ARDS LIppencott/Priority & New Priority

4 (A client who has been intubated for 10-14 days and still requires mechanical ventilation should have a surgically placed tracheostomy to prevent permanent vocal cord damage. WRONG #1 The client may eventually need a facility that accepts long term ventilator dependent clients, but the nurse would not anticipate this at this time. #2 The client on a vent will have ABGs ordered more often than daily. #3 The stem does not indicate the client is ready to be removed from the ventilator)

**NP R 57) The client in the ICU has been on a ventilator for 2 weeks with an ET tube in place. Which intervention should the nurse prepare the client for next? 1. Transfer to a LTC facility 2. Daily ABGs 3. Remove life support 4. Placement of a tracheostomy

1, 2, 4 ( The experienced LPN/LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/LVN. Independently completing the admission assessment, developing the nursing care plan, and evaluating a patient's abilities require additional education and skills within the scope of practice of the professional RN. Focus: Delegation, supervision)

1. An experienced LPN/LVN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/LVN? (Select all that apply.) 1. Auscultating breath sounds 2. Administering medications via metered-dose inhaler (MDI) 3. Completing in-depth admission assessment 4. Checking oxygen saturation using pulse oximetry 5. Developing the nursing care plan 6. Evaluating the patient's technique for using MDIs

4 ( The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations is urgent. In COPD patients, pulse oximetry oxygen saturations of more than 90% are acceptable. Focus: Prioritization)

15. After change of shift, you are assigned to care for the following patients. Which patient should you assess first? 1. 68-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory 2. 57-year-old with COPD and a pulse oximetry reading from the previous shift of 90% saturation 3. 72-year-old with pneumonia who needs to be started on IV antibiotics 4. 51-year-old with asthma who reports shortness of breath after using a bronchodilator inhaler

3 ( Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized and careful assessment and monitoring after the procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses. Focus: Assignment)

17. The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months of experience) floated from the surgical unit to the medical unit? 1. 58-year-old on airborne precautions for tuberculosis (TB) 2. 65-year-old who just returned from bronchoscopy and biopsy 3. 72-year-old who needs teaching about the use of incentive spirometry 4. 69-year-old with COPD who is ventilator dependent

2 ( For patients with chronic emphysema, the stimulus to breathe is a low serum oxygen level (the normal stimulus is a high carbon dioxide level). This patient's oxygen flow is too high and is causing a high serum oxygen level, which results in a decreased respiratory rate. If you do not intervene, the patient is at risk for respiratory arrest. Crackles, barrel chest, and assumption of a sitting position leaning over the nightstand are common in patients with chronic emphysema. Focus: Prioritization)

2. You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately? 1. Fine bibasilar crackles 2. Respiratory rate of 8 breaths/min 3. The patient sitting up and leaning over the nightstand 4. A large barrel chest

1

22. A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action? 1. Perform endotracheal intubation and initiate mechanical ventilation. 2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth. 3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT). 4. Call a code for respiratory arrest.

3 ( The endotracheal tube should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after endotracheal tube placement. The priority at this time is to verify that the tube has been correctly placed. Focus: Delegation, supervision, prioritization)

23. You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately? 1. Assessing for bilateral breath sounds and symmetrical chest movement 2. Auscultating over the stomach to rule out esophageal intubation 3. Marking the tube 1 cm from where it touches the incisor tooth or nares 4. Ordering a chest radiograph to verify that tube placement is correct

2 ( The UAP's educational preparation includes measuring vital signs, and an experienced UAP would know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN. Focus: Delegation, supervision)

24. You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced UAP? 1. Assessing the patient's respiratory status every 4 hours 2. Taking vital signs and pulse oximetry readings every 4 hours 3. Checking the ventilator settings to make sure they are as prescribed 4. Observing whether the patient's tube needs suctioning every 2 hours

4 ( Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower parts of the respiratory system. Focus: Prioritization)

25. After the respiratory therapist performs suctioning on a patient who is intubated, the UAP measures vital signs for the patient. Which vital sign value should the UAP report to the RN immediately? 1. Heart rate of 98 beats/min 2. Respiratory rate of 24 breaths/min 3. Blood pressure of 168/90 mm Hg 4. Tympanic temperature of 101.4° F (38.6° C)

2 ( Manual ventilation of the patient will allow you to deliver an Fio2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, and/or insertion of an oral airway, but the first step should be assessing the reason for the high-pressure alarm and resolving the hypoxemia. Focus: Prioritization)

27. The high-pressure alarm on a patient's ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next? 1. Reassure the patient that the ventilator will do the work of breathing for him. 2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. 3. Increase the fraction of inspired oxygen (Fio2) on the ventilator to 100% in preparation for endotracheal suctioning. 4. Insert an oral airway to prevent the patient from biting on the endotracheal tube.

4 ( The patient's history and symptoms suggest the development of ARDS, which will require intubation and mechanical ventilation. The maximum oxygen delivery with a nasal cannula is an Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia. Focus: Prioritization)

28. When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, you find that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? 1. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. 2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. 3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. 4. Switch the patient to a nonrebreather mask at 95% to 100% Fio2 and call the physician to discuss the patient's status.

3 ( Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP. Focus: Prioritization)

30. You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? 1. Administer ordered antibiotics as scheduled. 2. Hyperoxygenate the patient before suctioning. 3. Maintain the head of bed at a 30- to 45-degree angle. 4. Suction the airway when coarse crackles are audible.

3 ( When tracheostomy care is performed, a sterile field is set up and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate. Focus: Delegation, supervision)

4. You are supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause you to intervene? 1. Suctioning the tracheostomy tube before performing tracheostomy care 2. Removing old dressings and cleaning off excess secretions 3. Removing the inner cannula and cleaning using standard precautions 4. Replacing the inner cannula and cleaning the stoma site

b (Rationale: Normal levels of oxygen saturation are 95-100%. The client with an O2 level of 62% is not exchanging gases. Heart rate increase is a sign of many disorders and by itself does not signify impaired gas exchange. A respiratory rate of 60 signifies respiratory distress but does not imply impaired gas exchange. Bicarbonate levels are an indication of kidney function. )

A 12-year-old is being treated for acute respiratory distress syndrome. Which assessment finding would be indicative of the nursing diagnosis of impaired gas exchange? a Heart rate of 100 bpm b Oxygen saturation of 62% c Bicarbonate level of 38 mEq/L d Respiratory rate of 60/min

4 (This child is in severe resp distress with the potential for airway complete obstruction. The nurse should refrain from disturbing the child at this time to avoid irritating the epiglottis and causing it to completely obstruct the the childs airway. The child may have to be intubated or undergo a trach. However initially the child should be kept as calm as possible with little disruption as possible. any attempt to restrain the client, draw blood or insert an IV or examine her throat could result in total airway obstruction)

A 3 year old child is brought to the ED in her parents arms. The child mouth is open and she is drooling and lethargic. The parent states the child became ill suddenly within the past 2hrs. What should the nurse do first? 1. Draw blood cultures and CBC 2. Start an IV 3. Inspect the childs throat with a tongue blade 4. Maintain the child in an undisturbed, upright position

1 (manifestations of Adult respiratory distress syndrome ARDS, secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen below 50. The nurse should report the low arterial of 46 to the HCP. A rr of 12 is normal and not considered a sign of respiratory distress. Adventitious lung sounds such as crackles are typically found in clients with ARDS. Oxygen sat of 96% is satisfactory and does not represent hypoxemia or low arterial oxygen saturation)

A client Dx with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the hCP? 1. arterial oxygen level of 46 2. respirations of 12 3. lack of adventitious lung sounds 4. oxygen sat 96% on RA

2,3,4,5 (One of the 5 rights of med admin is "right medication", Cefazolin was not the med prescribed. The pharmacist is a professional resource and serves as a check to ensure the clients receive the right medication. Returning unwanted meds to the pharmacy will decrease the opportunity for a medication error by the nurse who follows the current nurse)

A client has developed a hospital acquired pneumonia. When preparing to administer cephalexin 500 mg, the nurse notices that the pharmacy sent cefazolin. What should the nurse do? SATA 1. administer the cefazolin 2. verify the medication prescription as written 3. contact the pharmacy and speak to the pharmacist 4. request the cephalexin be sent promptly 5. return the cefazolin to the pharmacy

b,c,d (Rationale ​Pancreatitis, systemic​ sepsis, and multiple blood transfusions are causes of indirect injury to the lungs. Smoke inhalation and fat embolisms are causes of direct injury to the lungs.)

A client is experiencing acute respiratory distress syndrome​ (ARDS). The client​'s spouse asks the nurse what caused ARDS. The nurse bases the response on which etiologies of indirect injury to the​ lungs? ​(Select all that​ apply.) a Fat embolism b Systemic sepsis c Multiple blood transfusions d Pancreatitis e Smoke inhalation

a (Rationale: One of the primary alterations occurring with ARDS is the collapse of alveoli, causing loss of ventilation in these areas. Perfusion may be normal, but gas exchange is impaired because of inadequate ventilation. Surfactant production decreases with ARDS, a factor that impairs adequate gas exchange. Air does not become trapped in hyperinflated alveoli in ARDS; instead, alveoli collapse. )

A client who develops acute respiratory distress syndrome (ARDS) is exhibiting hypoxemia that is unresponsive to oxygen therapy. Which concept would the nurse incorporate when explaining the client's condition to the family? a Blood is shunted past alveoli with no ventilation. b Thick secretions block the airways. c The individual has difficulty expelling air trapped in the alveoli. d There is excess surfactant production by the alveoli.

1,4,5 (ARDS may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries, Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidified oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases so the nurse should continue to assess breath sounds. SEdatives should be used with caution in clients with ARDS. The nurse should try other measures to relieve the clients restlessness and anxiety. The HOB should be elevated to 30 degrees to promote chest expansion and prevent atelectasis)

A client with ARDS has fine crackles at lung bases, and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? SATA 1. Monitor serum creatinine and BUN levels 2. Administer a sedative 3. Keep the HOB flat 4. Administer humidified O2 5. Auscultate the lungs

2 (The normal range for PaCO2 is 35-45. Thus the clients PACO2 level is low. The client is experiencing respiratory alkalosis (carbonic acid deficit) due to hyperventilation. The nurse should report this finding to the HCP. because it requires intervention. the increase in ventilation decreases the PaCO2 level, which leads to decreased carbonic acid and alkalosis. The bicarb level is normal in uncompensated respiratory alkalosis along with the normal PaO2 level. Normal serum PH is 7.35-7.45; in uncompensated respiratory alkalosis the serum PH is > 7.45)

A client with ARDS is showing signs of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived; PH 7.35 PaCO2 25 HCO3 22 PaO2 95 Which finding is abnormal? 1. PH 2. PaCO2 3 HCO3 4. PaO2

1 (Normal PaO2 level ranges from 80-100. When PaO2 falls to 50 the nurse should be alert for signs of hypoxia and impending respiratory failure. An O2 level this low poses a severe risk for respiratory failure. The client will require oxygenation at a concentration that maintains the PaO2 at 55-60 or more.)

A client with the following arterial blood gas values: PH 7.52 PaO2 50 PaCO2 28 HCO3 24 Based on the clients PaO2, which conclusion would be accurate? 1. The client is severely hypoxic 2. The O2 level is low but poses no risk for the client 3. The clients PaO2 level is wnl 4. The client requires oxygen therapy with very low O2 concentrations

3 (ABC priority administer high flow o2. WRONG: 1: xray to determine level of injury important, but not priority 2: chest tube insertion prep is important to facilitate lung expansion and restore normal intrapleural pressure but not priority at this time 4: Initiating IV important, but not priority action)

A nurse in the ED is assessing a client who was in a MVA. Findings include absent breath sounds in the L lower lobe, dyspnea, BP 118/68, HR 124 RR 38, T 101.4 (38.6 C) and SaO2 92% on room air. Which of the following actions should the nurse take first? 1. Obtain a chest x ray 2. Prepare for chest tube insertion 3. Admin O2 via high-flow mask 4. Initiate IV access

2 (2: a venturi mask incorporates an adapter that allows a precise amount of oxygen to be delivered. WRONG: 1. a non rebreather mask delivers an approximated amount of oxygen 3: A NC delivers an approximated amount of O2 4: A simple face mask delivers an approximated amount of O2)

A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? 1. non-rebreather mask 2. venturi mask 3. nasal cannula 4. simple face mask

2,5 (2: Pale skin is an early manifestation of hypoxemia. 5: Elevated BP is an early manifestation of hypoxemia. WRONG: 1: Confusion is a LATE sign 3. Bradycardia is a LATE sign 4: Hypotension is a LATE sign)

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? SATA 1. Confusion 2. Pale skin 3. Bradycardia 4. Hypotension 5. Elevated BP

4 (4: The nurse should assess the breath sounds of a client on mechanical ventilation every 1-2 hours. WRONG: 1: The nurse should apply soft wrist restraints to prevent self-extubation according to facility policies 2: The nurse should monitor ventilator settings hourly 3: The nurse should document tube placement in centimeters at the clients teeth or lips)

A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? 1. Apply a vest restraint if self extubation is attempted 2. Monitor ventilator settings every 8 hrs 3. Document tube placement in centimeters at the angle of the jaw 4. Assess breath sounds every 1-2 hours

2 (2: Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease o2 consumption. WRONG: 1: antibiotics treat infection 3. corticosteroids treat inflammation 4: benzodiazepines treat anxiety)

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has ARDS. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? 1. This medication is given to treat infection 2. This medication is given to facilitate ventilation 3. This medication is given to decrease inflammation 4. This medication is given to reduce anxiety

2 (2: PSV allows preset pressure delivered during spontaneous ventilation to decrease the work of breathing. WRONG: 1: PEEP maintains pressure in the lungs to keep alveoli open or prevent atelectasis 3: PSV does NOT guarantee minimal minute ventilation because no ventilator breaths are delivered 4. Assist-control (AC) mode delivers a preset ventilatory rate and tidal volume to the client)

A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates an understanding of PSV? 1. It keeps the alveoli open and prevents atelectasis 2. It allows preset pressure delivered during spontaneous respiration 3. It guarantees minimal minute ventilator 4. It delivers a preset ventilatory rate and Tidal volume to the client

2,3,4 (2: Synchronized intermittent mandatory ventilation requires that the client generate force to take spontaneous breaths. 3: CPAP requires the client generates force to take spontaneous breaths 4: Pressure support ventilation requires that the client generate force to take spontaneous breaths WRONG: 1: Assist-control takes over the work of breathing 5: Independent lung ventilation mode is used for unilateral lung disease to ventilate the lung individually)

A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation increases the effort of the clients respiratory muscles should the nurse include in the plan of care? SATA 1. Assist-control 2. Synchronized intermittent mandatory ventilation 3. Continuous positive airway pressure 4. Pressure support ventilation 5. Independent lung ventilation

1 3 4 2 (Because two major complications of endotracheal tube intubation, inadvertent extubation and aspiration, can be catastrophic events, assessment of this client is a first priority. Cellulitis is a serious infection as there is inflammation of SC tissues; third spacing of fluid may promote the formation of a FVD, which can be exacerbated by the fever due to insensible water loss. The nurse should assess this client to determine the current VS and fluid status. The nurse should assess the client with the IV fluids next because the new bag of fluids will need to be hung within 30-40 mins. IV therapy necessitates that the client be assessed for s/s of adequate hydration; moist mucous membranes, skin turgor, VS wnl, adequate urine output, and LOC wnl; and the IV access site needs to be assessed. From the info provided there is no indication that the client who had the CVA is unstable. Thus this client is last priority)

A nurse receives the taped change of shift report for assigned clients and prioritizes the client rounds. In what order from first to last should the nurse assess the clients? 1. A client who has an endotracheal tube and who will be transferred to a long term respiratory therapy care unit that day 2. A client with Type 2 diabetes who had a CVA 4 days ago 3. A client with cellulitis of the LLE with a fever of 100.8 4. A client receiving D5W IV at 125 mL/hr with 75 mL remaining

2 (The nurse should use mechanical force, back slaps and chest thrusts in an attempt to dislodge the object. Blind finger sweeps are not appropriate in infants and children. Subdiaphragmatic abdominal thrusts are not used for infants aged 1 year or younger because of risk to abd organs. If the object is not visible when opening the mouth, time is wasted in looking for it. Action is required to dislodge the object as quickly as possible,)

A nurse walks into the room just as a 10 month old infant places an object into his mouth and starts to choke. AFter opening the infants mouth, which should the nurse do next to clear the airway? 1 use blind finger sweeps 2. deliver back slaps and chest thrusts 3. apply 4 subdiaphragmatic abdominal thrusts 4. attempt to visualize the object

b (Rationale: The client with ARDS is at risk for developing multiorgan system failure related to ineffective tissue oxygenation, including kidney failure, liver failure, gastrointestinal failure, central nervous system failure, and cardiovascular failure. Blood clots, vision loss, and hearing impairment are not hallmarks of ARDS or multiorgan system failure)

An 82-year old client with an acute lung injury has developed acute respiratory distress syndrome (ARDS). The nurse monitors the client carefully for which complication of ARDS? a Vision loss b Multiorgan system failure c Blood clots d Hearing impairment

3 (To maintain the best perfusion it is recommended that compressions be given at a rate of 100 per minute in a ration of 30:3 for 1 rescuer CPR. Children are still more likely to have respiratory arrest than a cardiac arrest and are more likely to respond to opening the airway and rescue breaths. Therefore it is recommended that unless the collapse was witnessed a sole rescuer should attempt 5 cycles of CPR before leaving to call for help. Using 2-3 fingers for chest compressions is recommended for INFANT CPR only. Abdominal thrusts are no longer recommended for unconscious victims)

As part of a health education program the nurse teaches a group of parents CPR. The nurse determines that the teaching had been effective when a parent states: 1. If I am by myself I should call for help before starting CPR 2. I should compress a child chest using 2-3 fingers 3. I should deliver chest compression at a rate of 100 per min 4. If I cannot get the breaths to make the chest rise, I should administer abdominal thrusts

c (Rationale: Increased respiratory rate, tachycardia, and agitation are all early signs of respiratory distress. Cyanosis develops later in the progression of respiratory distress.)

In a client with respiratory distress, which observation by the nurse manifests a worsening clinical state? a Increased respiratory rate b Agitation c Cyanosis dTachycardia

4 (A PT/PTT will assess the client for any bleeding tendencies. This is priority before the surgery because bleeding is life threatening. WRONG #2 The client has ALREADY been dx with tonsillitis therefore culture not needed prior to surgery. #3 The client should NOT cough after this surgery because it could cause bleeding from the incision site. #1 The guardian must sign consent, not the teen)

NP 28 R) The clinic nurse is scheduling a 14 year old for a tonsillectomy. Which intervention should the nurse implement? 1 Obtain informed consent from the client 2. Send a throat culture to the lab 3. Discuss the need to cough and deep breathe 4. Request the lab draw a PT and PTT

3 (This client is stable and should be assigned to the new grad. orange colored urine is secondary to rifampin. WRONG: #1 Pain needs more experienced nurse, the rust colored sputum expected with lung cancer. #2 The client with atelectasis (collapsed lung) is having difficulty breathing needs a more experienced nurse to assess the client, this client is not stable. Wrong #4 The client is exhibiting respiratory compromise, the pulse ox should be greater than 93% and the CRT should be less than 3 seconds)

NP 3) Which client should the charge nurse assign to the new grad on the respiratory unit? 1. The client dx with lung cancer with rust colored sputum and chest pain on a scale of 1-10 2. The client dx with atelectasis who is having SOB and difficulty breathing 3. The client dx with TB who has a non productive cough and orange colored urine 4. The client dx with pneumonia who has a pulse oximeter reading of 91% and has a CRT >3 seconds

3 (A 24 week gestational woman with a BP of 142/96 would warrant intervention because the avg should be 90-140/60-85. This could indicate PIH. WRONG #4 elevated but not warrant nursing intervention. #1 Normal HR for 11 month old is 100-150. #2 Norm RR for a toddler is 20-30.)

NP 30 R) The clinic nurse is evaluating VS for clients being seen in the outpatien clinic. Which client would require nursing intervention? 1. The 10 month old infant who has a HR of 140 2. The 3 year old toddler who has RR 28 3. The 24 week gestation woman with a BP 142/96 4. The 42 year old who has a T 100.2

1 (The norm hgb level is 12 to 15. and norm hct is 39% to 45%. This clients H/H is low. Contact the client and make an appt. WRONG: #2 Norm WBC 4-10. #3 Norm K 3.5-5.5 #4 Norm Na 135-145)

NP 32 R) The clinic nurse is reviewing lab result for a client seen in the clinic Which client requires additional assessment by the nurse? 1. The client with a H/H 9 and 29% 2. The client with WBC 9 3. The client who has K 4.8 4. The client who has Ns 137

3 (The nurse must first determine whether the pain is expected for the clients condition or whether the client is experiencing a complication requiring nursing or medical intervention. This is the FIRST intervention. WRONG: #1 Documenting is not first. #2 Taking slow deep breaths will not address the pain of 6 #4 The nurse must check the MAR when it is determined the pain is expected and requires pain medication, it is not the first intervention)

NP CS 8) The client with a right sided chest tube is complaining of pain rated 6 on a 1-10 scale. Which intervention should the nurse implement first? 1 Document the clients pain in the nurses notes 2. Instruct the client to take slow, deep breaths and exhale slowly 3. Assess the clients respiratory status and chest tube insertion site 4. Check the clients MAR to determine when the last pain medication was administered

1,4,5 (1 The client should be in High Fowlers to facilitate lung expansion 4 The tubing should not have any dependent loops. Looping the tube prevents direct pressure on the chest tube itself and keeps tubing off the floor, addressing both safety and infection control issues. #5 The collection chamber of the Pleuravac should be marked at the end of every shift and is part of the total output of the client. WRONG: #2 The system must be patent and intact to function properly but it should be assessed more often then every shift. It should be assessed every 2-4 hrs. #3 The client can have bathroom privileges, and ambulation facilitates lung ventilation and expansion.)

NP CS R9) Care of the client with R sided chest tube, secondary to pneumothorax with a grad nurse. Which interventions should be discussed with the grad nurse? 1. Place the client in high fowlers 2. Assess the chest tube drainage system each shift 3. Maintain strict bed rest for the client 4. Ensure the tubing has no dependent loops 5. Mark the collection chamber for drainage every shift

3 (The client is having respiratory distress and the ventilator is sounding the alarm; therefore, the nurse should first assess the ventilator to determine the cause of the problem and correct it because the client is totally dependent on the ventilator for breathing. This is one of the few situations wherein the nurse would assess the equipment before assessing the client. WRONG: #1 The nurse must first address the clients acute resp distress and then notify others of the team. #2 If the ventilator system malfunctions the nurse must ventilate the client with a manual resuscitation bag (Ambu) until the problem is resolved. The nurse must first assess whether the nurse can remedy the situation by assessing the ventilator before beginning the manual ventilations. #4 In MOST situations assessing the client is the first intervention, but because the client is TOTALLY dependent on the ventilatory for breathing, the nurse should first assess the ventilator to determine the cause of the alarms)

NP R 10) The ICU nurse is caring for a client on a ventilator who is exhibiting respiratory distress The ventilator alarms are going off. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately 2. Ventilate with a manual resuscitation bag 3. Check the ventilator to resolve the problem 4. Auscultate the clients lung sounds

3 (The ABG shows respiratory ALKALOSIS; therefore the nurse should assess this client first to determine if the client is hyperventilating, in pain, or has an elevated temp. WRONG: #1 Although these ABGs are abnormal, ABG values respiratory acidosis, they are expected in client with COPD, therefore not the client to see first. #2 The Client with ARDS would be expected to have a low arterial oxygen level therefore, the nurse would not assess this client first #4 These are normal ABGs )

NP R 11) The charge nurse on the respiratory unit is evaluating arterial blood gas (ABG) values of several clients. Which client would require immediate intervention by the charge nurse? 1. The client with COPD who has a PH 7.34, PaO2 70, PaCo2 55, HCo3 26 2. The client with Adult respiratory Distress Syndrome who has a PH 7.35, PaO2 75, PaCo2 50, HCo3 26 3. The client with reactive airway disease with a PH 7.48, PaO2 80, PaCo2 30, HCo3 23 4. The client with pneumothorax with a PH 7.41, PaO2 98, PaCo2 43, HCo3 25

2 (The client who is exhibiitng air hunger indicates respiratory distress; therefore a tracheostomy tray should be obtained first. WRONG: #1 changing the dressing is not priority, #3, transcribing order is not more important. #4 The client needs calmed who is angry but is not priority)

NP R 12) The primary nurse in the critical care respiratory unit is very busy. Which nursing task should be the nurses priority? 1. Assist the HCP with a sterile dressing change for a client with a L pneumonectomy 2. Obtain a trach tray for a client exhibiting air hunger 3. Transcribe orders for a client with cystic fibrosis who was transferred from the ED 4. Assess the client dx with mesothelioma who is upset, angry and crying

2 (After 3 days the nurse should assess the lung sounds to determine whether the lungs have re-expanded. This would be the nurses first intervention. WRONG: #1 dependent loops wont cause this. #3 This will be done if it is determined the lungs have re expanded, but is not first intervention. #4 The nurse should notify the HCP if the lungs re expand, a chest x ray can be taken prior to removing the tubes)

NP R 13) The nurse is caring for a client dx with flail chest who has a chest tube for 3 days. The nurse notes there is no tidaling in the water-seal compartment. Which initial action should be taken by the nurse? 1. Check the tubing for any dependent loops 2. Auscultate the clients posterior breath sounds 3. Prepare to move the clients chest tubes 4. Notify the HCP that the lungs have re-expanded

2 (The nurse should first determine why there is no tidaling in the water-seal chamber. Since the client just had the chest tubes inserted it is probably a kink or dependent loop, or the client is lying on the tubing. The nurse should first check this prior to any other action.)

NP R 14) The client with R sided pneumothorax had chest tubes inserted 2 hrs ago. There is no fluctuation in the water seal chamber of the Pleurovac. Which intervention should the nurse implement first? 1. Assess the clients lung sounds 2. Check for any kinks in the tubing 3. Ask the client to take deep breaths 4. Turn the client from side to side

2 (The client with ARDS is expected to have difficulty breathing but of these four clients, the client with breathing difficulty has priority. ARDS is sudden failure of the respiratory system, A person with ARDS has very rapid breathing, difficulty getting enough air into the lungs and low blood oxygen levels. WRONG: #1 histoplasmosis expected to have excessive sweating and neck stiffness, its an infection of the lungs caused by inhaling the spores of fungus. #3 pulmonary sarcoidosis expected to have dry cough and mild chest pain; in pulmonary sarcoidosis small patches of inflamed cells can appear on the lungs small alveoli, bronchioles or lymph nodes, The lungs become stiff and may not hold as much air as a healthy lung. #4 asbestosis, expect productive cough and chest tightness, it is a disease that involves scarring of lung tissue as a result of breathing in asbestos fibers)

NP R 15) Which client requires the immediate attention of the ICU nurse? 1. The client with histoplasmosis who is having excessive diaphoresis and neck stiffness 2. The client with ARDS who has difficulty breathing 3. The client with pulmonary sarcoidosis who has a dry cough and mild chest pain 4. The client with asbestosis who has a productive cough and chest tightness

1,3,4,5 (There must be a manual resuscitation bag at the bedside in case the ventilator does not work appropriately. The nurse must use this to bag the client. The clients Resp status should be assessed freq. q2h The ventilator settings should be monitored throughout the shift. The respiratory therapist is a member of the team who is responsible for ventilators. WRONG: #2 The pulse oximeter reading should be done more often the every shift)

NP R 16) The client in the ICU is on a ventilator. Which interventions should the nurse implement? SATA 1. Ensure there is a manual resuscitation bag at the bedside 2. Monitor the clients pulse ox reading every shift 3. Assess the clients respiratory status every 2 hrs 4. Check the ventilator settings every 4 hrs 5. Collaborate with the respiratory therapist

4 (Praise is part of evaluation of the UAP This is the correct technique for bathing a client, the bed should be at a comfortable height for the UAP. All clients should be bathed)

NP R 17) The UAP is bathing the client dx with adult acute respiratory distress syndrome (ARDS) who is on a ventilator. The bed is in the high position with the opposite side rail elevated. Which action should the ICU nurse take? 1. Demonstrate the correct technique when giving a bed bath 2. Encourage the UAP to put the bed in the lowest position 3. Explain that the client on a ventilator should not be bathed 4. Give the UAP praise for performing the bath safely

3 (The ABG indicates metabolic alkalosis, which could be caused by too much hydrochloric acid being removed via the NG tube Therefore the nurse should check the NG wall section. )

NP R 19) The client dx with abdominal pain of unknown etiology has a NG tube draining green bile and reports abd pain of 8 on 0-10 scale. The clients ABG values are PH 7.48, PaO2 98, PaCo2 36, HCO3 28. Which intervention should the nurse implement based on the clients ABGS? 1. Assess the client to rule out complications secondary to the clients pain 2. Determine the last time the client was medicated for abd pain 3. Check the amt of suction in the clients NG tube 4. Admin the IV HCO3 to the client

a (Rationale A tracheostomy is used for​ long-term airway management. An oropharyngeal airway keeps the airway​ open, but it is not used for​ long-term airway management. A nasopharyngeal airway is not used for​ long-term airway management because it needs to be repositioned every 8 hours to prevent necrosis of the mucosa. An endotracheal​ airway, although the most commonly used​ airway, is not used for​ long-term airway management.)

The nurse is caring for a client with acute respiratory distress syndrome​ (ARDS) who needs an artificial airway to assist in maintaining an open airway. Which airway can the nurse anticipate being placed for​ long-term management? a Tracheostomy b Nasopharyngeal c Oropharyngeal d Endotracheal

3 (The float nurse from the medical unit is able to administer antibiotic therapy and complete respiratory assessments, therefore this client would be the most appropriate to assign to the float. WRONG: #1 this client is critical and possibility of organ rejection. #2 Normal CVP is 4-10 and an elevated CVP indicates R ventricular failure or volume overload therefore this client should not be assigned to a float nurse. #4 Hantavirus is a disease that results from a virus from rodent dropping, no specific treatment for this.)

NP R 20) The charge nurse in the ICU asks a nurse to float from the medical surgical unit to the ICU. Which client should the charge nurse assign to the float nurse? 1. The client who is 3 hrs postop lung transplant 2. The client with a CVP of 13 3. The client dx with bacterial pneumonia 4. The client dx with Hantavirus pulmonary syndrom

1 (The clients PaO2 is below the normal 80-100; therefore the nurse should administer oxygen. WRONG: #2 The client should take deep breaths if the clients PaCO2 is greater than 45. #3 The nurse should administer HCO3 if the clients HCO3 is less than 22. #4 The client needs oxygen due to the low arterial oxygen level, the client does not need a respiratory assessment)

NP R 21) The client has ABGs of PH 7.38, PaO2 40, HcO3 24, Which intervention should the critical care nurse implement? 1. Admin oxygen 6 L/min via NC 2. Encourage the client to take deep breaths 3. Admin IV HCO3 4. Assess the clients respiratory status

1 (The elderly client should be called first so the nurse can determine whether the dizziness is from meds or other reason, orthostatic hypotension can be life threatening, therefore, this client may need to be assessed immed. )

NP R 24, The clinic nurse is returning phone messages from clients. Which phone message should the nurse return first? 1. The elderly client with pneumonia who reports being dizzy when getting up 2. The client with cystic fibrosis who needs a prescription for pancreatic enzymes 3. The client with lung cancer on chemotherapy who reports nausea 4. The client with pertussis who reports coughing spells so severe they cause V

3 4 1 5 2 (3. The nurse needs to determine if the client is unresponsive prior to action 4 The AHA recommends 30 compressions follow with 2 breaths 1 After compressions, open the airway to ensure patent airway 5 The client should admin two breaths while the clients nose is pinched 2. The nurse then must determine whether the clients heart is pumping by checking carotid pulse)

NP R 34 The clinic nurse encounters a client who does not respond to verbal stimuli and initiates CPR. What should the nurse do? Prioritize actions from first to last. 1. Open the clients airway 2. Check the carotid pulse 3. Assess the client for unresponsiveness 4. Perform compressions at 30:2 5. Pinch the nose and give two breaths

1,4 (oxygen cant be delegated, considered a medication. And the housekeeping can empty the trashcans not the UAP)

NP R 4) Which tasks are appropriate to assign to the UAP? SATA 1. Perform mouth care on the client with pneumonia 2. Apply oxygen via nasal cannula to the client 3. Empty the trashcans in the clients rooms 4. Take the empty blood bag to the laboratory 5. Show the client how to ambulate on the walker

3 (One of the guidelines for admission to a hospice agency is a terminal process with expectancy of 6 months or less)

NP R 41) The client has just been told a medical condition cannot be treated and the client has a life expectancy of about 6 months. To whom should the nurse refer the client at this time? 1 Home health nurse 2. clients pastor 3 a hospice agency 4. the social worker

1 4 3 2 5 (1. The nurse should begin the care by assessing the client. REmember the nursing process. 4. The nurse hsould have the clients chest and dressing exposed and check to make sure the tube is securely taped at this time 3. The nurse then follows the chest tube to the drainage system and assesses the system 2 The last part of the chest tube drainage system to assess is the suction system 5. The nurse should make sure that emergency supplies are at the bedside last)

NP R 47) The nurse is caring for a client who has a chest tube. What should the nurse do ? PRioritize in order first to last 1. Assess the clients lung sounds 2. note the amount of suction being used 3. Check the chest tube for drainage 4. make sure the chest tube is securely taped 5. Place a bottle of sterile saline at the bedside

1 (Elderly clients with pneumonia may not have "normal" symptoms such as fever. The restlessness may indicate a decrease in oxygen to the brain. This client should be seen first. WRONG: #2 influenza would be expected to have elevated temp and headache. #3 Tidaling in the water seal is expected #4 Sinus drainage expected)

NP R 5) Which client should the nurse assess first after receiving report? 1. The 84 year old with pneumonia who is afebrile but getting restless 2. The 25 year old client dx with influenza who is febrile with a headache 3. The 56 year old client dx with L sided hemothorax with tidaling in the water seal compartment of the Pleurvac 4. The 38 year old client dx with a sinus infection who has green drainage from the nose

1 (Do no harm, letting the client know concern is heard but does not give the client bad news before surgery. Someone having surgery should be of sound mind and a dead child is horrific)

NP R 52) The client involved in a MVA is being prepped for surgery and asks the ED nurse, "What happened to my child?" The nurse knows the child is dead. Which statement is an example of the ethical principle of nonmalfeasance? 1. I will find out for you and let you know after surgery 2. I am sorry but your child died at the scene 3. you should concentrate on your surgery right now 4. You are concerned about your child. Would you like to talk?

1 (The ventilator should be checked to determine which alarm is sounding. This is the first step in assessing the clients problem. WRONG: #2 The nurse should assess the vent first and then notify the RT if needed. #3 The client should be assessed but the ventilator may require only a simple adjustment to fix the problem and turn off the alarm. This is one instance in which the nurse should assess the machine prior to assessing the client because the machine is breathing for the client. #4 The client should be manually ventilated if the nurse cannot determine the cause of the ventilator alarm)

NP R 61 ) While the nurse is caring for a client on a ventilator the ventilator alarm sounds. What is the first action taken by the nurse? 1. Silence the ventilator alarm 2. notify the respiratory therapist 3 Assess the clients respiratory status 4 Ventilate the client using a manual resuscitation bag

1 (Acute respiratory distress syndrome is dx when the client has an arterial blood gas of less than 50% while receiving oxygen at 10 LPM. The nurse should prepare the client to be intubated. WRONG: #2 The nurse should intervene while the client is breathing by calling the HCP and assisting in the intubation and setup of the mechanical ventilator. If the client has an arrest before this can be arranged, the client would be ventilated with a bag/mask #3 If the nurse does not intervene immed an arrest situation will occur at which time a Code Blue would be called and CPR started. #4 If the client does not have a patent IV the nurse should start one, but not before preparing for intubation)

NP R 62) The client DX with ARDS is having increased difficulty breathing. The ABG indicates an arterial oxygen level of 54% on O2 at 10L/min. Which intervention should the ICU nurse implement first? 1. PRepare the client for intubation 2. Bag the client with a bag/mask device 3. Call a code blue and initiate CPR 4. Start an IV with an 18 gauge catheter

1 (These blood gases indicate resp acidosis that could be caused by ineffective cough, with resulting air trapping. The nurse should encourage the client to turn cough and deep breathe WRONG: #2 The PaO2 level is wnl (80-100) Administering oxygen is not the first intervention. #3 The nurse knows the ABG level which is an accurate test. The pulse ox only provides an approx level. #4 This is not the first intervention The nurse can intervene to treat the client before notifying the HCP.)

NP R 63) The clients ABG results are PH 7.34, PaCo2 50, Hco3 24 ,PaO2 87. Which intervention should the nurse implement first? 1. Have the client turn cough and deep breathe 2. Place the client on O2 via NC 3. Check the clients pulse oximeter reading 4. Notify the HCP of the ABG results

3,5 (3 This clients status is uncertain. The ICU nurse would be an appropriate assignment for this client since the client will be moved to the ICU soon 5. The ICU nurse should care for the client requiring titration of multiple medications simultaneously. WRONG: #1 This client is nearing discharge, post op clients progress rapidly A med surg nurse could take care of this client. #2 Chest tubes are freq cared for on a med surg unit. The med surg nurse can care for this client. #4 A med surg nurse can care for this client.)

NP R 65) The charge nurse of the respiratory care unit is making shift assignments. Which clients should be assigned to the ICU nurse who is working on the respiratory care unit for the day? SELECT ALL THAT APPLY 1. The client who had 4 coronary artery bypass grafts 3 days ago 2. The client who has anterior and posterior chest tubes after a MVA 3. The client who will be moved to ICU when a bed is available 4. The client who has a DNR and is requesting to see the chaplain 5. The client on multiple IVs that need titration

1 (This position allows for access to the clients back area. The chest tube for a hemothorax is positioned low and posterior to allow for gravity to assist in the removal of fluid from the thoracic area. WRONG #2 This is the position for giving an enema. #3 This is for a lumbar puncture. #4 this is for resting not placement)

NP R 66) The ED nurse is preparing to assist the surgeon to insert chest tubes in a client with hemothorax. Which position is appropriate for this procedure? 1. have the client sit upright and bend over the bed table 2. Place the client in L lateral recumbent position 3. Have the client sit on the side of the bed with back arched like a cat 4 Place the client lying on the back with the HOB at 45 degrees.

4 (A client scheduled for bronchoscopy is stable and should be assigned to the LPN. This client is the most stable and least critical. WRONG: #1 The client suspected of having ARDS is not stable and should not be assigned to an LPN. A more experienced nurse should be assigned this client. #2 The LPN cannot administer blood, therefore this client should not be assigned to the LPN. #3 JVD and hypotension are signs of tension pneumothorax which is a medical emergency, and the client should be assigned to an RN)

NPCS R 10) Ms. Gail is making client assignment. Which client should Ms Gail asign to the LPN? 1. The client who is suspected of having ARDS 2 The client with a hemothorax who needs 2 units of blood 3. The client with chest tubes who has JVD and a BP of 96/60 4. The client who is scheduled for a bronchoscopy to R/O lung cancer

1 (The client needs oxygen to help perfuse the lungs, heart and body; therefore this is the first intervention to implement WRONG: #2 The client will need a vent/perf scan to confirm the dx of PE but its not first, #3 The nurse will notify the HCP but not prior to taking care of the client. #4 Assessing is indicated, but is not the first intervention in this situation. If the client is IN DISTRESS do not assess TAKE ACTION)

NPCS R 7) The client is getting out of bed, becomes very anxious and has a feeling of impending doom Which intervention should the nurse implement first after placing the client in high fowlers position? 1. Admin O2 via nc 2. Prepare the client for ventilation/perfusion scan 3. Notify the HCP 4 Auscultate the clients lung sounds

4 ( The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations is urgent. In COPD patients, pulse oximetry oxygen saturations of more than 90% are acceptable. Focus: Prioritization)

P R 15) After change of shift, you are assigned to care for the following patients. Which patient should you assess first? 1. 68-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory 2. 57-year-old with COPD and a pulse oximetry reading from the previous shift of 90% saturation 3. 72-year-old with pneumonia who needs to be started on IV antibiotics 4. 51-year-old with asthma who reports shortness of breath after using a bronchodilator inhaler

1 ( A nonrebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing. Focus: Prioritization)

P R 22)A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action? 1. Perform endotracheal intubation and initiate mechanical ventilation. 2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth. 3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT). 4. Call a code for respiratory arrest.

3 ( The endotracheal tube should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after endotracheal tube placement. The priority at this time is to verify that the tube has been correctly placed. Focus: Delegation, supervision, prioritization)

P R 23) You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately? 1. Assessing for bilateral breath sounds and symmetrical chest movement 2. Auscultating over the stomach to rule out esophageal intubation 3. Marking the tube 1 cm from where it touches the incisor tooth or nares 4. Ordering a chest radiograph to verify that tube placement is correct

2 ( The UAP's educational preparation includes measuring vital signs, and an experienced UAP would know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN. Focus: Delegation, supervision)

P R 24) You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced UAP? 1. Assessing the patient's respiratory status every 4 hours 2. Taking vital signs and pulse oximetry readings every 4 hours 3. Checking the ventilator settings to make sure they are as prescribed 4. Observing whether the patient's tube needs suctioning every 2 hours

4 ( Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower parts of the respiratory system. Focus: Prioritization)

P R 25) After the respiratory therapist performs suctioning on a patient who is intubated, the UAP measures vital signs for the patient. Which vital sign value should the UAP report to the RN immediately? 1. Heart rate of 98 beats/min 2. Respiratory rate of 24 breaths/min 3. Blood pressure of 168/90 mm Hg 4. Tympanic temperature of 101.4° F (38.6° C)

2 ( Manual ventilation of the patient will allow you to deliver an Fio2 of 100% to the patient while you attempt to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, and/or insertion of an oral airway, but the first step should be assessing the reason for the high-pressure alarm and resolving the hypoxemia. Focus: Prioritization)

P R 27) The high-pressure alarm on a patient's ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next? 1. Reassure the patient that the ventilator will do the work of breathing for him. 2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. 3. Increase the fraction of inspired oxygen (Fio2) on the ventilator to 100% in preparation for endotracheal suctioning. 4. Insert an oral airway to prevent the patient from biting on the endotracheal tube.

4 ( The patient's history and symptoms suggest the development of ARDS, which will require intubation and mechanical ventilation. The maximum oxygen delivery with a nasal cannula is an Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia. Focus: Prioritization)

P R 28) When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, you find that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? 1. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. 2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. 3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. 4. Switch the patient to a nonrebreather mask at 95% to 100% Fio2 and call the physician to discuss the patient's status.

3 ( Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP. Focus: Prioritization)

P R 30) You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? 1. Administer ordered antibiotics as scheduled. 2. Hyperoxygenate the patient before suctioning. 3. Maintain the head of bed at a 30- to 45-degree angle. 4. Suction the airway when coarse crackles are audible.

1 (The client may be fighting the ventilator breaths. SEdation is indicated to improve compliance with the ventilator in an attempt to lower peak inspiratory pressures. The workload of breathing does indicate the need for increased protein calories; however, this will not correct the respiratory problem with high pressures and respiratory rate. There is no indication the client is experiencing pain. Increasing the rate on the ventilator is not indicated with the clients increased spontaneous rate)

The client with ARDS is on a ventilator. The clients peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR technique for communication, the nurse calls the HCP with the recommendation for : 1. initiating IV sedation 2. starting a high protein diet 3. providing pain medication 4. increasing the ventilator rate

2 3 1 4 (The nurse should first assess the clients respiratory status to determine if there is a physiological reason for the clients confusion. Other physiological factors to assess include pain and elimination. Safety needs including medication interactions should then be evaluated. Requesting restraints in order to maintain client safety should be used as a last resort)

The nurse is caring for a client with pneumonia who is confused about time and place and has IV fluid infusing. Despite the nurses attempt to reorient the client and then provide distraction, the client has begun to pull at the IV tubing. AFter increasing the frequency of observation, in which order should the nurse implement interventions to ensure the clients safety? 1. review the clients medications for interactions that may cause or increase confusion 2. assess the clients respiratory status including o2 sat. 3. Ensure the client does not need toileting or pain meds 4. contact the HCP and request a prescription for soft wrist restraints

1 2 4 3 (The elderly client with elevated temp, pneumonia, and SOB is the most acutely ill client and should be the highest priority. The elevated temp and shortness of breath can lead to a decrease in O2 levels and can predispose the client to dehydration and confusion. Then the nurse should assess the client with pain and admin meds needed. The client with emphysema should be the next priority so that the bronchodilator can be administered on schedule as close as possible. The nurse would then assess the client with suspected TB and cough )

The nurse assignment consists of 4 clients. After receiving report, in which order from first to last should then nurse assess these clients? 1. an 85 year old with bacterial pneumonia, temp of 102.2 and shortness of breath 2. A 60 year old with chest tubes who is 2 days post op following a thoracotomy for lung cancer requesting something for pain 3. A 35 year old with suspected TB who has a cough 4. A 56 year old with emphysema who has a scheduled dose of a bronchodilator due to be administered with no report of acute respiratory distress

3 (CPR is done on children for a HR of less than 60 with signs of poor perfusion. rescuers should use a 15:2 compression to ventilation ratio for 2 person CPR for a child. Breaths without compression are indicated only for respiratory arrests where the HR remains above 60. The AED should be used as soon as it is ready, but rescuers should not DC compressions until the device is ready for use. The ratio for adult CPR is 30:2)

The nurse begins CPR on a 5 year old unresponsive child. When the emergency response team arrives the child continues to have no respiratory effort but has a HR of 50 with cyanotic legs What should the team do next? 1. DC compressions, but continue to administer breaths with a bag mask device 2. Establish an IV line with a large bore needle while preparing the defibrillator 3. Begin a 2 person CPR at a ratio of 2 breaths to 15 compressions 4. Begin 2 person CPR at a ration of 2 breaths to 30 compressions

c (Rationale: Patent airways are necessary to maintain effective alveolar ventilation and gas exchange. Keeping the client in a supine position does not promote a patent airway. If the airway is full of secretions, increasing tidal volume and maintaining oxygen concentration are not helpful in keeping the airway patent. )

The nurse caring for a client undergoing mechanical ventilation for acute respiratory distress syndrome (ARDS) plans which intervention to help maintain effective alveolar ventilation? a Increase the tidal volume on the ventilator. b Keep the client in a supine position. c Perform endotracheal suctioning as indicated. d Maintain ordered oxygen concentration.

b (Rationale Viral pneumonia is a known cause of infection that can lead to ARDS. Burn injury and lung contusions are traumas that can cause ARDS. Near drowning is an inhalation etiology for ARDS.)

The nurse educator is teaching a group of students about acute respiratory distress syndrome​ (ARDS). Which etiology is related to infection and is appropriate for the educator to include in the teaching​ session? a Burn injury b Viral pneumonia c Lung contusion d Near drowning

3,4,5 (The prone position is used to improve oxygenation, ventilation, and perfusion. The importance of placing clients with ARDS in prone positioning should be explained to the family. The positioning allows for mobilization of secretions, and the nurse can provide suctioning. Clinical judgment must be used to determine the length of time in the prone position. If the clients hemodynamic status, oxygenation, or skin is compromised, the client should be returned to the supine position for evaluation. Facial edema is expected in the prone position, but the skin breakdown is a concern)

The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 mins. Which factors would require the nurse to discontinue prone positioning and return the client to the supine position? SATA 1. The family is coming to visit 2. The client has increased secretions requiring frequent suctioning 3. The SpO2 and Po2 have decreased 4. The client is tachycardic with drop in BP 5. The face has increased skin breakdown and edema

2 (A hallmark of early ARDS is refractory hypoxemia. The clients Pao2 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur later in the disorder. Severe electrolyte imbalances are not indicators of ARDS)

The nurse interprets which finding as an early sign of acute respiratory distress syndrome? 1 elevated carbon dioxide level 2. hypoxia not responsive to O2 therapy 3. metabolic acidosis 4. severe unexplained electrolyte imbalance

d (Rationale PEEP is the ventilator mode that will promote pressure through the respiratory cycle. Tidal​ volume, sensitivity, and flow rate are ventilator settings and they do not promote pressure throughout the respiratory cycle.)

The nurse is caring for a client diagnosed with acute respiratory distress syndrome​ (ARDS) who requires mechanical ventilation. Which ventilator mode will promote pressure throughout the respiratory​ cycle? a Tidal volume b Flow rate c Sensitivity d Positive​ end-expiratory pressure​ (PEEP)

1,2,3,4 (gloves, gown, surgical mask, and eye protection are worn to protect healthcare workers and to help prevent spread of infection when clients are placed in droplet isolation. Because droplets are too heavy to be airborne, a respirator is not required when caring for a client in droplet precautions)

The nurse is caring for a client on droplet precautions. Which protective gear is required to take care of this client? SATA 1 gloves 2. gown 3. surgical mask 4. glasses 5. respirator

c (Rationale: Full recovery from ARDS takes about 6 months, so the client is taught measures to prevent further lung trauma. The client is not out of danger at discharge. One year is much longer than the typical recovery time. Some clients may never fully recover, but a 6-month time period is generally correct.)

The nurse is caring for a client who is being discharged after recovering from acute respiratory distress syndrome (ARDS). The family asks if the client is out of danger and if normal activities can be resumed. Which statement will the nurse provide to the client and family? a "The client will be ready for normal routines in about a year." b "The client is out of danger and can resume normal activities." c "Maximal respiratory function should return in 6 months." d "The client will never recover fully."

a,c (Rationale: The client with reduced anxiety will be able to rest and will have a relaxed facial expression. The intubated client, who thrashes the legs, keeps eyes open, and fights breathing with the ventilator, is demonstrating anxiety.)

The nurse is monitoring a client who is mechanically ventilated due to acute respiratory distress syndrome (ARDS). The nurse determines that the client has met the outcome for reduced anxiety when the client: (Select all that apply.) a has a relaxed facial expression. b keeps eyes open. c is able to rest. d thrashes the legs. e fights the ventilator.

b (Rationale When planning care for a client with​ ARDS, airway diagnoses are prioritized. Ineffective airway clearance would be the priority diagnosis for this client. Acute​ pain, anticipatory​ grieving, and knowledge deficit are appropriate but not the priority for this client.)

The nurse is planning care for a client with acute respiratory distress syndrome​ (ARDS). What nursing diagnosis is the priority for the nurse to​ initiate? a Acute pain b Ineffective airway clearance c Anticipatory grieving d Deficient knowledge

a (Rationale: The client with ARDS who is being weaned from the ventilator should not be given sedatives that depress respiration. When the client is being weaned, the nurse optimizes respiratory function to promote successful weaning. Daily hygiene, antibiotics, and suctioning are all appropriate for the weaning client. )

The nurse is working with the physician to wean a client with acute respiratory distress syndrome (ARDS) from the ventilator. Which intervention will the nurse avoid during the process of weaning? a Administration of sedatives b Daily hygiene care c Antibiotic administration d Suctioning the client

2 (RR of 36 and diminished wheezing are indicative of respiratory distress. This finding takes precedence over a client scheduled for an angiogram, a client with a HR of 90 needing a scheduled beta blocker, or a client with a PaO2 of 56, which is indicated for a client being discharged home on oxygen)

The nurse received a change of shift report on clients. Which client should the nurse assess first? 1. A client with CoPD with a PaO2 of 56 who is being discharged home on oxygen 2. A client with asthma with RR of 36 whose wheezing has diminished 3. A client with asthma who has a heart rate of 90 bpm and whose beta blocker is scheduled to be administered now 4. A client who is scheduled for an angiogram now and is ready to be transported

4

The nurse should use what type of precautions for the client being admitted with suspected tuberculosis? 1. hand hygiene 2. contact 3. droplet 4. airborne

1 (This chils is exhibiting signs and symptoms of epiglottis, which is a emergency due to the risk of complete airway obstruction. the 3 and 4 year olds are exhibiting s/s of croup. Symptoms often diminish after the child has been taken out in the cool night air. If symptoms do not improve the child may need a single dose of dexamethasone. Fever should also be treated with antipyretics. The 13 year old is exhibiting s/s of bronchitis Tx includes rest, antipyretics, and hydration)

The triage nurse is the ED must prioritize the children waiting to be seen, Which child is in the greatest need of emergency medical treatment? 1. A 6 year old with a T 104 (40 C), a muffled voice, no spontaneous cough, and drooling 2. A 3 year old with T 100 (37.8) a barky cough, and mild intercostal retractions 3. A 4 year old with a T 101 (38.3) a hoarse cough, inspiratory stridor and restlessness 4. a 13 year old with a T 104 (40 C) chills, and a cough with thick yellow secretions

4 (Prone position is used to improve oxygenation in clients with ARDS who are receiving mechanical ventilation. The positioning allows for recruitment of collapsed alveolar units, improvement in ventilation, reduction in shunting, mobilization of secretions, and improvement in functional reserve capacity (FRC). When the client is supine, side to side repositioning should be done every 2 hrs with the HOB elevated at least 30 degrees)

To improve the oxygenation of a client with ARDS who is receiving mechanical ventilation, the nurse should place the client in which position? 1. supine 2. semi-Fowlers 3. lateral side 4. prone

4 (The nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned q2h to help move secretions. every 4h is not enough. Administering sedatives to promote rest is contraindicated in ARDS because sedatives can depress respirations)

To promote effective airway clearance in a client with ARDS what should the nurse do? 1. Admin O2 every 2 hrs 2. Turn the client q4h 3. Admin sedatives to promote rest 4. Suction if cough is ineffective

a (Rationale Placing the client in a prone position several times each day is an independent nursing action that enhances oxygenation. While elevating the head of the bed to 30 degrees is an independent nursing​ intervention, this is done to decrease the risk of aspiration. Restricting fluid intake and administering oxygen are not independent nursing​ actions, and they require a prescription from the healthcare provider to administer.)

What independent action by the nurse will enhance oxygenation for a client diagnosed with acute respiratory distress syndrome​ (ARDS)? a Placing in a prone position several times each day b Administering oxygen c Elevating the head of the bed to 30 degrees d Restricting fluid intake each shift

3 (endotracheal intubation and mechanical ventilation are required in ARDS to maintain adequate respiratory support. Endotracheal intubation, not a tracheostomy, is usually the initial method of maintaining an airway. The client requires mechanical ventilation. nasal oxygen will not provide adequate oxygenation. Chest tubes are used to remove air or fluid from intrapleural spaces.)

Which action should the nurse anticipate in a client who has been diagnosed with ARDS? 1. tracheostomy 2.. use of a nasal cannula 3. mechanical ventilation 4. insertion of a chest tube

4 (Auscultation for bilateral breath sounds is the most appropriate method for determining cuff placement The nurse should also look for symmetrical rise and fall of the chest and should note the location of the exit mark on the tube. Assessments of skin color, rr, and the amt of cuff inflation cannot validate the placement of the endotracheal tube)

Which assessment is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client? 1. assessing the clients skin color 2. monitoring the rr 3. verifying the amount of cuff inflation 4. auscultating breath sounds bilaterally

1 (Rescue breaths should be administered slowly at a volume that makes the chest rise and fall. For a 5 year old the rate is 10 a min. If the nurse is also administering chest compressions, the rate is 2 breaths for every 30 compressions)

Which breathing rates should the nurse use for CPR when performing rescue breathing for a 5 year old? 1. 10 breaths/min 2. 12 breaths/min 3. 15 breaths/min 4. 20 breaths/min

1 (gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged mechanical ventilation because of the development of stress ulcers. Clients who are receiving steroid therapy and those with a previous hx of ulcers are most likely to be at risk. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis)

Which complication is associated with mechanical ventilation? 1. gastrointestinal hemorrhage 2. immunosuppression 3. increased cardiac output 4. pulmonary emboli

1 (The two risk factors most commonly associated with the development of ARDS are gram negative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or a systemic inflammatory response syndrome; which can be caused by any physiologic insult that leads to widespread inflammation; COPD, asthma, and HF are not direct causes of ARDS)

Which condition can place a client at risk for ARDS? 1. septic shock 2. COPD 3. asthma 4. HF

4 (One of the major risk factors for development of ARDS is hypovolemic shock. Adequate fluid replacement is essential to minimize the risk of ARDS in these clients. Teaching smoking cessation does not prevent ARDS. An abnormal serum K level and hypercapnia are not risk factors for ARDS)

Which nursing interventions would be most likely to prevent the development of ARDS? 1. teaching cigarette smoking cessation 2. maintaining adequate serum K levels 3. monitoring clients for signs of hypercapnia 4. replacing fluids adequately during hypovolemic status