Exam 4
Which finding might delay weaning a patient from mechanical ventilation support?a. Hematocrit = 42%b. Arterial PO2 = 70 mmHg on 40% FiO2c. Apical heart rate = 72 beats per mind. Oral temperature = 101
B
8. The client has three-chambered chest drainage system (Pleur-evac) in place to correct a hemothorax. Which action should the nurse take when caring for this client?1. Assess the client's respiratory status frequently.2. Loop any extra tubing to keep it off the floor.3. Maintain an open drainage system.4. Keep the client in a supine position.
1) correct - any client requiring a chest tube is at increased risk for developing dangerous respiratory changes and should be assessed frequently; physical assessment of respiration includes assessing respirations for rate, pattern, and depth; movements of chest wall and breath sounds are also asessed; normal adult brething is costal, regular, 12 to 20 breaths per minute; normal neonate breathing is diaphragmatic, irregular, and 30 to 50 breaths per minute; abnormal breathing patterns include: apnea, bradypnea, Cheye-Stokes respiration, dyspnea, hyperpnea, hyperventilation, hypoventilation, Kussmaul's respirations, orthopnea, and pradoxical respirations; ......
7. An adult is in a motorcycle accident and sustains three fractured ribs and a pneumothorax. A chest tube is inserted. The nurse should take which of the following actions?1. Monitor the fluctuation in the tube.2. Pin the tubes to the sheets.3. Clamp the tubes when transferring the patient to bed. 4. Empty the bottles every eight hours.
1) correct - closed drainage system that enables air and blood to drain from the pleural space; cessation of fluctuation may indicate blockage of the tube, or that the lung has re-expanded; fluctuation in the tube should be monitored
The high-pressure alarm of a patient's mechanical ventilator goes off. What are the potential causes for this? Select all that applya. Mucous plugb. Air leak in endotracheal tube cuffc. Patient fighting the ventilatord. Bronchospasme. Patient coughingf. Ventilator tubing disconnected
A,C,D,E
What conditions indicate the need to suction a mechanically ventilated patient? Select all that applya. Presence of rhonchi when listening to breath soundsb. Presence of moisture in the ventilator tubingc. Audible secretions in the endotracheal tubed. Low pressure alarm sounds offe. Increased peak inspiratory pressuref. Tubing becomes disconnected from the ventilator
A,C,E
What are the characteristics of a non-invasive pressure support such as BiPAP? Select all that applya. It provides noninvasive pressure support ventilation by nasal mask or face maskb. It takes over most of the work of breathing for the patientc. It is most often used for patients with sleep apnead. It delivers a breath when a patient does not breathee. It may be used for patients with respiratory muscle fatiguef. It can be used for impending respiratory failure to avoid more invasive ventilation methods
A,C,E,F
A patient with adult respiratory distress syndrome is currently in the exudative management stage. What is the focus of the nursing assessment?a. Monitor closely for progressive hypoxemiab. Note early changes in dyspnea and tachypneac. Review the x-ray reports for evidence of patchy infiltratesd. Monitor for multiple organ dysfunction syndrome
B
The nurse hears an alarm go off on a mechanical ventilator that signals the ventilator is not able to give the patient a breath. What are the possible reasons that would make this alarm go off? Select all that applya. The tubing has become disconnectedb. The patient is not breathing on his or her ownc. Pulse oximetry reading is below 90%d. The patient has become disconnected from the ventilatore. The patient needs to be suctionedf. The patient has a mucous plug blocking the airway
A,D,E,F
A patient in the critical care unit requires an emergency ET intubation. The nurse immediately obtains and prepares which supplies to assist with performing this procedure? Select all that applya. Tracheostomy tube or kitb. Resuscitation bag-valve mask devicec. Source for 100% oxygend. Suction equipmente. Airway equipment boxf. Oral airway
B,C,D,E,F
Kaplan - Thoracentesis4. The nurse is prepares a patient for a thoracentesis. The nurse should position the patient in which position?1. Semi-Fowler's 2. Upright3. On the affected side4. Prone
2) correct - a thoracentesis is the aspiration of pleural fluid or air from the pleural space; sitting upright on the edge of the bed allows for the best lung expansion, and allows for good access to the area which will be used for procedure
11. A patient with a chest tube asks the nurse about the bubbling he sees in the water seal chamber of his drainage equipment. Which response by the nurse is the MOST appropriate?1. "It's supposed to do that."2. "It shows your lung has not yet re-expanded."3. "Why don't you ask your doctor?"4. "What do you think it means?"
2) correct - this response provides a true, factual answer
The low-pressure alarm of a patient's mechanical ventilator goes off. What are potential causes for this? Select all that applya. Blockage in the circuitb. Cuff leak in the endotracheal or tracheostomy tubec. Patient stopping breathingd. Cuff of the endotracheal or tracheostomy tube over inflatede. Leak in the circuitf. Patient biting on oral endotracheal tube
B,C,E
A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?a.Assess the cause of the agitation.b.Reassure the client that he or she is safe.c.Restrain the client's hands.d.Sedate the client immediately.
A
A patient has a history of COPD on a mechanical ventilator. The nurse obtained an order for which type of dietary therapy for this patient?a. High fat nutritional supplementb. High protein nutritional supplementc. High carbohydrate nutritional supplementd. High calorie nutritional supplement
A
The charge nurse in the intensive care unit is reviewing the patient census and caseload to identify staffing needs and potential transfers. Which patient might take the longest time to wean from a ventilator?a. 54-year-old man with metastatic colon cancer who has been intubated for six daysb. 32-year-old woman recovering from a general anesthetic following a tubal ligationc. 25-year-old man intubated for 28 hours after an anaphylactic reactiond. 49-year-old man with a gunshot wound to the chest he was intubated for 8 hours
A
The nurse notices that a patient has a gradual increase in peak inspiratory pressure over the last several days. What is the best nursing intervention for this patient?a. Assess for a reason such as adult respiratory distress syndrome (ARDS) or pneumoniab. Continue to increase peak airway pressure as neededc. Change to another mode such as intermittent mandatory ventilation (IMV)d. Make arrangements for permanent ventilatory support
A
The nursing student is assisting in the care of a critically ill patient on a ventilator. Which action by the student nurse requires intervention by the supervising nurse?a. Deflates the cuff of the ET tube to check placementb. Applies soft wrist restraints as orderedc. Suctions the patient for 10 seconds at a timed. Maintains the correct placement of the ET tube
A
What is the cardiac problem that can occur from mechanical ventilation?a. Hypotensionb. Dehydrationc. Bradycardiad. Hypertension
A
Which patient has the greatest risk for developing adult respiratory distress syndrome (ARDS)?a. 74-year-old who aspirates a tube feedingb. 34-year-old with chronic renal failurec. 56-year-old with uncontrolled diabetes mellitusd. 18-year-old with a fractured femur
A
The nurse is caring for several patients on the medical surgical unit who are experiencing acute respiratory problems. Which conditions may eventually require a patient to be intubated? Select all that applya. Trouble maintaining a patent airway because of mucosal swellingb. History of congestive heart failure and demonstrating orthopneac. Copious secretions and lacking muscular strength to coughd. Pulse oximetry of 93% with a high flow oxygen face maske. Increasing fatigue because of the work of breathingf. COPD patient with SpO2 90% able to cough up secretions
A,C,E
Which intervention for a client in the intensive care unit (ICU) will decrease the incidence of "ICU psychosis?"A) Decreasing nighttime disruptionsB) Keeping the lights on to promote orientationC) Administering sedationD) Providing television or radio for stimulation(Chp. 32, elsevier resources)
A) Decreasing nighttime disruptions(Chp. 32, elsevier resources)
All of these nursing actions are included in the plan of care for a client who has just been extubated. Which action should the nurse delegate to unlicensed assistive personnel (UAP)?A) Keep the head of the bed elevated.B) Teach about incentive spirometer use.C) Monitor vital signs every 5 minutes.D) Adjust the nasal oxygen flow rate.(Chp. 32, elsevier resources)
A) Keep the head of the bed elevated.(Chp. 32, elsevier resources)
The nurse caring for a client who is intubated and receiving mechanical ventilation notes that her oxygen saturation is 89%, her heart rate is 120 beats/min, and she is increasingly agitated and restless. On auscultation, the nurse finds that the lung sounds are diminished on one side. Which action does the nurse perform first? A) Notify the provider, and prepare for re-intubation or repositioning the tube.B) Document the findings, and request sedation from the provider.C) Call respiratory therapy to obtain a set of arterial blood gases.D) Reposition the tube, and call radiology for a stat chest x-ray.(Chp. 32; p. 616)
A) Notify the provider, and prepare for re-intubation or repositioning the tube.(Chp. 32; p. 616)
The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)a.Adherence to proper hand hygieneb.Administering anti-ulcer medicationc.Elevating the head of the bedd.Providing oral care per protocole.Suctioning the client on a regular schedule
A,B,C,D
A patient has been successfully intubated by the healthcare provider, And the nurses and respiratory therapist are securing the tube in place. What does the nurse include in the documentation regarding the intubation procedure? Select all that applya. Presence of bilateral and equal breath soundsb. Level of the tubec. Changes in vital signs during the procedured. Rate of the IV fluidse. Presence (or absence) of dysrhythmiasf. Placement verification by end tidal carbon dioxide levels
A,B,C,E,F
The nurse is caring for a patient on a mechanical ventilator. Which assessment does the nurse perform for this patient? Select all that applya. Observe the patient's mouth around the tube for pressure ulcersb. Auscultate lungs for crackles, wheezes, equal breath sounds, and decreased or absent breath soundsc. Assess the placement of the ET tubed. Check at least every 24 hours to be sure the ventilator settings are as prescribede. Check to be sure alarms are setf. Observe the patients need for tracheal, oral, or nasal suctioning every two hours
A,B,C,E,F
The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.)a.Chest wall stiffnessb.Decreased muscle strengthc.Inability to cooperated.Less lung elasticitye.Poor vision and hearing
A,B,D
What are the characteristics of a mechanical ventilator that is time cycled? Select all that applya. It needs an artificial airway such as a tracheostomy or endotracheal tubeb. It is a positive pressure ventilatorc. Its tidal volumes are variabled. Preset inspiration and expiration rate can be set with possible variation of tidal volumee. Inspiratory time is variablef. A preset volume of air delivered with each breath
A,B,D
Which patient on mechanical ventilators are at high risk for barotraumas? Select all that applya. Patient with adult respiratory distress syndrome (ARDS)b. Patient with underlying chronic airflow limitationc. Patient on Bi-level positive airway pressure (BiPAP)d. Patient on positive end expiratory pressure (PEEP)e. Patient on synchronized intermittent mechanical ventilation (SIMV)f. Patient receiving low level of pressure support
A,B,D
A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)a.Allow visitors at the client's bedside.b.Ensure the client can communicate if awake.c.Keep the television tuned to a favorite channel.d.Provide back and hand massages when turning.e.Turn the client every 2 hours or more.
A,B,D,E
Which conditions are related to acute respiratory distress syndrome? Select all that applya. Lung fluid increasesb. A systemic inflammatory response occursc. The lungs dry out and become stiff lungd. Volume is decreasede. Hypoxemia resultsf. Surfactant production is increased
A,B,D,E
What are the characteristics of a mechanical ventilator that is volume cycled? Select all that applya. It pushes air into the lungs until a preset volume is deliveredb. A constant volume of air is delivered regardless of the pressure needed to deliver itc. Pressure limits very to prevent damage to the structures of the lungsd. Tidal volume delivered varies based on chest wall compliancee. It is a positive pressure ventilatorf. This ventilator is primarily used during surgery and postoperatively
A,B,E
Which action should the nurse take first for the client who is admitted to the emergency department (ED) with a panic attack and whose blood gases indicate respiratory alkalosis?A. Encourage the client to take slow breaths.B. Obtain a prescription for a fluid and electrolyte infusion.C. Administer oxygen using ED standard orders.D. Place an emergency cart close to the client's room.
A. Because respiratory alkalosis is caused by hyperventilation, the nurse's first action should be to assist the client in slowing the respiratory rate.
A new nurse graduate is caring for a postoperative client with the following arterial blood gases (ABGs): pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%. Which of these actions by the new graduate is indicated?A. Encourage the client to use the incentive spirometer and to cough.B. Administer oxygen by nasal cannula.C. Request a prescription for sodium bicarbonate from the health care provider.D. Inform the charge nurse that no changes in therapy are needed.
A. Encourage the client to use the incentive spirometer and to cough.Respiratory acidosis is caused by CO2 retention and impaired chest expansion secondary to anesthesia. The nurse takes steps to promote CO2 elimination, including maintaining a patent airway and expanding the lungs through breathing techniques.
A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax?a.When the insertion site becomes red and warm to the touchb.When the tube drainage decreases and becomes sanguineousc.When the client experiences pain at the insertion sited.When the tube becomes disconnected from the drainage system
D
. The nurse is caring for an infant with bronchopulmonary dysplasia (BPD) who has RSV. Which treatment measure does the nurse prepare to provide?a. Pancreatic enzymesb. Cool humidified oxygenc. Erythromycin intravenouslyd. Intermittent positive pressure ventilation
ANS: BHumidified oxygen is delivered if the oxygen saturation level drops to less than 90%. Pancreatic enzymes are used for patients with cystic fibrosis. Antibiotics are ineffective against viral illnesses. Assisted ventilation is not necessary in the treatment of RSV infections.
A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?a.Assessing that the ventilator settings are correctb.Ensuring there is a bag-valve-mask in the roomc.Obtaining personal protective equipmentd.Planning to suction the client upon arrival to the room
B
A patient is admitted after a near drowning and develops adult respiratory distress syndrome (ARDS), which is confirmed by the healthcare provider. The nurse prepares equipment for which treatment?a. Oxygen therapy via continuous positive airway pressure (CPAP)b. Mechanical ventilation and endotracheal tubec. High flow oxygen via face maskd. Tracheostomy tube
B
After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client's understanding. Which action demonstrates that the client correctly understands the teaching?a.The client lays on his or her side with his or her knees bent.b.The client places his or her hands on his or her abdomen.c.The client lays in a prone position with his or her legs straight.d.The client places his or her hands above his or her head.
B
The nurse is assisting with an emergency intubation for a patient in severe respiratory distress. Although the healthcare provider is experienced, the procedure is difficult because the patient has severe kyphosis. At what point does the nurse intervene?a. First intubation attempt last longer than 15 secondsb. First intubation attempt last longer than 30 secondsc. Second intubation attempt was unsuccessfuld. Second intubation attempt causes the patient to struggle
B
The nurse is caring for a patient on mechanical ventilator. During the shift, the nurse hears the patient talking to himself. What does the nurse do next?a. See if the patient has a change of mental statusb. Check the inflation of the pilot balloonc. Assess the pulse oximetry for saturation leveld. Evaluate the patient's readiness to be weaned
B
The nurse is reviewing the arterial blood gas results for a patient. The latest ABGs show pH 7.48, HCO3 23 mEq/L, PaC02 25 mmHg, and Pa02 98 mmHg. What is the correct interpretation of these lab findings?a. Chronic respiratory alkalosis with compensationb. Acute respiratory alkalosis and hyperventilationc. Acute respiratory acidosis and hypoventilationd. Chronic respiratory acidosis and hypoventilation
B
The nurse receives report on a patient with adult respiratory distress syndrome (ARDS) who has been intubated for six days and has progressive hypoxemia that responds poorly to high levels of oxygen. This patient is in which phase of ARDS case management?a. Exudative phaseb. Fibroproliferative phasec. Resolution phased. Recovery phase
B
The nursing student is assisting in the care of a patient on a mechanical ventilator. Which action by the student contributes to the prevention of ventilator acquired pneumonia (VAP)?a. Suctions the patient frequentlyb. Performs oral care every two hoursc. Encourages visitors to wear masksd. Obtains a sputum culture
B
While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first?a.Assess for drainage from the site.b.Cover the insertion site with sterile gauze.c.Contact the provider and obtain a suture kit.d.Reinsert the tube using sterile technique.
B
Which client needs immediate attention by the nurse?A) A 40-year-old who is receiving continuous positive airway pressure and has intermittent wheezingB) A 54-year-old who is mechanically ventilated and has tracheal deviationC) A 57-year-old who was recently extubated and is reporting a sore throatD) A 60-year-old who is receiving O2 by facemask and whose respiratory rate is 24 breaths/min
B) A 54-year-old who is mechanically ventilated and has tracheal deviation(Chp. 32, elsevier resources)
A ventilated client in the intensive care unit (ICU) begins to pick at the bedcovers. Which action should the nurse take next?A) Increase the sedation.B) Assess for adequate oxygenation.C) Explain to the client that he has a tube in his throat to help him breathe.D) Request that the family leave to decrease the client's agitation.(Chp. 32, elsevier resources)
B) Assess for adequate oxygenation.(Chp. 32, elsevier resources)
The nurse coming on shift prepares to perform an initial assessment of a sedated, ventilated client. Which are priorities for the nurse to carry out? Select all that apply.A) Ask visitors to leave.B) Assess the client's color and respirations.C) Confirm alarms and ventilator settings.D) Ensure that the tube cuff is inflated and is in the proper position.E) Listen for bilateral breath sounds.F) Provide routine tracheotomy and endotracheotomy and mouth care.(Chp. 32, elsevier resources)
B) Assess the client's color and respirations.C) Confirm alarms and ventilator settings.D) Ensure that the tube cuff is inflated and is in the proper position.E) Listen for bilateral breath sounds.(Chp. 32, elsevier resources)
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?A) Oropharyngeal airwayB) Bi-level positive airway pressure (BiPAP)C) Non-rebreather mask with 100% oxygenD) Positive end-expiratory pressure (PEEP)(Chp. 32, elsevier resources)
B) Bi-level positive airway pressure (BiPAP)(Chp. 32, elsevier resources)
The client with which condition is in greatest need of immediate intubation?A) Difficulty swallowing oral secretionsB) Hypoventilation and decreased breath soundsC) O2 saturation of 90%D) Thick, purulent secretions and crackles(Chp. 32, elsevier resources)
B) Hypoventilation and decreased breath sounds(Chp. 32, elsevier resources)
The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure. Which findings would cause the nurse to suspect a left-sided tension pneumothorax?A) The chest caves in on inspiration and "puffs out" on expiration.B) The trachea is deviated to the right side and cyanosis is present.C) The left lung field is dull to percussion with crackles present on auscultation.D) The client has bloody sputum and wheezes.(Chp. 32, elsevier resources)
B) The trachea is deviated to the right side and cyanosis is present.(Chp. 32, elsevier resources)
A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.)a.Production of pink sputumb.Tracheal deviationc.Sudden onset of shortness of breathd.Pain at insertion sitee.Drainage of 65 mL/hr
B,C
What are the characteristics of a mechanical ventilator that is pressure cycled?1. select all that applya. Preset inspiration and expiration rate is programmed with possible variation of tidal volume and pressureb. It is a positive pressure ventilatorc. It pushes air into the lungs until a preset airway pressure is reachedd. There is no need for an artificial airway such as a tracheostomy or endotracheal tubee. Tidal volumes and inspiratory times are variedf. The ventilator is used for a short period of time
B,C,E,F
A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.)a.Production of pink sputumb.Tracheal deviationc.Pain at insertion sited.Sudden onset of shortness of breathe.Drainage greater than 70 mL/hrf.Disconnection at Y site
B,D,E,F
The nurse is caring for a patient who has just been extubated. What interventions will the nurse use in caring for this patient? Select all applya. Monitor vital signs every 30 minutes at firstb. Assess the ventilatory pattern for manifestations of respiratory distressc. Place the patient in recumbent positiond. Instruct the patient to take deep breaths every half houre. Encourage use of an incentive spirometer every two hoursf. Advise the patient to limit speaking right after extubation
B,D,E,F
Which client is most likely to exhibit the following ABG results: pH, 7.30; PaCO2, 49; HCO3−, 26; PO2, 76?A. Client with kidney failureB. Client taking hydromorphone (Dilaudid)C. Client with anxiety disorderD. Client with hyperkalemia
B. Client taking hydromorphone (Dilaudid). this ABG reading reflects respiratory acidosis.Hydromorphone (Dilaudid), a narcotic analgesic, can cause respiratory depression, hypoventilation, and respiratory acidosis, as this blood gas reading demonstrates
A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?a.Apply oxygen at 100%.b.Assess the respiratory rate.c.Ensure a patent airway.d.Start two large-bore IV lines.
C
A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?a.Assess the client for sedation needs.b.Get family permission for restraints.c.Provide frequent oral care per protocol.d.Use nonverbal pain assessment tools.
C
A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?a.Ensure the client has adequate sedation.b.Find another provider to intubate.c.Interrupt the procedure to give oxygen.d.Monitor the client's oxygen saturation.
C
A patient in the emergency department required emergency intubation for status asthmaticus. Immediately after the insertion of the endotracheal tube, what is the most accurate method for the nurse and/or healthcare provider to use to verify correct placement?a. Observe for chest excursionb. Listen for expired air from the ET tubec. Check end tidal carbon dioxide levelsd. Wait for the results of the chest x-ray
C
A patient on a ventilator is biting and chewing at the endotracheal (ET) tube. Which nursing intervention is used for ET management?a. Reassure the patient that everything is okayb. Administer a paralyzing agentc. Insert an oral airwayd. Frequently suction the mouth
C
A patient with a tracheostomy who is on a mechanical ventilator is beginning to take spontaneous breaths at his own rate and tidal volume between set ventilator breaths. Which mode is the ventilator on?a. Assist control (AC) ventilationb. Bi-Level positive airway pressure (BiPAP)c. Synchronized intermittent ventilation (SIMV)d. Continuous flow (flow-by)
C
An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority?a.Determine if the tube is kinked.b.Ensure all connections are patent.c.Listen to the client's lung sounds.d.Suction the endotracheal tube.
C
The nurse hears in shift report that a patient has been agitated and pulling at the endotracheal tube. Soft restraints have recently been ordered and placed, but the patient continues to move his head and chew at the tube. What does the nurse do to ensure proper placement of the ET tube?a. Suction the patient frequently through the oral airwayb. Talk to the patient and tell him to calm downc. Mark the tube where it touches the patient's teethd. Auscultate for breath sounds every four hours
C
The nurse is assessing a patient who was extubated several hours ago. Which patient finding warrants notification of the rapid response team?a. Hoarsenessb. Report of sore throatc. Inability to expectorate secretionsd. 90% saturation on room air
C
The nurse is performing a check of the ventilator equipment. What is included during the equipment check?a. Drain the condensed moisture back into the humidifierb. Empty the humidifier and the drainage tubingc. Note the prescribed and actual settingsd. Turn off the alarms during the system check
C
Which assessment finding is considered an early sign of adult respiratory distress syndrome?a. Adventitious lung soundsb. Hyperthermia and hot, dry skinc. Intercostal and suprasternal retractionsd. Heightened mental acuity and surveillance
C
The nurse is teaching the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate?A) "Sedation is needed so your loved one does not rip the breathing tube out."B) "Suctioning is important to remove organisms from the lower airway."C) "Paralysis and sedatives help decrease the demand for oxygen."D) "We are encouraging oral and IV fluids to keep your loved one hydrated."(Chp. 32, elsevier resources)
C) "Paralysis and sedatives help decrease the demand for oxygen."(Chp. 32, elsevier resources)
Which critically ill client has the greatest risk for developing acute respiratory distress syndrome (ARDS)?A) Client with diabetic ketoacidosis (DKA)B) Client with atrial fibrillationC) Client with aspiration pneumoniaD) Client with acute kidney failure(Chp. 32, elsevier resources)
C) Client with aspiration pneumonia(Chp. 32, elsevier resources)
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?A) Check the ventilator alarm settings.B) Assess the set tidal volume.C) Listen to the client's breath sounds.D) Call the respiratory therapist.(Chp. 32, elsevier resources)
C) Listen to the client's breath sounds.(Chp. 32, elsevier resources)
A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take?a.Ambulate the client in the hallway to promote deep breathing.b.Auscultate the client's anterior and posterior lung fields.c.Encourage the client to take shallow breaths to help with the pain.d.Administer pain medication and encourage the client to take deep breaths.
D
The nurse is caring for a group of clients with acidosis. The nurse recognizes that Kussmaul respirations are consistent with which situation?A. Client receiving mechanical ventilationB. Use of hydrochlorothiazideC. Aspirin overdoseD. Administration of sodium bicarbonate
C. Aspirin overdose.. If acidosis is metabolic in origin, the rate and depth of breathing increase as the hydrogen ion level rises; this is known as Kussmaul respirations. Metabolic acidosis is caused by alcoholic beverages, methyl alcohol, and acetylsalicylic acid (aspirin)
The nurse is caring for a client with an oxygen saturation of 88% and accessory muscle use. The nurse provides oxygen and anticipates which of these physician orders?A. Administration of IV sodium bicarbonateB. Computed tomography (CT) of the chest, statC. Intubation and mechanical ventilationD. Administration of concentrated potassium chloride solution
C. Intubation and mechanical ventilation.Support with mechanical ventilation may be needed for clients who cannot keep their oxygen saturation at 90% or who have respiratory muscle fatigue.
Which acid-base disturbance does the nurse anticipate the client with morbid obesity may develop?A. Metabolic acidosisB. Metabolic alkalosisC. Respiratory acidosisD. Respiratory alkalosis
C. Respiratory acidosis is related to CO2 retention secondary to respiratory depression, inadequate chest expansion, airway obstruction, and reduced alveolar-capillary diffusion, common in the morbidly obese, who experience inadequate chest expansion owing to their size and work of breathing.
A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best?a."It will increase the motility of the gastrointestinal tract."b."It will keep the gastrointestinal tract functioning normally."c."It will prepare the gastrointestinal tract for enteral feedings."d."It will prevent ulcers from the stress of mechanical ventilation."
D
A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?a.Strip the tubing to minimize clot formation and ensure patency.b.Secure tubing junctions with clamps to prevent accidental disconnections.c.Connect the chest tube to wall suction at the level prescribed by the provider.d.Keep padded clamps at the bedside for use if the drainage system is interrupted
D
A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority?a.The client is able to initiate spontaneous breaths.b.The inspired oxygen has adequate humidification.c.The upper peak airway pressure limit alarm is off.d.The upper peak airway pressure limit alarm is on.
D
A patient is being extubated and the nurse has emergency equipment at the bedside. Which intervention is implemented during extubation?a. Ensure that the cuff is inflated at all timesb. Remove the tube during expirationc. Instruct the patient to pant while the tube is removedd. Instruct the patient to cough after the tube is removed
D
A patient who is on a mechanical ventilator needs a set volume and set rate delivered because the patient is not able to do the work of breathing. To what mode must the ventilator be set?a. Positive end expiratory pressure (PEEP)b. Continuous positive airway pressure (CPAP)c. Bi-level positive airway pressure (BiPAP)d. Assist control
D
A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best?a."It is chronic hypoxemia that accompanies restrictive airway disease."b."It is hypoxemia from lung damage due to mechanical ventilation."c."It is hypoxemia that continues even after the client is weaned from oxygen."d."It is hypoxemia that persists even with 100% oxygen administration."
D
The nurse is caring for a patient who was recently extubated. What is an expected assessment finding for this patient?a. Stridorb. Dyspneac. Restlessnessd. Hoarseness
D
The patient is to be extubated. What action does the nurse perform first?a. Hyperoxygenate the patientb. Rapidly deflate the cuff the ET tubec. Thoroughly suction both the ET tube and the oral cavityd. Explain the procedure
D
The provider instructs the nurse to watch for and report signs and symptoms of improvement so the patient can be weaned from the ventilator. Which assessment finding indicates the patient is ready to be weaned?a. Indications that respiratory infection is resolvingb. Showing signs of becoming ventilator dependentc. Maintaining blood gases within normal limitsd. Patient receiving only 1 to 2 mechanical ventilator breaths per minute
D
A client was intubated 30 minutes ago for acute respiratory distress syndrome and possible sepsis. The following orders have been given for the client. In what sequence would the nurse perform these orders for this client? 1. Infuse levofloxacin (Levaquin) 500 mg IV.2. Obtain baseline aerobic and anaerobic sputum cultures.3. Teach the client and family methods of communicating.4. Analyze postintubation arterial blood gases (ABGs).A) 2, 1, 3, 4B) 4, 3, 1, 2C) 3, 4, 2, 1D) 4, 2, 1, 3
D) 4, 2, 1, 3(Chp. 32, elsevier resources)
A student nurse is working with a client in the ICU who is intubated and being mechanically ventilated. What action by the student causes the registered nurse to intervene? A) Repositioning the client every 2 hoursB) Providing oral care with chlorhexidine rinseC) Checking tube placement at the client's incisorD) Turning off ventilator alarms while working in the room(Chp. 32; p. 619)
D) Turning off ventilator alarms while working in the room(Chp. 32; p. 619)
When caring for a group of clients at risk for respiratory acidosis, the nurse identifies which person as at highest risk?A. An athlete in trainingB. Pregnant woman with hyperemesis gravidarumC. Person with uncontrolled diabetesD. Client who smokes cigarettes
D. Client who smokes cigarettes.Cigarette smoking worsens gas exchange, leading to disorders that contribute to hypoventilation and respiratory acidosis
Therapy for BPD includes:
Good NutritionSupport Respiratory FunctionO2 with humidityChest Physiotherapy and medicationAgressive antibiotic with infectionsLONG TERM THERAPY:Tracheostomy
BPD is the result of what?
Positive-pressure ventilation and oxygen treatment for respiratory failure/distress.(damages and stretches alveoli)
Nursing Intervention/implementation includes:
Reduce physical stimulationPosition infant to breathe easierMedication as orderedProvide fluids and nutrition*Closely monitor fluids*High calorie formula
An infant with BPD will have the following manifestations?
Respiratory Distress Barrel-shaped ChestTachypnea Mucus PluggingNasal Flaring Air-trappingGrunting Broncho SpasmRetractionsWheezingCracklesIrritabilityCyanosis (severe cases)
A patient is intubated and has mechanical ventilation with positive and expiratory pressure. Because this patient is at risk for a tension pneumothorax, what is the nurses priority action?a. Assess lung sounds every 30 to 60 minutesb. Obtain an order for an arterial blood gasc. Have chest tube equipment on standbyd. Direct to the UAP to turn the patient every two hours
a
6. Which statement is most accurate?a. If drainage system is damaged, place disconnected drainage tube in sterile waterb. If drainage system is damaged, occlude drainage tube with surgical tapec. If drainage system is damaged, place disconnected drainage tube in isopropyl alcohold. If drainage system is damaged, twist drainage tube to prevent fluid losse. If drainage system is damaged, patch any leaks in the tubing with surgical tapef. If drainage system is damaged, place disconnected drainage tube in loosely wrapped gauze
a In the event that the drainage system breaks, it is critical to have a bottle of sterile water at the bedside. If this happens, insert the loose end of the patient's chest tube into a bottle of sterile water. Keep the bottle below the level of the chest until a new drainage system can be delivered.
2. During your assessment of a patient with a pneumothorax, which of the following is most likely to be seen?a. decreased or absent breath sounds on affected sideb. jugular venous distention (JVD)c. Rhonchi on unaffected sided. Inspiratory Stridord. increased breath sounds on affected sid
a The extent of the pneumothorax will determine how much air flow will occur through the lung. breath sounds will not be heard in the lobe(s) that are fully collapsed. Take note that some patients already present with diminished lung sounds because of their anatomy.
Picmonic - pneumothorax1. During your assessment of a patient with a pneumothorax, which of the following is most likely to be seen?a. crepitusb. meconium ileusc. steatorrhead. increased urine outpute. salty taste to skin
a Occurs in open pneumothorax. Air can become trapped in the subcutaneous tissue resulting in crepitus. Sometimes described as feeling like rice crispy treats under the skin.
3. Which statement is most acurate?a. if the dislodges from patient, clean with alcohol solutionb. if tube dislodges from patient, use petroleum gauze taped 3 waysc. if tube dislodges from patient, use zinc oxide & gauze taped 3 waysd. if tube dislodges from patient, use surgical tape over sitee. if tube dislodges from patient, clean with sterile waterf. if tube dislodges from patient, use regular gauze taped 3 ways
b If the chest tube dislodges from the patient, the insertion site should be covered with sterile occlusive dressing taped on 3 sides.
8. Which finding in the suction system indicates a significant air leak?a. shortness of breathb. excessive bubblingc. No bubblingd. hypoxemiae. chest painf. minimal bubbling
b Excessive bubbling in the water seal chamber indicates an air leak in the system. Regularly assess the system for possible causes or leaks. However, gentle intermittent bubbling should be expected with patients that have known pneumothorax.
When caring for a client with a pulse oximetry level of 89%, which action should the nurse take first?A. Get the client out of bed.B. Apply oxygen as prescribed.C. Notify the client's physician.D. Auscultate breath sounds.
b.Apply oxygen as prescribed. Applying oxygen is the first priority for a client with hypoxemia..
1. What is the physical exam finding associated with subcutaneous emphysema?a. respiratory depressionb. hematemesisc. dyspnea and respiratory distressd. crepituse. hypertventilationf. coughing
d Crepitus occurs when gas or air leaks into the subcutaneous layer of the skin, which is a phenomenon also called subcutaneous emphysema. This can indicte an air leak or the need for a dressing change. Notify the doctor if crepitus is felt.
4. Which finding should prompt urgent reevaluation of a patient with a chest tube?a. diarrheab. dry mouthc. constipationd. arthritise. shortness of breathf. malar rash
e Assess the patient's respiratory status regularly, and auscultate lung for any sound changes. Any clinical changes, such as the development of shortness of breath can indicate a functional problem. Air leaks, and extended pneumothorax, or a hemothorax can put the patient in respiratory distress.
7. When there is no oscillation in the water chamber, what should you check the suction system for?a. Excessive suctionb. Air leakc. Impaired oxygenationd. Inadequate suctione. contaminationf. kinking
f The water in the water seal chamber should oscillate; specifically, the level will move up during inhalation and move down during exhalation. When there is no oscillation in the chamber, check the line for kinks.
