NCLEX 285 Exam 2 Critical Care/Vent managment Etc...

When caring for a patient who has a pneumothorax, which of these actions should the healthcare provider include in the patient's plan of care? Choose 1 answer: 1- Encourage the patient to breathe deeply and cough regularly. 2- Empty the drainage chamber every shift and record the amount. 3- Vigorously massage the tube every 2 hours to promote drainage. 4- Change the insertion site dressing daily using aseptic technique.

1- Encourage the patient to breathe deeply and cough regularly. Routine massage (milking) of the chest tube may excessively increase intrapulmonary pressures and may damage the lung. Tracking the amount of drainage each shift is accomplished by marking on the collection chamber. The dressing is changed per protocol or as needed when it becomes soiled. Regular deep breathing and coughing will help re-expand the collapsed lung.

The healthcare provider is caring for a patient on a ventilator with an endotracheal tube in place. What assessment data indicate the tube has migrated too far down the trachea? Choose 1 answer: 1- A high pressure alarm sounds 2- Decreased breath sounds on the left side of the chest 3- Low pressure alarm sounds 4- Increased crackles auscultation bilaterally

2- Decreased breath sounds on the left side of the chest A low pressure alarm indicates a disconnection or a leak in the circuit. A high pressure alarm warns of rising pressures. If the endotracheal tube is inserted too far, it often goes into the right main stem bronchus. Air will then be delivered to the right lung and not the left.

Several family members of a patient diagnosed with a pleural effusion are concerned that the patient has not been "coughing up any of the fluid." The healthcare provider understands that nonproductive cough is expected because the: Choose 1 answer: 1- Effusion has most likely resolved. 2- Fluid collection is excreted through circulation. 3- Fluid collection is outside of the airways and alveoli. 4- Pressure of the fluid is restricting the airway.

3- Fluid collection is outside of the airways and alveoli. First, consider the location of the effusion. The effusion is located in the pleural space. The pleural space is located outside of the lung and airspace, so the cough will not be productive.

The healthcare provider is caring for a patient who has a pneumothorax. When assessing the patient and the chest tube drainage system, a large fibrin clot is noted in the tubing. Which additional assessment finding requires immediate action by the healthcare provider? Choose 1 answer: 1- Fluctuations in the water seal chamber 2- Increasing pain at the insertion site 3- Decreased water in the suction control chamber 4- A downward trend in blood pressure

4- A downward trend in blood pressure Fluctuations in the water seal chamber (tidaling) occur normally as the water level rises when the patient inhales and falls during exhalation. Water in the water-filled suction chamber tends to evaporate and should be replaced as needed. The parietal pleurae are innervated by the intercostal and phrenic nerves, so pain management is part of routine care for this patient. Clots in the system can cause occlusion and lead to a tension pneumothorax, which may be evidenced by a downward trend in blood pressure as increased pressure on the heart and great vessels impair cardiac output.

The healthcare provider is caring for a patient with a diagnosis of emphysema who is experiencing a sudden onset of dyspnea and pleuritic pain. Which of these assessment findings are expected if the patient is experiencing a pneumothorax? Select all that apply. Choose all answers that apply: 1- Inspiratory wheezing 2- Dysphasia 3- Tachycardia 4- Decreased diaphragmatic excursion 5- Paradoxical Chest movement

4- Decreased diaphragmatic excursion 5- Paradoxical Chest movement Dysphasia is associated with laryngeal cancer. Tachycardia is frequently seen whenever there is decreased available oxygen. Paradoxical chest movement is seen in flail chest, where the affected area moves in the opposite direction with respect to the intact portion of the chest. In a pneumothorax, there is restricted lung expansion so the diaphragmatic excursion will be decreased.

The healthcare provider's assessment of the patient includes rapid, shallow respirations, respiratory alkalosis, and inspiratory crackles. Which additional assessment finding would confirm a diagnosis of acute respiratory distress syndrome (ARDS)? Choose 1 answer: 1- Asymmetrical chest expansion 2- Pink, frothy sputum 3- Circumoral cyanosis 4- Hypoxemia unresponsive to supplemental oxygen

4- Hypoxemia unresponsive to supplemental oxygen ARDS causes a lot of damage to the alveolar-capillary membrane, where gas exchange occurs. Deoxygenated blood does not pick up oxygen in the lungs because of a right-to-left shunt. Because of the right-to-left shunt, supplemental oxygen is unable to benefit the patient. This is called refractory hypoxemia.

The healthcare provider enters the room of a patient with a diagnosis of tuberculosis and finds the patient dyspneic. The neck veins are also visibly distended. Which of these additional assessments should the healthcare provider perform immediately? Choose 1 answer: 1- Auscultate the heart for extra heart sounds 2- Palpate the upper chest for crepitus 3- Check bilateral pulses 4- Palpate for tracheal deviation

4- Palpate for tracheal deviation Tuberculosis is a risk factor for pneumothorax. If a pneumothorax occurs in this patient, air entering the lungs will not be able to exit. Pressure will eventually build up causing a shift of the mediastinal structures from midline.

The patient is undergoing a thoracentesis for a pleural effusion. After the procedure, the healthcare provider will monitor the patient for which of the following possible complications of the procedure? Choose 1 answer: 1- Respiratory acidosis 2- Pulmonary fibrosis 3- Coagulopathy 4- Pneumothorax

4- Pneumothorax Thoracentesis involves the aspiration of fluid from the pleural space by percutaneous insertion of a needle through the chest wall. Ultrasound guidance can help avoid damage to surrounding structures. If the needle does not stay in the pleural space and enters the lung tissue, a potential complication is pneumothorax.

The healthcare provider is caring for four patients. Which patient should be assessed first? Choose 1 answer: 1- The patient who is in a tripod position and breathing through pursed lips. 2- The patient with a pain rating of 7 on a 0 to 10 pain scale whose oxygen saturation is 91%t. 3- The patient with bilateral crackles, fever, and mucopurulent sputum. 4- The patient with a respiratory rate of 28 and asymmetric chest wall movement.

4- The patient with a respiratory rate of 28 and asymmetric chest wall movement. Identify which of these patients are relatively stable. Identify the patient with signs of the most serious acute problem. Tachypnea and asymmetric chest wall movement are signs of a pneumothorax, so this patient needs prompt assessment and intervention

The healthcare provider is assisting during the insertion of a pulmonary artery catheter. Which of these, if assessed in the patient, would indicate the patient is experiencing a complication from the catheter insertion? Choose 1 answer: 1- Diaphragmatic excursion of 3 cm 2- Vesicular breath sounds noted on auscultation 3- Inspiration phase is greater than expiration 4- Tracheal deviation from midline

4- Tracheal deviation from midline Vesicular breath sounds and diaphragmatic excursion of 3cm are normal findings. Inspiration phase is normally greater than expiration, but it may also be noted in pneumothorax. Tracheal deviation from midline is associated with a tension pneumothorax, which is a potential complication associated with central line insertion.

Which of the following symptoms are most important to assess for in a patient with disseminated intravascular coagulation (DIC)? Choose all answers that apply: 1- Shortness of breath 2- Chest tightness 3- Cool extremities 4- Agitation 5- Constipation

ANS 1,2,3,4 Disseminated intravascular coagulation (DIC) is characterized by inappropriate clotting and bleeding. Think about the symptoms that we would find with altered tissue perfusion. Shortness of breath, chest tightness, cool extremities, and agitation are all associated with altered tissue perfusion to the lungs, heart, and brain.

The healthcare provider is caring for a patient who has Pneumocystis jiroveci pneumonia and is receiving mechanical ventilation. Which of these assessment data provide evidence that the patient has sustained barotrauma to the lungs? Select all that apply. Choose all answers that apply: 1- Absent breath sounds on one side 2- Decreasing oxygen saturation 3- Inspiratory crackles 4- Unexplained hypotension 5- An increasing oxygen saturation

ANS 1,2,4 During mechanical ventilation, lung inflation pressures can distend the lungs and rupture alveoli. Air can escape into the pleural space from the ruptured alveoli. Pleural pressure can increase and collapse the lung, causing a pneumothorax, leading to decreased oxygen saturation and absent breath sounds on one side. The pneumothorax can evolve into a tension pneumothorax causing hypotension as pressure on the mediastinum increases.

A patient has a vitamin K deficiency. Which of the following lab results would be expected for a patient with this deficiency? Choose all answers that apply: 1- Prolonged prothrombin time (PT) 2- Prolonged activated partial thromboplastin time (aPTT) 3- Prolonged international normalized ratio (INR) 4- Low platelets 5- Normal prothrombin time (PT) 6- Normal activated partial thromboplastin time (aPTT)

ANS 1,3,6 Vitamin K is required for effective hemostasis. Some clotting factors are dependent on vitamin K. Function of the extrinsic clotting pathway is evaluated by prothrombin time (PT) and the International Normalized Ratio (INR), so both of these would be prolonged if Vitamin K deficiency is impaired. Activated partial thromboplastin time (aPTT) is not affected and would be normal.

The healthcare provider is caring for a patient who has sustained multiple injuries from a motor vehicle accident. Which of these assessment data would be present if the patient has sustained a hemothorax? Select all that apply. Choose all answers that apply: 1- Muffled heart sounds 2- Tachycardia 3- Dullness on chest percussion 4- Pallor and anxiety 5- Coarse rhonchi upon auscultation

ANS 2,3,4 Rhonchi may be caused by mucus in large airways. Muffled heart sounds are associated with cardiac tamponade. The patient may exhibit signs of hypovolemic shock. Percussion over a blood-filled space will produce a dull sound.

A patient who has a hemothorax has lost 1800mL of blood. Which additional data will the healthcare provider expect when assessing this patient? Select all that apply. Choose all answers that apply: 1= An S3 noted upon auscultation 2- Decreased urine output 3- Respiratory rate of 26 per minute 4- Capillary refill of 2 seconds 5- Systolic blood pressure of 75 mmHg

ANS 2,3,5 A capillary refill of 2 seconds is a normal finding. S3 is associated with rapid filling of the ventricles during diastole. Because of the amount of blood the patient has lost, the patient will have signs of hypovolemic shock. The low systolic blood pressure indicates the patient is decompensating.

Which of these lab values would indicate the patient is at increased risk for bleeding? Choose all answers that apply: 1- International normalization ratio (INR): 1.0 2- International normalization ratio (INR): 4.0 3- Positive leukocyte esterase urine test 4- Prothrombin time (PT): 45 seconds 5- Activated partial thromboplastin time (aPTT): 60 seconds

ANS 2.4.5 INR, PT and aPTT are used to assess coagulation . The therapeutic level for INR is between 2.0 and 3.0 The range for aPTT is between 3 to 4 seconds INR of 4.0, PT of 45 seconds, and aPTT of 60 seconds indicate increased risk for bleeding.

In which order will the nurse take these actions when assisting with oral intubation of a patient who is having respiratory distress? 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.

ANS: 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. DIF: Cognitive Level: Analysis REF: 1701-1702 OBJ: Special Questions: Alternate Item Format, Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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.

ANS: A 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. DIF: Cognitive Level: Application REF: 1710 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

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.

ANS: A 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. DIF: Cognitive Level: Application REF: 1702-1704 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse notes that a patient's 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 patient's lungs. b. Offer reassurance to the patient. c. Bag the patient at an FIO2 of 100%. d. Notify the patient's health care provider.

ANS: A 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. DIF: Cognitive Level: Application REF: 1701-1702 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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.

ANS: A The patient's 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. DIF: Cognitive Level: Application REF: 1686 TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

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.

ANS: B 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. DIF: Cognitive Level: Application REF: 1703-1704 OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

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.

ANS: B 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 also may be helpful if the verbal coaching is ineffective in reducing the patient's anxiety. DIF: Cognitive Level: Application REF: 1704-1705 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's 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.

ANS: B 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, increasing the tidal volume would further lower the PaCO2, and the PaCO2 and pH indicate a need to make the ventilator changes. DIF: Cognitive Level: Analysis REF: 1710-1711 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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 patient's enteral feedings. d. Instill 5 mL of sterile saline into the endotracheal tube (ET) before suctioning.

ANS: C 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. DIF: Cognitive Level: Application REF: 1703-1704 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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 patient's room. b. Discuss ICU visitation policies and encourage family visits. c. Describe the patient's injuries and the care that is being provided. d. Invite the family to participate in a multidisciplinary care conference.

ANS: C 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. DIF: Cognitive Level: Application REF: 1686-1687 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

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 patient's oxygen saturation is 93%. c. The patient respiratory rate is 32 breaths/min. d. The patient's spontaneous tidal volume is 500 mL.

ANS: C 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, 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. DIF: Cognitive Level: Application REF: 1713 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

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.

ANS: C The head of the patient's bed should be positioned at 30 to 45 degrees to prevent ventilator-acquired pneumonia. The other actions by the new RN are appropriate. DIF: Cognitive Level: Application REF: 1711 OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment

While assessing a patient with a central venous catheter, the nurse notes the catheter insertion site is red and tender and the patient's 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.

ANS: C 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. DIF: Cognitive Level: Application REF: 1696 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

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.

ANS: D 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 CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured. DIF: Cognitive Level: Application REF: 1701-1702 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

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).

ANS: D 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. DIF: Cognitive Level: Application REF: 1711-1712 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

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 hospital's rapid response team. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen.

ANS: D 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 patient's oxygenation. DIF: Cognitive Level: Application REF: 1704-1706 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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.

ANS: D 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. DIF: Cognitive Level: Comprehension REF: 1701-1702 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity