UWorld Critical Care Concepts

The student nurse and the registered nurse are caring for a mechanically ventilated client with an acute lung injury. Which statement by the student nurse indicates a need for further education? --"I will auscultate the neck to assess for endotracheal cuff leaks" --"I will perform endotracheal suctioning routinely after oral care" --"I will provide oral care and oral suctioning every 2 hours" --"I will reposition the client from side to side at least every 2 hours"

"I will perform endotracheal suctioning routinely after oral care" --ET suctioning improves ventilation in mechanically ventilated clients by removing mucus and secretions from the ET tube. Suctioning is performed based on clinical findings such as adventitious breath sounds, elevated peak airway pressure, coughing, or signs of acute respiratory distress. Frequent suctioning increases the risk of tracheal and bronchial trauma, bleeding, and hypoxia. Suctioning should be performed only when needed to reduce the risk for injury. Auscultating the neck to monitor for an ET tube cuff leak is a standard component of respiratory assessment in mechanically ventilated clients.

The student nurse observes the respiratory therapist preparing to draw an arterial blood gas from the radial artery. The RT performs the Allen's test and the student asks why this test performed the blood sample is drawn. Which statement made by the RT is most accurate? --"The Allen's test is done to determine if capillary refill is adequate" --"The Allen's test is done to determine if the radial pulse is palpable" --"The Allen's test is done to determine the patency of the ulnar artery" --"The Allen's test is done to determine the presence of a neurologic deficit"

"The Allen's test is done to determine the patency of the ulnar artery" --The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, is easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery can be confirmed with a positive modified Allen's test. If the Allen's test is positive, the arterial blood gas can be drawn; if negative and the palm does not return to a pink color, an alternate site must be used.

The ICU nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time? SATA --administer prescribed oral narcotics for throat pain --administer warmed, humidified oxygen via facemask --give the client ice chips to moisten the mouth --provide mouth care with oral sponges --start the client on incentive spirometer

--administer warmed, humidified oxygen via facemask --provide mouth care with oral sponges --start the client on incentive spirometer ----Recently extubated clients are at high risk for aspiration, airway obstruction, and respiratory distress. To prevent complications, clients are placed in high Fowler position to maximize lung expansion and prevent aspiration of secretions. Warmed, humidifies oxygen is administered immediately after extubation to provide high concentrations of supplemental oxygen without drying out the mucosa. Oral care is provided to decrease bacteria and contaminants, as well as promote comfort. Clients are instructed to frequently cough, deep breathe, and use an incentive spirometer to expand alveoli and prevent atelectasis.

Recommended criteria to consider when determining to call the rapid response team

--any provider worried about the condition of the client --or an acute change in any of the following: --- heart rate <40 or >90 mm Hg ---systolic blood pressure <90 mm Hg ---respiratory rate <8 or >28/min --- oxygen saturation <90 despite oxygen ---urine output <50 mL/4 hours ---level of consciousness

An ED nurse is sent to the scene of a massive motor vehicle collision. A client there reports neck pain. Which actions should the nurse perform at this time? SATA --apply a hard cervical collar --assess neck range of motion --inspect client's respiratory pattern --position client flat on the firm surface --use logrolling technique if moving client.

--apply a hard cervical collar --inspect client's respiratory pattern --position client flat on the firm surface --use logrolling technique if moving client. --The initial priorities for a client with a suspected cervical spin injury are to ensure a patent airway and immobilize the spine to prevent further injury. This includes applying a rigid hard collar, placing the client on a firm surface, and moving the client as a unit (logrolling) if required. A soft foam cervical collar does not provide immobilization. Further stabilization is achieved by taping down the client's head and using straps to immobilize the arms, especially if the client is not cooperating. After immobilizing the client, the nurse should obtain a baseline set of vital signs to monitor for neurogenic shock (hypotension, bradycardia, poikilothermia), a potential complication of spinal cord injury. The nurse should also assess the client's respiratory rate, pattern, and effort. Presence of abdominal breathing or increased work of breathing may indicate impending loss of airway and require prompt rapid-sequence intubation. Movement of the neck/upper extremities should be avoided until cervical spine injury is ruled out with imaging, which is done after the spine is immobilized with a hard collar.

The nurse is preparing to defibrillate a client who suddenly went into ventricular fibrillation. Which steps are essential prior to delivering a shock? SATA --apply defibrillator pads --call out and look around to ensure that everyone is "all clear" --continue chest compressions until ready to deliver shock --ensure adequate IV sedation has been given --ensure that the synchronization button is turned on

--apply defibrillator pads --call out and look around to ensure that everyone is "all clear" --continue chest compressions until ready to deliver shock ---IV sedation is not necessary to defibrillation as the client is already unconscious. It is often given prior to elective synchronized cardioversion to ease anxiety and decrease pain. Synchronized cardioversion delivers a shock on the R wave of the QRS complex and would not be appropriate for a client in Vfib. Rhythms that are ideal for synchronized cardioversion are supraventricular tachycardia, ventricular tachycardia with a pulse, and atrial fibrillation with rapid ventricular response

During assessment of a client with decerebrate posturing, what might be seen?

--arms and legs straight out --toes pointed down --head/neck arched back

An intoxicated client not wearing a seatbelt drives into a metal barricade near the entrance to the ED. The client's head has hit the windshield and the client is unconscious. What nurse actions are appropriate? SATA --assess the client for a carotid pulse --determine the client's GCS --maintain airway with head-tilt/chin-life maneuver --place a hard cervical collar on the client --remove the client from the car onto a backboard.

--assess the client for a carotid pulse --determine the client's GCS --place a hard cervical collar on the client --remove the client from the car onto a backboard. ----The transference of kinetic energy to the client's body from an opposing force during sudden deceleration causes bodily injury. If the client is not wearing a seatbelt during an automobile crash, the client may strike the windshield, causing blunt-force trauma to the head, neck, or spine. The unconscious client should first be assessed for adequate breathing and the presence of a pulse. Using a rigid cervical collar, cervical spine immobilization must be maintained throughout the client assessment to minimize further injury. The client should be removed and placed on a backboard after the cervical spine has been stabilized. The nurse should also perform Glasgow Coma Scale scoring to determine the level of neurological impairment. If a client with possible spinal injuries is not breathing, or if the airway is occluded, the nurse should use the jaw-thrust technique. The head-tilt/chin-life maneuver may hyperextend the neck, compromising the cervical spine.

The nurse caring for a client with pulmonary edema responds to the mechanical ventilator high-pressure alarm. The nurse would assess for which conditions that can trigger the high-pressure alarm? SATA --biting endotracheal tube --disconnected ventilator tubing --endotracheal tube cuff leak --excessive airway secretions --kinked ventilator tubing

--biting endotracheal tube --excessive airway secretions --kinked ventilator tubing --Mechanical ventilator alarms alert the nurse to potential problems caused by a change in the client's condition, a problem with the artificial airway, and/or problem with the ventilator. Peak airway pressure is the amount of pressure required to deliver a tidal volume. Any condition that increases the peak airway pressure can trigger the ventilator high-pressure limit alarm. When this alarm sounds, the nurse should assess for conditions that increase airway resistance and/or decrease lung compliance. Any condition that decreases airway resistance (tube disconnect, extubation, endotracheal or tracheostomy tube cuff leak) would trigger the low-pressure limit alarm.

The charge nurse responds to a cardiac arrest with resuscitation in progress of an adult client. Which of the following actions by a resuscitation team member would cause the charge nurse to intervene? SATA --chest compressions are performed at a rate of 70-80/min --chest compressions are stopped for a 10-second pulse check every 2 minutes --defibrillator pads are applied at the left and right sternal borders --manual breaths are delivered at a rate of 2 breaths per 30 chest compressions --resuscitation team is alerted to remain clear of client before defibrillation

--chest compressions are performed at a rate of 70-80/min --defibrillator pads are applied at the left and right sternal borders ---Chest compressions are performed at a rate of 100-120/min and a depth of 2.0-2.4 inches, allowing complete chest recoil between compressions. Defibrillatory pads are placed on the right upper chest, just below the clavicle, and on the left lateral chest, near the anterior axillary line below the nipple line.

Emergency medical service personnel are transporting a near-drowning victim who is currently hypothermic. Based on anticipated vital signs, the nurse needs to prepare for which interventions? SATA --covering client with warm blankets --logrolling the client from side to side frequently --mechanical ventilation --warmed blood administration --warmed IV fluids

--covering client with warm blankets --mechanical ventilation --warmed IV fluids ---The initial management of near-drowning victim focuses on airway management due to potential aspiration, pulmonary edema, or bronchospasm. Hypoxia is managed and prevented by ensuring a patent airway via intubation and mechanical ventilation is necessary. Careful handling of the hypothermic client is important because as the core temperature decreases, the cold myocardium becomes extremely irritable. Frequent turning could cause spontaneous ventricular fibrillation and should not be performed during the acute stage of hypothermia. Continuous cardiac monitoring should be initiated. Unless blood loss has occurred from trauma during the near-drowning incident, administration of blood products is not indicated.

A nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? SATA --apply occlusive dressings after rewarming --elevate affected extremities after rewarming --massage the areas to increase circulation --provide adequate analgesia --provide continuous warm water soaks

--elevate affected extremities after rewarming --provide adequate analgesia --provide continuous warm water soaks ---Frostbite involves tissue freezing, resulting in ice crystal formation in intracellular spaces that causes peripheral vasoconstriction, reduced blood flow, vascular stasis, and cell damage. Superficial frostbite can manifest as mottled, blue, or waxy yellow skin. Deeper frostbite may cause skin to appear white and hard and unable to sense touch.

Interventions to reduce the risk of ventilator-associated penumonia

--elevating HOB 30-45 degrees --providing oral care with antiseptic solutions and suctioning subglottic secretions --performing scheduled daily sedation vacations and maintaining appropriate client sedation levels --practicing strict hand hygiene

What is the mechanism of action of dopamine?

--enhance cardiac output by increasing myocardial contractility, increasing heart rate, and elevating blood pressure through vasoconstriction

The nurse cares for an intubated client on mechanical ventilation with worsening cerebral edema from increased intracranial pressure (ICP). Which nursing interventions help reduce ICP? SATA --clustering as many interventions as possible when providing care --hyperventilating before suctioning --maintaining a quiet, dark environment --maintaining the head in a neutral midline position --suctioning for 30 seconds to remove endotracheal tube secretions at regular intervals

--hyperventilating before suctioning --maintaining a quiet, dark environment --maintaining the head in a neutral midline position ---Most nursing activities increase intracranial pressure in brain injuries. The goal is to reduce ICP while managing basic client needs. During interventions, ICP should not exceed 25 mm Hg and should return to baseline within a few minutes. Metabolic demands (pain, straining, agitation, shivering, fever, hypoxia) increase blood supply and raise ICP. The nurse should suction a maximum of 10 seconds and only as necessary to remove secretions. Prolonged suctioning increases ICP.

Classic signs/symptoms of neurogenic shock?

--hypotension --bradycardia --pink/dry skin from the vasodilation

The steps to the modified Allen's test

--instruct the client to make a tight fist --occlude the radial and ulnar arteries using firm pressure --instruct the client to open the first; the palm will be white if both arteries are sufficiently occluded. --release the pressure on the ulnar artery; the palm should turn punk within 15 seconds as circulation is restored to the hand, indicating patency of the ulnar artery

Which nursing interventions are appropriate for managing the care of a client receiving mechanical ventilation and continuous IV sedation? SATA --maintain the HOB at 30-45 degrees --mute ventilator alarms at night to allow the client to rest --pause sedation daily to assess weaning readiness --perform oral care with chlorhexidine solution --place a manual resuscitation bag at the bedside

--maintain the HOB at 30-45 degrees --pause sedation daily to assess weaning readiness --perform oral care with chlorhexidine solution --place a manual resuscitation bag at the bedside ---Although the client should have a quiet environment at night, ventilator alarms should never be muted, as they may indicate life-threatening complications

The nurse is caring for an 11-month-old child in the pediatric hospital. Which of these child's findings would be a common criterion to activate the rapid response team? SATA --new-onset right-sided paralysis of extremities --pulse rate sustained at 120/min --respirations continued at 38/min --sudden inability to be aroused to an awake state --temperature of 101.3 degrees F

--new-onset right-sided paralysis of extremities --sudden inability to be aroused to an awake state ---Rapid response teams are formed as a means to get critical care specialists to the bedside of clients who are not in a critical care unit when acute, significant changes occur in their condition. Each institution sets its own criteria, but it usually includes acute changes in heart rate, systolic blood pressure, respiratory rate, oxygen saturation, level of consciousness, and/or urine output.

A nurse is caring for an intubated client receiving a continuous sedative infusion. Which interventions by the nurse reflect correct understanding of preventing ventilator-acquired pneumonia? SATA --elevated the HOB 30-45 degrees --performing hourly in-line endotracheal suctioning --practicing strict hand hygiene --providing frequent oral care with chlorhexidine --scheduling daily sedation vacations

--practicing strict hand hygiene --providing frequent oral care with chlorhexidine --scheduling daily sedation vacations and weaning protocols --elevated the HOB 30-45 degrees ---Mechanically ventilated clients are at risk for developing ventilator-associated pneumonia due to sedation and impairment of natural defenses by artificial airways.

Treatment of frostbite includes:

--remove clothing and jewelry to prevent constriction --do not massage, rub, or squeeze the area involved. --immerse the affected area in water heated to 98.6-102.2, preferably in a whirlpool. Higher temperatures do not significantly decrease rewarming time, but can intensify pain. --avoid heavy blankets or clothing to prevent tissue sloughing --provide analgesia as the rewarming procedure is extremely painful --as thawing occurs, the injured area will become edematous and may blister. Elevated injured area after rewarming to reduce edema --keep wounds open immediately after a water bath and allow them to dry before applying LOOSE, nonadherent sterile dressings --monitor for signs of compartment syndrome

Which would be the appropriate client criteria for activating a rapid response team at the hospital? SATA --GCS score of 9 throughout the shift --heart rate remaining at 58 beats/min for more than 1 hour --postoperative pain rated at 10 --respiratory rate maintaining an increase to 30 breaths/min --sustained change in level of consciousness for 10 minutes

--respiratory rate maintaining an increase to 30 breaths/min --sustained change in level of consciousness for 10 minutes ---The rapid response team is activated to marshal additional experienced and specialized resources for an acute need to try to prevent a client from deterioration into a code/arrest situation. The team has critical care expertise to provide immediate attention to unstable clients in noncritical care units and usually consists of a respiratory therapist, a critical care nurse, and a physician or advanced practice registered nurse.

Rhythms that are ideal for synchronized cardioversion includes...

--supraventricular tachycardia --ventricular tachycardia with a pulse --atrial fibrillation with rapid ventricular response

Significant adverse effects of dopamine includes

--tachycardia --dysrhythmias --myocardial ischemia

Steps to perform defibrillation include:

--turn on defibrillator --place defibrillator pads on the client's chest --charge defibrillator. Chest compressions should continue until defibrillator has charged and is ready to deliver the shock -before delivering the shock, ensure that the area is "all clear". Confirm that no personnel are touching the client, bed, or any equipment attached to the client. --deliver the shock --immediately resume chest compressions

What might a low tidal volume alarm be caused by?

-disconnection -loose connection -leak

Nursing interventions to control ICP

-elevating the head of the bed to 30 degrees with the head/neck in a neutral position to reduce venous congestion. --administer stool softeners to reduce the risk of straining --manage pain well while monitoring sedation --manage fever (cool sponges, ice, antipyretics) while preventing shivering --ensuring adequate oxygenation --hyperventilating and preoxygenating the client before suctioning; reducing CO2 by hyperventilation induces vasoconstriction and reduces ICP

common causes of sudden cardiac arrest in pregnant clients?

-embolism -eclampsia -magnesium overdoses -uterine rupture

What are the most specific characteristic signs/symptoms of malignant hyperthermia?

-hypercapnia --generalized muscle rigidity (jaw, trunk, extremities) --hyperthermia (later sign)

Early signs of malignant hyperthermia

-tachypnea -tachycardia -rigid jaw or generalized rigidity --will develop HIGH fever as the condition develops.

What is a normal urine output?

0.5-1 mL/kg/hr or >30 mL/hr

What is a normal heart rate for an infant (1-12months)?

100-160/min

What is a normal respiration rate for an infant (1-12 months)?

30-60/min

A client undergoing endotracheal intubation received IV sedation and succinylcholine. Shortly after respiratory status has been stabilized, the client becomes flushed and profusely diaphoretic and has a rigid jaw. Which medication should the nurse prepare to administer? --IM epinephrine --IV atropine --IV dantrolene --IV glucagon

IV dantrolene --malignant hyperthermia is a rare and life-threatening condition precipitated by certain medications used for anesthesia, including inhaled anesthetics (desflurane, isoflurane, halothane) and succinylcholine. Skeletal muscles become unable to control calcium levels, leading to a hypermetabolic state manifested by contracture and increased temperature. Early signs of MH include tachypnea, tachycardia, and a rigid jaw or generalized rigidity. As the condition progresses, the client develops a high fever. Muscle tissue is broken down, leading to hyperkalemia, cardia dysrhythmias, and myoglobinuria. MH requires emergent treatment with IV dantrolene to reverse the process by slowing metabolism. Succinylcholine should be discontinued. IM epinephrine is administered for cardiac arrest, anaphylatic reactions, or severe asthma attacks. IV atropine is used to treat bradycardia. Glucagon is given for severe hypoglycemia

The client is brought to the emergency department after falling off a roof and landing on his back. A T1 spinal fracture is diagnosed. The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry. What nursing action is a priority? --administer IV normal saline --determine if urinary occult blood is present --perform a neurological assessment --verify that there is no stool impaction

administer IV normal saline --This presentation is classic for neurologic shock, a distributive shock. Vascular dilation with decreased venous return to the heart is present due to loss of innervation from spine. Classic signs/symptoms are hypotension, bradycardia, and pink and dry skin from the vasodilation. Neurogenic shock usually occurs in cervical or high thoracic injuries. Administration of fluids is a priority to ensure adequate kidney and other organ perfusion.

What does it mean if there is bubbling in the water seal chamber?

an air leak is present

How is a stable client with ventricular tachycardia treated?

antiarrhythmic medications (amiodarone, procainamide, sotalol)

A client with massive trauma and possible spinal cord injury is admitted to the ED following a dirt bike accident. Which clinical manifestation does the nurse assess to help best confirm a diagnosis of neurogenic shock? --apical heart rate 48/min --blood pressure 186/92 mm Hg --cool, clammy skin --temperature 100 degrees F tympanic

apical heart rate 48/min --Neurogenic shock belongs to the group of distributive shock. It affects the vasomotor center in the medulla and causes a disruption in the sympathetic nervous system; the parasympathetic nervous system remains intact. The imbalance of activity between the SNS and PNS results in massive vasodilation and pooling of blood in the venous circulation, causing hypotension and bradycardia, the characteristics manifestations of neurogenic shock.

A client with palpitations is admitted with supraventricular tachycardia. The client's heart rate is 210/min. Which is the most appropriate initial intervention? --ask the client to bear down as if having a bowel movement --grab the crash cart and apply hands free defibrillation pads --place ECG leads on client to further assess electrical activity --place IV line distally from the heart fro adenosine administration

ask the client to bear down as if having a bowel movement --clients with paroxysmal SVT are initially treated with vagal maneuvers. The act of "bearing down" as if having a bowel movement is an example of these maneuvers and may need to be attempted more than once. Vagal maneuvers work by increasing intra-thoracic pressure and stimulating the vagus nerve, which supplies parasympathetic nerve fibers to the heart, resulting in slowed electrical conduction through the arterioventricular node. Cardioversion (not defibrillation) is used with this type of arrhythmia when it is refractory to medication. Adenosine is the drug of choice to treat SVT and has a 5-6 second half-life. Placing the IV line as close as possible, not distal, to the heart is essential for the drug to have full effect.

Client presents with ventricular tachycardia. Which action should the nurse take first? --assess client for a pulse --assess oxygen saturation --initiate cardiopulmonary resuscitation --prepare to defibrillate the client

assess the client for a pulse --Clients in ventricular tachycardia can be pulseless or have a pulse. Treatment is based on this assessment. VT with a pulse should be further assessed for clinical stability or instability. Signs of instability include hypotension, altered mental status, signs of shock, chest pain, and acute heart failure

The nurse is caring for a client who is 1 day postoperative extensive abdominal surgery for ovarian cancer. The client is receiving IV Ringer's lactate at 100 mL/hr and continual epidural morphine for pain control. The Foley catheter urine output has decreased to <20 mL/hr over the past 2 hours. The postoperative hematocrit is 36% and the hemoglobin is 12 g/dL Which action should the nurse carry out first? --assess vital signs --increase the IV rate to 125 mL/hr --notify the healthcare provider --perform a bladder scan

assess vital signs --Third-spacing of fluids can occur 24-72 hours after extensive abdominal surgery as a result of increased capillary permeability due to tissue trauma. It occurs when too much fluid moves from the intravascular into the interstitial or third space, a place between cells where fluid does not normally collect. This fluid serves no physiologic purpose, cannot be measured, and leads to decreased circulating volume and cardiac output. The priority intervention is to assess vital signs as the manifestations associated with third-spacing (weight gain, decreased urinary output, and signs of hypovolemia--tachycardia/hypotension). If third-spacing is not recognized and corrected early on, postoperative hypotension can lead to decreased renal perfusion, prerenal failure, and hypovolemic shock. the nurse will notify the healthcare provider to report oliguria after collecting all the data required. A bladder scan is not an appropriate action in this situation as the client has a Foley catheter.

A client with hypothermia has just arrived in the ED via ambulance. The client is being rewarmed with blankets, and the IV fluids are being changed over to warmed fluids. What additional intervention is a priority? --attaching the cardiac monitor --covering the client's head --drawing blood for electrolytes ad glucose --placing an additional large-bore IV catheter

attaching the cardiac monitor --Hypothermia occurs when the core temperature is below 95 degrees F and the body is unable to compensate for heat loss. As the core temperature decreases, the cold myocardium becomes extremely irritable and prone to dysrhythmias. The client should be handled gently as spontaneous ventricular fibrillation could develop when moved or touched. Therefore, placing the client on a cardiac monitor is a high priority; the nurse should anticipate defibrillation in these clients.

The nurse is caring for an intubated client whose oxygen saturation begins to drop. What action should the nurse take first? --auscultate lung sounds bilaterally --hyper-oxygenate with 100% oxygen --manually ventilate with bag valve mask --suction the endotracheal tube

auscultate lung sounds bilaterally --A drop in oxygen saturation signifies a problem with ventilation. When an artificial airway is present, the nurse should assess the client to determine the cause of hypoventilation. Auscultating lung sounds is the first step and quickest intervention to confirm proper tube placement. It is not uncommon for the tube to become displaced in the hypopharynx, which would not allow proper ventilation. Another important complication is pneumothorax, which can cause hypotension and a drop in oxygen saturation. Lung auscultation would help diagnose this as well.

The nurse is caring for a client on a mechanical ventilator. The settings on the ventilator have just been changed and the standing prescription is to draw arterial blood gases 30 minutes after a ventilatory change. In anticipation of this blood draw, what intervention should the nurse implement? --avoid suctioning the client --pre-oxygenate the client --raise the HOB --reduce the amount of sedation medication

avoid suctioning the client --ABGs indicate the acid-base balance in the body and how well oxygen is being carried to the tissues. It is common to measure ABGs after a ventilator change to assess how well the client has tolerated it. Factors such as changes in the client's activity level or oxygen settings, or suctioning within 20 minutes prior to the blood draw can cause inaccurate results. Unless the client's condition dictates otherwise, the nurse should avoid suctioning as it will deplete the client's oxygen level and cause inaccurate test results.

A client with acute respiratory distress syndrome is receiving positive pressure mechanical ventilation with 15 cm H2O positive end-expiratory pressure. The nurse should assess for which complication associated with PEEP? --barotrauma --decreased oxygen saturation --hypertension --oxygen toxicity

barotrauma --High levels of PEEP can cause overdistension and rupture of the alveoli, resulting in barotrauma to the lung. Air from ruptured alveoli can escape into the pulmonary interstitial space or pleural space, resulting in a pneumothorax and/or subcutaneous emphysema. PEEP applies a given pressure at the end of expiration during mechanical ventilation. It counteracts small airway collapse and keeps alveoli open so that they can participate in gas exchange. PEEP is usually kept at 5 cm H2). However, a higher level of PEEP is an effective treatment strategy for acute respiratory distress syndrome (ARDS), a type of progressive respiratory failure that causes damage to the type II surfactant-producing pneumocytes that the leads to atelectasis, noncompliant luns, poor gas exchange, and refractory hypoxia.

The home health nurse is providing care for a 6-year-old client who has a tracheostomy and is being mechanically ventilated when the ventilator's apnea alarm sounds. The nurse finds the client to be unresponsive and pulseless, and that there are no other caregivers present. Which action should the nurse take first? --begin chest compressions --deliver 2 breaths using a bag valve device connected to the tracheostomy --locate and apply an automated external defibrillator --use a phone to call 911

begin chest compressions --Cardiac arrest is the sudden cessation of cardiac output that is usually caused by an arrhythmia. Arrest ca be precipitated by a variety of factors and is a medical emergency. In children, cardiac arrest is commonly caused by hypoxia and respiratory failure. If the nurse is a single rescuer in a witnessed cardiac arrest of a pediatric client, the first action is to promptly initiate CPR, starting with chest compressions. For the pediatric client, initiating CPR before other interventions helps minimize risk for end organ damage and brain injury. The nurse should provide 30 chest compressions and 2 rescue breaths in each cycle of CPR.

Basilar Skull Fracture Signs/Symptoms

bruising behind the ear, battles sign, nasal drainage, raccoon eyes

What triggers malignant hyperthermia?

certain drugs used to induce general anesthesia in susceptible clients --the triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity.

A client who is 2 hours post aortic valve replacement is in the intensive care unit (ICU). The low pressure alarm for the client's radial arterial line sounds. Which action should the nurse take first? --check for bleeding at tube connection sites --perform a fast flush of the arterial line system --re-level the transducer to the phlebostatic axis --zero and re-balance the monitor and system

check for bleeding at tube connection sites --The low pressure alarm could signal hypotension. The nurse's first action should be to check the client for evidence of hypotension and the cause. Arterial lines carry the risk of hemorrhage and are most likely to occur at connection sites of the tubing and catheter. A client can lose a large amount of arterial blood in a short period of time. The nurse should verify that these connections are tight on admission of the client in the ICU. A fast flush of the arterial line system (square wave test) should be performed after the nurse has ruled out a physiological cause of the low pressure alarm. The transducer should be leveled to client's phlebostatic axis to measure arterial pressure correctly AFTER the client has been checked for a physiological cause of the alarm.

The nurse is caring for a client with surgical complications who requires continuous total parenteral nutrition. The nurse assists the healthcare provider with the insertion of a subclavian triple lumen central venous access device. What is the nurse's priority action before initiating the TPN infusion? --attach a filter to the IV tubing --check baseline fingerstick glucose check --check the results of the portable chest x-ray --program the electronic infusion pump

check the results of the portable chest x-ray --The priority action after placing a subclavian central venous catheter is to check the results of the chest x-ray to ensure that the catheter tip is placed correctly in the superior vena cava. Obtain verification before using the catheter as perforation of the visceral pleura can occur during insertion and lead to an iatrogenic pneumothorax or hemothorax. Although these complications are rare, due to the use of ultrasound to guide insertion, if present, the TPN would infuse into the pleural space.

The nurse is caring for a client in the immediate postoperative period following an exploratory lapraotomy after sustaining a gunshot wound to the abdomen. Which assessment finding is most important for the nurse to report to the healthcare provider? --cold and clammy skin --oxygen saturation of 92% --sinus tachycardia of 108/min --urine output of 0.6 mL/kg/hr

cold and clammy skin --hypovolemic shock may occur after abdominal trauma or surgery as mesenteric edema resolves and previously compressed sites of bleeding reopen. Cold, clammy skin indicates compensatory mechanisms and immediate intervention is necessary to prevent irreversible shock and death.

The nurse observes a nursing student performing chest compressions on an adult client. Which technique indicates that the student understands how to provide high-quality chest compressions during cardiopulmonary resuscitation? --compressing the chest to a depth of at least 2 in --pausing after each set of 15 compressions to allows for 2 rescue breaths --placing the heel of the hand on the upper half of the client's sternum --providing compressions at a rate of at least 80-100/min

compressing the chest to a depth of at least 2 in --the primary goal of CPR is adequate perfusion to the brain and vital organs. High-quality chest compressions for adults are at least 2 in deep to adequately pump blood but no more than 2.4 in deep to prevent unnecessary client injury. The chest should recoil completely after each compression to allow complete refilling of the heart chambers, which promotes effective perfusion

What is the absolute priority when treating a client with asystole or PEA?

continuous, high-quality CPR

A client with blunt trauma undergoes an exploratory laparotomy to repair the intraabdominal injury. After 24 hours, the client has a nasogastric tube attached to continual low suction, 2 hemovac closed-wound suction abdominal drains, and is receiving IV Ringer's lactate and continual epidural morphine. The client now develops hypotension, tachycardia, oliguria, and severe nausea. What is the client's priority nursing diagnosis at this time? --deficient fluid volume --impaired urinary elimination --nausea --risk for infection

deficient fluid volume --This client is exhibiting symptoms of hypovolemia, which include hypotension, tachycardia, and decreased urinary output. Therefore, the priority nursing diagnosis is deficient fluid volume related to active intravascular loss that is secondary to hemorrhage, gastric suction, wound drainage, and possible third spacing as evidenced by decreased urine output, hypotension, and tachycardia. The adverse effects of the epidural anesthesia can contribute to hypotension as well. This nursing diagnosis poses the greatest threat to survival because if not corrected, it can lead to decreased cardiac output, acute renal failure, and hypovolemic shock.

The nurse precepts a new nurse caring for a client showing signs of improvement from hypovolemic shock. Which action by the new nurse would cause the preceptor to immediately intervene? --change the oxygen mask to a nasal mask --delays requesting a new norepinephrine IV bag when the first is almost finished --postpones giving IV antibiotics due to inadequate IV access --questions prescription to change IV fluids from 0.9% to 0.45% normal saline

delays requesting a new norepinephrine IV bag when the first is almost finished --hypovolemic shock, the most common type of shock, occurs when blood volume decreases through hemorrhage or movement of fluid from the intravascular compartment into the interstitial space (third-spacing). Treatment involves preventing additional fluid loss, restoring volume through IV fluids, and improving hemodynamic stability through vasoactive medications (norepinephrine, dopamine). Norepinephrine causes vasoconstricton and improves heart contractility/output, but the effects end quickly. It should be tapered slowly and cautiously to avoid the progression or relapse of shock. Postponing antibiotics would be a greater concern if the client were in septic shock 0.45% normal saline is a hypotonic fluid that decreases circulatory volume. Clients in hypovolemic shock require isotonic solutions to increase circulatory volume.

A nurse in the ICU is caring for a client with sepsis who is on a mechanical ventilator. The client is exposed to the noise of the mechanical ventilator., monitoring equipment, and infusion pump alarms during the day and night. What should the nurse identify as the priority nursing diagnosis? --anxiety --disturbed sleep pattern --powerlessness --risk for acute confusion

disturbed sleep pattern --Sleep disturbance pattern can lead to anxiety, powerlessness, and acute confusion. Therefore, disturbed sleep pattern related to environmental factors such as excessive noise and changes in daylight-darkness exposure is the primary nursing diagnosis. A disturbance in sleep pattern refers to time-limited interruptions of the amount and quality of a client's sleep due to external factors (noise, light). Evidence shows that excessive noise and sleep disturbances in critically ill clients can affect outcomes as they can lead to significant psychologic and physiologic consequences. All other options were appropriate nursing diagnoses, but not the priority.

In the intensive care unit, the nurse cares for a client who is being treated for hypotension with a continuous infusion of dopamine. Which assessment finding indicates that the infusion rate may need to be adjusted? --central venous pressure is 6 mm Hg --heart rate is 120/min --mean arterial pressure is 78 mm Hg --systemic vascular resistance is 900 dynes/sec/cm^-5

heart rate is 120/min --dopamine is a sympathomimetic inotropic medication used therapeutically to improve hemodynamic status in clients with shock and heart failure. It enhances cardiac output by increasing myocardial contractility, increasing heart rate, and elevating blood pressure through vasoconstriction. Renal perfusion is also improved, resulting in increased urine output. All other options were within respective reference ranges and do not indicate a need to adjust dopamine administration.

What heart rate might indicate a decrease in dopamine infusion?

heart rate of 120/min

The nurse is caring for a client with sepsis and acute respiratory failure who was intubated and prescribed mechanical ventilation 3 days ago. The nurse assesses for which adverse effect associated with the administration of positive pressure ventilation? --dehydration --hypokalemia --hypotension --increased cardiac output

hypotension ---Positive pressure ventilation delivers positive pressure to the lungs using a mechanical ventilator, either invasively through a tracheostomy or endotracheal tube or noninvasively through a nasal mask, etc. The most common type used in the acute care setting for clients with acute respiratory failure is the volume cycled positive pressure MV, which delivers a present volume and concentration of oxygen with varying pressure. Positive pressure applied to the lungs compresses the thoracic vessels and increases intrathoracic pressure during inspiration. This leads to reduced venous return, ventricular preload, and cardiac output, which results in hypotension. The hypotensive effect of PPV is even greater in the presence of hypovolemia (hemorrhge, hypovolemic shock) and decreased venous tone (septic shock, neurogenic shock). Fluid and/or sodium retention usually occurs about 48-72 hours after initiation of PPV due to increased intrathoracic pressure and decreased cardiac output that stimulate the kidneys to release renin, physiologic stress that leads to the release of antidiuretic hormone and cortisol, and breathing through the ventilator's closed circuitry, which decreases insensible loss associated with respiration. Hypokalemia is not associated with PPV.

What are the hemodynamic effect of PEEP?

increased intrathoracic pressure, which leads to reduced venous return, decreased preload and cardiac output, and hypotension.

The nurse is caring for a client with an implantable cardioverter defibrillator (ICD). The client goes into ventricular tachycardia and is pulseless. The ICD has first twice. What action should the nurse take? --administer epinephrine 1 mg IV push --deactivate the ICD with a magnet --initiate chest compressions --take no action and let the ICD work

initiate chest compressions --The client with an ICD that is firing is receiving electrical shocks from the internal defibrillator to interrupt the dysrhythmia. It is still imperative that the client receive chest compressions in the form of CPR to provide circulation of blood to the vital organs. The nurse should implement the pulseless arrest algorithm.

In a client with COPD exacerbation

it is most important for the nurse to monitor mental status frequently and report changes such as restlessness, decreased level of consciousness, somnolence, difficult arousal, and confusion to the HCP.

The ED nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway? --head-tilt-lift in the supine position on a backboard --head-tilt-chin-lift in the Tendelenburg position --Jaw-thrust maneuver in semi-Fowler's position --jaw-thrust maneuver in the supine position on a backboard.

jaw-thrust maneuver in the supine position on a backboard. --Clinical situations involving trauma should follow ABC. Airway assessment is particularly critical in clients with injuries to the head, neck, and upper back. Injury to the upper back should be treated as spinal trauma until the client has been cleared by an Advance Trauma Life Support-qualified healthcare provider. Until thespine is appropriately assessed, the client should be placed on a backboard and stabilized. The nurse should use the jaw-thrust maneuver to avoid movement of an unstable spine. One provider should stabilize the cervical vertebra allowing the second provider to articulate the jaw independently of the spinal column. Although use of the backboard is appropriate, the head-tilt-chin-lift should not be used as it involves manipulation of the neck without proper stabilization. The head-tilt chin-lift does not stabilize the alignment of the head and neck and can cause spinal cord damage. In addition, the Trendelenburg position causes the abdominal organs to shift toward the diaphragm, which increases the work of breathing. Stabilization of the spine is best performed in the supine position, such as on a flat, hard surface of a backboard.

When caring for a client with a left radial artery catheter, which assessment data obtained by the nurse indicates the need to take immediate action? --capillary refill of less than 3 seconds --left hand cooler than right --mean arterial pressure of 65 mm Hg --pressure bag at 300 mm Hg

left hand cooler than right --Although the Allen's test is performed before cannulating the radial artery and determines the adequacy of ulnar artery blood flow, circulation to the extremity is monitored frequently. The nurse must assess color, capillary refill, sensation, temperature, and movement per institution policy. Impairment in any of these parameters must be reported immediately because it may indicate impaired circulation to the extremity, and removal of the catheter may be necessary. To maintain patency of the arterial blood pressure monitoring system, an intravenous bag of normal saline solution is placed in a pressure infuser device. The device is set to maintain continual pressure at 300 mm Hg. The pressure drops as the volume of solution in the bag decreases and can be pumped back up. This does not pose an immediate threat to the client.

The obtain accurate continuous blood pressure readings via a radial arterial catheter, the nurse places the air-filled interface of the stopcock at the phlebostatic axis. Where is it located? --angle of Louis at 2nd intercostal space to left of sternal border --aortic area at 2nd ICS to right of sternal border --level of atria at 4th ICS, 1/2 anterior-posterior diameter --5th intercostal space at midclavicular line

level of atria at 4th ICS, 1/2 anterior-posterior diameter --to measure pressures accurately using continual arterial and/or pulmonary artery pressure monitoring, the zeroing stopcock of the transducer system must be placed at the phlebostatic axis. This anatomical location, with the client in the supine position, is at the 4th ICS, at the midway point of the AP diameter of the chest wall

What type of dressing is used for burn injuries?

loose, nonadherent, sterile dressings

A nurse is caring for a client on a mechanical ventilator. The ventilator is sounding an alarm and displaying an alert about low tidal volumes. The nurse has checked all connections and the endotracheal tube, but the alarm perisists and the client's oxygen saturation is dropping. What should the nurse do next? --call the respiratory therapist to the bedside to troubleshoot --elevate the head of the bed and apply a nonrebreather mask --increase the oxygen delivery on the ventilator to 100% --manually ventilate with a resuscitation bag device attached to the endotracheal tube

manually ventilate with a resuscitation bag device attached to the endotracheal tube --A low tidal volume alarm indicates that the volume of air the ventilator is delivering is lower than the set volume. This is most often due to a disconnection, loose connection, or leak in the circuit. The nurse should troubleshoot the most common causes of the alarm, but if the client's condition is deteriorating clinically, then the nurse should disconnect the ventilator and manually ventilate the client's lungs with a resuscitation bag device at 10-15 L/min oxygen until the ventilator alarm state can be resolved.

Upon arrival in the post-anesthesia care unit, the nurse performs the initial assessment of a client who had surgery under general anesthesia. Which assessment finding prompts the nurse to notify the healthcare provider immediately? --difficult to arouse --muscle stiffness --pinpoint pupils --temperature of 94 degrees F

muscle stiffness --Malignant hyperthermia is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia in susceptible clients. The triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity. It can occur in the operating room or in the post-anesthesia care unit. A client who just arrived in the PACU after general anesthesia would be expected to be difficult to arouse and to have small pupil sizes. Hypothermia is common in the immediate postoperative period due to anesthetic-induced vasodilation, decreased basal metabolic rate, and a cool environment.

The client is brought to the ED after his face slammed into a brick wall during a gang fight. Which client assessment finding is most important for the nurse to consider before inserting a nasogastric tube? --an ecchymotic area on the forehead --frontal headache rated as 10 on a 1-10 scale --nasal drainage on gauze has a red spot surrounded by serous fluid --small amount of bright red blood oozing from cheek lacerations

nasal drainage on gauze has a red spot surrounded by serous fluid -No nasogastric or oral gastric tube should be inserted blindly when a basilar skull fracture is suspected

The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac arrest. The client does not allow commands and remains comatose. What intervention does the nurse anticipate being added to client's plan of care? --assisting the healthcare provider in discussing a do no resuscitate order with the family --obtaining equipment and cold fluids for induction of therapeutic hypothermia --planning for passive range-of-motion exercises to prevent contractures

obtaining equipment and cold fluids for induction of therapeutic hypothermia --Neurologic injury is the most common cause of mortality in clients who have had cardiac arrest, particularly ventricular fibrillation or pulseless ventricular tachycardia. Inducing therapeutic hypothermia in these clients within 6 hours of arrest and maintaining it for 24 hours has been shown to decrease mortality rates and improve neurologic outcomes It is indicated in all clients who are comatose or do not follow commands after resuscitation. It is too early to consider a do-not-resuscitate order. If the client does not respond to therapeutic hypothermia or these is evidence of neurologic impairment, it may be discussed at some point. Clients are generally kept NPO during therapeutic hypothermia and rewarming. The feeding tube may be needed after the rewarming process. Passive range-of-motion exercises would be indicated for this client, but are not the immediate priority.

How should a client be placed during gastric lavage?

on their side or with the head of the bed elevated to minimize aspiration risk

A client is admitted to the ICU with diabetic ketoacidosis. The client is most likely to exhibit which of the following arterial blood gas results? --pH 7.26, PaCO2 56 mm Hg, HCO3 3 mEq/L --pH 7.30, PaCO2 30 mm Hg, HCO3 15 mEq/L --pH 7,40, PaCO2 40 mm Hg, HCO3 24 mEq/L --pH 7.58, PaCO2 48 mm Hg, HCO3 44 mEq/L

pH 7.30, PaCO2 30 mm Hg, HCO3 15 mEq/L --The arterial blood gas result most consistent with diabetic ketoacidosis is metabolic acidosis or partially compensated metabolic acidosis.

A client at 3 weeks gestation goes into cardiac arrest. What is the nurse's best action while performing cardiopulmonary resuscitation for this client? --compress chest at second intercostal space, right sternal border --perform chest compressions slightly higher on the sternum --place hands just below the diaphragm to perform chest compressions --position client in the supine position for optimal compressions

perform chest compressions slightly higher on the sternum --Common causes of sudden cardiac arrest in pregnant clients include embolism, eclampsia, magnesium overdoses, and uterine rupture. If CPR is required, several modifications must be made to ensure efficacy of the rescue efforts. During pregnancy, the heart is displaced toward the left because the growing uterus pushes upward on the diaphragm, particularly in the third trimester. To accommodate this displacement, the hands should be placed on the sternum slightly higher than usual for chest compressions during CPR. In addition, a gravid uterus can significantly compress the client's vena cava and aorta, thereby hindering effective blood flow during CPR. The uterus should be manually displaced to the client's left to reduce this pressure. The nurse can also place a rolled blanket or wedge under the right hip to displace the uterus. If ROSC does not occur after 4 minutes of CPR, emergency cesarean section is usually initiated.

A 2 year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time? --continue CPR without using the automated external defibrillator until paramedics arrive --place one AED pad on the chest and the other on the back --place one AED pad on the upper right chest and the other on the lower left side -place one AED pad on the upper right chest and dispose of the other

place one AED pad on the chest and the other on the back --An AED should be used as soon as it is available. Pediatric AED pads or a pediatric attenuator should be used for children age birth to 8 years if available. Standard adult pads can be used as long as they do not overlap or touch. If adult AED pads are used, one should be placed on the chest and the other on the back

The charge nurse is evaluating the skills of a new RN assigned to care for a client with shock. Which action taken by the new RN indicates a need for further education? --administers furosemide to a client with pulmonary artery wedge pressure of 24 mm Hg with cardiogenic shock --increases norephinephrine infusion rate to maintain mean arterial pressure >65 mm Hg in a client with anaphylactic shock --moves pulse oximeter sensor from the finger to the forehead of a client with septic shock --places the head of bed for a client with hypovolemic shock in high Fowler's position

places the head of bed for a client with hypovolemic shock in high Fowler's position --The nurse manager would intervene when the new RN places the HOB of a client with hypovolemic shock in high Fowler's position. Raising the HOB causes blood pressure to decrease, especially in a client with hypovolemic shock and inadequate circulating vascular system. Furosemide is an appropriate drug for the nurse to administer to decrease left ventricular preload in a client in cardiogenic shock with PAWP of 24 mm Hg. Norepinephrine is a vasopressor used to increase stroke volume, cardiac output, and MAP. Titrating a norepinephrine infusion upward to maintain the MAP within normal limits is an appropriate nursing action for a client in anaphylactic shock

The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate? --lavage through a small-bored nasogastric tube --place client in Trendelenburg Position during lavage --prepare intubation and suction supplies at the bedside --wait an hour after gastric decompression to initiate lavage

prepare intubation and suction supplies at the bedside --Gastric lavage is performed through an orogastric tube to remove ingested toxins and irrigate the stomach. Gastric lavage is rarely performed as it is associated with a high risk of complications (aspirations, esophageal or gastric perforation, dysrhythmias). Gastric lavage is only indicated if the overdose is potentially lethal or if gastric lavage can be initiated within one hour of the overdose. Activated charcoal is the standard treatment for overdose, but it is ineffective for some drugs (lithium, iron, alcohol). Intubation and suction supplies should always be available at the bedside during gastric lavage in case the client develops aspiration or respiratory distress. Gastric lavage is usually performed through a large-bore orogastric tube so that a large volume of water or saline can be instilled in and out of the tube. During gastric lavage, clients should be placed on their side or with the head of bed elevated to minimize aspiration risk.

The nurse is supervising a graduate nurse on a telemetry unit. An assigned client develops asystole with no pulse, and emergency care interventions are initiated. Which action by the graduate nurse would cause the supervising nurse to interevene? --administers IV epinephrine --applies oxygen with bag-mask --initiates chest compressions --provides defibrillator shock

provides defibrillator shock --The client in asystole has a total absence of ventricular electrical activity and is pulseless, apneic, and unresponsive. The nurse should first verify the monitor reading by assessing the client and palpating for a pulse, and then call for help and initiate emergency care. Defibrillation is not indicated when there is no electrical activity present or when the heart muscle is not contracting despite an organized rhythm.

What is malignant hyperthermia (MH)?

rare, life-threatening inherited muscle abnormality.

The nurse is admitting a client with a possible diagnosis of Guillain-Barre syndrome. When collecting data to develop a plan of care for the client, the nurse should give priority to which of the following items? --orthostatic blood pressure changes --presence or absence of knee reflexes --pupil size and reaction to light --rate and depth of respirations

rate and depth of respirations --Guillain-Barre syndrome is an acute, immune-mediate polyneuropathy that is most often accompanied by ascending muscle paralysis and absence of reflexes/ Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves. Neuromuscular respiratory failure is the most life-threatening complication. The rate and depth of the respirations should be monitored. Measurement of serial bedside forced vital capacity is the gold standard for assessing early ventilation failure.

A RN is precepting a new nurse in the ICU. The client is sedated with propfol, on a mechanical ventilator, and is receiving enteral feeding via nasogastric tube. The new nurse performs interventions to prevent aspiration. The preceptor should intervene if the new nurse performs which of the following actions? --assesses gastric residual volumes every 4 hours --measures the number of centimeters the feeding tube is secured at the nare every 4 hours --requests that the physician change the client from continual to bolus feedings --uses a sedation scale to titrate down the sedation (if possible)

requests that the physician change the client from continual to bolus feedings --Critcially ill clients are at increased risk for aspiration of oropharyngeal secretions and gastric content. It is common in clients who are intubated, sedated, on a mechanical ventilator, and receiving enteral feedings. The nurse must provide nursing interventions to prevent aspiration and monitor for its signs and symptoms. Clients are at increased risk when receiving bolus rather than continual enteral feedings. Bolus feedings should be avoided in critically ill clients, who are already at increased risk for aspiration. Assessing gastric residual volumes is standard for clients receiving continual enteral feedings. Increased volumes may indicate poor absorption and increase the risk of regurgitation and aspiration. Measuring the number of centimeters at the nare ever 4 hours can determine if the tube has moved, but it can increase aspiration risk. X-ray confirmation may be necessary if the tube has moved. A sedation scale is use to assess level of sedation.

Decerebrate posturing is a sign of...

severe brain damage

The flight nurse assesses an alert and oriented client at an industrial accident scene who was impaled in the abdomen by a pair of scissors. Which nursing action is the immediate priority on arrival at the scene? --insert a large bore IV line and infuse normal saline --obtain blood for type and crossmatch and hemoglobin --remove constrictive clothing to enhance circulation --stabilize the scissors with sterile bulky dressings.

stabilize the scissors with sterile bulky dressings. --A sharp object that pierces the skin and lodges in the body may result in penetrating trauma to nearby tissue and organs. Common types of impaled objects include bullets or blast fragments from firearms as well as sharp objects. The embedded object creates a puncture wound and then controls potential bleeding by putting pressure on the wound. First responded should not manipulate or remove the impaled object. Manipulation or removal may cause further trauma and bleeding; therefore, stabilization of the object is the first priority to prevent it from moving during initial client assessment and later during transport to a healthcare facility where skilled trauma care is available. An IV line may be inserted and fluids begun on scene after stabilization of the object and initial assessment. Blood may be drawn after stabilization of the object and initial assessment. Clothing may be removed on scene after stabilization of the object and initial assessment.

How is an unstable client with ventricular tachycardia treated?

synchronized cardioversion

The nurse in the ICU is caring for a client who is postoperative from a cardiac surgery. The client has a mediastinal chest tube. During assessment, the nurse notes bubbling in the suction control chamber. Which nursing action is appropriate? --assess the insertion site for presence of subcutaneous emphysema --notify the surgeon of a large air leak --take no action as the chest tube is functioning appropriately --turn down the wall suction until the bubbling disappears

take no action as the chest tube is functioning appropriately --Gentle, continuous bubbling in the suction control chamber of a chest tube drainage unit indicates that suction is present and the unit is functioning appropriately. The nurse should document the finding and continue to monitor

Defibrillation is indicated in which clients?

those with ventricular fibrillation and pulseless ventricular tachycardia

What is the function of PEEP?

to provide pressure at the end of expiration during mechanical ventilation. This keeps alveoli open to participate in gas exchange.

What is the purpose of the square wave test?

to verify if the arterial line is functioning correctly.

The nurse is caring for a client who has a near-drowning accident in cold weather. Which assessment finding indicates the most severe injury? --decreased body temperature --toes pointed straight down --weak and thready pulses --wheezing on auscultation

toes pointed straight down --near-drowning occurs when a client is under water and unable to breathe for an extended period. In a matter of seconds, major body organs begin to shut down from lack of oxygen and permanent damage results. Decerebrate posturing is a sign of severe brain damage. During assessment, the nurse would observe arms and legs straight out, toes pointed down, and the head/neck arched back. These assessment findings indicate that severe injury has occurred. Hypothermia is generally seen in near-drowning victims. One of the first goals of treatment is to warm the client. Sustained hypothermia will eventually lead to organ failure, making this an urgent findings, but not initially life-threatening. A weak and thready pulse is generally detected in near-drowning victims due to hypothermia. Once the client is properly warmed, the pulse generally returns to normal. The wheezing may indicate that the client has bronchospam, but the client is still moving air and providing oxygen to the body, so this is not an immediate concern.