AMS Exam 2 Questions
The nurse should call the rapid response team for which patients? (Select all that apply) a. 53-year-old with pneumonia and severe respiratory distress b. 17-year-old with apnea following a severe head injury c. 24-year-old experiencing a severe asthmatic attack with stridor d. 73-year-old patient with bradycardia of 40 beats per minute e. 52-year-old patient with no palpable pulse
a. 53-year-old with pneumonia and severe respiratory distress c. 24-year-old experiencing a severe asthmatic attack with stridor d. 73-year-old patient with bradycardia of 40 beats per minute Rapid response teams (RRTs) or medical emergency teams focus on addressing changes in a patient's clinical condition before a cardiopulmonary arrest occurs. The patient without a pulse and the patient with apnea needs the code team activated.
The patient is diagnosed with abrupt onset of supraventricular tachycardia (SVT). The nurse prepares which medication to administer to the patient? a. Adenosine b. Amiodarone c. Diltiazem d. Procainamide
a. Adenosine Adenosine is the initial drug of choice for the diagnosis and treatment of supraventricular dysrhythmias. Adenosine has an onset of action of 10 to 40 seconds and duration of 1 to 2 minutes; therefore, it is administered rapidly.
The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.) a. Airway clearance therapies b. Antibiotic therapy c. Nutritional support d. Tracheostomy e. Lung transplant
a. Airway clearance therapies b. Antibiotic therapy c. Nutritional support e. Lung transplant The three cornerstones of care for a patient with CF are antibiotic therapy, airway clearance, and nutritional support. Lung transplant is a treatment modality for those who can get a match and who do not have current respiratory failure. A tracheostomy is not a standard treatment for CF.
When doing manual ventilations during a code, the nurse would administer ventilations following which guideline? a. Approximately 8 to 10 breaths per minute b. During the fifth chest compression c. Every 3 seconds or 20 times per minute d. While compressions are stopped
a. Approximately 8 to 10 breaths per minute Manual ventilations are delivered one breath every 6 to 8 seconds or approximately 8 to 10 breaths per minute.
A patient is admitted to the critical care unit with bradycardia at a heart rate of 39 beats/min and frequent premature ventricular contractions. The nurse notes that the patient is lethargic and reports dizziness for the past 12 hours. Which of the following are acceptable initial treatments for this patient? (Select all that apply.) a. Atropine b. Epinephrine c. Lidocaine d. Transcutaneous pacemaker e. Magnesium sulfate infusion
a. Atropine d. Transcutaneous pacemaker Administer atropine, 0.5 mg IV every 3 to 5 minutes to a total dose of 3 mg for symptomatic bradycardia. Transcutaneous pacing is also indicated for symptomatic bradycardia unresponsive to atropine. Epinephrine infusion can be used if atropine is not effective but it is not a first-line choice. Lidocaine is contraindicated in bradycardia because it can depress conduction, which would be detrimental with a heart rate of 39 beats/min. Magnesium is not indicated for bradycardia.
The patient's monitor shows bradycardia (heart rate of 40 beats/min) and frequent premature ventricular contractions (PVCs) with a measured blood pressure of 85/50 mm Hg. The nurse anticipates the use of which drug? a. Atropine 0.5 to 1 mg intravenous push b. Dopamine drip—continuous infusion c. Lidocaine 1 mg/kg intravenous push d. Transcutaneous pacemaker
a. Atropine 0.5 to 1 mg intravenous push This patient is having PVCs secondary to bradycardia. Atropine is a first-line drug for bradycardia. Administer atropine, 0.5 mg IV every 3 to 5 minutes to a total dose of 3 mg. Atropine is not indicated in second-degree atrioventricular (AV) block type II or third-degree AV block.
Laypersons should use which device to treat lethal ventricular dysrhythmias that occur outside a hospital setting? a. Automatic external defibrillator b. Carbon dioxide detector c. Pocket mask d. Transcutaneous pacemaker
a. Automatic external defibrillator Because of the ease of use and efficacy in treating lethal ventricular dysrhythmias, automatic external defibrillators are recommended to be placed in a variety of public settings where they may be used by laypersons.
The nurse chooses which method and concentration of oxygen administration until intubation is established in a patient who has sustained a cardiopulmonary arrest? a. Bag-valve-mask at FiO2 of 100% b. Bag-valve-mask at FiO2 of 50% c. Mouth-to-mask ventilation with supplemental oxygen d. Non-rebreather mask at FiO2 of 100%
a. Bag-valve-mask at FiO2 of 100% Oxygen can be delivered via mouth to mask or with a bag-valve device connected to a mask or endotracheal tube. During resuscitation efforts, 100% oxygen is administered.
The patient has pulseless electrical activity (PEA). What action by the nurse takes priority? a. Begin high-quality CPR. b. Assist with chest tube placement. c. Prepare equipment for a pericardiocentesis. d. Attach the patient to a transcutaneous pacemaker.
a. Begin high-quality CPR. A patient in PEA does not have a pulse or blood pressure. The nurse initiates high-quality CPR. Chest tube insertion, pericardiocentesis, and transcutaneous pacing are not required.
Identify diagnostic criteria for ARDS. (Select all that apply.) a. Bilateral infiltrates on chest x-ray study b. Decreased cardiac output c. PaO2/ FiO2 ratio of less than 200 d. Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg e. PAOP less than 18 mm Hg
a. Bilateral infiltrates on chest x-ray study c. PaO2/ FiO2 ratio of less than 200 Diagnostic criteria for ARDS include bilateral infiltrates, or "white out," on chest x-ray study and a low PaO2/FiO2 ratio. Decreased cardiac output and a high PAOP are seen in pulmonary edema associated with cardiac causes. The PAOP description was deleted from the current definition.
A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first? a. Cardiac rate and rhythm b. Skin and mucous membranes c. Musculoskeletal strength d. Level of orientation
a. Cardiac rate and rhythm Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographic changes will be present. Central nervous system and neuromuscular system changes do not occur with mild acidosis and should be monitored if the acidosis worsens. Skin and mucous membrane assessment is not a priority now, but will change as acidosis worsens.
Postresuscitation goals include which of the following? (Select all that apply) a. Control dysrhythmias b. Maintain airway c. Maintain blood pressure d. Wean off oxygen e. Early ambulation
a. Control dysrhythmias b. Maintain airway c. Maintain blood pressure Postresuscitation goals include optimizing tissue perfusion by airway, blood pressure maintenance, oxygenation, and control of dysrhythmias. Weaning off oxygen and early ambulation are good actions when possible but are not goals of postresuscitation care.
The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (Select all that apply.) a. Coughing or attempting to talk b. Disconnection from the ventilator c. Kinks in the ventilator tubing d. Need for suctioning e. Spontaneous breathing
a. Coughing or attempting to talk c. Kinks in the ventilator tubing d. Need for suctioning Coughing, kinks, and mucus in the airway can cause the inspiratory pressure to increase; ventilator disconnects result in low-volume alarms. A disconnection from the ventilator would result in a low exhaled volume alarm, not a high-pressure alarm. Spontaneous breathing does not trigger alarms.
Benefits of having the family present during resuscitation include which of the following? (Select all that apply) a. Facilitates the grief process b. Lets the family see that everything is being done c. Sustains patient-family relationships d. Allows the staff easy access to ask for organ transplant e. Provides a sense of closure
a. Facilitates the grief process b. Lets the family see that everything is being done c. Sustains patient-family relationships e. Provides a sense of closure Families who have been present during a code describe the benefits as knowing that everything possible was being done for their loved one, feeling supportive and helpful to the patient and staff, sustaining patient-family relationships, providing a sense of closure on a life shared together, and facilitating the grief process.
A patient's ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from 0.6 to 0.7, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patient's blood pressure drops from 120/76 mm Hg to 90/60 mm Hg. What is the most likely cause of this decrease in blood pressure? a. Decrease in cardiac output b. Hypovolemia c. Increase in venous return d. Oxygen toxicity
a. Decrease in cardiac output Positive end-expiratory pressure increases intrathoracic pressure and may result in decreased venous return. Cardiac output decreases as a result, and is reflected in the lower blood pressure. It is essential to assess the patient to identify optimal positive end-expiratory pressure—the highest amount that can be applied without compromising cardiac output. Although hypovolemia can result in a decrease in blood pressure, there is no indication that this patient has hypovolemia. As noted, higher levels of positive end-expiratory pressure may cause a decrease, not an increase, in venous return. Oxygen toxicity can occur in this case secondary to the high levels of oxygen needed to maintain gas exchange; however, oxygen toxicity is manifested in damage to the alveoli.
The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? a. Decreasing PaO2 levels despite increased FiO2 administration b. Elevated alveolar surfactant levels c. Increased lung compliance with increased FiO2 administration d. Respiratory acidosis associated with hyperventilation
a. Decreasing PaO2 levels despite increased FiO2 administration Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels are often diminished in ARDS. Compliance decreases in ARDS. In early ARDS, hyperventilation may occur along with respiratory alkalosis.
The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.) a. Drain condensate from the ventilator tubing away from the patient. b. Elevate the head of the bed 30 to 45 degrees. c. Instill normal saline as part of the suctioning procedure. d. Perform regular oral care with chlorhexidine. e. Awaken the patient daily to determine the need for continued ventilation.
a. Drain condensate from the ventilator tubing away from the patient. b. Elevate the head of the bed 30 to 45 degrees. d. Perform regular oral care with chlorhexidine. Condensate should be drained away from the patient to avoid drainage back into the patient's airway. Prevention guidelines recommend elevating the head of bed at 30 to 45 degrees. Regular antiseptic oral care, with an agent such as chlorhexidine, reduces oropharyngeal colonization. Daily "sedation holidays" help determine the need to continue mechanical ventilation. Normal saline is not recommended as part of the suctioning procedure, and it may increase the risk for infection.
Which of the following statements about defibrillation are correct? (Select all that apply) a. Early defibrillation (if warranted) is recommended before other actions. b. It is not necessary to ensure that personnel are clear of the patient if hands-off defibrillation is used. c. It is not necessary to synchronize the defibrillation shocks. d. Paddles/patches can be placed anteriorly and posteriorly on the chest. e. All models of defibrillators are the same for standardization.
a. Early defibrillation (if warranted) is recommended before other actions. c. It is not necessary to synchronize the defibrillation shocks. d. Paddles/patches can be placed anteriorly and posteriorly on the chest. Defibrillation is indicated as soon as possible because early defibrillation and CPR increase the chance of survival. Regardless of the method of defibrillation, all personnel must avoid contact with the patient or bed during the shock delivery. Shocks are delivered without synchronization. Anterior paddle placement is used most often; however, the alternative method is anteroposterior placement. Defibrillators come in many models, and nurses must ensure they are familiar with the model in use on their unit.
Which of the following devices is best suited to deliver 65% oxygen to a patient who is spontaneously breathing? a. Face mask with non-rebreathing reservoir b. Low-flow nasal cannula c. Simple face mask d. Venturi mask
a. Face mask with non-rebreathing reservoir Face masks with reservoirs (partial rebreathing and non-rebreathing reservoir masks) provide oxygen concentration of 60% or higher. The addition of the reservoir increases the amount of oxygen available to the patient during inspiration and allows for the delivery of concentrations of 35% to 60% (partial rebreather) or 60% to 80% (non-rebreather), depending on the flowmeter setting, the fit of the mask, and the patient's respiratory pattern. The high-flow nasal cannula, not the traditional low-flow models, can provide higher flows. The simple face mask can deliver flows up to 60%. The Venturi mask allows better regulation of oxygen concentration and generally does not deliver more than 60% oxygen.
Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.) a. Graduated compression stockings b. Heparin or low-molecular weight heparin for patients at risk c. Sequential compression devices d. Strict bed rest e. Leg massage
a. Graduated compression stockings b. Heparin or low-molecular weight heparin for patients at risk c. Sequential compression devices Graduated compression stockings, sequential compression devices, and anticoagulation can reduce the risk for DVT. Physical activity can also reduce the risk; bed rest increases the risk. Leg massage is not recommended.
What is the major reason for using a treatment to lower body temperature after cardiac arrest to promote better neurological recovery? a. Hypothermia decreases the metabolic rate by 7% for each decrease of 1C. b. Lower body temperatures are beneficial in patients with low blood pressure. c. Temperatures of 40 C may reduce neurological impairment. d. The lower body temperature leads to decreased oxygen delivery.
a. Hypothermia decreases the metabolic rate by 7% for each decrease of 1C. Hypothermia decreases the metabolic rate by 6% to 7% for every decrease of 1 C in temperature; decreased metabolic rate may protect neurological function. Induced hypothermia to a core body temperature of 32 C to 34 C for 12 to 24 hours may be beneficial in reducing neurological impairment after cardiac arrest.
A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism? a. Increased rate and depth of respirations b. Increased urinary output c. Increased thirst and hunger d. Increased release of acids from the kidneys
a. Increased rate and depth of respirations This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are manifestations of hyperglycemia but are not compensatory mechanisms for acid-base imbalances. The kidneys do not release acids.
Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.) a. Increases functional residual capacity b. Prevents collapse of unstable alveoli c. Improves arterial oxygenation d. Opens collapsed alveoli e. Improves carbon dioxide retention
a. Increases functional residual capacity b. Prevents collapse of unstable alveoli c. Improves arterial oxygenation d. Opens collapsed alveoli Ventilatory support for ARDS typically includes PEEP to restore functional residual capacity, open collapsed alveoli, prevent collapse of unstable alveoli, and improve arterial oxygenation. PEEP does not improve CO2 retention.
Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply.) a. Interrupt sedation each day to assess readiness to extubate. b. Maintain head of bed at least 30 degrees of elevation. c. Provide deep vein thrombosis prophylaxis. d. Provide prophylaxis for peptic ulcer disease. e. Swab the mouth with foam swabs every 2 hours.
a. Interrupt sedation each day to assess readiness to extubate. b. Maintain head of bed at least 30 degrees of elevation. c. Provide deep vein thrombosis prophylaxis. d. Provide prophylaxis for peptic ulcer disease. Options A, B, C, and D are components of the IHI ventilator bundle. Oral care with chlorhexidine has recently been added to the IHI bundle. Swabbing alone provides comfort care.
The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following? a. Management and protection of the airway b. Prevention of gastric aspiration c. Prevention of skin breakdown and nerve damage d. Psychological support to patient and family
a. Management and protection of the airway All are important, but protection of the airway is the most important intervention if the patient is placed in the prone position.
Which of the following are documented as part of the cardiopulmonary arrest record? (Select all that apply) a. Medication administration times b. Defibrillation times, joules, outcomes c. Rhythm strips of cardiac rhythm(s) noted d. Signatures of recorder and other personnel e. Model of defibrillator used.
a. Medication administration times b. Defibrillation times, joules, outcomes c. Rhythm strips of cardiac rhythm(s) noted d. Signatures of recorder and other personnel Documentation includes the time the code is called, the time CPR is started, any actions that are taken, and the patient's response (e.g., presence or absence of a pulse, heart rate, blood pressure, cardiac rhythm). Intubation and defibrillation (and the energy used) must be documented, along with the patient's response. The time and sites of IV initiations, types and amounts of fluids administered, and medications given to the patient must be accurately recorded. Rhythm strips are recorded to document events and response to treatment. Signatures of those involved in the code effort, including the recorder, are essential.
Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)? a. PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. b. Bradycardia and hyperventilation are classic symptoms of PE. c. Dyspnea, chest pain, and hemoptysis occur in nearly all patients with PE. d. Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis.
a. PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. Dyspnea, hemoptysis, and chest pain have been called the "classic" signs and symptoms for PE, but the three signs and symptoms actually occur in less than 20% of cases. Bradycardia and hyperventilation are not classic signs of PE. Most critically ill patients are at high risk for VTE, and all should receive prophylaxis.
The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the a. alveolar-capillary membrane. b. left ventricle. c. mainstem bronchus. d. trachea.
a. alveolar-capillary membrane. Damage to the alveolar-capillary membrane results in noncardiogenic pulmonary edema. None of the other responses apply.
During rounds, the provider alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is a. an optional treatment to improve ventilation. b. less of a risk for skin breakdown because the patient is face down. c. possible with minimal help from coworkers. d. used to provide continuous lateral rotational turning.
a. an optional treatment to improve ventilation. Proning is considered to improve ventilation by shifting perfusion from the posterior bases of the lung to the anterior portion. The patient is not responding to treatment, and all options should be considered. The patient remains at risk for skin breakdown due to immobility; during proning, the risk is in the dependent areas, such as the face. Proning is a labor-intensive procedure, and the nurse needs help from team members to ensure a safe turn, including protection of the airway. Continuous lateral rotation is a therapy done in the supine position with a specialized bed.
The nurse is caring for a patient who is mechanically ventilated. As part of the nursing care, the nurse understands that a. communication with intubated patients is often difficult. b. controlled ventilation is the preferred mode for most patients. c. patients with chronic obstructive pulmonary disease wean easily from mechanical ventilation. d. wrist restraints are applied to all patients to avoid self-extubation.
a. communication with intubated patients is often difficult. Communication difficulties are common because of the artificial airway. Restraints must be determined individually. Patients with chronic obstructive pulmonary disease often have difficulty weaning. Synchronized intermittent mandatory ventilation and assist/control ventilation are the commonly used modes.
The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.) a. high Fowler's. b. side lying with head of bed elevated. c. sitting in a chair. d. supine with the bed flat. e. Trendelenburg.
a. high Fowler's. b. side lying with head of bed elevated. c. sitting in a chair. Patients in respiratory distress are unable to tolerate a flat position. Trendelenburg would also be contraindicated as the weight of the organs on the lungs would inhibit movement. High Fowler's is appropriate. Side lying with head of bed elevated, sitting in a chair, and high Fowler's position are all appropriate ways to position the patient to facilitate gas exchange and comfort.
A patient's endotracheal tube is not secured tightly. The respiratory care practitioner assists the nurse in taping the tube. After the tube is retaped, the nurse auscultates the patient's lungs and notes that the breath sounds over the left lung fields are absent. The nurse suspects that a. the endotracheal tube is in the right mainstem bronchus. b. the patient has a left pneumothorax. c. the patient has aspirated secretions during the procedure. d. the stethoscope earpiece is clogged with wax.
a. the endotracheal tube is in the right mainstem bronchus. The endotracheal tube can become dislodged during repositioning and is likely to be in the right mainstem bronchus. It is important to reassess breath sounds after the retaping procedure. A pneumothorax would also result in diminished or absent breath sounds; however, it is not associated with repositioning the endotracheal tube. Aspiration may occur during the procedure but would be manifested in changes in the chest x-ray or by hypoxemia, for example. The stethoscope is not a factor.
The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse instructs, a. "If you get the pneumococcal vaccine, you'll never get pneumonia again." b. "It is important for you to get an annual influenza shot to reduce your risk of pneumonia." c. "Stay away from cold, drafty places because that increases your risk of pneumonia when you get home." d. "Since you have been treated for pneumonia, you now have immunity from getting it in the future."
b. "It is important for you to get an annual influenza shot to reduce your risk of pneumonia." The influenza vaccine reduces the risk of pneumonia by more than 50%. The pneumococcal vaccine is important but protects only against pneumococcal infection. Cold, drafty environments will not cause infection. Immunity for pneumonia does not occur as a result of getting it.
A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains to the patient: a. "I'm going to contact the pharmacist to see if you can take this medication by mouth." b. "This injection is being given to prevent blood clots from forming." c. "This medication will dissolve any blood clots you might get." d. "You should not be receiving this medication. I will contact the provider to get it stopped."
b. "This injection is being given to prevent blood clots from forming." Enoxaparin, or low-molecular weight heparin, is recommended for patients at high risk for PE. This patient is at high risk and the medication is indicated. It is given subcutaneously, not by mouth. The drug prevents clots from forming but does not dissolve them.
The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%). a. 46.8; meets criteria for ARDS b. 130; meets criteria for ARDS c. 468; normal lung function d. Not enough data to compute the ratio
b. 130; meets criteria for ARDS 78/0.60 = 130, which meets the criteria for ARDS.
A patient is admitted to the coronary care unit with an inferior wall myocardial infarction and develops symptomatic bradycardia with premature ventricular contractions every third beat (trigeminy). The nurse knows to prepare to administer which drug? a. Amiodarone b. Atropine c. Lidocaine d. Magnesium
b. Atropine Atropine is used to increase the heart rate by decreasing the vagal tone. It is indicated for patients with symptomatic bradycardia.
Which code drugs can be given safely through an endotracheal tube? (Select all that apply) a. Adenosine b. Atropine c. Epinephrine d. Vasopressin e. Amiodarone
b. Atropine c. Epinephrine d. Vasopressin Medications that can be administered through the endotracheal tube until IV access is established are atropine, epinephrine, lidocaine, and vasopressin.
Select all of the factors that may predispose the patient to respiratory acidosis. (Select all that apply.) a. Anxiety and fear b. Central nervous system depression c. Diabetic ketoacidosis d. Nasogastric suctioning e. Overdose of sedatives
b. Central nervous system depression e. Overdose of sedatives Central nervous system depression and drug overdose may result in hypoventilation and cause respiratory acidosis. Anxiety is a cause of hyperventilation and respiratory alkalosis. Diabetic ketoacidosis is a cause of metabolic acidosis. Nasogastric suctioning is a cause of metabolic alkalosis.
The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia? a. Bradycardia b. Change in sputum characteristics c. Hypoventilation and respiratory acidosis d. Pursed-lip breathing
b. Change in sputum characteristics Change in the character of sputum may signal the development of a respiratory infection in the patient with COPD. Additional symptoms include anxiety, wheezing, chest tightness, tachypnea, tachycardia, fatigue, malaise, confusion, fever, and sleeping difficulties.
The monitor technician notifies the nurse "stat" that the patient has a rapid, chaotic rhythm that looks like ventricular tachycardia. What is the nurse's first action? a. Call a code overhead. b. Check the patient immediately. c. Go to the nurses' station and look at the rhythm strip. d. Take the crash cart to the room.
b. Check the patient immediately. The first intervention in this situation is to assess unresponsiveness by checking the patient.
A patient is admitted to the cardiac surgical intensive care unit after cardiac surgery with the following arterial blood gas (ABG) levels. What action by the nurse is best? pH: 7.4 PaCO2: 40 mm Hg Bicarbonate: 24 mEq/L PaO2: 95 mm Hg O2 saturation: 97% Respirations: 20 breaths/min a. Call the provider to request rapid intubation. b. Document the findings and continue to monitor. c. Request that another set of ABGs be drawn and run. d. Correlate the patient's O2 saturation with the ABGs.
b. Document the findings and continue to monitor. These are normal values. All parameters are within normal limits. No action other than documentation and continued observation is warranted.
The nurse is assisting with endotracheal intubation and understands that correct placement of the endotracheal tube in the trachea would be identified by which of the following? (Select all that apply.) a. Auscultation of air over the epigastrium b. Equal bilateral breath sounds upon auscultation c. Position above the carina verified by chest x-ray d. Positive detection of carbon dioxide (CO2) through CO2 detector devices e. Fogging of the endotracheal tube
b. Equal bilateral breath sounds upon auscultation c. Position above the carina verified by chest x-ray d. Positive detection of carbon dioxide (CO2) through CO2 detector devices The position of the tube is assessed after intubation through auscultation of breath sounds, carbon dioxide testing, and chest x-ray. Auscultation of air over the epigastrium indicates placement in the esophagus rather than the trachea. Fogging of the ET tube does not indicate correct placement.
A patient is having difficulty weaning from mechanical ventilation. The nurse assesses the patient for which potential cause of this difficult weaning? a. Cardiac output of 6 L/min. b. Hemoglobin of 8 g/dL. c. Negative sputum culture and sensitivity. d. White blood cell count of 8000.
b. Hemoglobin of 8 g/dL. The low hemoglobin level will decrease oxygen-carrying capacity and may make weaning difficult. A cardiac output of 6 L/min is normal. A negative sputum culture indicates absence of lower respiratory infection, which should promote rather than hinder weaning. A white blood cell count of 8000 is normal and indicates absence of infection, which should promote rather than hinder weaning.
The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration? a. Hyperventilation and respiratory acidosis b. Hypoventilation and respiratory acidosis c. Hypoventilation and respiratory alkalosis d. Respiratory acidosis and normal oxygen levels
b. Hypoventilation and respiratory acidosis Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and respiratory acidosis. The overdose depresses the respiratory drive, which results in hypoventilation, not hyperventilation. Hypoxemia is expected secondary to depressed respirations.
Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Tooth brushing is performed every 2 hours for the greatest effect. b. Implementing a comprehensive oral care program is an intervention for preventing VAP. c. Oral care protocols should include oral suctioning and brushing teeth. d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP. e. Using oral swabs or toothettes are just as effective as brushing the teeth.
b. Implementing a comprehensive oral care program is an intervention for preventing VAP. c. Oral care protocols should include oral suctioning and brushing teeth. d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP. A comprehensive oral care protocol is an intervention for preventing VAP. It includes oral suction, brushing teeth every 12 hours, and swabbing. Chlorhexidine gluconate has been effective in patients who have undergone cardiac surgery. Actual toothbrushing is vital to the VAP bundle.
The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)? a. Increased oxygen saturation via pulse oximetry b. Increased peak inspiratory pressure on the ventilator c. Normal chest radiograph with enlarged cardiac structures d. PaO2/FiO2 ratio >300
b. Increased peak inspiratory pressure on the ventilator Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation decreases in ARDS. Chest x-ray study will show progressive infiltrates. In ARDS, a PaO2/FiO2 ratio of less than 200 is a criterion.
An acute exacerbation of asthma is treated with which of the following? a. Corticosteroids and theophylline by mouth b. Inhaled bronchodilators and intravenous corticosteroids c. Prone positioning or continuous lateral rotation d. Sedation and inhaled bronchodilators
b. Inhaled bronchodilators and intravenous corticosteroids Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the exacerbation of asthma; they promote dilation of the bronchioles and decreased inflammation of the airways. Proning and continuous lateral rotation are therapies to treat hypoxemia secondary to acute respiratory distress syndrome. Sedation is not recommended.
A patient is brought to the critical care unit after a motor vehicle crash. On admission, the patient reports dyspnea and chest pain. Upon examination, the nurse notes a lack of breath sounds on the left side and a tracheal shift. The patient suddenly experiences cardiac arrest. What assessment by the nurse takes priority? a. Heart tones b. Lung sounds c. Peripheral pulses d. Neurological status
b. Lung sounds The nurse should listen to lung sounds first. The signs and symptoms the patient experienced are consistent with a tension pneumothorax, which is a reversible cause of cardiac arrest. A tension pneumothorax occurs when air enters the pleural space but cannot escape. Pressure increases in the pleural space and causes the lung to collapse. Symptoms of a tension pneumothorax include dyspnea, chest pain, tachypnea, tachycardia, and jugular venous distension.
The nurse is assessing a patient with acute respiratory distress syndrome. An expected assessment is a. cardiac output of 10 L/min and low systemic vascular resistance. b. PAOP of 10 mm Hg and PaO2 of 55. c. PAOP of 20 mm Hg and cardiac output of 3 L/min. d. PAOP of 5 mm Hg and high systemic vascular resistance.
b. PAOP of 10 mm Hg and PaO2 of 55. A normal PAOP with hypoxemia is an expected assessment finding in ARDS although this has been deleted from the most current definition. Cardiac output of 10 L/min and low systemic vascular resistance are expected findings in sepsis. PAOP of 20 mm Hg and cardiac output of 3 L/min are expected findings in heart failure. PAOP of 5 mm Hg and high systemic vascular resistance are expected findings in hypovolemic shock.
It is determined that the patient needs a transcutaneous pacemaker until a transvenous pacemaker can be inserted. What is the most appropriate nursing intervention? a. Apply conductive gel to the skin. b. Provide adequate sedation and analgesia. c. Recheck leads to make sure that the rhythm is asystole. d. Set the milliamperes to 2 mA below the capture level.
b. Provide adequate sedation and analgesia. The alert patient who requires transcutaneous pacing may experience some discomfort. Because the skeletal muscles are stimulated, as well as the heart muscle, the patient may experience a tingling, twitching, or thumping feeling that ranges from mildly uncomfortable to intolerable. Sedation, analgesia, or both may be indicated.
During cardioversion, the nurse would synchronize the electrical charge to coincide with which wave of the ECG complex? a. P b. R c. S d. T
b. R During cardioversion, the electrical shock is synchronized to deliver shock on the R wave. This is to prevent the shock from being delivered during repolarization (T wave). Ventricular fibrillation may occur if the shock is delivered on the T wave.
The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is a. amniotic fluid embolus. b. deep vein thrombosis from lower extremities. c. fat embolus from a long bone fracture. d. vegetation that dislodges from an infected central venous catheter.
b. deep vein thrombosis from lower extremities. The most common cause of a pulmonary embolus is deep vein thrombosis. The other responses are less common causes.
The nurse knows that in advanced cardiac life support, the secondary survey includes steps A-B-C-D, in which "D" refers to: a. defibrillate. b. differential diagnosis. c. diltiazem intravenous push. d. do not resuscitate.
b. differential diagnosis. The A-B-C-D (airway, breathing, circulation, differential diagnosis) in the Advanced Cardiac Life Support (ACLS) secondary survey involves the performance of more in-depth assessments and interventions. Differential diagnosis involves investigation into the cause of the arrest. If a reversible cause is identified, a specific therapy can be initiated.
When fluid is present in the alveoli, a. alveoli collapse, and atelectasis occurs. b. diffusion of oxygen and carbon dioxide is impaired. c. hypoventilation occurs. d. the patient is in heart failure.
b. diffusion of oxygen and carbon dioxide is impaired. Fluid prevents the diffusion of gases. It does not cause atelectasis or hypoventilation. Fluid can be present in the alveoli secondary to heart failure; however, there are other causes as well, such as acute respiratory distress syndrome.
A patient has been successfully converted from ventricular tachycardia with a pulse to a sinus rhythm. Upon further assessment, it is noted that the patient is hypotensive. The appropriate treatment for her hypotension may include (Select all that apply) a. adenosine. b. dopamine infusion. c. magnesium. d. normal saline infusion. e. sodium bicarbonate.
b. dopamine infusion. d. normal saline infusion. The patient may need fluid resuscitation; dopamine is indicated for hypotension once hypovolemia has been corrected. Adenosine, magnesium, and sodium bicarbonate are not indicated in this situation
A PaCO2 of 48 mm Hg is associated with a. hyperventilation. b. hypoventilation. c. increased absorption of O2. d. increased excretion of HCO3.
b. hypoventilation. PaCO2 rises in patients with hypoventilation. Hyperventilation results in a decrease in PaCO2. PaCO2 does not affect oxygen absorption. Increased excretion of bicarbonate would result in metabolic acidosis.
A patient is admitted to the progressive care unit with a diagnosis of community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease and diabetes. A set of arterial blood gases obtained on admission without supplemental oxygen shows pH 7.35; PaCO2 55 mm Hg; bicarbonate 30 mEq/L; PaO2 65 mm Hg. These blood gases reflect: a. hypoxemia and compensated metabolic alkalosis. b. hypoxemia and compensated respiratory acidosis. c. normal oxygenation and partly compensated metabolic alkalosis. d. normal oxygenation and uncompensated respiratory acidosis.
b. hypoxemia and compensated respiratory acidosis. The PaO2 of 65 mm Hg is lower than normal range (80 to 100 mm Hg), indicating hypoxemia. The high PaCO2 indicates respiratory acidosis. The elevated bicarbonate indicates metabolic alkalosis. Because the pH is normal, the underlying acid-base alteration is compensated. Given the patient's history of chronic pulmonary disease and a pH that is at the lower end of normal range, it can be determined that this patient is hypoxemic with fully compensated respiratory acidosis.
Oxygen saturation (SaO2) represents a. alveolar oxygen tension. b. oxygen that is chemically combined with hemoglobin. c. oxygen that is physically dissolved in plasma. d. total oxygen consumption.
b. oxygen that is chemically combined with hemoglobin. Oxygen saturation value reflects the saturation of the hemoglobin. It does not represent alveolar oxygen tension, oxygen that is dissolved in plasma, or total oxygen consumption.
One of the early signs of hypoxemia on the nervous system is a. cyanosis. b. restlessness. c. agitation. d. tachypnea.
b. restlessness. Decreased oxygenation to the nervous system may result in restlessness and agitation—early signs of hypoxemia. Cyanosis is a late sign. Tachypnea may occur, but CNS changes tend to occur earlier. Agitation is not usually seen with hypoxemia.
The code team has just defibrillated a patient in ventricular fibrillation. Following CPR for 2 minutes, what is the next action to take? a. Administer amiodarone. b. Administer lidocaine. c. Assess rhythm and pulse. d. Prepare for transcutaneous pacing.
c. Assess rhythm and pulse. Reassess the patient frequently. Check for return of pulse, spontaneous respirations, and blood pressure.
Which rhythm would be an emergency indication for the application of a transcutaneous pacemaker? a. Asystole b. Bradycardia (heart rate 40 beats/min), normotensive and alert c. Bradycardia (heart rate 50 beats/min) with hypotension and syncope d. Supraventricular tachycardia (heart rate 150 beats/min), hypotensive
c. Bradycardia (heart rate 50 beats/min) with hypotension and syncope Transcutaneous (external noninvasive) cardiac pacing is used during emergencies to treat symptomatic bradycardia (hypotension, altered mental status, angina, pulmonary edema) that has not responded to atropine. This patient is symptomatic.
The patient has been admitted to a critical care unit with a diagnosis of acute myocardial infarction. Suddenly the monitor alarms and the screen shows a flat line. What action should the nurse take first? a. Administer epinephrine by intravenous push. b. Begin chest compressions. c. Check patient for unresponsiveness. d. Defibrillate at 360
c. Check patient for unresponsiveness. The first intervention is to assess unresponsiveness.
Ventricular fibrillation should initially be treated by which of the following? (Select all that apply) a. Administration of amiodarone, followed by defibrillation at 360 J b. Atropine 1 mg, followed by defibrillation at 200 J c. Defibrillation at 200 J with biphasic defibrillation d. Defibrillation at 360 J with monophasic defibrillation e. Dopamine continuous infusion.
c. Defibrillation at 200 J with biphasic defibrillation d. Defibrillation at 360 J with monophasic defibrillation If a biphasic defibrillator is available, use the dose at which that defibrillator has been shown to be effective for terminating VF (typically 120 to 200 J). If the dose is not known, use 200 J. If a monophasic defibrillator is available, use an initial shock of 360 J and use 360 J for subsequent shocks. Dobutamine is used for hypotension not related to hypovolemia. Amiodarone can be used for ventricular fibrillation not responsive to CPR, defibrillation, and vasopressors. Atropine is not used in this situation.
A patient develops frequent ventricular ectopy. The nurse prepares to administer which drug? a. Adenosine b. Atropine c. Lidocaine d. Magnesium
c. Lidocaine Lidocaine is an antidysrhythmic drug that suppresses ventricular ectopic activity.
A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation? a. Emergency tracheostomy and mechanical ventilation b. Mechanical ventilation via an endotracheal tube c. Noninvasive positive-pressure ventilation (NPPV) d. Oxygen at 100% via bag-valve-mask device
c. Noninvasive positive-pressure ventilation (NPPV) Noninvasive measures are often recommended in the initial treatment of the patient with chronic obstructive pulmonary disease to prevent intubation and ventilator dependence. The history of chronic obstructive pulmonary disease increases the risk for ventilator dependence, so noninvasive options are a priority. Bag-valve ventilation with 100% oxygen is not required at this time and could depress the respiratory drive that exists. Emergency tracheostomy is not indicated, as there is no indication of an obstructed airway.
The patient has a transcutaneous pacemaker in place. Pacemaker spikes followed by QRS complexes are noted on the cardiac rhythm strip. To determine if the pacemaker is working, the nurse must do which of the following? a. Obtain a 12-lead electrocardiogram (ECG). b. Call for a pacemaker interrogation. c. Palpate the pulse. d. Run a 2-minute monitor strip for analysis.
c. Palpate the pulse. The electrical and mechanical effectiveness of pacing is assessed. The electrical activity is noted by a pacemaker "spike" that indicates that the pacemaker is initiating electrical activity. The spike is followed by a broad QRS complex. Mechanical activity is noted by palpating a pulse during electrical activity.
Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
c. Respiratory acidosis Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is impaired, which causes respiratory acidosis.
A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min. He receives a dose of morphine sulfate, and his spontaneous respirations decrease to 4 breaths/min. Which acid-base disturbance will likely occur? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
c. Respiratory acidosis The morphine caused respiratory depression. As a result, the frequency and depth of respiration is compromised, which can lead to respiratory acidosis.
During a code, the nurse would place paddles for anterior defibrillation in what locations? a. Second intercostal space, left sternal border and fourth intercostal space, left midclavicular line b. Second intercostal space, right sternal border and fourth intercostal space, left midaxillary line c. Second intercostal space, right sternal border and fifth intercostal space, left midclavicular line d. Fourth intercostal space, right sternal border and fifth intercostal space, left midclavicular line
c. Second intercostal space, right sternal border and fifth intercostal space, left midclavicular line Anterior paddle placement is used most often for defibrillation. In the anterior method, one paddle or adhesive electrode pad is placed at the second intercostal space to the right of the sternum, and the other paddle or adhesive electrode pad is placed at the fifth intercostal space, midaxillary line, to the left of the sternum.
Intrapulmonary shunting refers to a. alveoli that are not perfused. b. blood that is shunted from the left side of the heart to the right and causes heart failure. c. blood that is shunted from the right side of the heart to the left without oxygenation. d. shunting of blood supply to only one lung.
c. blood that is shunted from the right side of the heart to the left without oxygenation. Shunting refers to blood that is not oxygenated in the lungs.
The nurse is assessing the exhaled tidal volume (EVT) in a mechanically ventilated patient. The rationale for this assessment is to a. assess for tension pneumothorax. b. assess the level of positive end-expiratory pressure. c. compare the tidal volume delivered with the tidal volume prescribed. d. determine the patient's work of breathing.
c. compare the tidal volume delivered with the tidal volume prescribed. The EVT is assessed to determine if the patient is receiving the tidal volume that is prescribed. Volume may be lost because of leaks in the ventilator circuit, around the endotracheal tube cuff, or around a chest tube. The assessment will not detect a pneumothorax and does not assess positive end-expiratory pressure or work of breathing.
The basic underlying pathophysiology of acute respiratory distress syndrome results in a. a decrease in the number of white blood cells available. b. damage to the right mainstem bronchus. c. damage to the type II pneumocytes, which produce surfactant. d. decreased capillary permeability.
c. damage to the type II pneumocytes, which produce surfactant. Acute respiratory distress syndrome results in damage to the pneumocytes, increased capillary permeability, and noncardiogenic pulmonary edema.
A strategy for preventing pulmonary embolism in patients at risk who cannot take anticoagulants is a. administration of two aspirin tablets every 4 hours. b. infusion of thrombolytics. c. insertion of a vena cava filter. d. subcutaneous heparin administration every 12 hours.
c. insertion of a vena cava filter. A filter may be inserted as a prevention measure in patients who are at high risk for pulmonary embolism. Aspirin is not a preventive therapy. Thrombolytics are given to treat, not prevent, pulmonary embolism. Heparin is administered as a prophylaxis in acute care settings. Coumadin is given for long-term prevention in patients at high risk for VTE.
A patient's status worsens and needs mechanical ventilation. The pulmonologist wants the patient to receive 10 breaths/min from the ventilator but wants to encourage the patient to breathe spontaneously between the mechanical breaths at his own tidal volume. This mode of ventilation is called a. assist/control ventilation. b. controlled ventilation. c. intermittent mandatory ventilation. d. positive end-expiratory pressure.
c. intermittent mandatory ventilation. The intermittent mandatory ventilation mode allows the patient to breathe spontaneously between breaths. The patient will receive a preset tidal volume at a preset rate. Any additional breaths that he initiates will be at his spontaneous tidal volume, which will likely be lower than the ventilator breaths. In assist/control ventilation, spontaneous effort results in a preset tidal volume delivered by the ventilator. Spontaneous effort during controlled ventilation results in patient/ventilator dyssynchrony. Positive end-expiratory pressure (PEEP) is application of positive pressure to breaths delivered by the ventilator. PEEP is an adjunct to both intermittent mandatory and assist/control ventilation.
The nurse is caring for a patient with an endotracheal tube. The nurse understands that endotracheal suctioning is needed to facilitate removal of secretions and that the procedure a. decreases intracranial pressure. b. depresses the cough reflex. c. is done as indicated by patient assessment. d. is more effective if preceded by saline instillation.
c. is done as indicated by patient assessment. Suctioning is performed as indicated by patient assessment. Suctioning is associated with increases in intracranial pressure; therefore, it is important to hyperoxygenate the patient before suctioning to reduce this complication. Suctioning can stimulate the cough reflex rather than depress this reflex. Saline instillation is associated with negative physiological outcomes and is not recommended as part of the suctioning procedure; it does not loosen secretions, which is a common misperception.
The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The provider prescribes a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the provider of this assessment and anticipates an order for a. continuous lateral rotation therapy. b. guided imagery. c. neuromuscular blockade. d. prone positioning.
c. neuromuscular blockade. Paralysis and additional sedation may be needed if the patient requires nontraditional ventilation. Guided imagery is an excellent nonpharmacological approach to manage anxiety; however, the nontraditional mode of ventilation usually requires that the patient receive neuromuscular blockade. Prone positioning is a treatment for refractory hypoxemia but not indicated to treat this patient, who is restless and appears to be in discomfort. Lateral rotation is not a mode of ventilation; it is used as part of a progressive mobility program for critically ill patients.
The nurse notes that the patient's arterial blood gas levels indicate hypoxemia. The patient is not intubated and has a respiratory rate of 22 breaths/min. The nurse's first intervention to relieve hypoxemia is to: a. call the provider for an emergency intubation procedure. b. obtain an order for bilevel positive airway pressure (BiPAP). c. notify the provider of values and obtain a prescription for oxygen. d. suction secretions from the oropharynx.
c. notify the provider of values and obtain a prescription for oxygen. Oxygen is administered to treat or prevent hypoxemia. Oxygen should be considered a first-line treatment in cases of hypoxemia. Emergency intubation is not warranted at this time. BiPAP may be considered if administration of supplemental oxygen does not correct the hypoxemia. There is no indication that the patient requires suctioning.
The primary mode of action of neuromuscular blocking agents is a. analgesia. b. anticonvulsant. c. paralysis. d. sedation.
c. paralysis. Neuromuscular blocking agents cause respiratory muscle paralysis. They do not have sedative, analgesic, or anticonvulsant effects.
A mode of pressure-targeted ventilation that provides positive pressure to decrease the workload of spontaneous breathing through the endotracheal tube is a. continuous positive airway pressure. b. positive end-expiratory pressure. c. pressure support ventilation. d. T-piece adapter.
c. pressure support ventilation. Pressure support (PS) is a mode of ventilation in which the patient's spontaneous respiratory activity is augmented by the delivery of a preset amount of inspiratory positive pressure. Positive end-expiratory pressure provides positive pressure at end expiration during mechanical breaths, and continuous positive airway pressure provides positive pressure during spontaneous breaths. The T-piece adapter is used to provide oxygen with spontaneous, unassisted breaths.
A definitive diagnosis of pulmonary embolism can be made by a. arterial blood gas (ABG) analysis. b. chest x-ray examination. c. pulmonary angiogram. d. ventilation-perfusion scanning.
c. pulmonary angiogram. The angiogram is one test that can confirm pulmonary embolism. A spiral CT scan is the other definitive test. Both tests have the limitation of not always being able to visualize small emboli in distal vessels. ABG would indicate only hypoxemia and/or acid-base abnormalities. A chest x-ray study is inconclusive. A ventilation-perfusion scan is inconclusive.
When assessing the patient for hypoxemia, the nurse recognizes that an early sign of the effect of hypoxemia on the cardiovascular system is a. heart block. b. restlessness. c. tachycardia. d. tachypnea.
c. tachycardia. Tachycardia can occur as a compensatory mechanism to increase cardiac output and oxygenation. Dysrhythmias may occur; however, they are not an early sign and tend to be premature ventricular contractions. Restlessness is an early neurological sign, whereas tachypnea is an early respiratory sign.
The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the patient to prevent exacerbation by: a. obtaining an appointment for follow-up pulmonary function studies 1 week after discharge. b. limiting activity until the patient is able to climb two flights of stairs. c. taking all asthma medications as prescribed. d. taking medications on a "prn" basis according to symptoms.
c. taking all asthma medications as prescribed. Exacerbation of asthma is often related to not adhering to the therapeutic regimen; patient teaching is essential. Follow-up studies will be determined by the physician. Activity is based on the patient's activity tolerance and is not limited. Medications are taken regularly to avoid exacerbation. Only rescue medications are used on a prn basis.
A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min. He receives a dose of morphine sulfate, and his respirations decrease to 4 breaths/min. What adjustments may need to be made to the patient's ventilator settings? a. Add positive end-expiratory pressure (PEEP). b. Add pressure support. c. Change to assist/control ventilation at a rate of 4 breaths/min. d. Increase the synchronized intermittent mandatory ventilation respiratory rate.
d. Increase the synchronized intermittent mandatory ventilation respiratory rate. The morphine caused respiratory depression. As a result, the frequency and depth of respiration is compromised, which can lead to respiratory acidosis. The respiratory rate on the mechanical ventilator needs to be increased. PEEP is added to improve oxygenation; it does not increase the rate or depth of respirations. Pressure support will not be effective in increasing the rate of spontaneous respiration. Changing to assist/control ventilation is an option; however, the rate needs to be set higher than 4 breaths/min.
A nursing home patient is admitted to the critical care unit with a severe case of pneumonia. No living will or designation of health care surrogate is noted on the chart. In the event this patient needs intubation and/or cardiopulmonary resuscitation, what should be the nurse's action? a. Activate the code team, but initiate a "slow" code. b. Call the nursing home to determine the patient's or family's wishes. c. Code the patient for 5 minutes and then cease efforts. d. Initiate intubation and/or cardiopulmonary resuscitation efforts.
d. Initiate intubation and/or cardiopulmonary resuscitation efforts. In the absence of a written order from a physician to withhold resuscitative measures, resuscitation efforts must be initiated if indicated.
The nurse is caring for a patient whose ventilator settings include 15 cm H2O of positive end-expiratory pressure (PEEP). What complication does the nurse assess the patient for? a. Fluid overload secondary to decreased venous return b. High cardiac index secondary to more efficient ventricular function c. Hypoxemia secondary to prolonged positive pressure at expiration d. Low cardiac output secondary to increased intrathoracic pressure
d. Low cardiac output secondary to increased intrathoracic pressure. Positive end-expiratory pressure, especially at higher levels, can result in a decreased cardiac output and index secondary to increased intrathoracic pressure, which impedes venous return. Fluid overload is not an expected finding. The cardiac index would likely decrease, not increase, along with cardiac output. PEEP is used to treat hypoxemia; it does not cause it.
The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following? a. Antiseptic oral care b. Bed rest with head of bed elevated c. Coughing and deep breathing d. Mobility
d. Mobility Mobility helps to prevent deep vein thrombosis and pulmonary embolus. Oral care, head of bed elevation, and coughing and deep breathing assist in preventing pneumonia.
During a code situation, the nurse would prepare to use which preferred intravenous fluid? a. 5% dextrose in 0.45% normal saline b. 5% dextrose in water c. Dopamine infusion d. Normal saline
d. Normal saline Normal saline is the preferred intravenous fluid during resuscitation efforts because it expands intravascular volume better than infusions containing dextrose.
The provider orders the following mechanical ventilation settings for a patient who weighs 75 kg. The patient's spontaneous respiratory rate is 22 breaths/min. Which arterial blood gas abnormality may occur if the patient continues to be tachypneic at these ventilator settings? Settings: Tidal volume: 600 mL (8 mL per kg) FiO2: 0.5 Respiratory rate: 14 breaths/min Mode assist/control Positive end-expiratory pressure: 10 cm H2O a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
d. Respiratory alkalosis Assist/control ventilation may result in respiratory alkalosis, especially when the patient is breathing at a higher rate that the ventilator rate. Each time the patient initiates a spontaneous breath—in this case 22 times per minute—the ventilator will deliver 600 mL of volume.
The nurse needs to evaluate arterial blood gases before the administration of which drug? a. Calcium chloride b. Magnesium sulfate c. Potassium d. Sodium bicarbonate
d. Sodium bicarbonate Bicarbonate therapy should be guided by the bicarbonate concentration or calculated base deficit from arterial blood gas analysis or laboratory measurement.
The nurse is caring for a mechanically ventilated patient. The providers are considering performing a tracheostomy because the patient is having difficulty weaning from mechanical ventilation. Related to tracheostomy, the nurse understands which of the following? a. Patient outcomes are better if the tracheostomy is done within a week of intubation. b. Percutaneous tracheostomy can be done safely at the bedside by the respiratory therapist. c. Procedures performed in the operating room are associated with fewer complications. d. The greatest risk after a percutaneous tracheostomy is accidental decannulation.
d. The greatest risk after a percutaneous tracheostomy is accidental decannulation. Optimal timing of tracheostomy is not yet known. Percutaneous procedures done at the bedside are not associated with any higher risks than those done in the operating room. Trained physicians safely perform percutaneous tracheostomies at the bedside. The greatest risk for percutaneous tracheostomy is accidental decannulation because the trachea is not surgically attached.
Positive end-expiratory pressure (PEEP) is a mode of ventilatory assistance that produces the following condition: a. Each time the patient initiates a breath, the ventilator delivers a full preset tidal volume. b. For each spontaneous breath taken by the patient, the tidal volume is determined by the patient's ability to generate negative pressure. c. The patient must have a respiratory drive, or no breaths will be delivered. d. There is pressure remaining in the lungs at the end of expiration that is measured in cm H2O.
d. There is pressure remaining in the lungs at the end of expiration that is measured in cm H2O. PEEP is the addition of positive pressure into the airways during expiration. PEEP is measured in centimeters of water.
Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery? a. Aspirin b. Embolectomy c. Heparin d. Thrombolytics
d. Thrombolytics Thrombolytics are useful in the management of pulmonary embolus and are given to dissolve the clot. Heparin will prevent further clot formation, but it will not dissolve the clot. Aspirin is not a thrombolytic agent. An embolectomy is a surgical procedure to remove the clot.
A patient has coronary artery bypass graft surgery and is transported to the surgical intensive care unit at noon and is placed on mechanical ventilation. Interpret the initial arterial blood gas levels pH: 7.31 PaCO2: 48 mm Hg Bicarbonate: 22 mEq/L PaO2: 115 mm Hg O2 saturation: 99% a. Normal arterial blood gas levels with a high oxygen level b. Partly compensated respiratory acidosis; normal oxygen c. Uncompensated metabolic acidosis with high oxygen levels d. Uncompensated respiratory acidosis; hyperoxygenated
d. Uncompensated respiratory acidosis; hyperoxygenated The high PaO2 level reflects hyperoxygenation; the PaCO2 and pH levels show respiratory acidosis. The respiratory acidosis is uncompensated as indicated by a pH of 7.31 (acidosis) and a normal bicarbonate level. No metabolic compensation has occurred.
The nurse is caring for a mechanically ventilated patient and notes the high pressure alarm sounding. The nurse cannot quickly identify the cause of the alarm and notes the patient's oxygen saturation is decreasing and heart rate and respiratory rate are increasing. The nurse's priority action is to a. ask the respiratory therapist to get a new ventilator. b. call the rapid response team to assess the patient. c. continue to find the cause of the alarm and fix it. d. manually ventilate the patient while calling for a respiratory therapist.
d. manually ventilate the patient while calling for a respiratory therapist. The nurse must quickly assess the patient and determine possible causes of the alarm. If the cause is not assessed within seconds, the nurse must manually ventilate the patient and secure assistance in troubleshooting the problem. The patient must be treated while the causes are being assessed by the nurse and respiratory therapist. Continuing to assess for the cause without manually ventilating the patient can result in patient compromise. The respiratory therapist, not the rapid response team, will assess and remedy the problem. A new ventilator may be needed, but that would be determined after the respiratory therapist has assessed the situation.
Pulse oximetry measures a. arterial blood gases. b. hemoglobin values. c. oxygen consumption. d. oxygen saturation.
d. oxygen saturation. Pulse oximetry measures oxygen saturation in the peripheral tissues. It does not measure arterial blood gases, but it does estimate the PaO2 that is obtained via a blood gas analysis. It does not measure hemoglobin levels or oxygen consumption.
The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this diagnosis is to a. elevate the head of the bed to 30 degrees. b. obtain an order for venous thromboembolism prophylaxis. c. provide adequate sedation. d. reposition the patient every 2 hours.
d. reposition the patient every 2 hours. Repositioning the patient will facilitate mobilization of secretions. Elevating the head of bed is an intervention to prevent infection. Venous thromboembolism prophylaxis is ordered to prevent complications of immobility. Sedation is an intervention to manage anxiety, and administration of sedatives increases the risk for retained secretions.
In assessing a patient, the nurse understands that an early sign of hypoxemia is a. clubbing of nail beds. b. cyanosis. c. hypotension. d. restlessness.
d. restlessness. Central nervous system signs, such as restlessness, are early indications of low oxygen levels. Clubbing is a sign of chronic hypoxemia. Cyanosis is a late sign of hypoxemia. Tachycardia and increased blood pressure, not hypotension, may be seen early in hypoxemia.
Current guidelines recommend the oral route for endotracheal intubation. The rationale for this recommendation is that nasotracheal intubation is associated with a greater risk for a. basilar skull fracture. b. cervical hyperextension. c. impaired ability to "mouth" words. d. sinusitis and infection.
d. sinusitis and infection. Nasotracheal intubation is associated with an increased risk for sinusitis, which may contribute to ventilator-associated infection. Nasal intubation is contraindicated in patients with basilar skull fracture. The procedure is sometimes performed in patients with cervical spine injury; the procedure can be done without hyperextending the neck. Patients with nasotracheal tubes are generally more comfortable and have a greater ability to "mouth words."
A patient presents to the emergency department demonstrating agitation and complaining of numbness and tingling in his fingers. His arterial blood gas levels reveal the following: pH 7.51, PaCO2 25, HCO3 25. The nurse interprets these blood gas values as: a. compensated metabolic alkalosis. b. normal values. c. uncompensated respiratory acidosis. d. uncompensated respiratory alkalosis.
d. uncompensated respiratory alkalosis. The low PaCO2 and high pH values show respiratory alkalosis. The bicarbonate level is normal.
The amount of effort needed to maintain a given level of ventilation is termed a. compliance. b. resistance. c. tidal volume. d. work of breathing.
d. work of breathing. Work of breathing is the amount of effort needed to maintain a given level of ventilation. Compliance is a measure of the distensibility, or stretchability, of the lung and chest wall. Resistance refers to the opposition to the flow of gases in the airways. Tidal volume is the volume of air in a typical breath.
