change the flush system and monitor the site. D. Check the site more frequently for any swelling.

A. Discontinue the catheter and culture the tip. Explanation/Rationale: The information indicates that the patient has a local and systemic infection caused by the catheter, and the catheter should be discontinued to avoid further complications such as endocarditis. Changing the flush system, continued monitoring, or using the line for fluids will not help prevent or treat the infection.

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)? A. Document the amount of drainage every 8 hours. B. Obtain samples of drainage for culture from the system. C. Assess patient pain level associated with the chest tube. D.Check the water-seal chamber for the correct fluid level.

A. Document the amount of drainage every 8 hours. Explanation/Rationale:UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.

A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? A. Elevate head of bed to 30 to 45 degrees. B. Give enteral feedings at no more than 10 mL/hr. C. Suction the endotracheal tube every 2 to 4 hours. D.Limit the use of positive end-expiratory pressure.

A. Elevate head of bed to 30 to 45 degrees. Explanation/Rationale:Elevation of the head decreases the risk for aspiration. Positive end-expiratory pressure is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient's high energy needs.

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect? A. Increased tactile fremitus B. Dry, nonproductive cough C. Hyperresonance to percussion D. A grating sound on auscultation

A. Increased tactile fremitus Explanation/Rationale:Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.

A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most likely to result in postponing the SBT? A. New ST segment elevation is noted on the cardiac monitor. B. Enteral feedings are being given through an orogastric tube. C. Scattered rhonchi are heard when auscultating breath sounds. D. hydromorphone (Dilaudid) is being used to treat postoperative pain.

A. New ST segment elevation is noted on the cardiac monitor. Explanation/Rationale: Myocardial ischemia is a contraindication for ventilator weaning. The ST segment elevation is an indication that weaning should be postponed until further investigation and/or treatment for myocardial ischemia can be done. Ventilator weaning can proceed when opioids are used for pain management, abnormal lung sounds are present, or enteral feedings are being used.

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. Explanation/Rationale:Because neuromuscular blockade is extremely anxiety provoking, it is essential that patients who are receiving neuromuscular blockade receive concurrent sedation and analgesia. Absence of response to stimuli is expected in patients receiving neuromuscular blockade. The O2 saturation is adequate.

The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? A. O2 saturation is 88%. B. Blood pressure is 155/90 mm Hg. C. Pain level is 5 (on 0 to 10 scale) with a deep breath. D. Respiratory rate is 24 breaths/minute when lying flat.

A. O2 saturation is 88%. Explanation/Rationale:O2 saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low O2 saturation is the priority.

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% Explanation/Rationale:The 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. The other patient data would be typical for a patient with ARDS and would not be the most important data to report to the health care provider.

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. Explanation/Rationale:Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiography and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. White blood count elevation might indicate infection but is not expected with cor pulmonale.

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 Explanation/Rationale:The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions.

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? A. Paradoxical chest movement B. Complaint of chest wall pain C. Heart rate of 110 beats/minute D. Large bruised area on the chest

A. Paradoxical chest movement Explanation/Rationale:Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.

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 Explanation/Rationale:The nasogastric drainage indicates possible gastrointestinal bleeding or stress ulcer and should be reported. The pH and PaCO2 are slightly abnormal, but current guidelines advocating for permissive hypercapnia indicate that these would not indicate an immediate need for a change in therapy. The BUN is slightly elevated but does not indicate an immediate need for action. Adventitious breath sounds are commonly heard in patients with ARDS.

Which information about prevention of lung disease should the nurse include for a patient with a 42 pack-year history of cigarette smoking? A. Resources for support in smoking cessation B. Reasons for annual sputum cytology testing C. Erlotinib (Tarceva) therapy to prevent tumor risk D.Computed tomography (CT) screening for cancer

A. Resources for support in smoking cessation Explanation/Rationale:Because smoking is the major cause of lung cancer, the most important role for the nurse is teaching patients about the benefits of and means of smoking cessation. CT scanning is currently being investigated as a screening test for high-risk patients. However, if there is a positive finding, the person already has lung cancer. Sputum cytology is a diagnostic test, but does not prevent cancer or disease. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer.

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. Explanation/Rationale: The hypotension suggests that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and (potentially) cardiac output. The other assessment data would not be a direct result of PEEP and mechanical ventilation.

When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider? A. The patient is very somnolent. B. The patient complains of weakness. C. The patient's blood pressure is 164/98. D. The patient's oxygen saturation is 90%.

A. The patient is very somnolent. Explanation/Rationale:Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest.

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. Explanation/Rationale:The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient's poor oxygenation.

When prone positioning is used for a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? A. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. B. Endotracheal suctioning results in clear mucous return. C. Sputum and blood cultures show no growth after 48 hours. D.The skin on the patient's back is intact and without redness.

A. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. Explanation/Rationale:The purpose of prone positioning is to improve the patient's oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective.

Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take action? A. The right hand feels cooler than the left hand. B. The mean arterial pressure (MAP) is 77 mm Hg. C. The system is delivering 3 mL of flush solution per hour. D. The flush bag and tubing were last changed 2 days previously

A. The right hand feels cooler than the left hand. The change in temperature of the right hand suggests that blood flow to the right hand is impaired. The flush system needs to be changed every 96 hours. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3 to 6 mL/hr of flush solution

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse? A. Use and side effects of isoniazid B. Standard four-drug therapy for TB C. Need for annual repeat TB skin testing D. Bacille Calmette-Guérin (BCG) vaccine

A. Use and side effects of isoniazid Explanation/Rationale:The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test result. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.

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. Explanation/Rationale: The initial response by the nurse should be to try to decrease the patient's anxiety by coaching the patient about how to coordinate respirations with the ventilator. The other actions may also be helpful if the verbal coaching is ineffective in reducing the patient's anxiety.

After assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis? A. Weak cough effort B. Profuse green sputum C. Respiratory rate of 28 breaths/minute D.Resting pulse oximetry (SpO2) of 85%

A. Weak cough effort Explanation/Rationale:The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.

An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding? A. Yellow-tinged sclera B. Orange-colored sputum C. Thickening of the fingernails D.Difficulty hearing high-pitched voices

A. Yellow-tinged sclera Explanation/Rationale:Noninfectious hepatitis is a toxic effect of isoniazid, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.

A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following drugs ordered. Which drug should the nurse discuss with the health care provider before giving? A. gentamicin 60 mg IV B. pantoprazole (Protonix) 40 mg IV C. sucralfate (Carafate) 1 g per nasogastric tube D.methylprednisolone (Solu-Medrol) 60 mg IV

A. gentamicin 60 mg IV Explanation/Rationale:Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other drugs are appropriate for the patient with ARDS.

A patient is in acute respiratory distress syndrome (ARDS) as a result of sepsis. Which measure would be implemented to maintain cardiac output? Position the patient in the Trendelenburg position. Perform chest physiotherapy and assist with staged coughing. Administer crystalloid fluids. Place the patient on fluid restriction and administer diuretics

Administer crystalloid fluids. Low cardiac output may necessitate crystalloid fluids in addition to lowering positive end-expiratory pressure (PEEP) or administering inotropes. The Trendelenburg position (not recommended to treat hypotension) and chest physiotherapy are unlikely to relieve decreased cardiac output, and fluid restriction and diuresis would be inappropriate interventions.

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? Airway constriction requiring immediate interventions Overworked intercostal muscles resulting in poor air exchange Spontaneous resolution of the acute asthma attack An acute development of bilateral pleural effusions

Airway constriction requiring immediate interventions When a patient in respiratory distress has inspiratory wheezing and then it ceases, it is an indication of airway obstruction. This finding requires emergency action to restore airway patency. Cessation of inspiratory wheezing does not indicate spontaneous resolution of the acute asthma attack, bilateral pleural effusion development, or overworked intercostal muscles in this asthmatic patient that is in acute respiratory distress

A patient with a persistent cough is diagnosed with pertussis. What treatment does the nurse anticipate administering to this patient? Cough suppressant Corticosteroid Bronchodilator Antibiotic

Antibiotic Pertussis, unlike acute bronchitis, is caused by a gram-negative bacillus, Bordetella pertussis, which must be treated with antibiotics. Corticosteroids and bronchodilators are not helpful in reducing symptoms. Cough suppressants and antihistamines are ineffective and may induce coughing episodes with pertussis.

When caring for older adult patients with respiratory failure, the nurse will add which intervention to individualize care? Provide early endotracheal intubation to reduce complications. Position the patient in the supine position primarily. Assess frequently for signs and symptoms of delirium. Delay activity and ambulation to provide additional healing time.

Assess frequently for signs and symptoms of delirium. Older adult patients are more predisposed to factors such as delirium, health care associated infections, and polypharmacy. Individualizing the older patient's care plan to address these factors will improve care. Older adult patients are not required to remain in a supine position only and should increase activity as soon as stability is determined. Endotracheal intubation is not provided early, and noninvasive positive pressure ventilation may be considered as an alternative. The nurse should consider that the aging process leads to decreased lung elastic recoil, weakened lung muscles and reduced gas exchange, which may make the patient difficult to wean from the ventilator.

The nurse is providing care for an older adult patient who is experiencing low partial pressure of oxygen in arterial blood (PaO2) as a result of worsening left-sided pneumonia. Which intervention should the nurse use to help the patient mobilize his secretions? Positioning the patient side-lying on his left side Frequent and aggressive nasopharyngeal suctioning Augmented coughing or huff coughing Application of noninvasive positive pressure ventilation (NIPPV)

Augmented coughing or huff coughing Augmented coughing and huff coughing techniques may aid the patient in the mobilization of secretions. If positioned side-lying, the patient should be positioned on his right side (good lung down) for improved perfusion and ventilation. Suctioning may be indicated but should always be performed cautiously because of the risk of hypoxia. NIPPV is inappropriate in the treatment of patients with excessive secretions.

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions? A. "I will call my health care provider if I still feel tired after a week." B. "I will continue to do deep breathing and coughing exercises at home." C. "I will schedule two appointments for the pneumonia and influenza vaccines." D."I will cancel my follow-up chest x-ray appointment if I feel better next week."

B. "I will continue to do deep breathing and coughing exercises at home." Explanation/Rationale:Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The pneumococcal and influenza vaccines can be given at the same time in different arms. A follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate? A. "PEEP will push more air into the lungs during inhalation." B. "PEEP prevents the lung air sacs from collapsing during exhalation." C. "PEEP will prevent lung damage while the patient is on the ventilator." D."PEEP allows the breathing machine to deliver 100% O2 to the lungs."

B. "PEEP prevents the lung air sacs from collapsing during exhalation." Explanation/Rationale:By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage (e.g., fibrotic changes that occur with ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.

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 Explanation/Rationale:The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.

The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2, the nurse assesses the patient's A. lipase level. B. temperature. C. urinary output. D. body mass index.

B. temperature. Elevated temperature increases metabolic demands and O2 use by tissues, resulting in a drop in O2 saturation of central venous blood. Information about the patient's body mass index, urinary output, and lipase will not help in determining the cause of the patient's drop in ScvO2.

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? A. A 23-yr-old patient with cystic fibrosis who has pulmonary function testing scheduled B. A 46-yr-old patient on bed rest who is complaining of sudden onset of shortness of breath C. A 77-yr-old patient with tuberculosis (TB) who has four medications due in 15 minutes D. A 35-yr-old patient who was admitted with pneumonia and has a temperature of 100.2° F (37.8° C)

B. A 46-yr-old patient on bed rest who is complaining of sudden onset of shortness of breath Explanation/Rationale:Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as O2 administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse? A. The patient is offered a tissue from the box at the bedside. B. A surgical face mask is applied before visiting the patient. C. A snack is brought to the patient from the unit refrigerator. D.Hand washing is performed before entering the patient's room.

B. A surgical face mask is applied before visiting the patient. Explanation/Rationale:A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient's room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient's room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take? A. Clamp the chest tube in two places. B. Administer the prescribed morphine. C. Milk the chest tube to remove any clots. D.Assist the patient with incentive spirometry.

B. Administer the prescribed morphine. Explanation/Rationale:Treat the pain. The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Milking or stripping chest tubes is no longer recommended because these practices can dangerously increase intrapleural pressures and damage lung tissues. Position tubing so that drainage flows freely to negate need for milking or stripping. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax.

While close family members are visiting, a patient has a respiratory arrest, and resuscitation is started. Which action by the nurse is best? A. Tell the family members that watching the resuscitation will be very stressful. B. Ask family members if they wish to remain in the room during the resuscitation. C. Take the family members quickly out of the patient room and remain with them. D. Assign a staff member to wait with family members just outside the patient room.

B. Ask family members if they wish to remain in the room during the resuscitation. Evidence indicates that many family members want the option of remaining in the room during procedures such as cardiopulmonary resuscitation (CPR) and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient.

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. Explanation/Rationale:The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 4-hour rest period at this time may allow the O2 saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the left side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? A. Chest x-ray via stretcher B. Blood cultures from two sites C. Ciprofloxacin (Cipro) 400 mg IV D.Acetaminophen (Tylenol) rectal suppository

B. Blood cultures from two sites Explanation/Rationale:Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.

. A patient who has been in the intensive care unit for 4 days has disturbed sensory perception from sleep deprivation. Which action should the nurse include in the plan of care? A. Administer prescribed sedatives or opioids at bedtime to promote sleep. B. Cluster nursing activities so that the patient has uninterrupted rest periods. C. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps. D. Eliminate assessments between 2200 and 0600 to allow uninterrupted sleep.

B. Cluster nursing activities so that the patient has uninterrupted rest periods. Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing all assessments during the night.

A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate? A. Adjust the dial on the wall regulator. B. Continue to monitor the collection device. C. Document the presence of a large air leak. D.Notify the surgeon of a possible pneumothorax.

B. Continue to monitor the collection device. Explanation/Rationale:Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.

A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? A. Administration of 100% O2 by non-rebreather mask B. Endotracheal intubation and positive pressure ventilation C. Insertion of a mini-tracheostomy with frequent suctioning D.Initiation of continuous positive pressure ventilation (CPAP)

B. Endotracheal intubation and positive pressure ventilation Explanation/Rationale:The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Giving high-flow O2 will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.

After surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action should the nurse take? A. Administer IV diuretic medications. B. Increase the IV fluid infusion per protocol. C. Increase the infusion rate of IV vasodilators. D. Elevate the head of the patient's bed to 45 degrees.

B. Increase the IV fluid infusion per protocol. A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head or increasing vasodilators may decrease cerebral perfusion.

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. Explanation/Rationale:Increasing O2 flow rate will usually improve O2 saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care? A. Avoid the use of anticoagulant medications. B. Measure the patient's urinary output every hour. C. Provide passive range of motion for all extremities. D. Position the patient supine with head flat at all times

B. Measure the patient's urinary output every hour. Explanation/Rationale: Monitoring urine output will help determine whether the patient's cardiac output has improved and also help monitor for balloon displacement blocking the renal arteries. The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon.

A patient admitted with acute respiratory failure has ineffective airway clearance related to thick secretions. Which nursing intervention would specifically address this patient problem? A. Encourage use of the incentive spirometer. B. Offer the patient fluids at frequent intervals. C. Teach the patient the importance of ambulation. D.Titrate oxygen level to keep O2 saturation above 93%.

B. Offer the patient fluids at frequent intervals. Explanation/Rationale:Because the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. Patients should be instructed to use the incentive spirometer on a regular basis (e.g., every hour) to facilitate the clearance of the secretions. The other actions may also be helpful in improving the patient's gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.

Which action should the nurse plan to prevent aspiration in a high-risk patient? A. Turn and reposition an immobile patient at least every 2 hours. B. Place a patient with altered consciousness in a side-lying position. C. Insert a nasogastric tube for feeding a patient with high calorie needs. D. Monitor respiratory symptoms in a patient who is immunosuppressed.

B. Place a patient with altered consciousness in a side-lying position. Explanation/Rationale:With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and O2 saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching? A. Listening to the patient's lung sounds several times during the shift B. Placing the patient on droplet precautions in a private hospital room C. Monitoring patient serology results to identify the infecting organism D.Increasing the O2 flow rate to keep the O2 saturation over 90%

B. Placing the patient on droplet precautions in a private hospital room Explanation/Rationale:Fungal infections are not transmitted from person to person. Therefore no isolation procedures are necessary. The other actions by the new nurse are appropriate.

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? A. Start a peripheral IV line to administer sedatives. B. Position the patient sitting up on the side of the bed. C. Obtain a collection device to hold 3 liters of pleural fluid. D. Remind the patient not to eat or drink anything for 6 hours.

B. Position the patient sitting up on the side of the bed. Explanation/Rationale:When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema.

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. Explanation/Rationale:All of these interventions are part of the ventilator bundle that is recommended to prevent VAP. Arterial blood gases may be done daily but are not always necessary and do not help prevent VAP.

Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse gives to reduce a patient's left ventricular afterload? A. Mean arterial pressure (MAP) B. Systemic vascular resistance (SVR) C. Pulmonary vascular resistance (PVR) D. Pulmonary artery wedge pressure (PAWP)

B. Systemic vascular resistance (SVR) SVR reflects the resistance to ventricular ejection, or afterload. The other parameters may be monitored but do not reflect afterload as directly.

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. Explanation/Rationale: The closed-suction technique is used when patients require high levels of PEEP (>10 cm H2O) to prevent the loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be scheduled routinely, but it should be done only when patient assessment data indicate the need for suctioning. Taping connections between the ET and ventilator tubing would restrict the ability of the tubing to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for ventilator-associated pneumonia and are not indicated routinely.

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. Explanation/Rationale:The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not specific indications that PEEP should be reduced.

The nurse is caring for a patient who has an arterial catheter in the left radial artery for arterial pressure‒based cardiac output (APCO) monitoring. Which information obtained by the nurse requires a report to the health care provider? A. The patient has a positive Allen test result. B. There is redness at the catheter insertion site. C. The mean arterial pressure (MAP) is 86 mm Hg. D. The dicrotic notch is visible in the arterial waveform

B. There is redness at the catheter insertion site. Explanation/Rationale: Redness at the catheter insertion site indicates possible infection. The Allen test is performed before arterial line insertion, and a positive test result indicates normal ulnar artery perfusion. A MAP of 86 mm Hg is normal, and the dicrotic notch is normally present on the arterial waveform.

An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to A. give PRN lorazepam (Ativan) and cancel the transfer. B. inform the receiving nurse and then transfer the patient. C. notify the health care provider and postpone the transfer. D. obtain an order for restraints as needed and transfer the patient.

B. inform the receiving nurse and then transfer the patient. Explanation/Rationale: The patient's history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the ICU environment. Informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation.

The intensive care unit (ICU) nurse educator determines that teaching a new staff nurse about arterial pressure monitoring has been effective when the nurse A. balances and calibrates the monitoring equipment every 2 hours. B. positions the zero-reference stopcock line level with the phlebostatic axis. C. ensures that the patient is supine with the head of the bed flat for all readings. D. rechecks the location of the phlebostatic axis with changes in the patient's position.

B. positions the zero-reference stopcock line level with the phlebostatic axis. For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment every 2 hours. Accurate hemodynamic readings are possible with the patient's head raised to 45 degrees or in the prone position. The anatomic position of the phlebostatic axis does not change when patients are repositioned.

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. Explanation/Rationale: End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion are also used, but they are not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured.

The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance? Oxygen saturation of 85% Basilar crackles Respiratory rate of 28 breaths/min Presence of greenish sputum

Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem but do not definitely support the nursing diagnosis of ineffective airway clearance.

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? Administer prescribed lorazepam (Ativan) to reduce anxiety. Observe stools for frank bleeding and occult blood. Maintain head of the bed elevation at 30 to 45 degrees. Begin enteral feedings as soon as bowel sounds are present.

Begin enteral feedings as soon as bowel sounds are present. Stress ulcers prevention includes early initiation of enteral nutrition to protect the gastrointestinal (GI) tract from mucosal damage. Antiulcer agents such as histamine (H2)-receptor antagonists, proton pump inhibitors, and mucosal protecting agents are also indicated to prevent stress ulcers. Monitoring for GI bleeding does not prevent stress ulcers. Ventilator-associated pneumonia related to aspiration is prevented by elevation of the head of bed to 30 to 45 degrees Stress ulcers are not caused by anxiety. Stress ulcers are related to GI ischemia from hypotension, shock, and acidosis.

A patient with idiopathic pulmonary fibrosis had bilateral lung transplantation and is now experiencing exertional dyspnea, nonproductive cough, and wheezing. What does the nurse determine is most likely occurring in this patient? Pulmonary infarction Cytomegalovirus (CMV) Bronchiolitis obliterans (BOS) Pulmonary hypertension

Bronchiolitis obliterans (BOS) BOS is a manifestation of chronic rejection and is characterized by airflow obstruction progressing over time with a gradual onset of exertional dyspnea, nonproductive cough, wheezing, and/or low-grade fever. Pulmonary infarction occurs with lack of blood flow to the bronchial tissue or preexisting lung disease. With pulmonary hypertension, the pulmonary pressures are elevated and can be idiopathic or secondarily due to parenchymal lung disease that causes anatomic or vascular changes leading to pulmonary hypertension. CMV pneumonia is the most common opportunistic infection 1 to 4 months after lung transplant.

A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which is the best initial response by the nurse? A. "Are you ready to talk with your family members about dying now?" B. "Would you like to talk to the hospital chaplain about your feelings?" C. "Can you tell me what it is that makes you think you will die so soon?" D."Do you think that taking an antidepressant medication would be helpful?"

C. "Can you tell me what it is that makes you think you will die so soon?" Explanation/Rationale:The nurse's initial response should be to collect more assessment data about the patient's statement. The answer beginning "Can you tell me what it is" is the most open-ended question and will offer the best opportunity for obtaining more data. The remaining answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective? A. "I will take the bus instead of driving." B. "I will stay indoors whenever possible." C. "My spouse will sleep in another room." D."I will keep the windows closed at home."

C. "My spouse will sleep in another room." Explanation/Rationale:Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation.

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate? A. "Are you afraid that the surgery will be very painful?" B. "Did you have bad experiences with previous surgeries?" C. "Tell me what you know about the treatments available." D."Surgery is the treatment of choice for stage I lung cancer."

C. "Tell me what you know about the treatments available." Explanation/Rationale:More assessment of the patient's concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, "Surgery is the treatment of choice" is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient's reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In non-small cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery.

The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will most directly treat this finding? A. Reposition the patient every 1 to 2 hours. B. Increase suctioning frequency to every hour. C. Add additional water to the patient's enteral feedings. D. Instill 5 mL of sterile saline into the ET before suctioning.

C. Add additional water to the patient's enteral feedings. Explanation/Rationale: Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions.

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan? A. Purpose of antibiotic therapy B. Ways to limit oral fluid intake C. Appropriate use of cough suppressants D.Safety concerns with home O2 therapy

C. Appropriate use of cough suppressants Explanation/Rationale:Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home O2 is not prescribed for acute bronchitis, although it may be used for chronic bronchitis.

A patient diagnosed with active tuberculosis (TB) is homeless and has a history of alcohol abuse. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? A. Repeat warnings about the high risk for infecting others several times. B. Give the patient written instructions about how to take the medications. C. Arrange for a daily meal and drug administration at a community center. D.Arrange for the patient's friend to administer the medication on schedule.

C. Arrange for a daily meal and drug administration at a community center. Explanation/Rationale:Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient's situation.

Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure? A. Chest x-ray B. O2 saturation C. Arterial blood gas analysis D.Central venous pressure monitoring

C. Arterial blood gas analysis Explanation/Rationale:Arterial blood gas (ABG) analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs provide information about the PaCO2 and pH. The other tests may also be done to help in assessing oxygenation or determining the cause of the patient's ventilatory failure.

After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? A. Teach about drug-resistant TB. B. Schedule directly observed therapy. C. Ask the patient whether medications have been taken as directed. D. Discuss the need for an injectable antibiotic with the health care provider. Correct Answer:C

C. Ask the patient whether medications have been taken as directed. Explanation/Rationale:The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.

Which action should the nurse take when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery? A. Fast flush the arterial line. B. Check the left hand for pallor. C. Assess for cardiac dysrhythmias. D. Re-zero the monitoring equipment.

C. Assess for cardiac dysrhythmias. The low pressure alarm indicates a drop in the patient's blood pressure, which may be caused by cardiac dysrhythmias. There is no indication to re-zero the equipment. Pallor of the left hand would be caused by occlusion of the radial artery by the arterial catheter, not by low pressure. There is no indication of a need for flushing the line.

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance? A. Restrict oral fluids during the day. B. Teach pursed-lip breathing technique. C. Assist the patient to splint the chest when coughing. D. Encourage the patient to wear the nasal O2 cannula.

C. Assist the patient to splint the chest when coughing. Explanation/Rationale:Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal O2 will improve gas exchange, but will not improve airway clearance. Pursed-lip breathing is used to improve gas exchange in patients with chronic obstructive pulmonary disease but will not improve airway clearance.

An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met? A. Urine output of 25 mL/hr B. Heart rate of 110 beats/minute C. Cardiac output (CO) of 5 L/min D. Stroke volume (SV) of 40 mL/beat

C. Cardiac output (CO) of 5 L/min Explanation/Rationale: A CO of 5 L/min is normal and indicates that the IABP has been successful in treating the shock. The low SV signifies continued cardiogenic shock. The tachycardia and low urine output also suggest continued cardiogenic shock.

The family members of a patient who has been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take first? A. Explain ICU visitation policies and encourage family visits. B. Escort the family from the waiting room to the patient's bedside. C. Describe the patient's injuries and the care that is being provided. D. Invite the family to participate in an interprofessional care conference

C. Describe the patient's injuries and the care that is being provided. Explanation/Rationale: Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the patient's appearance and the ICU environment before visiting the patient for the first time. ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse.

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness? A. Ask the patient about any visual changes in red-green color discrimination. B. Question the patient about experiencing shortness of breath, hives, or itching. C. Explain that orange discolored urine and tears are normal while taking this medication. D.Advise the patient to stop the drug and report the symptoms to the health care provider.

C. Explain that orange discolored urine and tears are normal while taking this medication. Explanation/Rationale:Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occurs when taking ethambutol, which is a different tuberculosis medication.

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care? A. Bed rest for the first 24 hours B. Positioning only on the right side C. Frequent use of an incentive spirometer D. Chest tube placement to continuous suction

C. Frequent use of an incentive spirometer Explanation/Rationale:Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space.

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. Explanation/Rationale: The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions are also appropriate, but detection and correction of tube malposition are the most critical actions.

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first? A. Assist the patient to sit upright in a chair. B. Splint the patient's chest during coughing. C. Medicate the patient with prescribed morphine. D. Observe the patient use the incentive spirometer.

C. Medicate the patient with prescribed morphine. Explanation/Rationale:A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance, but should be done after the morphine is given.

The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2° F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action should the nurse take next? A. Give the scheduled IV antibiotic. B. Give the PRN acetaminophen (Tylenol). C. Obtain oxygen saturation using pulse oximetry. D.Notify the health care provider of the patient's vital signs.

C. Obtain oxygen saturation using pulse oximetry. Explanation/Rationale:The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Giving the scheduled antibiotic and the PRN acetaminophen will also be done, but they are not the highest priority for a patient who may be developing ARDS.

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. Explanation/Rationale:The patient's low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.

A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving? A. Patient's chest x-ray indicates clear lung fields. B. Heart rate is between 60 and 100 beats/minute. C. Patient reports a decrease in exertional dyspnea. D.Blood pressure (BP) is less than 140/90 mm Hg.

C. Patient reports a decrease in exertional dyspnea. Explanation/Rationale:Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the therapy is not effective.

After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first? A. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator B. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring C. Patient who was successfully weaned and extubated 4 hours ago and has no urine output for the last 6 hours D. Patient with a central venous O2 saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP)

C. Patient who was successfully weaned and extubated 4 hours ago and has no urine output for the last 6 hours Explanation/Rationale: The decreased urine output may indicate acute kidney injury or that the patient's cardiac output and perfusion of vital organs have decreased. Any of these causes would require rapid action. The data about the other patients indicate that their conditions are stable and do not require immediate assessment or changes in their care. Continuous PETCO2 monitoring is frequently used when patients are intubated. The rest mode should be used to allow patient recovery after a failed SBT, and an ScvO2 of 69% is within normal limits.

When caring for a patient with pulmonary hypertension, which parameter will the nurse use to directly evaluate the effectiveness of the treatment? A. Central venous pressure (CVP) B. Systemic vascular resistance (SVR) C. Pulmonary vascular resistance (PVR) D. Pulmonary artery wedge pressure (PAWP)

C. Pulmonary vascular resistance (PVR) PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters may also be monitored but do not directly assess for pulmonary hypertension

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease? A. Treat workers with pulmonary fibrosis. B. Teach about symptoms of lung disease. C. Require the use of protective equipment. D.Monitor workers for coughing and wheezing.

C. Require the use of protective equipment. Explanation/Rationale:Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation.

The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted? A. Heart rate is slow at 58 beats/min. B. Mean arterial pressure (MAP) is 56 mm Hg. C. Systemic vascular resistance (SVR) is elevated. D. Pulmonary artery wedge pressure (PAWP) is low

C. Systemic vascular resistance (SVR) is elevated. Explanation/Rationale: Vasoconstrictors such as norepinephrine will increase SVR, and this will increase the work of the heart and decrease peripheral perfusion. The infusion rate may need to be decreased. Bradycardia, hypotension (MAP of 56 mm Hg), and low PAWP are not associated with norepinephrine infusion.

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take? A. Teach about the reason for the blood tests. B. Schedule an appointment for a chest x-ray. C. Teach the patient about providing specimens for 3 consecutive days. D. Instruct the patient to collect several separate sputum specimens today.

C. Teach the patient about providing specimens for 3 consecutive days. Explanation/Rationale:Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for Mycobacterium tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting? A. Providing supportive care to patients diagnosed with pertussis B. Teaching family members about the need for careful hand washing C. Teaching patients about the need for adult pertussis immunizations D. Encouraging patients to complete the prescribed course of antibiotics

C. Teaching patients about the need for adult pertussis immunizations Explanation/Rationale:The increased rate of pertussis in adults is thought to be caused by decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made.

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse? A. The O2 saturation is 90%. B. The blood pressure is 98/56 mm Hg. C. The epoprostenol (Flolan) infusion is disconnected. D.The international normalized ratio (INR) is prolonged.

C. The epoprostenol (Flolan) infusion is disconnected. Explanation/Rationale:The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion.

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. Explanation/Rationale: Tachypnea is a sign that the patient's work of breathing is too high to allow weaning to proceed. The patient's heart rate is within normal limits, but the nurse should continue to monitor it. An O2 saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable range.

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. Explanation/Rationale: The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed and not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An O2 saturation of 93% is acceptable and does not suggest that immediate suctioning is needed.

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective? A. Bronchial breath sounds are heard at the right base. B. The patient coughs up small amounts of green mucus. C. The patient's white blood cell (WBC) count is 9000/µL. D. Increased tactile fremitus is palpable over the right chest.

C. The patient's white blood cell (WBC) count is 9000/µL. Explanation/Rationale:The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.

During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first? A. Give the prescribed PRN sedative drug. B. Offer reassurance and reorient the patient. C. Use pulse oximetry to check the oxygen saturation. D.Notify the health care provider about the patient's status.

C. Use pulse oximetry to check the oxygen saturation. Explanation/Rationale:Agitation may be an early indicator of hypoxemia. The other actions may also be appropriate, depending on the findings about O2 saturation.

The nurse is caring for a 55-yr-old man who has a catheter in the right radial artery for invasive arterial blood pressure monitoring after abdominal aortic aneurysm surgery. Which observation by the nurse would require an emergency intervention? Patient's head of bed elevation is at 30 degrees. Arterial pressure bag is inflated to 250 mm Hg. Capillary refill time in the right hand is 5 seconds. Calculated mean arterial pressure is 74 mm Hg.

Capillary refill time in the right hand is 5 seconds. Neurovascular status distal to the arterial insertion site is monitored hourly. If arterial flow is compromised, the limb will be cool and pale, with capillary refill time longer than 3 seconds. Symptoms of neurologic impairment include paresthesia, pain, or paralysis. Neurovascular impairment can result in loss of a limb and is an emergency. The pressure bag should be inflated to 300 mm Hg. Normal range for mean arterial pressure is 70 to 105 mm Hg. The backrest elevation may be up to 45 degrees unless the patient has orthostatic changes.

The postanesthesia care unit (PACU) has several patients with endotracheal tubes. Which patient should receive the least amount of endotracheal suctioning? Transplantation of a kidney Replacement of aortic valve Cerebral aneurysm resection Formation of an ileal conduit

Cerebral aneurysm resection The nurse should avoid suctioning the patient after a craniotomy until it is necessary because suctioning will increase this patient's intracranial pressure. The patients with a kidney transplantation, aortic valve replacement, or formation of an ileal conduit will not be negatively affected by suctioning, although it should only be done when needed, not routinely.

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? Chest tube with a loose-fitting dressing Small pneumothorax at CT insertion site Water-seal chamber has 5 cm of water. No new drainage in collection chamber

Chest tube with a loose-fitting dressing If the dressing at the CT insertion site is loose, an air leak will occur and will need to be sealed. The water-seal chamber usually has 2 cm of water, but having more water will not contribute to an air leak, and it should not be drained from the CDS. No new drainage does not indicate an air leak but may indicate the CT is no longer needed. If there is a pneumothorax, the chest tube should remove the air.

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? Pack the chest wound with sterile saline soaked gauze and tape securely. Cover the chest wound with a nonporous dressing taped on three sides. Apply a pressure dressing over the wound to prevent excessive loss of blood. Stabilize the chest wall with tape and initiate positive pressure ventilation.

Cover the chest wound with a nonporous dressing taped on three sides. The patient has a sucking chest wound (open pneumothorax). Air enters the pleural space through the chest wall during inspiration. Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides. During inspiration, the dressing pulls against the wound, preventing air from entering the pleural space. During expiration, the dressing is pushed out and air escapes through the wound and from under the dressing.

The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates to the nurse that the teaching has been effective? A. "I will make an appointment to see the doctor every year." B. "I will stop taking the prednisone if I experience a dry cough." C."I will not worry if I feel a little short of breath with exercise." D. "I will call the health care provider right away if I develop a fever."

D. "I will call the health care provider right away if I develop a fever." Explanation/Rationale:Low-grade fever may indicate infection or acute rejection so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team. Annual health care provider visits would not be sufficient. Home O2 use is not an expectation after lung transplant. Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough, and O2 desaturation are signs of rejection. Immunosuppressive therapy, including prednisone, needs to be continued to prevent rejection.

After change-of-shift report, which patient should the nurse assess first? A. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet B. A 28-yr-old with a history of a lung transplant and a temperature of 101° F (38.3° C) C. A 40-yr-old with a pleural effusion who is complaining of severe stabbing chest pain D. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion

D. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion Explanation/Rationale:The patient's history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.

Which nursing action is needed when preparing to assist with the insertion of a pulmonary artery catheter? A. Determine if the cardiac troponin level is elevated. B. Auscultate heart sounds before and during insertion. C. Place the patient on NPO status before the procedure. D. Attach cardiac monitoring leads before the procedure

D. Attach cardiac monitoring leads before the procedure Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anesthesia, and the patient will not need to be NPO. Changes in cardiac troponin or heart and breath sounds are not expected during pulmonary artery catheter insertion.

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient? A. Emergency pericardiocentesis B. Stabilization of the chest wall C. Bronchodilator administration D. Chest tube connected to suction

D. Chest tube connected to suction Explanation/Rationale:The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient's clinical manifestations are not consistent with these problems.

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. Explanation/Rationale: The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team are also appropriate after the nurse has stabilized the patient's oxygenation.

After change-of-shift report, which patient should the progressive care nurse assess first? A. Patient who was extubated this morning and has a temperature of 101.4°F (38.6°C) B. Patient with bilevel positive airway pressure (BiPAP) for obstructive sleep apnea and a respiratory rate of 16 C. Patient with arterial pressure monitoring who is 2 hours post-percutaneous coronary intervention and needs to void D. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 101 sec

D. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 101 sec Explanation/Rationale: The findings for this patient indicate high risk for bleeding from an elevated (nontherapeutic) PTT. The nurse needs to adjust the rate of the infusion (dose) per the health care provider's parameters. The patient with BiPAP for sleep apnea has a normal respiratory rate. The patient recovering from the percutaneous coronary intervention will need to be assisted with voiding and this task could be delegated to unlicensed assistive personnel. The patient with a fever may be developing ventilator-associated pneumonia, but addressing the bleeding risk is a higher priority.

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first? A. Codeine B. Guaifenesin C. Acetaminophen (Tylenol) D. Piperacillin/tazobactam (Zosyn)

D. Piperacillin/tazobactam (Zosyn) Explanation/Rationale:Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.

A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented? A. Chest x-ray shows no upper lobe infiltrates. B. TB medications have been taken for 6 months. C. Mantoux testing shows an induration of 10 mm. D. Sputum smears for acid-fast bacilli are negative.

D. Sputum smears for acid-fast bacilli are negative. Explanation/Rationale:Repeated negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment.

The nurse notes premature ventricular contractions (PVCs) while suctioning a patient's endotracheal tube. Which next action by the nurse is indicated? A. Plan to suction the patient more frequently. B. Decrease the suction pressure to 80 mm Hg. C. Give antidysrhythmic medications per protocol. D. Stop and ventilate the patient with 100% oxygen

D. Stop and ventilate the patient with 100% oxygen Explanation/Rationale: Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The nurse should stop suctioning and ventilate the patient with 100% O2. There is no indication that more frequent suctioning is needed. Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the suctioning is stopped and patient is well oxygenated.

A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take? A. Keep the head of the patient's bed positioned flat. B. Cover the wound tightly with an occlusive dressing. C. Position the patient so that the left chest is dependent. D. Tape a nonporous dressing on three sides over the wound.

D. Tape a nonporous dressing on three sides over the wound. Explanation/Rationale:The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.

The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education? A. The RN increases the FIO2 to 100% before suctioning. B. The RN secures a bite block in place using adhesive tape. C. The RN asks for assistance to resecure the endotracheal tube. D. The RN positions the patient with the head of bed at 10 degrees

D. The RN positions the patient with the head of bed at 10 degrees Explanation/Rationale: The head of the patient's bed should be positioned at 30 to 45 degrees to prevent ventilator-associated pneumonia. The other actions by the new RN are appropriate.

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. Explanation/Rationale: The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal volume would further lower the PaCO2.

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. Explanation/Rationale: Increases in jugular venous distention in a patient with a subarachnoid hemorrhage may indicate an increase in intracranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 20, O2 saturation of 93%, and green nasogastric tube drainage are within normal limits.

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. Explanation/Rationale: The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patient's size. Cuff pressure should be maintained at 20 to 25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon.

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. Explanation/Rationale:Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema.

While waiting for heart transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. When planning care for this patient, the nurse should anticipate A. preparing the patient for a permanent VAD. B. administering immunosuppressive medications. C. teaching the patient the reason for complete bed rest. D. monitoring the surgical incision for signs of infection.

D. monitoring the surgical incision for signs of infection. Explanation/Rationale: The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immunosuppression is not necessary for nonbiologic devices such as the VAD.

When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most pertinent measurement for the nurse to obtain is A. central venous pressure (CVP). B. systemic vascular resistance (SVR). C. pulmonary vascular resistance (PVR). D. pulmonary artery wedge pressure (PAWP).

D. pulmonary artery wedge pressure (PAWP). PAWP reflects left ventricular end diastolic pressure (or left ventricular preload) and is a sensitive indicator of cardiac function. Because the patient is high risk for left ventricular failure, the PAWP must be monitored. An increase will indicate left ventricular failure. The other values would also provide useful information, but the most definitive measurement of changes in cardiac function is the PAWP.

While assisting with the placement of a pulmonary artery (PA) catheter, the nurse notes that the catheter is correctly placed when the balloon is inflated and the monitor shows a A. typical PA pressure waveform. B. tracing of the systemic arterial pressure. C. tracing of the systemic vascular resistance. D. typical PA wedge pressure (PAWP) tracing.

D. typical PA wedge pressure (PAWP) tracing. The purpose of a PA line is to measure PAWP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAWP readings are available. After insertion, the balloon is deflated and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line, and the systemic vascular resistance is a calculated value, not a waveform.

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test? A. "Do you take any over-the-counter (OTC) medications?" B. "Do you have any family members with a history of TB?" C. "How long has it been since you moved to the United States?" D."Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"

D."Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?" Explanation/Rationale:Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (e.g., chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? A. "I am going to buy a rib binder to wear during the day." B. "I can take shallow breaths to prevent my chest from hurting." C. "I should plan on taking the pain pills only at bedtime so I can sleep." D."I will use the incentive spirometer every hour or two during the day."

D."I will use the incentive spirometer every hour or two during the day." Explanation/Rationale:Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis.

After receiving change-of-shift report on a medical unit, which patient should the nurse assess first? A. A patient with cystic fibrosis who has thick, green-colored sputum B. A patient with pneumonia who has crackles bilaterally in the lung bases C. A patient with emphysema who has an oxygen saturation of 90% to 92% D.A patient with septicemia who has intercostal and suprasternal retractions

D.A patient with septicemia who has intercostal and suprasternal retractions Explanation/Rationale:This patient's history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of O2 and use of positive-pressure ventilation. The other patients should also be assessed, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.

When assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse finds a new onset of agitation and confusion. Which action should the nurse take first? A. Observe for facial symmetry. B. Notify the health care provider. C. Attempt to calm and reorient the patient. D.Assess oxygenation using pulse oximetry.

D.Assess oxygenation using pulse oximetry. Explanation/Rationale:Because agitation and confusion are frequently the initial indicators of hypoxemia, the nurse's initial action should be to assess O2 saturation. The other actions are also appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider.

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first? A. Administer anticoagulant drug therapy. B. Notify the patient's health care provider. C. Prepare patient for a spiral computed tomography (CT). D.Elevate the head of the bed to a semi-Fowler's position.

D.Elevate the head of the bed to a semi-Fowler's position.

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first? A. Administer anticoagulant drug therapy. B. Notify the patient's health care provider. C. Prepare patient for a spiral computed tomography (CT). D.Elevate the head of the bed to a semi-Fowler's position.

D.Elevate the head of the bed to a semi-Fowler's position. Explanation/Rationale:The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and O2 is started). A spiral CT may be ordered by the health care provider to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the priority? A. Hyperthermia related to infectious illness B. Impaired transfer ability related to weakness C. Ineffective airway clearance related to thick secretions D.Impaired gas exchange related to respiratory congestion

D.Impaired gas exchange related to respiratory congestion Explanation/Rationale:All of these nursing diagnoses are appropriate for the patient, but the patient's O2 saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.

Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/LVN) working in the intensive care unit? A. Assess breath sounds every hour. B. Monitor central venous pressures. C. Place patient in the prone position. D.Insert an indwelling urinary catheter.

D.Insert an indwelling urinary catheter. Explanation/Rationale:Insertion of indwelling urinary catheters is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff, and should be supervised by an RN. Assessment of breath sounds and obtaining central venous pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient.

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). Explanation/Rationale:Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for another pneumothorax.

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess? A. Teach the patient to avoid the use of over-the-counter expectorants. B. Assist the patient with chest physiotherapy and postural drainage. C. Notify the health care provider immediately about any bloody or foul-smelling sputum. D.Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

D.Teach about the need for prolonged antibiotic therapy after discharge from the hospital. Explanation/Rationale:Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul-smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough.

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. Explanation/Rationale:Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.

A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding by the nurse is most important to report to the health care provider? A. The patient has bibasilar lung crackles. B. The patient is sitting in the tripod position. C. The patient's pulse oximetry indicates a 91% O2 saturation. D.The patient's respirations have dropped to 10 breaths/minute

D.The patient's respirations have dropped to 10 breaths/minute Explanation/Rationale:A drop in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore immediate action such as positive-pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An O2 saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.

The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed? A. UAP assist the patient to ambulate to the bathroom. B. UAP help splint the patient's chest during coughing. C. UAP transfer the patient to a bedside chair for meals. D.UAP lower the head of the patient's bed to 15 degrees.

D.UAP lower the head of the patient's bed to 15 degrees. Explanation/Rationale:Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.

The patient has pulmonary fibrosis and experiences hypoxemia during exercise but not at rest. To plan patient care, the nurse should know the patient is experiencing which physiologic mechanism of respiratory failure? Ventilation-perfusion mismatch Diffusion limitation Intrapulmonary shunt Alveolar hypoventilation

Diffusion limitation The patient with pulmonary fibrosis has a thickened alveolar-capillary interface that slows gas transport, and hypoxemia is more likely during exercise than at rest. Intrapulmonary shunt occurs when alveoli fill with fluid (e.g., acute respiratory distress syndrome, pneumonia). Alveolar hypoventilation occurs when there is a generalized decrease in ventilation (e.g., restrictive lung disease, central nervous system diseases, neuromuscular diseases). Ventilation-perfusion mismatch occurs when the amount of air does not match the amount of blood that the lung receives (e.g., chronic obstructive pulmonary disease, pulmonary embolus).

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 The patient is pre-oxygenated with a bag-valve-mask system for 3 to 5 minutes before intubation and then placed in a supine position. After the intubation, the cuff on the endotracheal tube is inflated to occlude and protect the airway. Tube placement is assessed first with an end-tidal CO2 sensor and then with chest x-ray examination

In which order will the nurse take these actions when assisting with oral intubation of a patient who is having respiratory distress? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Obtain a portable chest-x-ray. b. Place the patient in the supine position. c. Inflate the cuff of the endotracheal tube. d. Attach an end-tidal CO2 detector to the endotracheal tube. e. Oxygenate the patient with a bag-valve-mask system for several minutes.

E, B, C, D, A The patient is pre-oxygenated with a bag-valve-mask system for 3 to 5 minutes before intubation and then placed in a supine position. Following the intubation, the cuff on the endotracheal tube is inflated to occlude and protect the airway. Tube placement is assessed first with an end-tidal CO2 sensor, then with a chest x-ray.

A 68-yr-old male patient diagnosed with sepsis is orally intubated on mechanical ventilation. Which nursing action is most important?' Administer morphine for discomfort. Limit noise and cluster care activities. Elevate the head of the bed 30 degrees. Use the open-suctioning technique.

Elevate the head of the bed 30 degrees. The two major complications of endotracheal intubation are unplanned extubation and aspiration. To prevent aspiration, all intubated patients and patients receiving enteral feedings must have the head of the bed elevated a minimum of 30 to 45 degrees unless medically contraindicated. Closed-suction technique is preferred over the open-suction technique because oxygenation and ventilation are maintained during suctioning, and exposure to secretions is reduced. The nurse should provide comfort measures such as morphine to relieve anxiety and pain associated with intubation. To promote rest and sleep, the nurse should limit noise and cluster activities.

A patient's vital signs are pulse 90, respirations 24, and BP 128/64 mm Hg, and cardiac output is 4.7 L/min. The patient's stroke volume is _____ mL. (Round to the nearest whole number.)

Explanation/Rationale: 52 Stroke volume = Cardiac output/heart rate 52 mL = (4.7 L x 1000 mL/L)/90

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? Frequent position changes and agitation Cyanosis and increased capillary refill time Kussmaul respirations and hypotension Tachycardia and pursed lip breathing

Frequent position changes and agitation A change in mental status is an early indication of respiratory failure. The brain is sensitive to variations in oxygenation, arterial carbon dioxide levels, and acid-base balance. Restlessness, confusion, agitation, and combative behavior suggest inadequate oxygen delivery to the brain.

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? Hypercapnic respiratory failure related to alveolar hypoventilation Hypoxemic respiratory failure related to diffusion limitation Hypercapnic respiratory failure related to increased airway resistance Hypoxemic respiratory failure related to shunting of blood

Hypercapnic respiratory failure related to alveolar hypoventilation The patient's respiratory rate is decreased as a result of barbiturate overdose, which caused respiratory depression. The patient is at risk for hypercapnic respiratory failure due to an obtunded airway causing decreased respiratory rate and thus decreased CO2 elimination. Barbiturate overdose does not lead to shunting of blood, diffusion limitations, or increased airway resistance.

The nurse is caring for a patient with ineffective airway clearance. What is the priority nursing action to assist this patient expectorate thick lung secretions? Humidify the oxygen as able. Increase fluid intake to 3 L/day if tolerated. Teach patient to splint the affected area. Administer cough suppressant q4hr.

Increase fluid intake to 3 L/day if tolerated. Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.

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? Change the maintenance intravenous (IV) rate from 75 to 125 mL/hr. Initiate a dobutamine infusion at 3 mcg/kg/min. Increase positive end-expiratory pressure (PEEP) from 10 to 15 cm H2O. Administer 1 unit of packed red blood cells over the next 2 hours.

Increase positive end-expiratory pressure (PEEP) from 10 to 15 cm H2O. Patients on PPV and PEEP frequently experience decreased cardiac output (CO) and cardiac index (CI). High levels of PEEP increase intrathoracic pressure and cause decreased venous return which results in decreased CO. Interventions to improve CO include lowering the PEEP, administering crystalloid fluids or colloid solutions, and use of inotropic drugs (e.g., dobutamine, dopamine). Packed red blood cells may also be administered to improve CO and oxygenation if the hemoglobin is less than 9 or 10 mg/dL.

The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation should the nurse expect to find? Increased vocal fremitus on palpation Vesicular breath sounds in all lobes Hyperresonance on percussion Fine crackles in all lobes on auscultation

Increased vocal fremitus on palpation A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.

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? Perform chest physical therapy four times per day. Administer albuterol inhaler prn. Increase fluid intake to 2500 mL per 24 hours. Initiate oxygen at 2 liters/minute by nasal cannula.

Initiate oxygen at 2 liters/minute by nasal cannula. The arterial blood gas results indicate the patient is in uncompensated respiratory acidosis with moderate hypoxemia. Oxygen therapy is indicated to correct hypoxemia secondary to V/Q mismatch. Supplemental oxygen should be initiated at 1 to 3 L/min by nasal cannula, or 24% to 32% by simple face mask or Venturi mask to improve the PaO2. Albuterol would be administered next if needed for bronchodilation. Hydration is indicated for thick secretions, and chest physical therapy is indicated for patients with 30 mL or more of sputum production per day.

The patient has developed cardiogenic shock after a left anterior descending myocardial infection. Which circulatory-assist device should the nurse expect to use for this patient? Intraaortic balloon pump (IABP) Cardiopulmonary bypass Impedance cardiography (ICG) Central venous pressure (CVP) measurement

Intraaortic balloon pump (IABP) The most commonly used mechanical circulatory assist device is the IABP, and it is used to decrease ventricular workload, increase myocardial perfusion, and augment circulation. Cardiopulmonary bypass provides circulation during open heart surgery. It is not used as an assist device after surgery. ICG is a noninvasive method to obtain cardiac output and assess thoracic fluid status. CVP measurement is an invasive measurement of right ventricular preload and reflects fluid volume problems.

The patient had video-assisted thoracic surgery (VATS) to perform a lobectomy. What does the nurse know is the reason for using this type of surgery? Chest tubes will not be needed postoperatively. Less discomfort and faster return to normal activity The incision will be medial sternal or lateral. The patient has lung cancer.

Less discomfort and faster return to normal activity The VATS procedure uses minimally invasive incisions that cause less discomfort and allow faster healing and return to normal activity as well as lower morbidity risk and fewer complications. Many surgeries can be done for lung cancer, but pneumonectomy via thoracotomy is the most common surgery for lung cancer. The incision for a thoracotomy is commonly a medial sternotomy or a lateral approach. A chest tube will be needed postoperatively for VATS.

The nurse in the cardiac care unit is caring for a patient who has developed acute respiratory failure. Which medication is used to decrease patient pulmonary congestion and agitation? Morphine Albuterol Methylprednisolone Azithromycin

Morphine For a patient with acute respiratory failure related to the heart, morphine is used to decrease pulmonary congestion as well as anxiety, agitation, and pain. Albuterol is used to reduce bronchospasm. Azithromycin is used for pulmonary infections. Methylprednisolone is used to reduce airway inflammation and edema.

The nurse is developing a plan of care for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking. For what should the nurse monitor this patient? Reflex bronchoconstriction Cough reflex Ability to filter particles from the air Mucociliary clearance

Mucociliary clearance Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions and particles, chronic cough, and frequent respiratory infections.

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? Tidal volume Negative inspiratory force Forced vital capacity Minute ventilation

Negative inspiratory force The negative inspiratory force measures inspiratory muscle strength. Tidal volume and minute ventilation assess the patient's respiratory endurance. Forced vital capacity is not used as a measure to determine weaning from a ventilator.

While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing action is most appropriate? Move the oximetry probe from the finger to the earlobe. Obtain a physician's order for supplemental oxygen. Obtain a physician's order for arterial blood gas. Continue with ambulation.

Obtain a physician's order for supplemental oxygen. An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen. The patient will need to rest to resaturate. ABGs or moving the probe will not be needed as the pulse oximeter was working at the beginning of the walk.

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? Obtain a sputum specimen for culture and Gram stain. Take the temperature, pulse, and respiratory rate. Check the patient's oxygen saturation by pulse oximetry. Teach the patient to cough and deep breathe.1

Obtain a sputum specimen for culture and Gram stain. A sputum specimen for culture and Gram stain to identify the organism should be obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be readily obtained because delays in antibiotic therapy can increase morbidity and mortality risks.

A patient is diagnosed with a lung abscess. What should the nurse include when teaching the patient about this diagnosis? IV antibiotic therapy will be used for a 6-month period of time. Lobectomy surgery is usually needed to drain the abscess. Culture and sensitivity tests are needed for 1 year after resolving the abscess Oral antibiotics will be used until there is evidence of improvement.

Oral antibiotics will be used until there is evidence of improvement. IV antibiotics are used until the patient and radiographs show evidence of improvement. Then oral antibiotics are used for a prolonged period of time. Culture and sensitivity testing is done during the course of antibiotic therapy to ensure that the infecting organism is not becoming resistant to the antibiotic as well as at the completion of the antibiotic therapy. Lobectomy surgery is only needed when reinfection of a large cavitary lesion occurs or to establish a diagnosis when there is evidence of a neoplasm or other underlying problem.

When caring for a patient with acute respiratory distress syndrome (ARDS), which finding indicates therapy is appropriate? PaO2 is greater than or equal to 60 mm Hg. PEEP increased to 20 cm H2O caused BP to fall to 80/40. pH is 7.32. No change in PaO2 when patient is turned from supine to prone position

PaO2 is greater than or equal to 60 mm Hg. The overall goal in caring for the patient with ARDS is for the PaO2 to be greater than or equal to 60 mm Hg with adequate lung ventilation to maintain a normal pH of 7.35 to 7.45. PEEP is usually increased for ARDS patients, but a dramatic reduction in BP indicates a complication of decreased cardiac output. A positive occurrence is a marked improvement in PaO2 from perfusion better matching ventilation when the anterior air-filled, nonatelectatic alveoli become dependent in the prone position.

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? Cardiac output of 2.7 L/min PaO2 of 60 mm Hg Tidal volume of 700 mL Inspiration to expiration ratio of 1:2

PaO2 of 60 mm Hg Severe hypoxemia (PaO2 less than 40 mm Hg) occurs with ARDS, and PEEP is increased to improve oxygenation and prevent oxygen toxicity by reducing FIO2. A PaO2 level of 60 mm Hg indicates that treatment is effective and oxygenation status has improved. Decreased cardiac output is a complication of PEEP. Normal cardiac output is 4 to 8 L/minute. Normal tidal volume is 6 to 10 mL/kg. PSV delivers a preset pressure but the tidal volume varies with each breath. I:E ratio is usually set at 1:2 to 1:1.5 and does not indicate patient improvement.

An older adult patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing action is most appropriate during admission of this patient? Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. Perform a comprehensive health history with the patient to review prior respiratory problems. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems.

Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed when the patient's acute respiratory distress is being managed.

During discharge teaching for an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? Staphylococcus aureus Haemophilus influenzae Bacille-Calmette-Guérin (BCG) Pneumococcal

Pneumococcal The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 years or older, or living in a long-term care facility. A Staphylococcus aureus vaccine has been researched but not yet been effective. The Haemophilus influenzae vaccine would not be recommended as adults do not need it unless they are immunocompromised. The BCG vaccine is for infants in parts of the world where tuberculosis is prevalent.

A 72-yr-old woman with aspiration pneumonia develops severe respiratory distress. Her PaO2 is 42 mmHg and FIO2 is 80%. Which intervention should the nurse complete first? Position the patient with arms supported away from the chest Place the patient in a prone position on a rotational bed Stat portable chest radiography Administer lorazepam (Ativan) 1 mg IV push

Position the patient with arms supported away from the chest The nurse will first position the patient to facilitate ventilation. Additional oxygen support may be necessary. Refractory hypoxemia indicates the patient is not demonstrating acute lung injury but has now developed acute respiratory distress syndrome (ARDS). If the PaO2 is 42 mm Hg on 80% FIO2 (fraction of inspired oxygen; room air is 21% FIO2), then the PaO2/FIO2 ratio is 52.5, indicating ARDS (PaO2/FIO2 ratio < 200). Stat portable chest radiography may show worsening infiltrates or "white lung." A rotational bed placing the patient in prone position would be a strategy to use for select patients with ARDS. This patient's age, diagnosis, and comorbidities may indicate appropriateness for this treatment. Administration of lorazepam (Ativan) 1 mg may be harmful to this patient's oxygenation status. Further assessment would be needed to determine safety.

The nurse is caring for a patient with unilateral malignant lung disease. What is the priority nursing action to enhance oxygenation in this patient? Performing postural drainage every 4 hours Positioning patient on right side Positioning patient with "good lung" down Maintaining adequate fluid intake

Positioning patient with "good lung" down Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.

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? Prevention of barotrauma to the lung tissue Increased fraction of inspired oxygen concentration (FIO2) administration Increased inflation of the lungs Prevention of alveolar collapse during expiration

Prevention of alveolar collapse during expiration PEEP is positive pressure that is applied to the airway during exhalation. This positive pressure prevents the alveoli from collapsing, improving oxygenation and enabling a reduced FIO2 requirement. PEEP does not cause increased inflation of the lungs or prevent barotrauma. Actually auto-PEEP resulting from inadequate exhalation time may contribute to barotrauma.

The nurse is caring for a 34-yr-old woman with acute decompensated heart failure who has a pulmonary artery catheter. Which assessment indicates the patient's condition is improving? Systemic vascular resistance (SVR) is 1500 dynes/sec/cm-5. Pulmonary artery wedge pressure (PAWP) is 10 mm Hg. Cardiac output (CO) is 3.5 L/min. Central venous pressure (CVP) is 10 mm Hg.

Pulmonary artery wedge pressure (PAWP) is 10 mm Hg. PAWP is the most sensitive indicator of cardiac function and fluid volume status. Normal range for PAWP is 6 to 12 mm Hg. PAWP is increased in heart failure. Normal range for CVP is 2 to 8 mm Hg. An elevated CVP indicates right-sided heart failure or volume overload. CO is decreased in heart failure. Normal cardiac output is 4 to 8 L/minute. SVR is increased in left-sided heart failure. Normal SVR is 800 to 1200 dynes/sec/cm-5.

The nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4°F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action? Conduct a thorough assessment of the chest pain. Notify the health care provider. Sit the patient up in bed as tolerated and apply oxygen. Administer a nitroglycerin tablet sublingually.

Sit the patient up in bed as tolerated and apply oxygen. The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient's respirations. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time.

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime to the patient? Sputum culture and sensitivity Orthostatic blood pressures Serum laboratory studies ordered for AM Pulmonary function evaluation

Sputum culture and sensitivity The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime because this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic blood pressures, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.

A 64-yr-old male patient admitted to the critical care unit for gastrointestinal hemorrhage complains of feeling tense and nervous. He appears restless with increased blood pressure and pulse. If the physical assessment shows no other changes, it is most important for the critical care nurse to take which action? Teach the patient how to use guided imagery to reduce anxiety. Stay with the patient and encourage expression of concerns. Administer prescribed IV dose of lorazepam (Ativan). Ask a family member to remain at the bedside with the patient.

Stay with the patient and encourage expression of concerns . Anxiety is a common problem for critically ill patients. The nurse should first stay with the patient and encourage the patient to express concerns and needs. After expression of feelings, the nurse should determine the appropriate intervention if needed (e.g., lorazepam, guided imagery, family presence). In addition, staying with the patient will allow the nurse to continue to assess for physiologic changes associated with recurrent gastrointestinal bleeding.

An older adult patient living alone is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, observed by the nurse, indicates that the patient is likely to be hypoxic? Clutching chest on inspiration Coarse crackles in lung bases Sudden onset of confusion Oral temperature of 102.3oF

Sudden onset of confusion Confusion or stupor (related to hypoxia) may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain with guarding may occur with pneumonia, but these symptoms do not indicate hypoxia.

Which hematologic problem significantly increases the risks associated with pulmonary artery (PA) catheter insertion? Thrombocytopenia Hypovolemia Leukocytosis Hemolytic anemia

Thrombocytopenia PA catheter insertion carries a significant risk of bleeding, which is exacerbated when the patient has low levels of platelets. Leukocytosis, hypovolemia, and anemia are less likely to directly increase the risks associated with PA insertion.

The nurse is caring for a patient with a nursing diagnosis of hyperthermia related to pneumonia. What assessment data does the nurse obtain that correlates with this nursing diagnosis (select all that apply.)? a. A productive cough with yellow sputum b. Reports of unable to have a bowel movement for 2 days c. Heart rate of 120 beats/min d. Respiratory rate of 20 breaths/min e. A temperature of 101.4°F

a. A productive cough with yellow sputum c. Heart rate of 120 beats/min e. A temperature of 101.4°F A fever is an inflammatory response related to the infectious process. A productive cough with discolored sputum (which should be clear) is an indication that the patient has pneumonia. A respiratory rate of 20 breaths/min is within normal range. Inability to have a bowel movement is not related to a diagnosis of pneumonia. A heart rate of 120 beats/min indicates that there is increased metabolism due to the fever and is related to the diagnosis of pneumonia.

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action is best for the nurse to take next? a. Administer the prescribed PRN morphine. b. Assist the patient to deep breathe and cough. c. Milk the chest tube gently to remove any clots. d. Tape the area around the insertion site of the chest tube.

a. Administer the prescribed PRN morphine. The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy.

While family members are visiting, a patient has a cardiac arrest and is being resuscitated. Which action by the nurse is best? a. Ask family members if they wish to remain in the room during the resuscitation. b. Explain to family members that watching the resuscitation will be very stressful. c. Assign a staff member to wait with family members just outside the patient room. d. Escort family members quickly out of the patient room and then remain with them.

a. Ask family members if they wish to remain in the room during the resuscitation. Research indicates that family members want the option of remaining in the room during procedures such as CPR and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient.

After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next? a. Ask the patient whether medications have been taken as directed. b. Discuss the need to use some different medications to treat the TB. c. Schedule the patient for directly observed therapy three times weekly. d. Educate about using a 2-drug regimen for the last 4 months of treatment.

a. Ask the patient whether medications have been taken as directed. The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. A two-drug regimen will be used only if the sputum smears are negative for AFB.

A patient with bacterial pneumonia has rhonchi and thick sputum. Which action will the nurse use to promote airway clearance? a. Assist the patient to splint the chest when coughing. b. Educate the patient about the need for fluid restrictions. c. Encourage the patient to wear the nasal oxygen cannula. d. Instruct the patient on the pursed lip breathing technique.

a. Assist the patient to splint the chest when coughing. Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen will improve gas exchange, but will not improve airway clearance. Pursed lip breathing is used to improve gas exchange in patients with COPD, but will not improve airway clearance.

A 70-yr-old patient in the intensive care unit (ICU) has become agitated and inattentive since his heart surgery. The nurse knows that ICU delirium frequently occurs in individuals with preexisting dementia, history of alcohol abuse, and severe disease. What interventions should the nurse provide to improve the patient's cognition (select all that apply.)? a. Enable the patient to sleep on a schedule with dim lights. b. Have the family stay with the patient. c. Initiate early mobilization. d. Provide a small amount of beer. e. Encourage conversation in the patient's room to help reorient. f. Improve oxygenation.

a. Enable the patient to sleep on a schedule with dim lights. b. Have the family stay with the patient. c. Initiate early mobilization. f. Improve oxygenation. ICU delirium is common in ICU patients. Improving oxygenation, enabling the patient to sleep, early mobilization, and decreasing sensory overload along with orientation is all helpful in improving the patient's cognition. The beer may or may not be allowed for this patient, and the nurse should not assume that it will help. Having a family member stay with the patient to reorient the patient is helpful, but the family group may increase sensory overload with conversations not involving the patient.

Following surgery, a patients central venous pressure (CVP) monitor indicates low pressures. Which action will the nurse anticipate taking? a. Increase the IV fluid infusion rate. b. Administer IV diuretic medications. c. Elevate the head of the patients bed to 45 degrees. d. Document the CVP and continue to monitor

a. Increase the IV fluid infusion rate. A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head may decrease cerebral perfusion. Documentation and continued monitoring is an inadequate response to the low CVP.

A patient who was admitted the previous day with pneumonia complains of a sharp pain whenever I take a deep breath. Which action will the nurse take next? a. Listen to the patients lungs. b. Administer the PRN morphine. c. Have the patient cough forcefully. d. Notify the patients health care provider.

a. Listen to the patients lungs. The patients statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.

The nurse notes that a patients endotracheal tube (ET), which was at the 21-cm mark, is now at the 24-cm mark and the patient appears anxious and restless. Which action should the nurse take first? a. Listen to the patients lungs. b. Offer reassurance to the patient. c. Bag the patient at an FIO2 of 100%. d. Notify the patients health care provider.

a. Listen to the patients lungs. The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions also are appropriate, but detection and correction of tube malposition are the most critical actions.

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

a. Lower the positive end-expiratory pressure (PEEP). Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for pneumothorax.

The nurse is caring for a patient with an alteration in airway clearance. What nursing actions would be a priority to promote airway clearance (select all that apply.)? a. Maintain adequate fluid intake. b. Maintain a 30-degree elevation. c. Maintain a semi-Fowler's position. d. Splint the chest when coughing. e. Instruct patient to cough at end of exhalation.

a. Maintain adequate fluid intake. d. Splint the chest when coughing. e. Instruct patient to cough at end of exhalation. Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.

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.)? a. Negative inspiratory force (NIF) of -15 cm H2O b. Minute volume of 8 L/min c. Serum hemoglobin of 6 g/dL d. Respirations of 28 breaths/min e. Mean arterial pressure (MAP) of 45 mm Hg f. Patient follow commands

a. Negative inspiratory force (NIF) of -15 cm H2O c. Serum hemoglobin of 6 g/dL e. Mean arterial pressure (MAP) of 45 mm Hg Findings that support readiness for weaning are minute volume of 8 L/min, patient is alert and follow commands, and respirations of 28 breaths/min. Findings that indicate the patient is not ready for weaning include serum hemoglobin of 6 g/dL, mean arterial pressure (MAP) of 45 mm Hg, and negative inspiratory force (NIF) of -15 cm H2O. Extubating a patient with severe anemia, poor perfusion, and weakened breathing effort will likely result in poor outcomes such as worsening of condition and reintubation.

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.)? a. Obesity b. Pneumonia c, Cigarette smoking d. Malignancy e. Prolonged air travel

a. Obesity c, Cigarette smoking d. Malignancy e. Prolonged air travel An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, and surgery within the previous 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.

A patient with ARDS who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV) has settings of fraction of inspired oxygen (FIO2) 80%, tidal volume 500, rate 18, and positive end-expiratory pressure (PEEP) 5 cm. Which assessment finding is most important for the nurse to report to the health care provider? a. Oxygen saturation 99% b. Patient respiratory rate 22 breaths/min c. Crackles audible at lung bases d. Apical pulse rate 104 beats/min

a. Oxygen saturation 99% The FIO2 of 80% increases the risk for oxygen toxicity. Since the patients O2 saturation is 99%, a decrease in FIO2 is indicated to avoid toxicity. The other patient data would be typical for a patient with ARDS and would not need to be urgently reported to the health care provider.

A patient with respiratory failure has hemodynamic monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 10 cm H2O. Which information indicates that a change in the ventilator settings may be required? a. The arterial line shows a blood pressure of 90/46. b. The pulmonary artery pressure (PAP) is decreased. c. The cardiac monitor shows a heart rate of 58 beats/min. d. The pulmonary artery wedge pressure (PAWP) is increased.

a. The arterial line shows a blood pressure of 90/46. The hypotension indicates that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and cardiac output (CO). The other assessment data would not be caused by mechanical ventilation.

Which assessment data obtained by the nurse when caring for a patient with a left radial arterial line indicates a need for the nurse to take action? a. The left hand is cooler than the right hand. b. The mean arterial pressure (MAP) is 75 mm Hg. c. The system is delivering only 3 mL of flush solution per hour. d. The flush bag and tubing were last changed 3 days previously.

a. The left hand is cooler than the right hand. The change in temperature of the left hand suggests that blood flow to the left hand is impaired. The flush system needs to be changed every 96 hours. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3 to 6 mL/hour of flush solution.

Which assessment finding by the nurse when caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates that the PEEP may need to be decreased? a. The patient has subcutaneous emphysema. b. The patient has a sinus bradycardia with a rate of 52. c. The patients PaO2 is 50 mm Hg and the SaO2 is 88%. d. The patient has bronchial breath sounds in both the lung fields.

a. The patient has subcutaneous emphysema. The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not indications that PEEP should be reduced.

When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? a. The patient is somnolent. b. The patients SpO2 is 90%. c. The patient complains of weakness. d. The patients blood pressure is 162/94.

a. The patient is somnolent. Increasing somnolence will decrease the patients respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest.

When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The patients PaO2 is 90 mm Hg, and the SaO2 is 92%. b. Endotracheal suctioning results in minimal mucous return. c. Sputum and blood cultures show no growth after 24 hours. d. The skin on the patients back is intact and without redness.

a. The patients PaO2 is 90 mm Hg, and the SaO2 is 92%. The purpose of prone positioning is to improve the patients oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective.

Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The respiratory rate is 32 breaths/min. b. The pulse oximeter shows a SpO2 of 93%. c. The patient has not been suctioned for the last 6 hours. d. The lungs have occasional audible expiratory wheezes.

a. The respiratory rate is 32 breaths/min. The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An SpO2 of 93% is acceptable and does not suggest that immediate suctioning is needed.

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis? a. Weak, nonproductive cough effort b. Large amounts of greenish sputum c. Respiratory rate of 28 breaths/minute d. Resting pulse oximetry (SpO2) of 85%

a. Weak, nonproductive cough effort The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.

Which information will the nurse include in the patient teaching plan for a patient who is receiving rifampin (Rifadin) for treatment of tuberculosis? a. Your urine, sweat, and tears will be orange colored. b. Read a newspaper daily to check for changes in vision. c. Take vitamin B6 daily to prevent peripheral nerve damage. d. Call the health care provider if you notice any hearing loss.

a. Your urine, sweat, and tears will be orange colored. Orange-colored body secretions are a side effect of rifampin. The other adverse effects are associated with other antituberculosis medications.

. A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142, BP reading of 100/60, and respirations of 42. The nurses first action should be to a. elevate the head of the bed to 45 to 60 degrees. b. administer the ordered pain medication. c. notify the patients health care provider. d. offer emotional support and reassurance.

a. elevate the head of the bed to 45 to 60 degrees. The patient has symptoms consistent with a pulmonary embolism. Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and oxygen is started).

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patients oxygen saturation (SpO2) from 94% to 88%. The nurse will a. increase the oxygen flow rate. b. suction the patients oropharynx. c. assist the patient to cough and deep breathe. d. help the patient to sit in a more upright position.

a. increase the oxygen flow rate. Increasing oxygen flow rate usually will improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep-breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

An elderly patient who has stabilized after being in the intensive care unit (ICU) for a week is preparing for transfer to the step down unit when the nurse notices that the patient has new onset confusion. The nurse will plan to a. inform the receiving nurse and then transfer the patient. b. notify the health care provider and postpone the transfer. c. administer PRN lorazepam (Ativan) and cancel the transfer. d. obtain an order for restraints as needed and transfer the patient.

a. inform the receiving nurse and then transfer the patient. The patients history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the ICU environment, and informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation.

A patient develops increasing dyspnea and hypoxemia 2 days after having cardiac surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with a. inserting a pulmonary artery catheter. b. obtaining a ventilation-perfusion scan. c. drawing blood for arterial blood gases. d. positioning the patient for a chest radiograph.

a. inserting a pulmonary artery catheter. Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema.

The nurse observes nursing assistive personnel (NAP) doing all the following activities when caring for a patient with right lower lobe pneumonia. The nurse will need to intervene when NAP a. lower the head of the patients bed to 10 degrees. b. splint the patients chest during coughing. c. help the patient to ambulate to the bathroom. d. assist the patient to a bedside chair for meals.

a. lower the head of the patients bed to 10 degrees. Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.

When assisting with insertion of a pulmonary artery (PA) catheter, the nurse identifies that the catheter is correctly placed when the a. monitor shows a typical PAWP tracing. b. PA waveform is observed on the monitor. c. systemic arterial pressure tracing appears on the monitor. d. catheter has been inserted to the 22-cm marking on the line.

a. monitor shows a typical PAWP tracing. The purpose of a PA line is to measure PAWP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAWP readings are available. After insertion, the balloon is deflated and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line. The length of catheter needed for insertion will vary with patient size.

A patient experiences a steering wheel injury as a result of an automobile accident. During the initial assessment, the emergency department nurse would be most concerned about a. paradoxic chest movement. b. the complaint of chest wall pain. c. a heart rate of 110 beats/minute. d. a large bruised area on the chest.

a. paradoxic chest movement. Paradoxic chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.

The intensive care unit (ICU) charge nurse will determine that teaching about hemodynamic monitoring for a new staff nurse has been effective when the new nurse a. positions the zero-reference stopcock line level with the phlebostatic axis. b. balances and calibrates the hemodynamic monitoring equipment every hour. c. rechecks the location of the phlebostatic axis when changing the patients position. d. ensures that the patient is lying supine with the head of the bed flat for all readings.

a. positions the zero-reference stopcock line level with the phlebostatic axis. For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment hourly. Accurate hemodynamic readings are possible with the patients head raised to 45 degrees or in the prone position. The anatomic position of the phlebostatic axis does not change when patients are repositioned.

A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the a. use and side effects of isoniazid (INH). b. standard four-drug therapy for TB. c. need for annual repeat TB skin testing. d. bacille Calmette-Gurin (BCG) vaccine.

a. use and side effects of isoniazid (INH). The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States and would not be helpful for this individual, who already has a TB infection.

When teaching the patient who is receiving standard multidrug therapy for tuberculosis (TB) about possible toxic effects of the antitubercular medications, the nurse will give instructions to notify the health care provider if the patient develops a. yellow-tinged skin. b. changes in hearing. c. orange-colored sputum. d. thickening of the fingernails

a. yellow-tinged skin. Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.

During assessment of the chest in a patient with pneumococcal pneumonia, the nurse would expect to find a. vesicular breath sounds. b. increased tactile fremitus. c. dry, nonproductive cough. d. hyperresonance to percussion.

b. increased tactile fremitus. Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical.

The health care provider inserts a chest tube in a patient with a hemopneumothorax. When monitoring the patient after the chest tube placement, the nurse will be most concerned about 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. The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. A large air leak would be expected immediately after chest tube placement for pneumothorax. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax.

Which action should the nurse take when the low pressure alarm sounds for a patient who has an arterial line in the right radial artery? a. Check the right hand for pallor. b. Assess for cardiac dysrhythmias. c. Flush the arterial line with saline. d. Rezero the monitoring equipment.

b. Assess for cardiac dysrhythmias. The low pressure alarm indicates a drop in the patients blood pressure, which may be caused by cardiac dysrhythmias. There is no indication to rezero the equipment. Pallor of the right hand would be caused by occlusion of the radial artery by the arterial catheter, not by low pressure. There is no indication of a need for flushing the line.

A patient with newly diagnosed lung cancer tells the nurse, I think I am going to die pretty soon. Which response by the nurse is best? a. Would you like to talk to the hospital chaplain about your feelings? b. Can you tell me what it is that makes you think you will die so soon? c. Are you afraid that the treatment for your cancer will not be effective? d. Do you think that taking an antidepressant medication would be helpful?

b. Can you tell me what it is that makes you think you will die so soon? The nurses initial response should be to collect more assessment data about the patients statement. The answer beginning Can you tell me what it is is the most open-ended question and will offer the best opportunity for obtaining more data. The answer beginning, Are you afraid implies that the patient thinks that the cancer will be immediately fatal, although the patients statement may not be related to the cancer diagnosis. The remaining two answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.

The nurse is performing tuberculosis (TB) screening in a clinic that has many patients who have immigrated to the United States. Before doing a TB skin test on a patient, which question is most important for the nurse to ask? a. Is there any family history of TB? b. Have you received the bacille Calmette-Gurin (BCG) vaccine for TB? c. How long have you lived in the United States? d. Do you take any over-the-counter (OTC) medications?

b. Have you received the bacille Calmette-Gurin (BCG) vaccine for TB? Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.

Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) can the RN delegate to an experienced LPN/LVN working in the intensive care unit? a. Assess breath sounds b. Insert a retention catheter c. Place patient in the prone position d. Monitor pulmonary artery pressures

b. Insert a retention catheter Insertion of retention catheters is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff and should be supervised by an RN. Assessment of breath sounds and obtaining pulmonary artery pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient.

A patient has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action will be best for the nurse to include in the plan of care? a. Encourage use of the incentive spirometer. b. Offer the patient fluids at frequent intervals. c. Teach the patient the importance of coughing. d. Increase oxygen level to keep O2 saturation >95%.

b. Offer the patient fluids at frequent intervals. Since the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. The use of the incentive spirometer should be more frequent in order to facilitate the clearance of the secretions. The other actions also may be helpful in improving the patients gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.

Which assessment information obtained by the nurse when caring for a patient who has just had a thoracentesis is most important to communicate to the health care provider? a. BP is 150/90 mm Hg. b. Oxygen saturation is 89%. c. Pain level is 5/10 with a deep breath. d. Respiratory rate is 24 when lying flat

b. Oxygen saturation is 89%. Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.

Which nursing action will be most effective in preventing aspiration pneumonia in patients who are at risk? a. Turn and reposition immobile patients at least every 2 hours. b. Place patients with altered consciousness in side-lying positions. c. Monitor for respiratory symptoms in patients who are immunosuppressed. d. Provide for continuous subglottic aspiration in patients receiving enteral feedings.

b. Place patients with altered consciousness in side-lying positions. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings.

Premature ventricular contractions (PVCs) occur while the nurse is suctioning a patients endotracheal tube. Which action by the nurse is best? a. Decrease the suction pressure to 80 mm Hg. b. Stop and ventilate the patient with 100% oxygen. c. Document the dysrhythmia in the patients chart. d. Give prescribed PRN antidysrhythmic medications.

b. Stop and ventilate the patient with 100% oxygen. Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation, and the nurse should stop suctioning and ventilate the patient with 100% oxygen. Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the patient is well oxygenated.

To determine the effectiveness of medications that a patient has received to reduce left ventricular afterload, which hemodynamic parameter will the nurse monitor? a. Central venous pressure (CVP) b. Systemic vascular resistance (SVR) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

b. Systemic vascular resistance (SVR) Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other parameters will be monitored, but do not reflect afterload as directly.

When the nursing supervisor is evaluating the performance of a new RN, which action indicates that the new RN is safe in providing care to a patient who is receiving mechanical ventilation with 10 cm of peak end-expiratory pressure (PEEP)? a. The RN plans to suction the patient every 2 hours. b. The RN uses a closed-suction technique to suction the patient. c. The RN tapes connection between the ventilator tubing and the ET. d. The RN changes the ventilator circuit tubing routinely every 24 hours.

b. The RN uses a closed-suction technique to suction the patient. The closed-suction technique is suggested when patients require high levels of PEEP to prevent the loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be scheduled routinely, but it should be done only when patient assessment data indicate the need for suctioning. Taping connections between the ET and the ventilator tubing would restrict the ability of the tubing to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for ventilator-associated pneumonia (VAP) and are not indicated routinely.

A patient who is receiving mechanical ventilation is anxious and is fighting the ventilator. Which action should the nurse take first? a. Ventilate the patient with a manual resuscitation bag. b. Verbally coach the patient to breathe with the ventilator. c. Sedate the patient with the ordered PRN lorazepam (Ativan). d. Increase the rate for the ordered propofol (Diprivan) infusion.

b. Verbally coach the patient to breathe with the ventilator. The initial response by the nurse should be to try to decrease the patients anxiety by coaching the patient about how to coordinate respirations with the ventilator. The other actions also may be helpful if the verbal coaching is ineffective in reducing the patients anxiety.

Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patients arterial blood gas (ABG) results include a pH of 7.50, PaO2 of 80 mm Hg, PaCO2 of 29 mm Hg, and HCO3 of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to a. increase the FIO2. b. decrease the respiratory rate. c. increase the tidal volume (VT). d. leave the ventilator at the current settings.

b. decrease the respiratory rate. The patients PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD, increasing the tidal volume would further lower the PaCO2, and the PaCO2 and pH indicate a need to make the ventilator changes.

A patient with respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. The nurse will anticipate assisting with a. administration of 100% oxygen by non-rebreather mask. b. endotracheal intubation and positive pressure ventilation. c. insertion of a mini-tracheostomy with frequent suctioning. d. initiation of bilevel positive pressure ventilation (BiPAP).

b. endotracheal intubation and positive pressure ventilation. The patients lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patients respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patients respiratory rate or oxygenation. BiPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.

A patient with acute respiratory distress syndrome (ARDS) and acute renal failure has the following medications prescribed. Which medication should the nurse discuss with the health care provider before administration? a. ranitidine (Zantac) 50 mg IV b. gentamicin (Garamycin) 60 mg IV c. sucralfate (Carafate) 1 g per nasogastric tube d. methylprednisolone (Solu-Medrol) 40 mg IV

b. gentamicin (Garamycin) 60 mg IV Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS.

While waiting for cardiac transplantation, a patient with severe heart failure has a ventricular assist device (VAD) implanted. When developing the plan of care, the nursing actions should include a. administration of immunosuppressive medications. b. monitoring the surgical incision for signs of infection. c. teaching the patient the reason for continuous bed rest. d. preparing the patient to have the VAD in place permanently.

b. monitoring the surgical incision for signs of infection. The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immunosuppression is not necessary for nonbiologic devices like the VAD.

When the nurse is caring for an obese patient with left lower lobe pneumonia, gas exchange will be best when the patient is positioned a. on the left side. b. on the right side. c. in the tripod position. d. in the high-Fowlers position.

b. on the right side. The patient should be positioned with the good lung in the dependent position to improve the match between ventilation and perfusion. The obese patients abdomen will limit respiratory excursion when sitting in the high-Fowlers or tripod positions.

When developing a teaching plan for a patient with a 42 pack-year history of cigarette smoking, it will be most important for the nurse to include information about a. computed tomography (CT) screening for lung cancer. b. options for smoking cessation. c. reasons for annual sputum cytology testing. d. erlotinib (Tarceva) therapy to prevent tumor risk.

b. options for smoking cessation. Because smoking is the major cause of lung cancer, the most important role for the nurse is educating patients about the benefits of and means of smoking cessation. Early screening of at-risk patients using sputum cytology, chest x-ray, or CT scanning has not been effective in reducing mortality. Erlotinib may be used in patients who have lung cancer but not to reduce risk for developing tumors.

A patient with a pleural effusion is scheduled for a thoracentesis. Before the procedure, the nurse will plan to a. start a peripheral intravenous line to administer the necessary sedative drugs. b. position the patient sitting upright on the edge of the bed and leaning forward. c. remove the water pitcher and remind the patient not to eat or drink anything for 6 hours. d. instruct the patient about the importance of incentive spirometer use after the procedure.

b. position the patient sitting upright on the edge of the bed and leaning forward. When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The lung will expand after the effusion is removed; incentive spirometry is not needed to assure alveolar expansion. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious.

A patient with primary pulmonary hypertension (PPH) is receiving nifedipine (Procardia). The nurse will evaluate that the treatment is effective if a. the BP is less than 140/90 mm Hg. b. the patient reports decreased exertional dyspnea. c. the heart rate is between 60 and 100 beats/minute. d. the patients chest x-ray indicates clear lung fields.

b. the patient reports decreased exertional dyspnea. Since a major symptom of PPH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor effectiveness of therapy for a patient with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective.

After the nurse has received change-of-shift report about the following four patients, which patient should be assessed first? a. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes b. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled c. A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath. d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2 F (37.8 C)

c. A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath. Sudden onset shortness of breath in a patient with a deep vein thrombosis suggests a pulmonary embolism and requires immediate assessment and actions such as oxygen administration. The other patients also should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.

The nurse notes thick, white respiratory secretions for a patient who is receiving mechanical ventilation. Which intervention will be most effective in resolving this problem? a. Suction the patient every hour. b. Reposition the patient every 2 hours. c. Add additional water to the patients enteral feedings. d. instill 5 mL of sterile saline into the endotracheal tube (ET) before suctioning.

c. Add additional water to the patients enteral feedings. Because the patients secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions.

To evaluate the effectiveness of prescribed therapies for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse? a. Chest x-rays b. Pulse oximetry c. Arterial blood gas (ABG) analysis d. Pulmonary artery pressure monitoring

c. Arterial blood gas (ABG) analysis ABG analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs provide information about the PaCO2 and pH. The other tests also may be done to help in assessing oxygenation or determining the cause of the patients ventilatory failure.

During admission of a patient diagnosed with non-small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer (select all that apply.)? a. Chronic interstitial fibrosis b. Geographic area in which he was born c. Asbestos exposure d. History of cigarette smoking e. Exposure to uranium

c. Asbestos exposure d. History of cigarette smoking e. Exposure to uranium Non-small cell carcinoma is associated with cigarette smoking and exposure to environmental carcinogens, including asbestos and uranium. Chronic interstitial fibrosis is associated with the development of adenocarcinoma of the lung. Exposure to cancer-causing substances in the geographic area where the patient has lived for some time may be a risk but not necessarily where the patient was born.

The pulse oximetry for a patient with right lower lobe pneumonia indicates an oxygen saturation of 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is best for the nurse to take? a. Position the patient on the right side. b. Place a humidifier in the patients room. c. Assist the patient with staged coughing. d. Schedule a 2-hour rest period for the patient.

c. Assist the patient with staged coughing. The patients assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 2-hour rest period at this time may allow the oxygen saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the right side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.

The family members of a patient who has just been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take first? a. Immediately take the family members to the patients room. b. Discuss ICU visitation policies and encourage family visits. c. Describe the patients injuries and the care that is being provided. d. Invite the family to participate in a multidisciplinary care conference.

c. Describe the patients injuries and the care that is being provided. Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the patients appearance and the ICU environment before visiting the patient for the first time. ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse.

To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation? a. Avoid use of positive end-expiratory pressure (PEEP). b. Suction every 2 hours. c. Elevate head of bed to 30 to 45 degrees. d. Give enteral feedings at no more than 10 mL/hr.

c. Elevate head of bed to 30 to 45 degrees. Elevation of the head decreases the risk for aspiration. PEEP is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patients high energy needs.

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. Hyperoxygenate the patient for 30 seconds. d. Insert a few drops of normal saline into the ET to break up secretions. e. Perform hand hygiene before performing the procedure. f. Perform a cardiopulmonary assessment.

c. Hyperoxygenate the patient for 30 seconds. f. Perform a cardiopulmonary assessment. Suctioning is preceded by a thorough assessment and hyperoxygenation for 30 seconds. Sterile, not clean, gloves are necessary, and it is not necessary to administer a bronchodilator. Instillation of normal saline into the ET tube is not an accepted standard practice.

Which statement by a patient who has been hospitalized for pneumonia indicates a good understanding of the discharge instructions given by the nurse? a. I will call the doctor if I still feel tired after a week. b. I will need to use home oxygen therapy for 3 months. c. I will continue to do the deep breathing and coughing exercises at home. d. I will schedule two appointments for the pneumonia and influenza vaccines.

c. I will continue to do the deep breathing and coughing exercises at home. Patients should continue to cough and deep breathe after discharge. Fatigue for several weeks is expected. Home oxygen therapy is not needed with successful treatment of pneumonia. The pneumovax and influenza vaccines can be given at the same time.

When caring for a patient who has an intraaortic balloon pump in place, which action will be included in the plan of care? a. Avoid the use of anticoagulant medications. b. Keep the head of the bed elevated 45 degrees. c. Measure the patients urinary output every hour. d. Provide passive range of motion for all extremities.

c. Measure the patients urinary output every hour. Monitoring urine output will help determine whether the patients cardiac output has improved and also help monitor for balloon displacement. The head of the bed should be no higher than 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon.

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit up at the bedside. b. Splint the patients chest during coughing. c. Medicate the patient with the prescribed morphine. d. Have the patient use the prescribed incentive spirometer.

c. Medicate the patient with the prescribed morphine. A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance but should be done after the morphine is given.

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action will the nurse take? a. Repeat the tuberculin skin testing. b. Teach about the reason for the blood tests. c. Obtain consecutive sputum specimens from the patient for 3 days. d. Instruct the patient to expectorate three specimens as soon as possible.

c. Obtain consecutive sputum specimens from the patient for 3 days. Three consecutive sputum specimens are obtained on different days for bacteriologic testing for M. tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. Once skin testing is positive, it is not repeated.

The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2 F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? a. Administer the scheduled IV antibiotic. b. Give the PRN acetaminophen (Tylenol) 650 mg. c. Obtain oxygen saturation using pulse oximetry. d. Notify the health care provider of the patients vital signs.

c. Obtain oxygen saturation using pulse oximetry. The patients increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Administration of the scheduled antibiotic and administration of Tylenol also will be done, but they are not the highest priority for a patient who may be developing ARDS.

When caring for a patient with pulmonary hypertension, which parameter will the nurse monitor to evaluate whether treatment has been effective? a. Mean arterial pressure (MAP) b. Central venous pressure (CVP) c. Pulmonary vascular resistance (PVR) d. Pulmonary artery wedge pressure (PAWP)

c. Pulmonary vascular resistance (PVR) PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters also may be monitored, but do not directly assess for pulmonary hypertension.

The nurse is caring for a patient receiving a continuous norepinephrine (Levophed) IV infusion. Which patient assessment information indicates that the infusion rate may be too high? a. Heart rate is 58 beats/min. b. Mean arterial pressure is 55 mm Hg. c. Systemic vascular resistance (SVR) is elevated. d. Pulmonary artery wedge pressure (PAWP) is low.

c. Systemic vascular resistance (SVR) is elevated. Vasoconstrictors such as norepinephrine (Levophed) will increase SVR, and this will increase the work of the heart and decrease peripheral perfusion. Bradycardia, hypotension, and low PAWP are not associated with norepinephrine infusion.

A patient is admitted to the emergency department with an open stab wound to the right chest. What is the first action that the nurse should take? a. Position the patient so that the right chest is dependent. b. Keep the head of the patients bed at no more than 30 degrees elevation. c. Tape a nonporous dressing on three sides over the chest wound. d. Cover the sucking chest wound firmly with an occlusive dressing.

c. Tape a nonporous dressing on three sides over the chest wound. The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the right side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.

When the charge nurse is evaluating the care that a new RN staff member provides to a patient receiving mechanical ventilation, which action by the new RN indicates the need for more education? a. The RN turns the FIO2 up to 100% before suctioning. b. The RN secures a bite block in place using adhesive tape. c. The RN positions the patient with the head of bed at 10 degrees. d. The RN asks for assistance to turn the patient to the prone position.

c. The RN positions the patient with the head of bed at 10 degrees. The head of the patients bed should be positioned at 30 to 45 degrees to prevent ventilator-acquired pneumonia. The other actions by the new RN are appropriate.

Which information obtained by the nurse about a patient who has been diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease is most important to communicate to the health care provider? a. The Mantoux test had an induration of only 8 mm. b. The chest-x-ray showed infiltrates in the upper lobes. c. The patient is being treated with antiretrovirals for HIV infection. d. The patient has a cough that is productive of blood-tinged mucus.

c. The patient is being treated with antiretrovirals for HIV infection. Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat tuberculosis. The other data are expected in a patient with HIV and TB disease.

When the nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation, which patient assessment indicates that the weaning protocol should be discontinued? a. The patient heart rate is 98 beats/min. b. The patients oxygen saturation is 93%. c. The patient respiratory rate is 32 breaths/min. d. The patients spontaneous tidal volume is 500 mL.

c. The patient respiratory rate is 32 breaths/min. Tachypnea is a sign that the patients work of breathing is too high to allow weaning to proceed. The patients heart rate is within normal limits, although the nurse should continue to monitor it. An oxygen saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 500 mL is within the acceptable range.

The nurse is caring for a 22-year-old patient who came to the emergency department with acute respiratory distress. Which information about the patient requires the most rapid action by the nurse? a. Respiratory rate is 32 breaths/min. b. Pattern of breathing is shallow. c. The patients PaO2 is 45 mm Hg. d. The patients PaCO2 is 34 mm Hg.

c. The patients PaO2 is 45 mm Hg. The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patients poor oxygenation.

The nurse is caring for a patient with primary pulmonary hypertension who is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action? a. The BP is 98/56 mm Hg. b. The oxygen saturation is 94%. c. The patients central intravenous line is disconnected. d. The international normalized ratio (INR) is prolonged.

c. The patients central intravenous line is disconnected. The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion.

A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea. Which assessment finding by the nurse is most important to report to the health care provider? a. The patient has bibasilar lung crackles. b. The patient is sitting in the tripod position. c. The patients respiratory rate has decreased from 30 to 10 breaths/min. d. The patients pulse oximetry indicates an O2 saturation of 91%

c. The patients respiratory rate has decreased from 30 to 10 breaths/min. A decrease in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore immediate action such as positive pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An oxygen saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.

After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective? a. Bronchial breath sounds are heard at the right base. b. The patient coughs up small amounts of green mucus. c. The patients white blood cell (WBC) count is 9000/l. d. Increased tactile fremitus is palpable over the right chest.

c. The patients white blood cell (WBC) count is 9000/l. The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.

When caring for a patient who has an arterial catheter in the radial artery to monitor blood pressure, which information obtained by the nurse is most important to report to the health care provider? a. The patient has a positive Allen test. b. The mean arterial pressure (MAP) is 86 mm Hg. c. There is redness at the catheter insertion site. d. The dicrotic notch is visible in the waveform.

c. There is redness at the catheter insertion site. Redness at the catheter insertion site indicates possible infection. The Allen test is performed before arterial line insertion, and a positive test indicates normal ulnar artery perfusion. A MAP of 86 is normal and the dicrotic notch is normally present on the arterial waveform.

A patient who has just been admitted with pneumococcal pneumonia has a temperature of 101.6 F with a frequent cough and is complaining of severe pleuritic chest pain. Which of these prescribed medications should the nurse give first? a. guaifenesin (Robitussin) b. acetaminophen (Tylenol) c. azithromycin (Zithromax) d. codeine phosphate (Codeine)

c. azithromycin (Zithromax) Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications also are appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.

An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. An assessment finding indicating to the nurse that the goals of treatment with the IABP are being met is a a. heart rate of 110 beats/min. b. urine output of 20 mL/hr. c. cardiac output (CO) of 5 L/min. d. stroke volume (SV) of 40 mL/beat.

c. cardiac output (CO) of 5 L/min. A CO of 5 L/min is normal and indicates that the IABP has been successful in treating the shock. The low SV signifies continued cardiogenic shock. The tachycardia and low urine output also suggest continued cardiogenic shock.

The nurse recognizes that the goals of teaching regarding the transmission of pulmonary tuberculosis (TB) have been met when the patient with TB a. demonstrates correct use of a nebulizer. b. washes dishes and personal items after use. c. covers the mouth and nose when coughing. d. reports daily to the public health department.

c. covers the mouth and nose when coughing. Covering the mouth and nose will help decrease airborne transmission of TB. The other actions will not be effective in decreasing the spread of TB.

While assessing a patient with a central venous catheter, the nurse notes the catheter insertion site is red and tender and the patients temperature is 101.8 F. The nurse will plan to a. administer analgesics and antibiotics. b. check the site frequently for any swelling. c. discontinue the catheter and culture the tip. d. change the flush system and monitor the site.

c. discontinue the catheter and culture the tip. The information indicates that the patient has a local and systemic infection caused by the catheter and the catheter should be discontinued. Changing the flush system, administration of analgesics, and continued monitoring will not help prevent or treat the infection. Administration of antibiotics is appropriate, but the line should still be discontinued to avoid further complications such as endocarditis.

When providing preoperative instruction for a patient scheduled for a left pneumonectomy for cancer of the lung, the nurse informs the patient that the postoperative care includes a. positioning on the right side. b. bed rest for the first 24 hours. c. frequent use of an incentive spirometer. d. chest tubes to water-seal chest drainage.

c. frequent use of an incentive spirometer. Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Chest tubes are not usually used after pneumonectomy because the affected side is allowed to fill with fluid. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis.

When caring for a patient who is hospitalized with active tuberculosis (TB), the nurse observes a family member who is visiting the patient. The nurse will need to intervene if the family member a. washes the hands before entering the patients room. b. hands the patient a tissue from the box at the bedside. c. puts on a surgical face mask before visiting the patient. d. brings food from a fast-food restaurant to the patient.

c. puts on a surgical face mask before visiting the patient. A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patients room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before visiting the patient is not necessary, but there is no reason for the nurse to stop the family member from doing this. Because anorexia and weight loss are frequent problems in patients with TB, bringing food from outside the hospital is appropriate. The family member should wash the hands after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.

The mixed venous oxygen saturation (SvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased SvO2, the nurse assesses the patients a. weight. b. amylase. c. temperature. d. urinary output.

c. temperature. Elevated temperature increases metabolic demands and oxygen use by tissues, resulting in a drop in oxygen saturation of mixed venous blood. Information about the patients weight, urinary output, and amylase will not help in determining the cause of the patients drop in SvO2.

After receiving change-of-shift report, which patient will the nurse assess first? a. A patient with cystic fibrosis who has thick, green-colored sputum b. A patient with pneumonia who has coarse crackles in both lung bases c. A patient with emphysema who has an oxygen saturation of 91% to 92% d. A patient with septicemia who has intercostal and suprasternal retractions

d. A patient with septicemia who has intercostal and suprasternal retractions This patients history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation. The other patients also should be assessed as quickly as possible, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.

An alcoholic and homeless patient is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen? a. Educating the patient about the long-term impact of TB on health b. Giving the patient written instructions about how to take the medications c. Teaching the patient about the high risk for infecting others unless treatment is followed d. Arranging for a daily noontime meal at a community center and giving the medication then

d. Arranging for a daily noontime meal at a community center and giving the medication then Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help to ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients, but are not likely to be as helpful with this patient.

When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first? a. Check pupil reaction to light. b. Notify the health care provider. c. Attempt to calm and reassure the patient. d. Assess oxygenation using pulse oximetry.

d. Assess oxygenation using pulse oximetry. Since agitation and confusion are frequently the initial indicators of hypoxemia, the nurses initial action should be to assess oxygen saturation. The other actions also are appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider.

A patient has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action will the nurse include in the plan of care? a. Discontinue assessments during the night to allow uninterrupted sleep. b. Administer prescribed sedatives or opioids at bedtime to promote sleep. c. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps. d. Cluster nursing activities so that the patient has uninterrupted rest periods.

d. Cluster nursing activities so that the patient has uninterrupted rest periods. Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing assessments during the night.

After discharge teaching has been completed for a patient who has had a lung transplant, the nurse will evaluate that the teaching has been effective if the patient states a. I will make an appointment to see the doctor every year. b. I will not turn the home oxygen up higher than 2 L/minute. c. I will not worry if I feel a little short of breath with exercise. d. I will call the health care provider right away if I develop a fever.

d. I will call the health care provider right away if I develop a fever. Low-grade fever may indicate infection or acute rejection, so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team; annual health care provider visits would not be sufficient. Home oxygen use is not an expectation after lung transplant. Shortness of breath should be reported.

When the ventilator alarm sounds, the nurse finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take first? a. Offer reassurance to the patient. b. Activate the hospitals rapid response team. 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. The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team also are appropriate after the nurse has stabilized the patients oxygenation.

When caring for the patient with a pulmonary artery pressure catheter, the nurse notes that the PA waveform indicates that the catheter is in the wedged position. Which action should the nurse take? a. Inflate the PA balloon. b. Change the flush system. c. Zero balance the transducer. d. Notify the health care provider.

d. Notify the health care provider. When the catheter is in the wedge position, blood flow past the catheter is obstructed, placing the patient at risk for pulmonary infarction. A health care provider or specially trained nurse should be called to reposition the catheter. The other actions will not correct the wedging of the PA catheter.

Which of these orders will the nurse act on first for a patient who has just been admitted with probable bacterial pneumonia and sepsis? a. Administer aspirin suppository. b. Send to radiology for chest x-ray. c. Give ciprofloxacin (Cipro) 400 mg IV. d. Obtain blood cultures from two sites

d. Obtain blood cultures from two sites Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest radiograph and aspirin administration can be done last.

The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider? a. Cough that is productive of blood-tinged sputum b. Scattered crackles throughout the posterior lung bases c. Temperature of 101.5 F (38.6 C) after 2 days of IV antibiotic therapy d. Oxygen saturation (SpO2) has dropped to 90% with administration of 100% O2 by non-rebreather mask.

d. Oxygen saturation (SpO2) has dropped to 90% with administration of 100% O2 by non-rebreather mask. The patients low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patients blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct? a. PEEP will prevent fibrosis of the lung from occurring. b. PEEP will push more air into the lungs during inhalation. c. PEEP allows the ventilator to deliver 100% oxygen to the lungs. d. PEEP prevents the lung air sacs from collapsing during exhalation.

d. PEEP prevents the lung air sacs from collapsing during exhalation. By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.

Which action by the occupational health nurse at a manufacturing plant where there is potential exposure to inhaled dust will be most helpful in reducing incidence of lung disease? a. Teach about symptoms of lung disease. b. Treat workers who inhale dust particles. c. Monitor workers for shortness of breath. d. Require the use of protective equipment.

d. Require the use of protective equipment. Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease, but will not be effective in prevention of lung damage.

A lobectomy is scheduled for a patient with stage I nonsmall cell lung cancer. The patient tells the nurse, I would rather have radiation than surgery. Which response by the nurse is most appropriate? a. Are you afraid that the surgery will be very painful? b. Did you have bad experiences with previous surgeries? c. Surgery is the treatment of choice for stage I lung cancer. d. Tell me what you know about the various treatments available.

d. Tell me what you know about the various treatments available. More assessment of the patients concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, Surgery is the treatment of choice is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patients reasons for not wanting surgery.

Which information about a patient who has a recent history of tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions? a. Chest x-ray shows no upper lobe infiltrates. b. TB medications have been taken for 6 months. c. Mantoux testing shows an induration of 10 mm. d. Three sputum smears for acid-fast bacilli are negative.

d. Three sputum smears for acid-fast bacilli are negative. Negative sputum smears indicate that M. tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done since it will not change even with effective treatment.

When preparing to assist with the insertion of a pulmonary artery catheter, the nurse will plan to a. check cardiac enzymes before insertion. b. auscultate heart sounds during insertion. c. place the patient on NPO status before the procedure. d. attach cardiac monitoring leads before the procedure.

d. attach cardiac monitoring leads before the procedure. Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anesthesia, and the patient will not need to be NPO. Changes in cardiac enzymes or heart sounds are not expected during pulmonary artery catheter insertion.

A patient with pneumonia has a fever of 101.2 F (38.5 C), a nonproductive cough, and an oxygen saturation of 89%. The patient is very weak and needs assistance to get out of bed. The priority nursing diagnosis for the patient is a. hyperthermia related to infectious illness. b. impaired transfer ability related to weakness. c. ineffective airway clearance related to thick secretions. d. impaired gas exchange related to respiratory congestion.

d. impaired gas exchange related to respiratory congestion. All these nursing diagnoses are appropriate for the patient, but the patients oxygen saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.

A patient with a subarachnoid hemorrhage is intubated and placed on a mechanical ventilator. When monitoring the patient, the nurse will need to notify the health care provider if the patient develops a. oxygen saturation of 94%. b. respirations of 18 breaths/min. c. green nasogastric tube drainage. d. increased jugular vein distention (JVD).

d. increased jugular vein distention (JVD). Increases in JVD in a patient with a subarachnoid hemorrhage may indicate an increase in intra-cranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 18, O2 saturation of 94%, and green nasogastric tube drainage are normal.

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

d. injects air into the cuff until a slight leak is heard only at peak inflation. The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patients size. Cuff pressure should be maintained at 20 to 25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon.

When assessing a 24-year-old patient who has just arrived after an automobile accident, the emergency department nurse notes that the breath sounds are absent on the right side. The nurse will anticipate the need for a. emergency pericardiocentesis. b. stabilization of the chest wall with tape. c. administration of an inhaled bronchodilator. d. insertion of a chest tube with a chest drainage system.

d. insertion of a chest tube with a chest drainage system. The patients history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patients clinical manifestations are not consistent with these problems.

To determine the effectiveness of prescribed therapies for a patient with cor pulmonale and right-sided heart failure, which assessment will the nurse make? a. Lung sounds b. Heart sounds c. Blood pressure d. peripheral edema

d. peripheral edema Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular vein distention, and right upper-quadrant abdominal tenderness would be expected. Abnormalities in lung sounds, blood pressure, or heart sounds are not caused by cor pulmonale.

When monitoring for the effectiveness of treatment for a patient with left ventricular failure, the most important information for the nurse to obtain is a. mean arterial pressure (MAP). b. systemic vascular resistance (SVR). c. pulmonary vascular resistance (PVR). d. pulmonary artery wedge pressure (PAWP).

d. pulmonary artery wedge pressure (PAWP). PAWP reflects left ventricular end diastolic pressure (or left ventricular preload). Because the patient in left ventricular failure will have a high PAWP, a decrease in this value will be the best indicator of patient improvement. The other values would also provide useful information, but the most definitive measurement of improvement is a drop in PAWP.

A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. The most appropriate action by the nurse is to a. document the presence of a large air leak. b. obtain and attach a new collection device. c. notify the surgeon of a possible pneumothorax. d. take no further action with the collection device.

d. take no further action with the collection device. Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. A new collection device is needed when the collection chamber is filled.

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

d. use an end-tidal CO2 monitor to check for placement in the trachea. End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion also are used, but they are not as accurate as end-tidal CO2monitoring. A chest x-ray confirms the placement but is done after the tube is secured.