evolve chap 34

The registered nurse is overseeing a nursing student who is administering medications to a group of clients with pulmonary disorders. Under which circumstance does the nurse correct the student?

"You will receive enoxaparin (Lovenox) through the intravenous line for 3 days."

Which client has a higher risk for developing a pulmonary embolism (PE)?

25-year-old woman who frequently flies to different countries

Which client needs immediate attention by the RN?

54-year-old who is mechanically ventilated and has tracheal deviation

The nurse is caring for a group of clients. Which person does the nurse identify as having the highest risk for pulmonary embolism (PE)?

A client returning from an open reduction and internal fixation of the tibia

The nurse is caring for a group of critically ill clients. Which client has the greatest risk for developing acute respiratory distress syndrome (ARDS)?

A client with aspiration pneumonia

1The ventilated client in the intensive care unit begins to pick at the bedcovers. Which action should the nurse take next

Assess for adequate oxygenation,

The nurse coming on shift prepares to perform an initial assessment of the sedated ventilated client. Which are priorities for the nurse to carry out? Select all that apply.

Assess the client's color and respirations. confirm alarms and ventilator settings. Ensure that the tube cuff is inflated and is in the proper position. Listen for bilateral chest sounds.

The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which method provides an alternative to mechanical ventilation

Bi-level positive airway pressure (BiPAP)

The nurse is caring for a group of clients. Which clients should be monitored closely for respiratory failure? Select all that apply.

Client with a brainstem tumor Client with acute pancreatitis Client using patient-controlled analgesia

Which intervention for the client in the intensive care unit will decrease the incidence of "ICU psychosis"?

Decreasing nighttime disruptions

The nurse is assessing a client with possible pulmonary embolism. For which symptoms should the nurse assess? Select all that apply.

Dizziness and fainting Inspiratory chest pain

The nurse is caring for a group of clients. The client with which condition is in greatest need of immediate intubation?

Hypoventilation and decreased breath sounds

The nurse is developing the plan of care for the client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority?

Hypoxemia related to ventilation-perfusion mismatch

The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action should the nurse take first?

Listen to the client's breath sounds.

The client has been admitted for a pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care?

Monitor the platelet count daily.

The nurse is teaching the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate?

Paralysis and sedatives help decrease the demand for oxygen.

Which intervention will be most effective in reducing anxiety in the client with a pulmonary embolism (PE)?

Remain with the client, and provide oxygen in a calm manner

The medical-surgical unit nurse should call the Rapid Response Team to assess which of these clients?

The client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright red hemoptysis

The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure (PEEP). Which findings would cause the nurse to suspect a left-sided tension pneumothorax?

Trachea is deviated to the right side and cyanosis is present.

The nurse is caring for a client who was discharged 3 weeks ago after a diagnosis of pulmonary embolism (PE). He is currently admitted with gastrointestinal bleeding and an international normalized ratio (INR) of 6.9. For which of the following should the nurse assess this client?

Use of aspirin or salicylates

All of these nursing actions are included in the plan of care for a client who has just been extubated. Which action should the RN delegate to unlicensed assistive personnel (UAP)?

a. Keep the head of the bed elevated.

When caring for a client with pulmonary embolism, which blood gas result does the nurse anticipate early in the course of the disease?

pH 7.46, PCO2 30, HCO 26, PO2 68