Unang Pagsusulit AH3

A health care provider prescribes lidocaine HCl (Xylocaine), 1.5 mg per minute, for a client whose ECG tracing reveals multiple premature ventricular complexes (PVCs). The nurse adds 500 mg of lidocaine HCl to 100 mL of D5W. To administer the correct amount of medication, at what rate should the nurse set the intravenous (IV) infusion pump? Record your answer as a whole number. ___ mL/hr

18 The health care provider prescribed 1.5 mg of lidocaine HCl (Xylocaine) to be administered per minute. Multiply the 1.5 mg times 60 minutes to determine the hourly dosage to be administered. Then solve the problem using ratio and proportion.

A client weighing 125 kilograms (275 pounds), is considered to be in septic shock when the mean arterial pressure is less than 65 mm Hg or the systolic blood pressure is less than 90 mm Hg after receiving how many liters of intravenous crystalloids? 1. 0.5 L 2. 1 L 3. 2 L 4. 5 L

5 L This question requires the learner to apply the formula for defining septic shock to the scenario described. A septic client is considered to be in septic shock if the client remains hypotensive, as defined in the stem of the question, in spite of receiving 20-40 mL/kg of crystalloids, making 5 L the correct option.

A client is in cardiogenic shock. What explanation of cardiogenic shock should the nurse include when responding to a family member's questions about the condition? 1. An irreversible phenomenon 2. A failure of the circulatory pump 3. Usually a fleeting reaction to tissue injury 4. Generally caused by decreased blood volume

A failure of the circulatory pump Shock may have different etiologies (e.g., hypovolemic, cardiogenic, septic, anaphylactic) but always involves a drop in blood pressure and failure of the peripheral circulation because of sympathetic nervous system involvement. In cardiogenic shock, the failure of peripheral circulation is caused by the ineffective pumping action of the heart. Shock can be reversed by the administration of fluids, plasma expanders, and vasoconstrictors. It may be a reaction to tissue injury, but there are many different etiologies (e.g., hypovolemia, sepsis, anaphylaxis); it is not fleeting. Hypovolemia is only one cause.

A client complains of left-sided chest pain after the client finished playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify: 1. Dull sound on percussion 2. Vocal fremitus on palpation 3. Rales with rhonchi on auscultation 4. Absence of breath sounds on auscultation

Absence of breath sounds on auscultation The left lung is collapsed; therefore, there are no breath sounds. A tympanic, not a dull, sound will be heard with a pneumothorax. There is no vocal fremitus because there is no airflow into the left lung as a result of the pneumothorax. Rales with rhonchi will not be heard because there is no airflow into the left lung as a result of the pneumothorax.

A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client? 1. Distended neck veins 2. Paradoxical respirations 3. Increasing amounts of purulent sputum 4. Absence of breath sounds over the affected area

Absence of breath sounds over the affected area When the lung is collapsed, air is not moving into and out of the area, and therefore breath sounds are absent. Distended neck veins are associated with failure of the right side of the heart and can occur with a mediastinal shift, but there is no evidence of either. Paradoxical respirations occur with flail chest, not pneumothorax. Purulent sputum is a sign of infection, not pneumothorax.

A client is receiving warfarin (Coumadin) for a pulmonary embolism. Which drug is contraindicated when taking warfarin? 1. Ferrous sulfate 2. Acetylsalicylic acid (aspirin) 3. Atenolol (Tenormin) 4. Chlorpromazine (Thorazine)

Acetylsalicylic acid (aspirin) Acetylsalicylic acid can cause decreased platelet aggregation, increasing the risk for undesired bleeding that may occur with administration of anticoagulants. Ferrous sulfate does not affect warfarin; it is used for red blood cell synthesis. Atenolol is a beta blocker that reduces blood pressure; it does not affect bleeding. Chlorpromazine is a neuroleptic; it does not affect bleeding.

The laboratory international normalized ratio (INR) results of a client receiving warfarin (Coumadin) have been variable. The nurse interviews the client to determine factors contributing to the problem. Which is most important for the nurse to identify? 1. Use of analgesics 2. Serum glucose level 3. Serum potassium levels 4. Adherence to the prescribed drug regimen

Adherence to the prescribed drug regimen The dosage of warfarin is adjusted according to INR results; if the client fails to take the drug as prescribed, test results will not be reliable in monitoring the client's response to therapy. Although some medications can affect the absorption or metabolism of warfarin and should be investigated, this is less likely to be a cause of fluctuations in laboratory values. Serum glucose level and serum potassium levels do not affect the absorption of warfarin.

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

Air will move from the lung into the pleural space. As a person with a tear in the lung inhales, air moves through that opening into the intrapleural space; this creates a positive pressure and causes partial or complete collapse of the lung. Mediastinal shift occurs toward the unaffected side. Greater negative pressure within the chest cavity is normal; with a pneumothorax there is a loss of intrathoracic negative pressure. Collapse of the other lung will occur if not treated immediately is not an impending problem.

A client who is obtund has a blood pressure of 80/35 mm Hg after a blood transfusion. In an effort to support renal perfusion, the nurse administers dopamine (Intropin) at 2 mcg/kg/min as prescribed. What is the most relevant outcome indicating effectiveness of the medication for this client? 1. A decrease in blood pressure 2. An increase in urinary output 3. A decrease in core temperature 4. An increase in level of consciousness

An increase in urinary output As renal perfusion increases, urinary output also should increase; doses greater than 10 mcg/kg/min can cause renal vasoconstriction and decreased urinary output. A change in blood pressure is not a direct predictor of the effectiveness of dopamine given at a level of 2 mcg/kg/min; at 10 mcg/kg/min a client will experience an increased cardiac output and an increased blood pressure. Body temperature does not indicate improved renal perfusion. In this situation, improvement of renal perfusion is not directly related to the client's level of consciousness.

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock? 1. Arteriolar constriction occurs. 2. The cardiac workload decreases. 3. Contractility of the heart decreases. 4. The parasympathetic nervous system is triggered.

Arteriolar constriction occurs Cooing, babbling, and chuckling in a 3-month-old infant indicate normal development. A 3-month-old infant can pull at blankets or clothes and can raise his or her head to a 45- to 90-degree angle from the table. The grasp reflex generally disappears by the age of 3 months. A 3-month-old infant may not able to put his or her feet in the mouth when lying in the supine position. Generally a 5-month-old infant can put his or her feet in the mouth when lying in the supine position.

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

Aspirating gastric contents Aspirating gastric contents is a common cause of ARDS. Gastric enzymes injure alveolar-capillary membranes, which release inflammatory mediators; the process progresses to pulmonary edema, vascular narrowing and obstruction, pulmonary hypertension, and impaired gas exchange. Getting an opioid overdose is not as common a cause of ARDS as is aspiration pneumonia; this more likely will cause depressed respirations. Although anaphylaxis may cause ARDS, it is not a common cause. Although multiple blood transfusions have been known to precipitate ARDS, they are not a common cause.

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

Assess client's vital signs and lung sounds Administer oxygen via a ventilation bag Insert the catheter without applying suction Rotate the catheter while suction is applied The nurse should first assess the client's vital signs and lung sounds to determine if suctioning is needed. Then 100% oxygen should be administered to compensate for the lack of oxygen intake during the suctioning process. Suctioning should not be applied during catheter insertion to limit trauma. Rotating the catheter during withdrawal ensures thorough removal of secretions.

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

Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. The high-pressure alarm signifies increased pressure in the tubing or the respiratory tract; obstruction usually is caused by excessive secretions. Regulating the PEEP according to the rate and depth of the client's respirations is a dependent function of the nurse and cannot be implemented without a health care provider's prescription. High-volume low-pressure cuffs make assessing the need for suctioning unnecessary; it will decrease the effectiveness of the ventilator and compromise respiratory status. The temperature can remain constant, usually at about 5° F to 10° F below body temperature.

A nurse is caring for clients with a variety of problems. Which health problem does the nurse determine poses the greatest risk factor for the development of a pulmonary embolus? 1. Atrial fibrillation 2. Forearm laceration 3. Migraine headache 4. Respiratory infection

Atrial fibrillation Inadequate atrial contraction leads to venous pooling that contributes to the formation of thrombi that become emboli. The other health problems do not cause venous stasis or blood viscosity that contributes to venous thromboembolism.

A nurse is planning to administer albuterol (Proventil) to a 4-year-old child. The nurse should evaluate the effectiveness of this medication by: 1. Auscultating breath sounds 2. Collecting a sputum sample 3. Conducting a brief neurological examination 4. Palpating chest excursion to gauge promotion of intercostal contractility

Auscultating breath sounds Albuterol is an adrenergic drug that stimulates β-receptors, leading to relaxation of the smooth muscles of the airway. The lungs should be auscultated to evaluate the effectiveness of this medication. Albuterol does not affect intercostal contractility; chest excursion is not the appropriate assessment. Albuterol does not affect the consistency of pulmonary secretions. Albuterol will not cause central nervous system stimulation.

A client who is in hypovolemic shock has a hematocrit value of 25%. The nurse anticipates that the primary health care provider will prescribe: 1. Ringer's lactate 2. Serum albumin 3. Blood replacement 4. High molecular dextran

Blood replacement Blood replacement is needed to increase the oxygen-carrying capacity of the blood; the expected hematocrit for women is 37% to 47% and for men is 42% to 52%. Ringer's lactate does not increase the oxygen-carrying capacity of the blood. Serum albumin helps maintain volume but does not affect the hematocrit level. Although dextran does expand blood volume, it decreases the hematocrit because it does not replace red blood cells.

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply. 1. Bradycardia 2. Hypotension 3. Spastic paralysis 4. Bladder dysfunction 5. Increased pulse pressure

Bradycardia Hypotension Bladder dysfunction Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in hypotension. Bladder dysfunction in the form of urinary retention or oliguria may occur in spinal shock. Initially flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. There is a decreased, not increased, pulse pressure associated with hypotension and shock.

What should the nurse include in a teaching plan to help reduce the side effects associated with diltiazem (Cardizem)? 1. Lie down after meals. 2. Change positions slowly. 3. Avoid dairy products in diet. 4. Take the drug with an antacid.

Change positions slowly. Changing positions slowly will help prevent the side effect of orthostatic hypotension. Lying down after meals can relax the esophagus and lead to acid reflux. Avoiding dairy products and taking the drug with an antacid are not necessary.

What should the nurse include in a teaching plan for a client taking calcium channel blockers such as Nifedipine (Procardia)? Select all that apply. 1. Reduce calcium intake. 2. Change positions slowly. 3. Report peripheral edema. 4. Expect temporary hair loss. 5. Avoid drinking grapefruit juice.

Change positions slowly. Report peripheral edema. Avoid drinking grapefruit juice. Changing positions slowly helps reduce orthostatic hypotension. Peripheral edema may occur as a result of heart failure and must be reported. Grapefruit juice affects the metabolism of calcium channel blockers and should be avoided. Reducing calcium intake is unnecessary because calcium levels are not affected. Hair loss does not occur.

A nurse is caring for a client who has had multiple myocardial infarctions and has now developed cardiogenic shock. Which clinical manifestation supports this diagnosis? 1. Cold, clammy skin 2. Slow, bounding pulse 3. Increased blood pressure 4. Hyperactive bowel sounds

Cold, clammy skin The action of the sympathetic nervous system causes vasoconstriction, and as cellular hypoperfusion progresses, the skin becomes cold, cyanotic, or mottled. The heart rate increases in an attempt to meet the body's oxygen demands and circulate blood to vital organs; it has a low volume (weak, thready) because of peripheral vasoconstriction. The blood pressure decreases because of continued hypoperfusion and multiorgan failure. Bowel sounds are hypoactive or absent, not hyperactive.

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

Crackles Atelectasis Hypoxemia Severe dyspnea Crackles occur as fluid leaks into the alveolar interstitial space. The alveoli collapse from surfactant dysfunction and infiltrate from inflammation. Arterial hypoxemia that does not respond to supplemental oxygen is a characteristic sign of ARDS. Severe dyspnea can occur 12 to 48 hours after the initial onset of ARDS, which usually is an inflammatory trigger. Pulmonary wedge pressure is unaffected in ARDS; pulmonary wedge pressure is elevated in problems with cardiogenic origin.

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

Decreased filling of the right heart Pressure within the pleural cavity causes a shift of the heart and great vessels to the unaffected side. This not only decreases the capacity of the unaffected lung but also impedes the filling of the right side of the heart and leads to a decreased cardiac output. Rupture of the pericardium might occur with severe chest trauma, not with a mediastinal shift. Infection is not caused by a mediastinal shift. The volume of the unaffected lung may decrease because of pressure from the shift.

The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response is based on the principle that bed rest: 1. Prevents the further aggregation of platelets 2. Enhances the peripheral circulation in the deep vessels 3. Decreases the potential for further dislodgment of emboli 4. Maximizes the amount of blood available to damaged tissues

Decreases the potential for further dislodgment of emboli Activity may encourage the dislodgment of more microemboli. Bed rest may enhance platelet aggregation and the formation of thrombi because of venous stasis. Bed rest supports venous stasis, rather than enhanced circulation. Bed rest supports venous stasis rather than the circulation of blood to damaged tissues.

A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. The nurse should: 1. Question the client about the confusion 2. Change the method of oxygen delivery 3. Percuss and vibrate the client's chest wall 4. Discontinue or decrease the oxygen flow rate

Discontinue or decrease the oxygen flow rate With emphysema it is believed that the respiratory center no longer responds to elevated carbon dioxide as the stimulus to breathe but rather to lowered oxygen levels; therefore, the oxygen being delivered must be lowered to supply enough for oxygenation without being so elevated that it negates the stimulus to breathe. However, the results of one recent study of clients with stable chronic obstructive pulmonary disease (COPD) indicate that the hypercarbic drive is preserved. More research is needed before this theory is applied clinically. A confused client cannot answer questions about the confusion. The client has CO2 intoxication (CO2 narcosis); it is believed that increasing oxygen administration will diminish further the respiratory drive. However, the results of one recent study of clients with stable COPD indicate that the hypercarbic drive is preserved. More research is needed before this theory is applied clinically. There are no indications that respiratory secretions have increased.

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

Drain the fluid from the tubing Emptying the fluid from the tubing is necessary to prevent flooding of the trachea with fluid; some systems have receptacles attached to the tubing to collect the fluid and others have to be temporarily disconnected while emptying the fluid. This circumstance does not require assistance from a respiratory therapist. Humidity is necessary to preserve moistness of the respiratory tract and help liquefy secretions. The amount of condensation is irrelevant when recording total intake and output.

A nurse is caring for several postoperative clients. For what clinical manifestations of a pulmonary embolus should the nurse monitor these clients? Select all that apply. 1. Apathy 2. Dyspnea 3. Hemoptysis 4. Bronchial wheezes 5. Feeling of impending doom

Dyspnea Hemoptysis Feeling of impending doom Dyspnea is the most common symptom of a pulmonary embolus because of increased alveolar dead space, which impedes ventilation. With a pulmonary embolus, pulmonary blood flow is obstructed partially or completely; when infarcted areas have alveolar damage, red blood cells move into alveoli, resulting in hemoptysis. Clients with a pulmonary embolus have severe dyspnea and chest pain that precipitate a feeling of impending doom. Clients with a pulmonary embolus usually are apprehensive and hyperalert, not apathetic. Crackles, not bronchial wheezes, occur. Wheezes are associated with reactive airway disorders, such as asthma.

Following surgery in the inguinal area, the client complains of pain on the right side of the chest, becomes dyspneic, and begins to cough violently. The nurse suspects that a pulmonary embolus has occurred. What is the priority nursing action? 1. Auscultate the chest 2. Obtain the vital signs 3. Elevate the head of the bed 4. Position the client on the right side

Elevate the head of the bed Elevating the head of the bed promotes breathing by reducing the pressure of the abdominal organs on the diaphragm and increasing thoracic excursion. Auscultating the chest may confirm diminished breath sounds but will not facilitate breathing. Obtaining the vital signs should be doneeventually, but it is not the priority. Positioning the client on the right side will impede aeration of the right lung fields.

A nurse is caring for a client with a pneumothorax who has a chest tube in place. What should the nurse do when caring for this client? 1. Encourage range of motion to the client's arm on the affected side. 2. Administer the prescribed cough suppressant at the prescribed times. 3. Empty and measure the drainage in the collection chamber each shift. 4. Apply clamps below the insertion site when getting the client out of bed.

Encourage range of motion to the client's arm on the affected side. Range-of-motion exercises to the client's arm on the affected side promote aeration of the reexpanding lung and maintenance of function in the arm and shoulder. Cough suppressants are not indicated because coughing and deep breathing are encouraged to help reexpand the lung. Drainage is marked with time tapes on the side of the device. The closed system is not entered for emptying; when full, the entire device is replaced. Clamps are not necessary and should be avoided because of the danger of precipitating a tension pneumothorax.

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

Exudative Exudative (injury) phase of ARDS usually occurs within 24 to 48 hours after injury, although it can take up to 7 days. Engorgement of peribronchial and perivascular interstitial spaces produces interstitial edema of the lung. Fluid enters alveolar spaces, interfering with oxygenation. Damage to alveolar cells results in surfactant malfunction and atelectasis or alveolar collapse. Fibrotic (chronic or late) phase of ARDS occurs two to three weeks after injury; at this time, the injured area is sparsely collagenous, diffusely scarred, and fibrotic, resulting in pulmonary hypertension and decreased lung compliance and gas exchange. Reparative (proliferative) phase starts one to two weeks after injury; it is characterized by the inflammatory process as the lung attempts to repair itself. If this phase is arrested, injury resolves; if this phase persists for a prolonged time, extensive fibrosis results. Reparative (proliferative) phase starts one to two weeks after injury; it is characterized by the inflammatory process as the lung attempts to repair itself. If this phase is arrested, injury resolves; if this phase persists for a prolonged time, extensive fibrosis results.

A spontaneous pneumothorax is suspected in a client with a history of emphysema. In addition to calling the health care provider, what action should the nurse take? 1. Place the client on the unaffected side. 2. Administer 60% oxygen via a Venturi mask. 3. Prepare for intravenous (IV) administration of electrolytes. 4. Give oxygen at 2 L per minute via nasal cannula.

Give oxygen at 2 L per minute via nasal cannula. Oxygen is supplied to prevent anoxia, but not in high concentrations without a prescription. In an individual with emphysema, a low oxygen level, not high carbon dioxide level, may be the respiratory stimulus. Another reason is the Haldane effect; as hemoglobin molecules become more saturated with high concentrations of oxygen, they are unable to transport carbon dioxide out of the body, leading to hypercapnia. Placing the client on the unaffected side might increase the risk for mediastinal shift and interfere with expansion of the unaffected lung. Although oxygen is administered to prevent hypoxia, this concentration is too high for a client with emphysema because it may precipitate carbon dioxide narcosis. Preparing for an IV administration of electrolytes requires presciptions as to specific electrolytes.

A client with supraventricular tachycardia (SVT) is being treated with diltiazem hydrochloride (Cardizem). What assessment indicates to the nurse that the diltiazem hydrochloride is effective? 1. Blood pressure of 90/60 mm Hg 2. Heart rate of 110 beats per minute 3. No longer complaining of heart palpations 4. Increased urine output

Heart rate of 110 beats per minute Diltiazem hydrochloride's purpose is to slow the heart rate down. SVT has a heart rate of 150 to 250 beats per minute. A heart rate of 110 indicates that the diltiazem hydrochloride is having the desired effect. Hypotension is a side effect of diltiazem hydrochloride, not a desired effect. Heart palpations are experienced by some with various dysrhythmias. A decreased sensation of heart palpations is a positive finding but is not present in all clients. Increased urine output may occur over a period of time because of the increased ventricular filling time, but would not occur until after the heart rate had stabilized.

After a spontaneous pneumothorax, the client becomes extremely drowsy, and pulse and respirations increase. What do these client responses indicate to the nurse? 1. Hypercapnia 2. Hypokalemia 3. Increased Po2 4. Respiratory alkalosis

Hypercapnia Pneumothorax results in decreased surface area for gas exchange. If unaffected pleural regions cannot compensate, carbon dioxide builds up in the blood (hypercapnia). The client will become drowsy and may lose consciousness. The body attempts to compensate by increasing respiratory and pulse rates , and by the kidneys retaining bicarbonate. Hypokalemia causes extreme muscle weakness, abdominal distention, and changes in the ECG pattern. The Po2 is decreased with a pneumothorax because of the decreased surface area for gas exchange. Respiratory acidosis occurs with an elevated PCO2 .

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, the nurse should: 1. Apply suction for no more than 10 seconds while inserting the catheter 2. Hyperoxygenate with 100% oxygen before and after suctioning 3. Use the technique of short, pushing movements when applying suction 4. Suction two or three times in quick succession to remove secretions

Hyperoxygenate with 100% oxygen before and after suctioning Suctioning removes not only secretions but also oxygen, which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client before and after suctioning. To prevent trauma to the trachea, suction should be applied only while removing the catheter, not while inserting. Short, pushing movements can cause tracheal damage. Suction should be performed only as needed to maintain a patent airway; excessive suctioning irritates the mucosa, which increases secretion production.

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

Hyperoxygenate with 100% oxygen before and after suctioning. Suctioning also removes oxygen, which can cause cardiac dysrhythmias; the nurse attempts to prevent this by hyperoxygenating the client before and after suctioning. To prevent trauma to the trachea and hypoxia, suction should be applied only during catheter removal. Using short, jabbing movements of the catheter may cause tracheal damage and therefore is contraindicated. Suctioning should be performed only as needed; excessive suctioning irritates the mucosa, which increases secretion production.

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

Hyperoxygenate with 100% oxygen before and after suctioning. Suctioning also removes oxygen, which can cause cardiac dysrhythmias; the nurse should try to prevent this by hyperoxygenating the client before and aftersuctioning. Suction should be applied only while removing the catheter to prevent trauma to the trachea. Suction only as needed; excessive suctioning irritates the mucosa, which increases secretion production. Using rapid movements of the suction catheter to loosen secretions may cause tracheal damage.

A client sustains a spinal cord injury above the T6 level. The nurse should monitor the client for which indicator of spinal shock? 1. Tachycardia 2. Hypoventilation 3. Bladder distention 4. Elevated blood pressure

Hypoventilation A cervical spine injury may result in respiratory distress because of impaired muscle function, and respiratory monitoring can guide the decision to use mechanical ventilation. If not treated, atelectasis, pneumonia, and aspiration can occur. The client should be monitored for bradycardia and decreased cardiac output, not tachycardia. Although bladder distention can occur because of loss of autonomic and reflex control, it is not life threatening because an indwelling urinary catheter can ensure emptying of the bladder. Hypotension, not hypertension, will occur.

A nurse is obtaining an admission history for a client who is scheduled for surgery to repair a ruptured abdominal aneurysm. Which type of shock is this client at risk for developing? 1. Vasogenic 2. Neurogenic 3. Cardiogenic 4. Hypovolemic

Hypovolemic Hypovolemic shock occurs when an abdominal aneurysm ruptures. Shock ensues because fluid volume becomes depleted as the heart continues to pump blood out of the ruptured vessel. Vasogenic shock results from the action of humoral or toxic substances directly on the blood vessels, causing vasodilation. Neurogenic shock results from decreased neuromuscular tone, which reduces vasoconstriction. Cardiogenic shock results from a decrease in cardiac output.

The nurse understands that shock associated with a ruptured abdominal aneurysm is called: 1. Vasogenic shock 2. Neurogenic shock 3. Cardiogenic shock 4. Hypovolemic shock

Hypovolemic shock When an abdominal aneurysm ruptures, hypovolemic shock ensues because fluid volume depletion occurs as the heart continues to pump blood out of the ruptured vessel. Vasogenic shock results from humoral or toxic substances acting directly on the blood vessels, causing vasodilation. Neurogenic shock results from decreased neuromuscular tone, causing decreased vasoconstriction. Cardiogenic shock results from a decrease in cardiac output.

A nurse gave a client naloxone (Narcan). To evaluate the effectiveness of the medication, the nurse should assess for: 1. Change in level of consciousness. 2. Increased pain. 3. Increased respiration. 4. Decreased heart rate.

Increased respiration. Naloxone is given for decreased respirations caused by opioid overdose. The amount given is determined by the respiratory status, not the level of consciousness. An undesirable side effect of naloxone is pain and rapid heart rate with dysrhythmias.

A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct? 1. Strip the chest tube periodically. 2. Administer the prescribed cough suppressant at the scheduled times. 3. Empty and measure the drainage in the collection chamber each shift. 4. Keep the drainage system lower than the level of the client's chest.

Keep the drainage system lower than the level of the client's chest. The drainage system is kept below the chest to allow gravity to drain the pleural space. The chest tube should not be stripped because this action can cause negative pressure and damage lung tissue. Cough suppressants are not indicated because coughing and deep breathing are encouraged to help reexpand the lung. The closed system is not entered for emptying; when full, the entire device is replaced.

Which complication of anaphylactic shock in the adolescent client is most important for the nurse to detect early? 1. Urticaria 2. Tachycardia 3. Restlessness 4. Laryngeal edema

Laryngeal edema Laryngeal edema with severe acute upper airway obstruction may be life threatening in anaphylactic shock and requires rapid intervention. The reaction may also involve symptoms of irritability, tachycardia, and cutaneous signs of urticaria, but these are not as life threatening as laryngeal edema. Ensuring an open airway is priority.

A client has severe diarrhea, and the health care provider prescribes intravenous fluids, sodium bicarbonate, and an antidiarrheal medication. Which most frequently prescribed antidiarrheal drug does the nurse expect the health care provider to prescribe? 1. Bisacodyl (Dulcolax) 2. Psyllium (Metamucil) 3. Loperamide (Imodium) 4. Docusate sodium (Colace)

Loperamide (Imodium) Loperamide inhibits peristalsis and prolongs transit time by its effect on the nerves in the muscle wall of the intestines. Bisacodyl is a laxative, not an antidiarrheal; it increases gastrointestinal motility. Psyllium is not an antidiarrheal; it is a bulk laxative that promotes easier expulsion of feces. Docusate sodium corrects constipation, not diarrhea; water and fat are increased in the intestine, permitting easier expulsion of feces.

A client with a history of cirrhosis of the liver develops heart failure and is experiencing bigeminal premature ventricular complexes. What should the nurse expect about the dose of lidocaine (Xylocaine) prescribed by the health care provider? 1. Higher to compensate for the impaired liver function 2. Lower because the drug is metabolized at a diminished rate 3. Reduced because other organs will compensate for the sluggish liver 4. Equal to that needed for other clients to provide a loading dose for the myocardium

Lower because the drug is metabolized at a diminished rate The client has heart failure, which causes liver congestion, further compromising liver function; therefore, less than the usual adult dose will be prescribed because the liver will not be able to break down lidocaine as effectively as necessary. A dose higher to compensate for the impaired liver function increases the concentration of lidocaine in the blood, leading to toxicity. Lidocaine is metabolized by the liver; other organs cannot assist in the process. This may be life threatening because the client cannot metabolize lidocaine at the required rate, and toxicity may result.

When a client is experiencing hypovolemic shock with decreased tissue perfusion, the nurse expects that the body initially attempts to compensate by: 1. Producing less antidiuretic hormone (ADH) 2. Producing more red blood cells 3. Maintaining peripheral vasoconstriction 4. Decreasing mineralocorticoid production

Maintaining peripheral vasoconstriction With shock, arteriolar vasoconstriction occurs, raising the total peripheral vascular resistance and shifting blood to the major organs. With shock, more ADH is produced to promote fluid retention, which will elevate the blood pressure. Although producing more red blood cells is a response to hypoxia, peripheral vasoconstriction is a more effective compensatory mechanism. With shock the mineralocorticoids increase to promote fluid retention, which elevates the blood pressure.

The arterial blood gases of a client with chronic obstructive pulmonary disease (COPD) deteriorate, and respiratory failure is impending. For which clinical indicator should the nurse assess first? 1. Cyanosis 2. Bradycardia 3. Mental confusion 4. Distended neck veins

Mental confusion Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).

A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. Clients that are in late shock develop: 1. Hypokalemia 2. Metabolic acidosis 3. Respiratory alkalosis 4. Decreased PCO2 levels

Metabolic acidosis Decreased oxygen increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Hyperkalemia will occur because of renal shutdown; hypokalemia can occur in early shock. Respiratory alkalosis can occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The PCO2 level will increase in profound shock. Study Tip: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience.

A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, what response does the nurse expect? 1. Hypokalemia 2. Metabolic acidosis 3. Respiratory alkalosis 4. Decreased carbon dioxide level

Metabolic acidosis Decreased oxygen promotes the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Arterial blood gases do not assess serum potassium levels. Hyperkalemia will occur with shock because of renal shutdown; hypokalemia may occur in early shock. Respiratory alkalosis may occur in early shock because of rapid, shallow breathing, but in late shock, metabolic or respiratory acidosis occurs. The carbon dioxide level will be increased in profound shock.

During the progressive stage of shock, anaerobic metabolism occurs. For which complication should the nurse assess the client? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

Metabolic acidosis Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid associated with the progressive stage of shock. Respiratory acidosis can result from decreased respiratory function in late shock, further compounding metabolic acidosis. Respiratory alkalosis occurs as a result of hyperventilation during early shock.

During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially the anaerobic metabolism causes: 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

Metabolic acidosis Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid. Eventually respiratory acidosis can result from decreased respiratory function in late shock, further compounding metabolic acidosis. Respiratory alkalosis may occur as a result of hyperventilation during early shock.

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

Monitor serum carbon dioxide levels routinely Controlled ventilation induces hypocapnia; subsequently, it causes vasoconstriction and reduced cerebral blood flow. The fluid may be cerebrospinal fluid; clearing the ear may cause further damage. Because of manipulation during a craniotomy, anticonvulsants are given prophylactically to prevent seizures. Elevating the head of the bed 30 degrees will not increase cerebral blood flow.

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

Mucosal necrosis Mucosal necrosis is prevented because these cuffs do not compress the capillary beds. A minimal air leak is desirable to ensure the lowest possible pressure in the cuff while placement of the tube is maintained. Surgical asepsis, not use of these cuffs, prevents infection. Secretions will be increased because the cuff is a foreign body in the trachea.

A nurse is caring for a client with a pneumothorax that has a chest tube attached to a closed chest drainage system. If the chest tube and closed-chest drainage system are effective, the type of pressure that will be reestablished is: 1. Neutral pressure in the pleural space 2. Negative pressure in the pleural space 3. Atmospheric pressure in the thoracic cavity 4. Intrapulmonic pressure in the thoracic cavity

Negative pressure in the pleural space Removal of air and fluid from the pleural space reestablishes negative pressure, resulting in lung expansion. Neutral pressure in the pleural space will cause collapse of the lung. Atmospheric pressure in the thoracic cavity will cause collapse of the lung. Intrapulmonic pressure refers to pressure within the lung itself, not the pressure within the thoracic cavity.

A nurse is caring for a client who had emergency surgery for a ruptured appendix. What action should the nurse take when the client manifests signs and symptoms of shock? 1. Prepare for a blood transfusion 2. Elevate the head of the bed 30 degrees 3. Administer 2 L oxygen via nasal cannula 4. Notify the health care provider immediately

Notify the health care provider immediately Peritonitis and shock are potentially life-threatening complications that may occur after abdominal surgery; prompt, rigorous treatment is necessary. Fluids, not blood, will be needed to expand and maintain the circulating blood volume. The head of the bed should be flat to increase tissue perfusion and oxygenation to vital organs. Two liters of oxygen is inadequate; a higher flow rate is necessary.

On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. The nurse should: 1. Prepare for blood transfusions 2. Notify the surgeon immediately 3. Give the client nothing by mouth (NPO) 4. Administer the prescribed sedative

Notify the surgeon immediately Immediate surgical intervention to clamp the aorta is necessary for survival; the aneurysm has ruptured. Preparing for blood transfusions may be done eventually, but notifying the surgeon is the priority. The client is already NPO. Sedatives mask important signs and symptoms.

A client has emergency surgery for a ruptured appendix. While in the postanesthesia care unit, the client manifests signs and symptoms of shock. The nurse should: 1. Prepare for a blood transfusion 2. Notify the surgeon immediately 3. Elevate the head of the bed 30 degrees 4. Order an electrocardiogram (ECG)

Notify the surgeon immediately Peritonitis and shock are potentially life-threatening complications following abdominal surgery; prompt, rigorous treatment is necessary. The surgeon should be notified Fluids, not blood, are needed to expand and maintain the circulating blood volume. The head of the bed should be flat to increase tissue perfusion and oxygenation to the vital organs. An ECG does not treat shock.

A client has an endotracheal tube and is receiving mechanical ventilation. The nurse identifies that periodic suctioning may be necessary. The nurse follows a specific protocol when performing this procedure. Place the steps in the order that they should be performed. 1. Obtain the vital signs. 2. Auscultate lung sounds. 3. Hyperoxygenate for 30 seconds. 4. Suction for approximately 10 seconds. 5. Rotate the catheter during its withdrawal.

Obtain the vital signs. Auscultate lung sounds. Hyperoxygenate for 30 seconds. Suction for approximately 10 seconds. Rotate the catheter during its withdrawal. Obtaining the vital signs first provides a baseline for evaluating the client's response to suctioning if it is performed. Next, the nurse should assess the client's lung sounds to determine if suctioning is needed and to provide a baseline for comparison to evaluate the effectiveness of the intervention. Hyperoxygenation for 30 seconds before suctioning compensates for the removal of oxygen during the suctioning process, but it is done after auscultation of breath sounds. Suctioning occurs after the lung sounds have been auscultated and the client has been preoxygenated; the catheter is inserted into the endotracheal tube. Suctioning for less than 15 seconds is appropriate because suctioning for longer than this irritates the mucosal lining of the respiratory tract as well as induces hypoxia. Rotating the catheter during its withdrawal is done near the end of the procedure, when the catheter is rotated and removed.

A client has a colon resection with an anastomosis. What assessments by the nurse support a suspicion of impending shock? Select all that apply. 1. Oliguria 2. Lethargy 3. Irritability 4. Hypotension 5. Slurred speech

Oliguria Irritability Hypotension Restlessness, not lethargy, usually occurs because of decreased cerebral blood flow. Irritability, along with restlessness and anxiety, occurs because of a decrease in oxygen to the brain. Hypotension and a narrowing of the pulse pressure occur because of declining blood volume. Decreased blood flow to the kidneys leads to oliguria or anuria. There are various changes in sensorium, but slurred speech is not a manifestation of shock.

A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by: 1. Providing more oxygen to lung tissue. 2. Adding pressure to lung tissue, which improves gas exchange. 3. Opening collapsed alveoli and keeping them open. 4. Opening collapsed bronchioles, which allows more oxygen to reach lung tissue.

Opening collapsed alveoli and keeping them open. The primary mechanism of PEEP is to deliver positive pressure to the lung at the end of expiration. This helps to open collapsed alveoli and keep them open. With the primary mechanism of PEEP to open the alveoli and maintain them open, exchange of carbon dioxide and oxygen can take place more efficiently, thus improving oxygenation by providing more oxygen to the lung tissue and improving gas exchange. PEEP may have an indirect effect on opening bronchioles.

A nurse is assessing a client with cardiogenic shock. Which clinical findings should the nurse expect? Select all that apply. 1. Pallor 2. Nausea 3. Tachycardia 4. Narrow pulse pressure 5. Decreased respirations

Pallor Tachycardia Narrow pulse pressure Pale skin, tachycardia, and narrow pulse pressure are signs of cardiogenic shock. Nausea and decreased respirations are not expected with cardiogenic shock.

A client develops subcutaneous emphysema after a chest injury with suspected pneumothorax. What assessment by the nurse is the best method for detecting this complication? 1. Percussing the neck and chest. 2. Palpating the neck or face. 3. Auscultating for abnormal breath sounds. 4. Observing for asymmetry of chest movement.

Palpating the neck or face. Subcutaneous emphysema refers to the presence of air in the tissue that surrounds an opening in the normally closed respiratory tract; the tissue appears puffy, and a crackling sensation is detected when trapped air is compressed between the nurse's palpating fingertips and the client's tissue. Percussion is not an appropriate method for assessment; breath sounds are not affected. Asymmetry of chest movements may occur because of the pneumothorax but are not indicative of subcutaneous emphysema.

A low-dose intravenous dopamine hydrochloride (Dopamine) infusion drip is prescribed for a client in acute renal failure (ARF). What is the most appropriate way for the nurse to administer this intravenous medication to the client? 1. Peripherally inserted central line catheter (PICC) line 2. #20 angiocatheter in either antecubital area 3. Femoral line 4. Large gauge butterfly needle in hand

Peripherally inserted central line catheter (PICC) line Dopamine hydrochloride is a vesicant and if it infiltrates into the skin it can cause tissue necrosis. It must be infused through a central line catheter such as a PICC line. An angiocatheter and butterfly are not central lines. A femoral line is a central line but is used only in extreme emergencies because of the risk of insertion site infection.

A client who has experienced a fracture of the femur is experiencing respiratory difficulties, and the nurse suspects a pulmonary embolus. Which of these assessment findings is specific to a fat embolism? 1. Chest pain 2. Dyspnea 3. Petechiae 4. Decreased SaO2

Petechiae Petechiae on the chest and shoulders suggest fat emboli after fractures. The petechial rash occurs from occlusion of small dermal capillaries, leading to extravasation of red blood cells. Both a fat embolism and a blood clot embolism in the lungs may cause symptoms, such as altered mental status, chest pain, dyspnea, decreased SaO2, and increased respirations and pulse.

A client sustains a fracture of the head of the femur and the nurse is concerned about the client experiencing a fat embolus. The nurse should assess the client for which clinical indicator common to a fat pulmonary embolus? 1. Unilateral chest pain 2. Sudden onset of dyspnea 3. Impending sense of doom 4. Petechial hemorrhages on the chest

Petechial hemorrhages on the chest Petechiae on the chest and shoulders suggest fat emboli after fractures. The petechial rash occurs from occlusion of small dermal capillaries leading to extravasation of red blood cells. Unilateral chest pain, sudden onset of dyspnea, and impending sense of doom are not specific for just a fat embolus; these may occur with emboli of any origin, such as from thrombophlebitis.

After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? 1. Pink 2. Clear 3. Green 4. Yellow

Pink With a pulmonary embolus there is partial or complete occlusion of pulmonary blood flow; when infarcted areas or areas of atelectasis produce alveolar damage, red blood cells move into the alveoli, resulting in hemoptysis. Clear sputum is associated with a viral infection. Green and yellow sputum are associated with a bacterial infection.

A nurse is caring for a client with severe burns. The nurse determines that this type of client is at risk for hypovolemic shock because of the: 1. Decreased rate of glomerular filtration 2. Excessive blood loss through the burned tissues 3. Plasma proteins moving out of the intravascular compartment 4. Sodium retention occurring as a result of the aldosterone mechanism

Plasma proteins moving out of the intravascular compartment The shift of plasma proteins into the burned area increases the shift of fluid from the intravascular to the interstitial compartment; the result is decreased blood volume and hypovolemic shock. Decreased glomerular filtration may occur because of hypovolemia; it does not cause hypovolemia. Extracellular fluid, not blood, is lost through burned tissue. Sodium is not retained; it passes to the burned area and helps cause blister formation.

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

Positive end-expiratory pressure (PEEP) Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation. Fluid is not in the pleural space, so chest tube insertion is not indicated. Aggressive diuretic therapy and administration of beta blockers are contraindicated because of severe hypotension from the fluid shift into the interstitial spaces in the lungs.

For what client response must the nurse monitor to determine the effectiveness of amiodarone (Cordarone)? 1. Results of fasting lipid profile 2. Presence of cardiac dysrhythmias 3. Degree of blood pressure control 4. Incidence of ischemic chest pain

Presence of cardiac dysrhythmias Amiodarone is a class III antidysrhythmic used to treat ventricular and supraventricular tachycardia, and conversion of atrial fibrillation. Results of fasting lipid profile are expected with antilipidemics. Degree of blood pressure control is expected with antihypertensives. Incidence of ischemic chest pain is expected with antianginal agents, such as nitrates.

A client with a pneumothorax has a chest tube inserted and attached to a closed-chest drainage system. The client asks, "Why is the tube in my chest hooked up to a contraption with water in it?" The nurse explains that the water: 1. Promotes pleural drainage via gravity 2. Measures the pressures in the chest wall 3. Prevents reflux of air back into the chest 4. Ensures bubbling in the water-seal chamber

Prevents reflux of air back into the chest Water acts as a seal, preventing air from entering the pleural space, which will interfere with expansion of the lung. Removal of air (drainage) is promoted by negative pressure, not gravity, in the closed-chest drainage system. Water in the system does not facilitate measurement of pressures in the chest wall; this is not the purpose of a water-seal drainage system. Although air exiting the pleural space will cause bubbling in the water-seal chamber, water in the system does not ensure bubbling in the water-seal chamber; this is not the purpose of the water-seal chamber.

Which relationship does the nurse consider reflective of the relationship of naloxone (Narcan) to morphine sulfate? 1. Aspirin to warfarin (Coumadin) 2. Amoxicillin (Amoxil) to systemic infection 3. Protamine sulfate to parenteral heparin 4. Enoxaparin (Lovenox) to dalteparin (Fragmin)

Protamine sulfate to parenteral heparin Protamine sulfate is the antidote for heparin overdose and naloxone will reverse the effects of opioids such as morphine. Aspirin and warfarin both interfere with coagulation. While amoxicillin is used to treat some infections, an infection is not a medication, so amoxicillin cannot be considered an antidote. Both enoxaparin and dalteparin are low molecular weight heparins.

Warfarin (Coumadin) is prescribed for a client who has been receiving intravenous (IV) heparin for a partial occlusion of the left common carotid artery. The client expresses concern about why both drugs are needed at the same time. The nurse explains that this approach: 1. Allows clot dissolution while preventing new clot formation. 2. Permits the administration of smaller doses of each medication. 3. Immediately provides maximum protection against clot formation. 4. Provides an anticoagulant intravenously until the oral drug reaches therapeutic levels.

Provides an anticoagulant intravenously until the oral drug reaches therapeutic levels. Warfarin is administered orally for two or three days to achieve the desired effect on the international normalized ratio (INR) level before heparin is discontinued. These drugs do not dissolve clots already present. Because each drug affects a different part of the coagulation mechanism, dosages must be adjusted separately. That this approach immediately provides maximum protection against clot formation does not account for the reason for the administration of both drugs; warfarin will not exert an immediate therapeutic effect.

The nurse is caring for a client who had a massive myocardial infarction and developed cardiogenic shock. Which clinical manifestations support these diagnoses? Select all that apply. 1. Rapid pulse 2. Deep respirations 3. Warm, flushed skin 4. Increased blood pressure 5. Decreased urinary output

Rapid pulse Decreased urinary output The heart rate increases (tachycardia) in an attempt to meet the body's oxygen demands and circulate blood to vital organs; the pulse is weak and thready because of peripheral vasoconstriction. The urinary output decreases because increased catecholamines and activation of the renin-angiotensin-aldosterone system increase fluid reabsorption in the kidneys. The respirations are rapid and shallow, not deep. The skin is cold and clammy because of vasoconstriction caused by the shunting of blood to vital organs. The blood pressure is decreased, not increased, because of continued hypoperfusion and multiorgan failure.

A client has a chest tube for a pneumothorax. The nurse discovers that the chest tube has become disconnected from the drainage system, and the client is experiencing respiratory difficulty. What initial action should the nurse take? 1. Obtain a new sterile drainage system 2. Use two padded hemostats to clamp the drainage tubing 3. Reconnect the client's tube to the drainage system 4. Place the client in the high-Fowler position immediately

Reconnect the client's tube to the drainage system To prevent another pneumothorax, the nurse should reconnect the tube. Obtaining a new sterile drainage system is unnecessary. Clamping is appropriate for changing a broken drainage system or to check for an air leak; it should not be done in this situation. Placing the client in the high-Fowler position immediately will not remedy this problem.

A client has a chest tube for a pneumothorax. The nurse finds the client in respiratory difficulty, with the chest tube separated from the drainage system. What should the nurse do? 1. Obtaining a new sterile drainage system. 2. Place the client in the high-Fowler position. 3. Use two clamps to close the drainage tube. 4. Reconnect the client's tube to the drainage system.

Reconnect the client's tube to the drainage system. To prevent further possibility of pneumothorax, the nurse should reconnect the tube immediately. Obtaining a new sterile drainage system is unnecessary. Clamping the tube is appropriate when changing a broken drainage system or for checking for an air leak. The high-Fowler position is appropriate for a client in respiratory distress, but it does not remedy the problem.

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

Remain with the client to assess responses. This is a critical time; the client's response to reduction of ventilator support must be observed closely and evaluated for signs of respiratory distress (e.g., shallow breathing, restlessness, use of accessory respiratory muscles, tachycardia, pallor, and tachypnea). Allowing family members to participate in the process delegates professional responsibility inappropriately. Permitting the client more extended times alone for independence will not ensure the client's safety. Observing monitoring devices at the control panel of the ventilator will not provide the client with support and professional assistance.

A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" The nurse explains that the purpose of the chest tube is to: 1. Check for bleeding in the lung 2. Monitor the function of the lung 3. Drain fluid from the pleural space 4. Remove air from the pleural space

Remove air from the pleural space With a pneumothorax, a chest tube attached to a closed chest drainage system removes trapped air and helps to reestablish negative pressure within the pleural space; this results in lung reinflation. A closed chest drainage system may be inserted to remove blood related to a hemothorax, not to assess for bleeding. Monitoring the function of the lung is not the purpose of inserting chest tubes; the function of the lungs is monitored through the assessment of vital signs, breath sounds, arterial blood gases, and chest x-ray. Draining fluid from the pleural space is the reason for use of a closed chest drainage system when there is fluid in the pleural space. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

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

Remove secretions by suctioning. Secretions in the airway will increase pressure by blocking air flow and must be removed. The nurse must identify/correct the problem so that the set tidal volume can be delivered. Connections that are not intact would cause a low-pressure alarm. ABGs are used to assess client status, but are not taken each time a pressure alarm is heard.

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

Respiratory alkalosis Increased rate and depth of breathing result in excessive elimination of CO2, and respiratory alkalosis can result. Hypoxia is associated with respiratory acidosis, not respiratory alkalosis, which is related to hyperventilation. With hyperventilation, CO2 levels will be decreased (hypocapnia), not elevated. Metabolic acidosis results from excess hydrogen ions caused by a metabolic problem, not a respiratory problem.

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock? 1. Respirations of 10 2. Urine output of 30 ml/hour 3. Lethargy 4. Restlessness

Restlessness In the early stage shock, the client has increased epinephrine secretion. This, in turn, causes the client to become restless, anxious, nervous, and irritable. Decreased respiratory rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. What is the primary purpose of the chest tube? 1. Lessens the client's chest discomfort 2. Restores negative pressure in the pleural space 3. Drains accumulated fluid from the pleural cavity 4. Prevents subcutaneous emphysema in the chest wall

Restores negative pressure in the pleural space Negative pressure is exerted by gravity drainage or by suction through the closed system. Though the discomfort may be lessened as a result of the insertion of the chest tube, this is not the primary purpose. There is an accumulation of air, not fluid, when a pneumothorax occurs in a client with COPD. Subcutaneous emphysema in the chest wall is associated most commonly with clients receiving air under pressure, such as that received from a ventilator.

To evaluate the effectiveness of a chest tube inserted in a client with a pneumothorax, the nurse assesses for: 1. Productive coughing 2. Return of breath sounds 3. Increased pleural drainage in the chamber 4. Constant bubbling in the water-seal chamber

Return of breath sounds The return of breath sounds indicates that the lung has reinflated. A cough that raises sputum (productive cough) may indicate a complication, such as infection. The drainage should decrease, not increase. Constant bubbling in the water-seal chamber indicates that there is a leak in the closed chest drainage system. Bubbling may occur in this chamber when air exits the pleural space with a cough or forceful expiration; the fluid will rise and fall in this chamber with pleural pressure changes associated with inspiration and expiration (tidaling).

A client has a chest tube inserted to treat a right hemopneumothorax. In which position should the nurse place the client to facilitate chest drainage? 1. Supine 2. Left Sims 3. Immobilized 4. Right side-lying

Right side-lying Lying on the affected right side increases drainage from the pleural space and allows the unaffected lung to expand to the fullest extent. The supine position is undesirable because this may not allow the unaffected lung to fully expand and provide maximum oxygenation. The left Sims position is undesirable because this may not allow the unaffected lung to fully expand and provide maximum oxygenation. Immobilization promotes stasis of respiratory secretions. The client should be encouraged to perform deep breathing and coughing exercises and periodically move around in bed.

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

Rupture of a subpleural bleb The etiology of a spontaneous pneumothorax is commonly the rupture of blebs on the lung surface. Blebs are similar to blisters, but are filled with air. Pleural friction rub results in pain on inspiration, not a pneumothorax. A tracheoesophageal fistula causes aspiration of food and saliva, resulting in respiratory distress. The client has no history of trauma.

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

Shortness of breath Unilateral chest pain With the reduction of surface area for gaseous exchange the client experiences shortness of breath, tachycardia, and rapid, shallow respirations. Sudden chest pain occurs on the affected side; it may also involve the arm and shoulder. Bloody vomitus is unrelated to pneumothorax. Decreased chest motion occurs because of failure to inflate the involved lung. The shift toward the unaffected side results from pressure from the pneumothorax.

A client with a history of a pulmonary embolus is to receive 3 mg of warfarin (Coumadin) daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? 1. Poached eggs 2. Spinach salad 3. Sweet potatoes 4. Cheese sandwich

Spinach salad Dark green, leafy vegetables are high in vitamin K. Influencing the level of vitamin K alters the activity of warfarin because vitamin K acts as a catalyst in the liver for the production of blood-clotting factors and prothrombin. The intake of foods containing vitamin K must be consistent to regulate the warfarin dose so that the INR remains within the therapeutic range. Eggs contain protein and are permitted on the diet. Yellow vegetables contain vitamin A and are permitted on the diet. Dairy products containing protein and bread supplying carbohydrates are permitted on the diet.

After surgery a client develops a deep vein thrombosis and a pulmonary embolus. Heparin via a continuous drip at 1200 units/hr is prescribed. Several hours later, vancomycin (Vancocin) 500 mg intravenously every 12 hours is prescribed. The client has one intravenous (IV) site: a peripheral line in the left forearm. What action should the nurse take? 1. Stop the heparin, flush the line, and administer the vancomycin. 2. Use a piggyback setup to administer the vancomycin into the heparin. 3. Start another IV line for the vancomycin and continue the heparin as prescribed. 4. Hold the vancomycin and tell the health care provider that the drug is incompatible with heparin.

Start another IV line for the vancomycin and continue the heparin as prescribed. The vancomycin and heparin are incompatible in the same IV and therefore must be administered separately. By instituting a second line for the antibiotic, heparin can continue to infuse. Twice a day both drugs must run concurrently. Also, flushing the line may not eliminate remnants of the heparin, which is incompatible with vancomycin. Using a piggyback setup to administer the vancomycin into the heparin is unsafe because heparin and vancomycin are incompatible and should not be administered via the same intravenous line. The client has two medications prescribed, and it is a nurse's responsibility, not the health care provider's, to administer them safely.

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

Suction as needed The nurse should observe the clients need for tracheal/oral/nasal suctioning every two hours and provide adequate suctioning as needed. The nurse should not administer sedatives around the clock, but administer sedatives as appropriate. The nurse should turn the client every two hours; not four. The nurse should not adjust vent settings as needed; however, the nurse should check ventilation settings at least once a shift.

A health care provider in the emergency department identifies that a client is in mild hypovolemic shock. Which type of drug should the nurse anticipate will be prescribed? 1. Loop diuretic 2. Cardiac glycoside 3. Sympathomimetic 4. Alpha-adrenergic blocker

Sympathomimetic Sympathomimetics are vasopressors that induce arterial constriction, which increases venous return and cardiac output. Diuretics promote excretion of fluid, which will exacerbate hypovolemia associated with hypovolemic shock. Cardiac glycosides slow and strengthen the heartbeat; they do not increase the blood pressure and may decrease it. Alpha-adrenergic blockers decrease peripheral resistance, resulting in a decreased blood pressure.

A nurse administers albuterol to a child with asthma. For what common side effect should the nurse monitor the child? 1. Flushing 2. Dyspnea 3. Tachycardia 4. Hypotension

Tachycardia Albuterol produces sympathetic nervous system side effects such as tachycardia and hypertension. Pallor, not flushing, is a common side effect. Dyspnea is not a common side effect; this medication is given to decrease respiratory difficulty. Hypertension, not hypotension, is a common side effect.

A nurse is assessing an adolescent after the administration of epinephrine. What side effect is most important for the nurse to identify? 1. Tachycardia 2. Hypoglycemia 3. Constricted pupils 4. Decreased blood pressure

Tachycardia Epinephrine is a sympathetic nervous system stimulant that causes tachycardia. Hyperglycemia, not hypoglycemia, may result. The pupils will be dilated, not constricted. Epinephrine is more likely to cause hypertension than hypotension.

A 12-year-old child has just received a dose of epinephrine. What is the priority assessment after this medication is administered? 1. Tachycardia 2. Hypoglycemia 3. Constricted pupils 4. Decreased blood pressure

Tachycardia Epinephrine is a sympathetic nervous system stimulant that causes tachycardia. Hyperglycemia, not hypoglycemia, may result. The pupils will dilate, not constrict. Epinephrine is more likely to cause hypertension than hypotension because of its effect of peripheral vasoconstriction.

A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock? Select all that apply. 1. Tachycardia 2. Restlessness 3. Warm, moist skin 4. Decreased urinary output 5. Bradypnea

Tachycardia Restlessness Decreased urinary output The heart rate increases and the respiratory rate increases in an attempt to meet the oxygen demands of the body. Restlessness occurs because of cerebral hypoxia. The urine output drops to less than 30 mL/hr because of decreased arterial perfusion to the kidneys and the compensatory mechanism of reabsorbing fluid to increase the circulating blood volume. The skin becomes cool and pale as blood shunts from the peripheral blood vessels to the vital organs.

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? 1. Limit the client's fluid intake. 2. Teach the client how to exercise the legs. 3. Encourage use of the incentive spirometer. 4. Maintain the knee gatch position at an angle.

Teach the client how to exercise the legs. The client who is prescribed bed rest must exercise the legs; dorsiflexion of the feet prevents venous stasis and thrombus formation. Limiting fluid intake may lead to hemoconcentration and subsequent thrombus formation. An incentive spirometer improves pulmonary function but does not prevent venous stasis. Maintaining the knee gatch position at an angle is unsafe because it promotes venous stasis by compressing the popliteal space.

A client has a pneumothorax, and a closed-chest drainage system is inserted to allow the lung to reinflate. Identify the chamber in the figure below that provides the water seal. 1. A 2. B 3. C 4. D

The water seal chamber acts as a one-way valve to allow air from the pleural space to escape into the suction chamber but prevent a backflow of air from within the system to the client. A provides suction control. B and D collect drainage from the client.

A nurse providing care to a client who had major abdominal surgery monitors the client for postoperative complications. Which clinical findings are indicators of impending hypovolemic shock? 1. Diuresis, irritability, and fever 2. Lethargy, cold skin, and hypertension 3. Thirst, cool skin, and orthostatic hypotension 4. Bounding pulse, restlessness, and slurred speech

Thirst, cool skin, and orthostatic hypotension With hypovolemic shock extravascular fluid depletion leads to thirst, peripheral vasoconstriction produces cool skin, and inadequate venous return leads to orthostatic hypotension. Although irritability may occur with hypovolemic shock, decreased blood flow to the kidney leads to oliguria; the temperature usually decreases with hypovolemic shock. Restlessness, not lethargy, occurs with hypovolemic shock; hypotension and cool skin are signs of hypovolemic shock. Although restlessness may occur with hypovolemic shock, the pulse is thready, not bounding; subtle changes in sensorium will not result in slurred speech.

A nurse is administering an intravenous titrated drip of lidocaine HCl (Xylocaine) to a client. The nurse monitors the client for what serious side effect associated with this medication? 1. Tremors 2. Anorexia 3. Tachycardia 4. Hypertension

Tremors Tremors are a precursor to the major adverse effect of seizures. Although anorexia can occur, it is not a serious side effect. Bradycardia occurs, which can lead to heart block. Hypotension, not hypertension, occurs.

What potentially adverse effect of an intravenous titrated drip of lidocaine (Xylocaine) should the nurse immediately report to the healthcare provider? 1. Tremors 2. Anorexia 3. Tachycardia 4. Hypertension

Tremors Tremors are a precursor to the major adverse effect of seizures. Although anorexia may occur, it is not a serious side effect. Bradycardia, which may lead to heart block, may occur, not tachycardia. Hypotension, not hypertension, may occur.

A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? Select all that apply. 1. Tremors 2. Lethargy 3. Palpitations 4. Visual disturbances 5. Decreased pulse rate

Tremors Palpitations Albuterol's sympathomimetic effect causes central nervous stimulation, precipitating tremors, restlessness, and anxiety. Albuterol's sympathomimetic effect causes cardiac stimulation that may result in tachycardia and palpitations. Albuterol may cause restlessness, irritability, and tremors, not lethargy. Albuterol may cause dizziness, not visual disturbances. Albuterol will cause tachycardia, not bradycardia.

A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus? 1. Bradycardia 2. Flushed face 3. Unilateral chest pain 4. Decreased blood pressure

Unilateral chest pain Pleuritic chest pain is caused by an inflammatory reaction of lung parenchyma or by pulmonary infarction or ischemia induced by obstruction of small pulmonary arteries. Pain is sudden in onset and is exacerbated by breathing. Tachycardia, not bradycardia, occurs in an attempt to meet oxygen demands of the body and respond to increased vascular resistance in the lung. The face will be pale, not flushed, because of reduced oxygenation and possible shock. The blood pressure is not an indicator of a pulmonary embolus. However, eventual hemodynamic instability will influence blood pressure.

A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess this client? Select all that apply. 1. Unilateral chest pain 2. Acute onset of dyspnea 3. Pain in the residual limb 4. Absence of the popliteal pulse 5. Blanching of the affected extremity

Unilateral chest pain Acute onset of dyspnea Emboli can occur with crushing injuries of the extremities. Lodging of a thrombus in the pulmonary system results in a lack of oxygen to pulmonary tissues, causing localized pain. Lodging of a thrombus in the pulmonary system will result in decreased breath sounds and dyspnea. Pain in the residual limb is related not to a pulmonary embolus but to severed nerve endings in the residual limb. A pulmonary embolus will not interfere with arterial circulation to a distal portion of an extremity. Blanching of the affected extremity is associated with interference with arterial circulation to an extremity.

To prevent septic shock in the hospitalized client, the nurse should: 1. Maintain the client in a normothermic state. 2. Administer blood products to replace fluid losses. 3. Use aseptic technique during all invasive procedures. 4. Keep the critically ill client immobilized to reduce metabolic demands.

Use aseptic technique during all invasive procedures. Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures. Maintaining the client in a normothermic state, administering blood products, and keeping the critically ill client immobilized are not directly related to the prevention of septic shock.