Critical Care Exam 2
A health care provider writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The nurse determines that the process of weaning will occur by which mechanism? 1.Gradually decreasing the respiratory rate until the client can assume the work of breathing without ventilatory assistance 2.Attaching a T-piece to the ventilator and providing supplemental oxygen at a concen
1
A nurse is caring for an agitated and anxious patient who was intubated 6 hours ago and is now on mechanical ventilation. Communication efforts to calm the patient have failed, and the nurse is now turning to pharmacological intervention. Which medication does the nurse anticipate administering? 1) Lorazepam 2) Morphine sulfate 3) Pancuronium 4) Fentanyl
1 Although Pancuronium (a neuromuscular blocking agent) CAN be used, it is best to try a sedative first. If satisfactory oxygen levels still cannot be maintained, then a neuromuscular blocking agent (WITH PAIN MEDICATION AND SEDATION!) can be used.
The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. 1.Water or a kink in the tubing 2.Biting on the endotracheal tube 3.Increased secretions in the airway 4.Disconnection or leak in the system 5.The client stops spontaneous breathing.
123
A client who is intubated and receiving mechanical ventilation has a problem of risk for infection. The nurse should include which measures in the care of this client? Select all that apply. 1.Monitor the client's temperature. 2.Use sterile technique when suctioning. 3.Use the closed-system method of suctioning. 4.Monitor sputum characteristics and amounts. 5.Drain water from the ventilator tubing into the humidifier bottle.
1234
The RN is supervising a nursing student who will suction a patient on a mechanical ventilator. Which actions indicate that the student has a correct understanding of this procedure? Select all that apply. 1.) The student nurse uses a sterile catheter and glove. 2.)The student nurse applies suction while inserting the catheter. 3.)The student nurse applies suction during catheter removal. 4.) The student nurses uses a twirling motion when withdrawing the catheter. 5.)The student nurse uses a no.
1345 The standard size catheter for an adult is a no. 12 or 14 French. Infection is possible because each catheter pass can introduce bacteria into the trachea. In the hospital, use sterile technique for suctioning and for all suctioning equipment (e.g., suction catheters, gloves, saline or water). Apply suction only during catheter withdrawal and use a twirling motion to prevent the catheter from grabbing tracheal mucosa and leading to damage to tracheal tissue. Apply suction for no more than 10 seconds to minimize hypoxemia during suctioning.
A nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which finding? 1.A disconnection of the ventilator tubing 2.An exaggerated client inspiratory effort 3.Accumulation of respiratory secretions 4.Generation of extreme negative pressure by the client
3
A 19 year-old patient being administered PEEP begins to have copious amounts of secretions that she says she "just cannot cough up." Which of the following nursing actions is most appropriate at this time? 1) Assess the patient further and utilize bedside suction equipment. 2) Assess O2 sats and continue to monitor patient if results are 95% or above. 3) Obtain respiratory therapy consult. 4) Obtain an order for a mucolytic agent from the physician.
3 At this time, the nurse should obtain a respiratory therapy consult. Any break in the closed ventilator system causes the loss of PEEP, so respiratory therapy needs to be consulted to add in-line suctioning.
The nurse caring for a client who is mechanically ventilated is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up? 1.Muscle weakness in the arms and legs 2.A temperature of 98.6° F decreased from 99.0° F 3.A blood pressure of 90/60 mm Hg decreased from 112/78 mm Hg 4.A heart rate of 80 beats per minute decreased from 85 beats per minute
3 Complications of mechanical ventilation include the following: (1) hypotension caused by application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart; (2) pneumothorax or subcutaneous emphysema as a result of positive pressure; (3) gastrointestinal alterations such as stress ulcers; (4) malnutrition if nutrition is not maintained; (5) infections; (6) muscular deconditioning; and (7) ventilator-dependence or inability to wean. Some muscle weakness is expected. Options 1, 2, and 4 present normal assessment findings.
A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action? 1.Ask a family member to stay with the client at all times. 2.Ask the health care provider for a prescription for succinylcholine. 3.Encourage the client to sleep until arterial blood gas results improve. 4.Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.
4
The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication? 1.Excessive secretions 2.Kinks in the ventilator tubing 3.The presence of a mucous plug 4.Displacement of the endotracheal tube
4
A client who is diagnosed with acute respiratory distress syndrome (ARDS) requires mechanical ventilation. Which ventilator mode should the nurse expect to implement to promote pressure throughout the respiratory cycle? A. Positive end-expiratory pressure (PEEP) B. Sensitivity C. Flow rate D. Tidal volume (TV)
A
A patient in acute respiratory failure is receiving ACV with a positive end-expiratory pressure (PEEP) of 10 cm H20. What sign alerts the nurse to undesirable effects of increased airway and thoracic pressure? a. decreased BP b. decreased PaO2 c. increased crackles d. decreased spontaneous respirations
A
In what ventilation setting does the vent deliver tidal volume at a preset rate because the patient is not breathing spontaneously? A. Controlled Mandatory Ventilation B. Assisted Control C. Synchronized Intermittent Mandatory Ventilation D. Continuous Positive Airway Pressure
A
Mr. G requires neuromuscular blockade to facilitate mechanical ventilation. Which is not a true statement when providing nursing care to paralyzed patients? A) Because patients under neuromuscular blockade are unable to react to the environment, special safety precautions are not needed. B) Pain medication is required because neuromuscular blocking agents do not have an analgesic effect. C) Patients under the influence of neuromuscular blocking agents are fully aware of activity around them. D)
A
The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A) Stable vital signs and ABGs B) Pulse oximetry above 80% and stable vital signs C) Stable nutritional status and ABGs D) Normal orientation and level of consciousness
A
The nurse is caring for a 65-yr-old man with acute respiratory distress syndrome (ARDS) who is on pressure support ventilation (PSV), fraction of inspired oxygen (FIO2) at 80%, and positive end-expiratory pressure (PEEP) at 15 cm H2O. The patient weighs 72 kg. What finding would indicate that treatment is effective? a. PaO2 of 60 mm Hg b. Tidal volume of 700 mL c. Cardiac output of 2.7 L/min d. Inspiration to expiration ratio of 1:2
A
The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order? A) Removal from the ventilator, tube, and then oxygen B) Removal from oxygen, ventilator, and then tube C) Removal of the tube, oxygen, and then ventilator D) Removal from oxygen, tube, and then ventilator
A
The purpose of adding PEEP to positive pressure ventilation is to a. increase functional residual capacity and improve oxygenation b. increase FIO2 in an attempt to wean the patient and avoid O2 toxicity c. determine if the patient is in synchrony with the ventilator or needs to be paralyzed d. determine is the patient is able to be weaned and avoid the risk of pneumomediastinum
A
Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The respiratory rate is 32 breaths/min. b. The pulse oximeter shows a SpO2 of 93%. c. The patient has not been suctioned for the last 6 hours. d. The lungs have occasional audible expiratory wheezes.
A
The peak pressure alarm is sounding on the ventilator of the client with a recent tracheostomy. What intervention should be done first? A. Assess the client's respiratory status B. Decrease the sensitivity of the alarm C. Ensure that the connecting tubing is not kinked D. Suction the client
A The client must always be assessed before attention is turned to equipment.
ANS: B The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. BiPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange
A patient with respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. The nurse will anticipate assisting with a. administration of 100% oxygen by non-rebreather mask. b. endotracheal intubation and positive pressure ventilation. c. insertion of a mini-tracheostomy with frequent suctioning. d. initiation of bilevel positive pressure ventilation (BiPAP).
Although his oxygen saturation is above 92%, an orally intubated, mechanically ventilated patient is restless and very anxious. What interventions will most likely decrease the risk of accidental extubation? Select all that apply a. administer sedatives b. have a caregiver stay with the patient c. obtain an order and apply soft wrist restraints d. remind the patient that he needs the tube inserted to breathe e. move the patient to an area close to the nurse's station for closer observation
AB
The nurse is caring for a patient who was just placed on mechanical ventilation and is observing the patient's vital signs because positive-pressure ventilation can lead to: (Select all that apply.) A) decreased cardiac output. B) decreased venous return. C) increased renal function. D) decreased intracranial pressure. E) increased hepatic function.
ABD
The nurse is caring for a client who is in the process of weaning off of mechanical ventilation. Which assessment finding should the nurse report to the healthcare provider?(Select all that apply.) A. Agitation B. Pallor C. Oxygen saturation level of 98% D. Respiratory rate of 18 beats/min E. Abdominal breathing
ABE
What is included in the description of positive pressure ventilation? Select all that apply a. peak inspiratory pressure predetermined b. consistent volume delivered with each breath c. increased risk for hyperventilation and hypoventilation d. preset volume of gas delivered with variable pressure based on compliance e. volume delivered varies based on selected pressure and patient lung compliance
ACE
What characteristics describe positive pressure ventilators? Select all that apply a. require an artificial airway b. applied to outside of body c. most similar to physiologic ventilation d. most frequently used with critically ill patients e. frequently used in the home for neuromuscular or nervous system disorders
AD
A patient who is receiving mechanical ventilation is anxious and is fighting the ventilator. Which action should the nurse take first? a. Ventilate the patient with a manual resuscitation bag. b. Verbally coach the patient to breathe with the ventilator. c. Sedate the patient with the ordered PRN lorazepam (Ativan). d. Increase the rate for the ordered propofol (Diprivan) infusion.
B
Before weaning a male client from a ventilator, which assessment parameter is most important for the nurse to review? a. Fluid intake for the last 24 hours b. Baseline arterial blood gas (ABG) levels c. Prior outcomes of weaning d. Electrocardiogram (ECG) results
B
Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patients arterial blood gas (ABG) results include a pH of 7.50, PaO2 of 80 mm Hg, PaCO2 of 29 mm Hg, and HCO3 of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to a. increase the FIO2. b. decrease the respiratory rate. c. increase the tidal volume (VT). d. leave the ventilator at the current settings.
B
Synchronized Intermittent Mechanical Ventilation is best for which patient? A. The patient with sleep apnea B. The patient trying to wean from mechanical ventilation C. The patient who is receiving neuromuscular blocking agents D. The patient who has respiratory drive but cannot sustain normal tidal volume
B
The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess? A) Fluid intake for the last 24 hours B) Baseline arterial blood gas (ABG) levels C) Prior outcomes of weaning D) Electrocardiogram (ECG) results
B
The nurse determines that alveolar hypoventilation is occurring in a patient on a ventilator when what happens? a. the patient develops cardiac dysrhythmias b. auscultation reveals an air leak around the ET tube cuff c. ABG results show a PaCO2 of 32 mm Hg and a pH of 7.47 d. the patient tries to breathe faster than the ventilator setting
B
The nurse is assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? a. Assessing the patient's respiratory status every 4 hours b. Taking vital signs and pulse oximetry readings every 4 hours c. Checking the ventilator settings to make sure they are as prescribed d. Observing whether the patient's tube needs suctioning every 2 hours
B
The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall? A) Between 10 and 15 mm Hg B) Between 15 and 20 mm Hg C) Between 20 and 25 mm Hg D) Between 25 and 30 mm Hg
B
The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patients high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurses best response? A) CPAP allows a higher percentage of oxygen to be safely used. B) CPAP allows a lower percentage of oxygen to be used with a similar effect. C) CPAP allows for greater humidification of the oxygen that is administered. D) CPAP allows for the elimination of bacterial growth i
B
What plan should the nurse use when weaning a patient from a ventilator? a. decrease the delivered FIO2 concentration b. intermittent trials of spontaneous ventilation followed by ventilatory support to provide rest c. substitute ventilator support with manual resuscitation bag if the patient becomes hypoxic d. implement weaning procedures around the clock until the patient does not experience ventilator fatigue
B
What ventilation setting delivers preset tidal volume whenever the patient exerts inspiration, and still ensures that the patient recieves a breath if they do not spontaneously trigger the ventilator? A. Controlled Mandatory Ventilation B. Assisted Control C. Synchronized Intermittent Mandatory Ventilation D. Continuous Positive Airway Pressure
B
Beep Beep Beep. The high pressure alarm is sounding in the patient's room. Which of the following is the most likely cause. A) The ventilator tubing has become disconnected B) The patient is trying to talk to his friend C) There is a leak in the cuff D) The patient is c/o pain 9/10
B High pressure alarms sound when anything is blocking the air from going down the tube. Some possible causes include biting the tube, excess secretions, kinking, condensation in tubing, the patient gagging, coughing, or talking, or a more serious complication like pneumothorax or bronchospasm. Disconnected tubing would most likely set off a low pressure alarm. A leak in the cough would prevent all the air to go into the lungs efficiently. Pain itself would not affect the pressure.
A nurse is reviewing the plan of care for a client who is receiving mechanical ventilation. Which of the following ventilator modes will increase the client's work of breathing? Select all that apply a. assist-control b. synchronized intermittent mandatory ventilation c. continuous positive airway pressure d. pressure support ventilation e. independent lung ventilation
BCD
What is the advantage of using Volume Cycled Ventilation? (SATA) A. the ventilator pushes air into lungs until a preset airway pressure is reached B. the ventilator pushes air into the lungs until a preset volume is reached C. a constant tidal volume is delivered regardless of pressure needed to deliver the tidal volume D. limits excessive pressure being exerted on the lungs E. allows the health care team to determine if intubation is really neccessary
BCD
A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? Select all that apply a. confusion b. pale skin c. bradycardia d. hypotension e. elevated blood pressure
BE
Which patient's medical diagnoses should the nurse know are most likely to need mechanical ventilation? Select all that apply a. sleep apnea b. cystic fibrosis c. acute kidney injury d. type 2 DM e. acute respiratory distress syndrome (ARDS)
BE
A patient receiving mechanical ventilation is very anxious and agitated, and neuromuscular blocking agents are used to promote vasodilation. What should the nurse recognize about the care of this patient? a. the patient will be too sedated to be aware of the details of care b. caregivers should be encouraged to provide stimulation and diversion c. the patient should always be addressed and explanations of care given d. communication will not be possible with the use of neuromuscular blocking ag
C
Strategies to prevent ventilator associated pneumonia include: A) rotating the patient's position every 2 hours with HOB at 10 degrees. B) daily oral care with peroxide. C) peptic ulcer disease prophylaxis. D) biweekly assessment of readiness to extubate.
C
The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? a. administer oxygen b. check the client's vital signs c. ventilate the client manually d. start CPR
C
The nurse is 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? a. Administer ordered antibiotics as scheduled. b. Hyperoxygenate the patient before suctioning. c. Maintain the head of bed at a 30- to 45-degree angle. d. Suction the airway when coarse crackles are audible
C
The nurses monitors the patient with positive pressure mechanical ventilation for a. paralytic ileus because pressure on the abdominal contents affects bowel motility b. diuresis and sodium depletion because of increased release of atrial natriuretic peptide c. signs of cardiovascular insufficiency because pressure in the chest impedes venous return d. respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO2 levels
C
The nursing management of a patient with an artificial airway includes a. maintaining the ET tube cuff pressure at 30 cm H20 b. routine suctioning of the tube at least every 2 hours c. observing for cardiac dysrhythmias during suctioning d. preventing tube dislodgment by limiting mouth care to lubrication of the lips
C
To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation? a. Avoid use of positive end-expiratory pressure (PEEP). b. Suction every 2 hours. c. Elevate head of bed to 30 to 45 degrees. d. Give enteral feedings at no more than 10 mL/hr.
C
When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect? a. Increased inflation of the lungs b. Prevention of barotrauma to the lung tissue c. Prevention of alveolar collapse during expiration d. Increased fraction of inspired oxygen concentration (FIO2) administration
C
When the nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation, which patient assessment indicates that the weaning protocol should be discontinued? a. The patient heart rate is 98 beats/min. b. The patients oxygen saturation is 93%. c. The patient respiratory rate is 32 breaths/min. d. The patients spontaneous tidal volume is 500 mL.
C
The client with respiratory failure has been intubated and placed on a ventilator and is requiring 100% oxygen delivery to maintain adequate oxygenation. Twenty-four hours later, the nurse notes new-onset crackles and decreased breath sounds, and the most recent ABGs show a PaO2 level of 95 mm Hg. The ventilator is not set to provide positive end-expiratory pressure (PEEP). Why is the nurse concerned? A. The low PaO2 level may result in oxygen toxicity B. The 100% oxygen delivery requirement in
C High levels of oxygen delivery can result in collapsed alveoli and absorption atelectasis. PEEP can help alveoli remain properly inflated.
In the patient using Controlled Mandatory Ventilation, what drug are they on to suppress respiratory effort? A. Morphine, Fentanyl, or Hydromorphone B. Propofol C. Rocuronium, Pancuronium, or Nimbex D. Formoterol, Salmeterol, or Arformoterol
C Rocuronium, Pancuronium, & Nimbex are all non-Depolarizing Neuromuscular Blocking Agents. But, be considerate that the patient recieving this type of ventilation will also require sedation and opioids.
Which finding indicates that rehydration is complete and hypovolemic shock has been successfully treated in a patient? 1. CVP = 8 mm Hg 2. MAP = 45 mm Hg 3. Urinary output of 0.1 mL/kg/hr 4. Hct = 54%
Correct Answer: 1 Rationale 1: A CVP reading of 8 mm Hg is within normal range and rehydration has been restored. Rationale 2: The mean arterial pressure (MAP) should be between 60 to 70 mm Hg as evidence of positive fluid resuscitation efforts. Rationale 3: Urinary output to reflect adequate rehydration begins at 0.5 to 1 mL/kg/hr. Therefore, 0.1 mL is too small and renal insufficiency may be present due to inadequate circulating blood volume. Rationale 4: Hematocrit (Hct) is the percentage of the number of RBCs per fluid volume. The normal range is 35% to 45% for an adult. The higher percentage represents a decreased fluid-to-cell ratio, which implies a fluid deficit and rehydration is not complete. An Hct of 54% is critical and increases the risk of clots, strokes, and other vessel obstruction from potential hemolysis and sluggishness of cellular movements.
A patient is being treated for pericarditis. The nurse will plan interventions to prevent the onset of which type of shock? 1. Obstructive 2. Hypovolemic 3. Distributive 4. Cardiogenic
Correct Answer: 1 Rationale 1: Acute pericarditis and the development of fluid accumulation in the pericardial space can lead to the development of obstructive shock. Rationale 2: Pericarditis is not a risk factor for the development of hypovolemic shock. Rationale 3: Pericarditis is not a risk factor for the development of distributive shock. Rationale 4: Pericarditis is not a risk factor for the development of cardiogenic shock.
Which assessment finding indicates that an infusion of intravenous epinephrine 4 mcg/min is effective in the treatment of a patient with anaphylactic shock? 1. Reduced wheezing 2. Heart rate 55 and regular 3. Blood pressure 98/50 mm Hg 4. Respiratory rate 28
Correct Answer: 1 Rationale 1: An expected action for epinephrine is bronchodilation as evidenced by less wheezing. Rationale 2: Epinephrine increases heart rate. Rationale 3: Epinephrine increases blood pressure. Rationale 4: Epinephrine lowers the respiratory rate. This respiratory rate indicates that epinephrine has not been effective.
A patient is diagnosed with cardiac tamponade. When planning care, the nurse will include interventions to address which type of shock? 1. Obstructive 2. Hypovolemic 3. Distributive 4. Cardiogenic
Correct Answer: 1 Rationale 1: Cardiac tamponade can lead to obstructive shock. Rationale 2: Cardiac tamponade will not lead to hypovolemic shock. Rationale 3: Cardiac tamponade will not lead to distributive shock. Rationale 4: Cardiac tamponade will not lead to cardiogenic shock.
A patient is demonstrating signs of obstructive shock but the cause has yet to be determined. Which finding indicates the patient is experiencing a pulmonary embolism as the cause for obstructive shock? 1. Chest pain 2. Hypotension 3. Tachycardia 4. Oliguria
Correct Answer: 1 Rationale 1: Chest pain is a symptom associated with a massive pulmonary embolus. Rationale 2: Hypotension is seen in other causes of obstructive shock and is not a symptom that differentiates the cause as being from a pulmonary embolus. Rationale 3: Tachycardia is seen in other causes of obstructive shock and is not a symptom that differentiates the cause as being from a pulmonary embolus. Rationale 4: Oliguria is seen in other causes of obstructive shock and is not a symptom that differentiates the cause as being from a pulmonary embolus.
A patient is experiencing an anaphylactic reaction to a medication. The nurse is concerned that the patient will develop distributive shock because: 1. The release of histamine causes vasodilation with plasma leakage. 2. Sympathetic innervation is interrupted. 3. Microorganisms overwhelm the vascular system. 4. Parasympathetic innervation functions are unopposed.
Correct Answer: 1 Rationale 1: In an anaphylactic reaction leading to distributive shock, the release of histamine causes vasodilation with plasma leakage. Vasodilation leads to profound hypotension, hypovolemia from fluid extravasation, reduced reload, and reduced cardiac output. Rationale 2: Sympathetic innervation is not interrupted in an anaphylactic reaction. Rationale 3: Microorganisms do not overwhelm the vascular system in an anaphylactic reaction. Rationale 4: Parasympathetic innervation functioning unopposed is not a characteristic of an anaphylactic reaction.
A patient with cardiomyopathy is demonstrating signs of cardiogenic shock. The nurse realizes that this type of shock is due to: 1. Reduced cardiac output 2. Increased stroke volume 3. Reduced blood volume 4. Blood flow blocked in the pulmonary circulation
Correct Answer: 1 Rationale 1: In cardiogenic shock, cardiac output is reduced, leading to poor tissue perfusion. Rationale 2: In cardiogenic shock, stroke volume is decreased. Rationale 3: There is not a reduction of blood volume in cardiogenic shock. Rationale 4: There is not a blockage of blood flow through the pulmonary circulation in cardiogenic shock.
A patient is brought to the emergency department with hypotension, tachycardia, reduced capillary refill, and oliguria. During the assessment, the nurse determines the patient is experiencing cardiogenic shock because of which additional finding? 1. Jugular vein distention 2. Dry mucous membranes 3. Poor skin turgor 4. Thirst
Correct Answer: 1 Rationale 1: Jugular vein distention is a manifestation of cardiogenic shock. Rationale 2: The mucous membranes are not dry in cardiogenic shock. Rationale 3: The skin turgor is not poor in cardiogenic shock. Rationale 4: Thirst is not a manifestation of cardiogenic shock.
The nurse, caring for a patient recovering from an acute myocardial infarction, is planning interventions to reduce the risk of which type of shock? 1. Cardiogenic 2. Hypovolemic 3. Distributive 4. Obstructive
Correct Answer: 1 Rationale 1: One etiology of cardiogenic shock is a myocardial infarction. Rationale 2: Acute myocardial infarction does not cause hypovolemic shock. Rationale 3: Acute myocardial infarction does not cause distributive shock. Rationale 4: Acute myocardial infarction does not cause obstructive shock.
A patient is prescribed vasopressin 0.03 units/minute as treatment for septic shock. What action will the nurse take when providing this medication? 1. Provide the vasopressin infusion in addition to a norepinephrine infusion. 2. Infuse through a peripheral line. 3. Utilize a rapid infuser. 4. Administer with 0.9% normal saline.
Correct Answer: 1 Rationale 1: The dose of 0.03 units/min is usually added to a norepinephrine infusion. Rationale 2: This medication should always be administered via an infusion pump. Rationale 3: A rapid infuser is used to deliver large amounts of warmed crystalloid or blood to a patient over a short period of time. It is not used for medication administration. Rationale 4: This medication does not need to be administered with 0.9% normal saline.
A patient is receiving phenylephrine 50 mcg/min as treatment for shock. Which assessment finding indicates this medication is effective? 1. Blood pressure 110/68 mm Hg 2. Heart rate 110 3. Respiratory rate 12 and regular 4. Decreased peripheral pulses
Correct Answer: 1 Rationale 1: The expected effect of this medication is an increase in blood pressure. Rationale 2: Phenylephrine does not increase the heart rate. Rationale 3: Phenylephrine does not affect the respiratory rate. Rationale 4: Decreased peripheral pulses is a side/toxic effect of this medication.
The nurse is concerned that a patient is at risk for developing obstructive shock because of which assessment findings? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Age 80 2. History of atrial fibrillation 3. Bacteremia 4. T3 spinal cord injury 5. Latex allergy
Correct Answer: 1,2 Rationale 1: Advanced age increases the risk for development of pulmonary emboli, which is one cause of obstructive shock. Rationale 2: Atrial fibrillation increases the risk for developing pulmonary emboli, which is one cause of obstructive shock. Rationale 3: Bacteremia increases a patient's risk of developing septic shock and not obstructive shock. Rationale 4: A spinal cord injury increases the risk for developing distributive shock and not obstructive shock. Rationale 5: A latex allergy increases the risk for developing distributive shock and not obstructive shock.
A patient is receiving norepinephrine 30 mcg/min for treatment of refractory shock. Which assessment findings suggest the patient is experiencing peripheral vasoconstriction from the medication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Decreased peripheral pulses 2. Drop in body temperature 3. Onset of paresthesias 4. Drop in blood pressure 5. Increased cardiac output
Correct Answer: 1,2,3 Rationale 1: At high doses of norepinephrine, decreased peripheral pulses indicates significant vasoconstriction. Rationale 2: At high doses of norepinephrine, a drop in body temperature indicates significant vasoconstriction. Rationale 3: At high doses of norepinephrine, paresthesias indicate significant vasoconstriction. Rationale 4: This medication does not cause a drop in blood pressure. Rationale 5: An increase in cardiac output is an expected effect of this medication and does not indicate significant vasoconstriction.
A patient is experiencing acute respiratory distress after eating an item of a known food allergy. What interventions will the nurse implement when providing emergency care to this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Administer epinephrine 1:1000 intramuscularly. 2. Apply oxygen via face mask as prescribed. 3. Provide diphenhydramine 25 mg intravenous. 4. Administer vasopressin. 5. Prepar
Correct Answer: 1,2,3 Rationale 1: Epinephrine produces bronchodilation, improving the respiratory status. The route of administration is initially intramuscular. Rationale 2: Supplemental oxygen is used in the treatment of anaphylactic shock. Rationale 3: Hydrogen ion blockers such as diphenhydramine may be administered to block the histamine effects. Rationale 4: Vasopressin is not used in the treatment of anaphylactic shock. Rationale 5: Antithrombolytic agents are not used in the treatment of anaphylactic shock.
During an assessment the nurse is concerned that a patient is developing cardiogenic shock. What did the nurse assess in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Systolic blood pressure 82 mm Hg 2. Capillary refill 10 seconds 3. Crackles bilateral lung bases 4. Heart rate 55 and regular 5. Warm dry skin
Correct Answer: 1,2,3 Rationale 1: Hypotension is a manifestation of cardiogenic shock. Rationale 2: Delayed capillary refill is a manifestation of cardiogenic shock. Rationale 3: Crackles are a manifestation of cardiogenic shock. Rationale 4: Bradycardia is not a manifestation of cardiogenic shock. Rationale 5: Warm dry skin is not a manifestation of cardiogenic shock.
The nurse is caring for a patient recovering from a spinal cord injury sustained during a motor vehicle crash. What assessment findings indicate that the patient is developing neurogenic shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Hypotension 2. Bradycardia 3. Warm dry skin 4. Abdominal cramps 5. Palpitations
Correct Answer: 1,2,3 Rationale 1: Hypotension is a manifestation of neurogenic shock because of the loss of autonomic reflexes. Rationale 2: Bradycardia occurs because of the loss of sympathetic innervation. Rationale 3: Warm dry skin occurs because of a loss of cutaneous control of sweat glands. Rationale 4: Abdominal cramping is not a manifestation of neurogenic shock. Rationale 5: Palpitations are not seen in neurogenic shock.
A patient, experiencing vasodilation, is diagnosed with distributive shock. The nurse will assess the patient for which etiologies? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Sepsis 2. Spinal cord injury 3. Anaphylaxis 4. Hemorrhage 5. Pulmonary embolism
Correct Answer: 1,2,3 Rationale 1: One etiology of distributive shock is sepsis. Rationale 2: One etiology of distributive shock is spinal cord injury. Rationale 3: One etiology of distributive shock is anaphylaxis. Rationale 4: Hemorrhage is not an etiology of distributive shock. Rationale 5: Pulmonary embolism is not an etiology of distributive shock.
A patient being treated for cardiogenic shock is being hemodynamically monitored. Which findings are consistent with the patient's diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Elevated pulmonary arterial wedge pressure 2. Elevated central venous pressure 3. Elevated systemic vascular resistance index 4. Elevated mean arterial pressure 5. Elevated stroke volume
Correct Answer: 1,2,3 Rationale 1: This finding is consistent with pulmonary vascular congestion. Rationale 2: This finding is consistent with fluid volume overload. Rationale 3: This finding is consistent with pulmonary vascular congestion. Rationale 4: This finding is not consistent with cardiogenic shock. Rationale 5: This finding is not consistent with cardiogenic shock.
A patient is brought to the emergency department with manifestations of anaphylactic shock. What will the nurse assess as possible causes for this disorder? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Recent bee sting 2. Ingestion of drugs 3. History of latex allergy 4. Recent diagnostic imaging tests 5. Recent myocardial infarction
Correct Answer: 1,2,3,4 Rationale 1: Venoms such as bee stings can trigger anaphylactic shock. Rationale 2: Drugs can trigger anaphylactic shock. Rationale 3: Latex can trigger anaphylactic shock. Rationale 4: Contrast media for diagnostic tests can trigger anaphylactic shock. Rationale 5: Myocardial infarction is not a trigger for anaphylactic shock.
The nurse is explaining the mechanism of a pulmonary embolism to the family of a patient diagnosed with the disorder. Place in order the steps the nurse will use to instruct the family about this disease process. Standard Text: Click and drag the options below to move them up or down. Choice 1. Blood clot causes backup of blood in the right ventricle. Choice 2. Blood clot blocks blood to the left ventricle. Choice 3. Left ventricle does not get enough blood to pump through the body. Choice 4. A
Correct Answer: 1,2,3,4,5,6 Rationale 1: The obstruction caused by the pulmonary embolism increases the afterload of the right ventricle, causing right ventricular failure. Rationale 2: The embolus prevents adequate blood flow from the pulmonary circulation to the left ventricle. Rationale 3: Because blood flow from the pulmonary circulation is blocked, left ventricular preload drops. Rationale 4: Because left ventricular preload is decreased, there is not enough blood in the heart to pump, causing decreased cardiac output. Rationale 5: A lack of blood circulating will lead to hypotension. Rationale 6: When the blood is backed up and is not being pumped into the general circulation, tissue perfusion is reduced.
The nurse is preparing medications for a patient being treated for cardiogenic shock. Which medications will the nurse most likely provide to this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Dopamine 2. Norepinephrine 3. Dobutamine 4. Epinephrine 5. Phenylephrine
Correct Answer: 1,2,3,5 Rationale 1: Dopamine is commonly used in the treatment of cardiogenic shock. Rationale 2: Norepinephrine is commonly used in the treatment of cardiogenic shock. Rationale 3: Dobutamine may be used in the patient with cardiogenic shock who has an adequate blood pressure. Rationale 4: Epinephrine is not used in the treatment of cardiogenic shock. Rationale 5: Phenylephrine is a vasopressor and may be used in the patient with cardiogenic shock who is receiving dobutamine.
Which finding indicates that a patient is experiencing increased peripheral resistance and vasoconstriction? 1. Strong bounding pulse with deep red coloring 2. Pale, cool extremities with decreased pulses 3. Increased venous engorgement with strong pulses 4. Faster than normal capillary refill time
Correct Answer: 2 Rationale 1: An increased blood supply would increase color and bounding pulses as seen with vasodilation (blood engorgement) and is not present with increased peripheral resistance and vasoconstriction. Rationale 2: Increased peripheral resistance causes the blood supply to decrease and results in decreased blood to the tissues, which causes pallor and decreased skin temperatures. The pulses would decrease in intensity with a decreased blood supply. Rationale 3: Venous engorgement would not result from vasoconstriction of the arteries. Strong pulses would not be present with vasoconstriction from increased peripheral resistance. Rationale 4: Capillary refill times are delayed or slowed due to decreased blood flow through the vessels caused by the vasoconstriction from increased peripheral resistance.
The nurse should warm intravenous fluids when a rapid infuser is being utilized to prevent which complication? 1. Hemorrhagic shock 2. Hypothermia 3. Sepsis 4. Cardiogenic shock
Correct Answer: 2 Rationale 1: Hemorrhagic shock is caused by a loss of cells or blood volume and is not a result of infusing fluids too quickly. Rationale 2: Hypothermia can result when providing room temperature fluids at a faster pace than the body can warm them. Rationale 3: Bacterial contamination can be avoided by sterile technique, and sepsis is not caused by the rate or temperature of the fluid being administered. Rationale 4: Cardiogenic shock results from poor ventricular functioning, not from the temperature of the intravenous fluids being administered too rapidly.
A patient is demonstrating pulmonary edema, hypotension, and delayed capillary refill. The nurse suspects the patient is experiencing which type of shock? 1. Hypovolemic 2. Cardiogenic 3. Anaphylactic 4. Obstructive
Correct Answer: 2 Rationale 1: Pulmonary edema would not be present in hypovolemic shock. Rationale 2: In cardiogenic shock, there is a low cardiac output, hypotension, and pulmonary edema. Rationale 3: Pulmonary edema would not be present in anaphylactic shock. Rationale 4: Pulmonary edema would not be present in obstructive shock
Which laboratory finding should cause the nurse to suspect that a patient is developing hypovolemic shock? 1. Serum sodium of 130 mEq/L (130 mmol/L) 2. Metabolic acidosis validated by arterial blood gases 3. Serum lactate of 3 mmol/L 4. SvO2 greater than 80%
Correct Answer: 2 Rationale 1: The sodium level in hypovolemic shock is elevated above the normal values of 135 to 145 mEq/L, not reduced. Rationale 2: Metabolic acidosis is present due to an accumulation of carbonic acid, leaving a bicarbonate deficit from decreased tissue perfusion. Rationale 3: Serum lactate is greater than 4 mmol/L as a result of tissue ischemia, hypoxia, and breakdown from decreased blood flow with hypovolemic shock. Rationale 4: SvO2 (mixed venous oxygen saturation) would be less than 60% due to decreased circulating blood volume or decrease in cells to carry the oxygen. Therefore, O2 is carried less efficiently and decreased, not increased.
Which solution would be the most appropriate initial volume replacement for a patient with severe GI bleeding? 1. 200 mL of normal saline (NS) per hour for 5 hours 2. A liter of Ringer's lactate (RL) over 15 minutes 3. Two liters of D5W over half an hour 4. 500 mL of 0.45% normal saline (1/2 NS) over half an hour
Correct Answer: 2 Rationale 1: This is not an adequate amount of fluid replacement. Rationale 2: The patient requires immediate infusion of an adequate amount of fluid. Fluid resuscitation begins with 500 to 1,000 mL of an isotonic solution. Rationale 3: This is a hypotonic solution and would not help with fluid resuscitation. Rationale 4: This is a hypotonic solution and would not help with fluid resuscitation.
Which life-threatening complications would the nurse anticipate developing in the patient being treated for hypovolemic shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Fluid volume overload 2. Renal insufficiency 3. Cerebral ischemia 4. Gastric stress ulcer 5. Pulmonary edema
Correct Answer: 2,3 Rationale 1: Fluid volume overload is not an identified complication of hypovolemic shock. Rationale 2: Renal insufficiency is a serious complication because of the prerenal etiology of hypovolemia. Rationale 3: Early identification and correction of the fluid volume deficit in hypovolemic shock is necessary to prevent cerebral ischemia. Rationale 4: Although physiologic stress can increase the risk for the development of stress ulcers, it is not considered one of the common or life-threatening complications of hypovolemic shock. Rationale 5: Pulmonary edema is not an identified complication of hypovolemic shock.
What will the nurse identify as symptoms of hypovolemic shock in a patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Temperature of 97.6°F (36.4°C) 2. Restlessness 3. Decrease in blood pressure of 20 mm Hg when the patient sits up 4. Capillary refill time greater than 3 seconds 5. Sinus bradycardia of 55 beats per minute
Correct Answer: 2,3,4 Rationale 1: Fever will increase oxygen demands but is unrelated to hypovolemic shock unless prolonged fever has caused severe dehydration, reducing the circulating blood volume. Hypovolemic shock reduces temperatures by peripheral shunting of blood away from the extremities and reducing the core metabolic rate. Rationale 2: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, cerebral hypoxia occurs, leading to a change in mental status. Rationale 3: Orthostatic hypotension is a manifestation of hypovolemic shock. Rationale 4: Due to decreased blood flow to the brain and peripheral areas when blood is shunted to maintain the vital organs, capillary refill time will be reduced. Rationale 5: Bradycardia is not present. The compensatory response is to increase the heart rate to circulate the blood faster to make up for the fluids that are not present in hypovolemic shock.
The nurse recognizes that which patient would be most likely to develop hypovolemic shock? A patient with: 1. Decreased cardiac output 2. Severe constipation, causing watery diarrhea 3. Ascites 4. Syndrome of inappropriate ADH (SIADH)
Correct Answer: 3 Rationale 1: Although ECG changes reflect the effectiveness of the heart's pumping when circulating the blood, it is not a risk factor for hypovolemic shock, which reflects a decreased circulating volume from either blood or fluid losses within the intravascular system. Rationale 2: Severe constipation does not affect the circulating blood volume. Rationale 3: Third spacing shifts move the fluids from the intravascular space into the interstitial space, causing a drop in the circulating blood volume. Therefore, third spacing is a risk factor for the development of hypovolemic shock. Rationale 4: Overhydration does not lead to hypovolemic shock. It leads to fluid overload, which might cause cardiogenic shock, congestive heart failure, and pulmonary edema.
The nurse, caring for a patient in hypovolemic shock, will not utilize a hypotonic solution for fluid resuscitation because hypotonic solutions: 1. Move quickly into the interstitial spaces and can cause third spacing 2. Stay longer to expand the intravascular space but deplete intracellular fluid levels 3. Do not stay in the intravascular space long enough to expand the circulating blood volume 4. Need a smaller bore needle to run at a slower rate to keep the intravascular space low
Correct Answer: 3 Rationale 1: Hypotonic solutions do not cause third spacing. Rationale 2: Hypotonic solutions do not stay in the intravascular space long enough to expand the circulating blood volume. Rationale 3: Hypotonic solutions do not stay in the intravascular space long enough to expand the circulating blood volume. Rationale 4: The bore size of the needle does not affect the displacement or shifting of fluids.
A patient with neurogenic shock is demonstrating bradycardia. What action will the nurse take at this time? 1. Limit patient movement. 2. Prepare to administer crystalloids. 3. Administer phenylephrine as prescribed. 4. Administer atropine as prescribed.
Correct Answer: 4 Rationale 1: Limiting movement will not correct bradycardia in the patient with neurogenic shock. Rationale 2: Crystalloids are used to correct vasodilation. Rationale 3: Phenylephrine is used in the patient with neurogenic shock to correct hypotension. Rationale 4: Bradycardia in neurogenic shock is corrected by the administration of atropine at the dose of 0.5 to 1.0 mg intravenous every 5 minutes to a total dose of 3 mg.
A patient weighing 220 lbs is prescribed 10 mcg/kg/min of dopamine to improve cardiac output from cardiogenic shock. How many milligrams of dopamine will the patient receive in an hour?
Correct Answer: 60 Rationale : Determine the patient's weight in kg by dividing 220 lbs by 2.2 or 100 kg. Then multiply the number of mcg of medication the patient is to receive per minute by 100 kg or 10 mcg × 100 kg = 1,000 mcg. This is the dosage the patient will receive in 1 minute. To determine the amount of medication in 1 hour, multiply 1,000 mcg × 60 = 60,000 mcg. Using the conversion 1 mg = 1,000 mcg, divide 60,000 mcg by 1,000 mcg to determine that the patient will receive 60 mg of dopamine in 1 hour.
A 68-yr-old male patient diagnosed with sepsis is orally intubated on mechanical ventilation. Which nursing action is most important? a. Use the open-suctioning technique. b. Administer morphine for discomfort. c. Limit noise and cluster care activities. d. Elevate the head of the bed 30 degrees.
D
A patient recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the patient? A) Assure the patient that everything will be all right and that remaining calm is the best strategy. B) Ask a family member to interpret what the patient is trying to communicate. C) Ask the physician to wean the patient off the mechanical ventilator to allow the patient to speak freely. D)
D
A patient with a subarachnoid hemorrhage is intubated and placed on a mechanical ventilator. When monitoring the patient, the nurse will need to notify the health care provider if the patient develops a. oxygen saturation of 94%. b. respirations of 18 breaths/min. c. green nasogastric tube drainage. d. increased jugular vein distention (JVD).
D
Assisted Control Ventilation is best for which patient? A. The patient with sleep apnea B. The patient trying to wean from mechanical ventilation C. The patient who is receiving neuromuscular blocking agents D. The patient who has respiratory drive but cannot sustain normal tidal volume
D
The decision has been made to discharge a ventilator-dependent patient home. The nurse is developing a teaching plan for this patient and his family. What would be most important to include in this teaching plan? A) Administration of inhaled corticosteroids B) Assessment of neurologic status C) Turning and coughing D) Signs of pulmonary infection
D
The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate? A) Keep the patient in a low Fowlers position. B) Perform tracheostomy care at least once per day. C) Maintain continuous bedrest. D) Monitor cuff pressure every 8 hours.
D
The nurse is caring for a client who has been using mechanical ventilation for several months after an episode of sepsis and acute respiratory distress syndrome (ARDS). Which ventilator setting should the nurse anticipate the healthcare provider ordering for weaning? A. Positive end-expiratory pressure (PEEP) B. Bilevel ventilation (BIPAP) C. Assist-control mode ventilation (ACMV) D. Synchronized intermittent mandatory ventilation (SIMV)
D
What should the nurse recognize as a factor commonly responsible for sodium and fluid retention in the patient on mechanical ventilation? a. increased release of ADH b. increased release of atrial natriuretic factor c. increased insensible water loss via the airway d. decreased renal perfusion with release of renin
D
You are caring for Ms. Y. She is scheduled to begin weaning from mechanical ventilation today. Which assessment would be the best indicator of her readiness to be weaned? A) Minute ventilation greater than 10 L/min B) Respiratory rate at least 30/min C) FiO2 less than 50% D) Rapid shallow breathing index (RSBI)
D
The nurse and the UAP are helping to take care of the patient who is on a mechanical ventilator. Which of the following, if done by the UAP, requires intervention by the nurse? A) Once a day the UAP moves the ETT tube from one side of the mouth to the other B) The UAP monitors for any alarms coming from the machine C) Performs ROM exercises with the client D) Asks the patient to rate his pain using his marker board
D The nurse is responsible for assessing pain on a patient, not the UAP. All other parts are fully within the UAP's scope of practice.
ANS: C The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 2-hour rest period at this time may allow the oxygen saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the right side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung. DIF: Cognitive Level: Application REF: 1754-175
The pulse oximetry for a patient with right lower lobe pneumonia indicates an oxygen saturation of 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is best for the nurse to take? a. Position the patient on the right side. b. Place a humidifier in the patient's room. c. Assist the patient with staged coughing. d. Schedule a 2-hour rest period for the patient.
ANS: C ABG analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs provide information about the PaCO2 and pH. The other tests also may be done to help in assessing oxygenation or determining the cause of the patient's ventilatory failure. DIF: Cognitive Level: Application REF: 1752-1754 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
To evaluate the effectiveness of prescribed therapies for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse? a. Chest x-rays b. Pulse oximetry c. Arterial blood gas (ABG) analysis d. Pulmonary artery pressure monitoring
ANS: A Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest. DIF: Cognitive Level: Application REF: 1751 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? a. The patient is somnolent. b. The patient's SpO2 is 90%. c. The patient complains of weakness. d. The patient's blood pressure is 162/94.
ANS: B The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions. DIF: Cognitive Level: Application REF: 1754-1755 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
When the nurse is caring for an obese patient with left lower lobe pneumonia, gas exchange will be best when the patient is positioned a. on the left side. b. on the right side. c. in the tripod position. d. in the high-Fowler's position.
ANS: A Increasing oxygen flow rate usually will improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep-breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation. DIF: Cognitive Level: Application REF: 1747-1749 | 1754 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. The nurse will a. increase the oxygen flow rate. b. suction the patient's oropharynx. c. assist the patient to cough and deep breathe. d. help the patient to sit in a more upright position.
