Gas Exchange lvl4 exam 2
A young adult female patient with cystic fibrosis (CF) tells the nurse that she is not sure about getting married and having children someday. Which initial response by the nurse is best?
"Do you need any information to help you with that decision?"
A client who experienced a pulmonary embolus is receiving heparin therapy. The client will now also start receiving sodium warfarin (Coumadin). When the client asks the nurse why both medications are being given, the best response by the nurse is
"It takes several days for the warfarin to become therapeutic."
A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, "Will my children have cystic fibrosis?" How should the nurse respond?
"Since you have a family history of cystic fibrosis, I would encourage you and your partner to be test."
A client as a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?
"The blood clot interferes with perfusion in the lungs."
A pt with pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (SATA
) Delegate a back rub to the unlicensed assistive personnel (UAP), Give simple explanations of what is happening, Acknowledge the frightening nature of the illness, Stay with the patient and speak in a quiet, calm voice.
The nurse receives change of shift report on the following four patients. Which patient should the nurse assess first?
A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath.
A 62 y/o man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory findings to include:
A hemoglobin (Hgb) of 8.6 g/dL (86g/L).
A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority?
Administer oxygen
As part of immediate care plan for a client with pulmonary edema and a nursing diagnosis of Impaired Gas Exchange, the nurse would?
Administer oxygen as ordered using high-flow rebreather bag.
A client who underwent surgery is intubated and receiving mechanical ventilation. The client is receiving a neuromuscular blocking agent to stop spontaneous breathing that is not in synchrony with the ventilator. The appropriate approach by the nurse to the client' s postoperative pain control would be?
An analgesic is needed specifically for pain control and must be given as needed along with the neuromuscular blocker & a sedative or anxiolytic.
A patient is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)
Apply water- soluble ointment to nares and lips.
A nurse answers a call light and finds a patient anxious, SOB, reporting chest pain, and having a blood pressure of 88/52 mmHg. Which action by the nurse takes priority?
Assess the patient's lung sounds
A pt with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, BP of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first?
Elevate the HOB to a semi-Fowler's position.
A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an oxygen saturation (Sp02) of 88%. The patient is increasingly lethargic. Which Intervention will the nurse anticipate?
Endotracheal intubation and positive pressure ventilation.
A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority?
Ensure patient has patent airway.
A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best?
Give the client pain medication if it is time for another dose.
A client is admitted to the hospital with a diagnosis of pulmonary embolism. Which problem should the nurse address first?
Impaired gas exchange
A patient is on intravenous heparin to treat a pulmonary embolism. The patients most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
Increase the heparin rate.
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen (Sp02) from 94% to 88%. Which action should the nurse take first?
Increase the oxygen flow rate.
The nurse is assessing the lab work of a client with a pulmonary embolism. The client's INR is 5.8. The most appropriate action by the nurse is to
Institute safety precautions for the client
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?
Interrupt the procedure to give oxygen.
A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?
Keep the lower extremities warm.
A patient is being discharged soon on warfarin (coumadin). What menu selection for dinner indicates that the patient needs more education regarding this medication?
Large chef's salad and muffin.
A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation... pneumothorax. Which action will the nurse anticipate taking next?
Lower the positive end- expiratory pressure (PEEP).
A client presents to the emergency department having a severe sickle cell crisis. The nurse should initially do which of the following interventions? (SATA)
Offer heat therapy, Start an IV with normal saline, Administer oxygen, Prepare to give IV morphine.
A young female client with cystic fibrosis (CF) wishes to become pregnant but is concerned about the effect of CF on fertility. The nurse bases a response with the understanding that:
Only about 20% of women with CF are infertile.
To determine if the client has a risk factor related to pernicious anemia, the nurse could ask, "Has the client had a...
Operation involving the stomach?"
A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care?
Perform chest physiotherapy every 4 hours
A nurse is caring for four patients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect occurred?
Platelet count: 82,000/L (82 x 10^9/L)
Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?
Potential complications: Infection
A client who extubated 2 hours ago is becoming increasingly restless. The last vital signs before extubating were pulse 88 beats/min, respirations 18 breaths/min, blood pressure 138/78 mmHg, and PaC02 4SmmHg. Current vital signs include pulse 104 beats/min, respirations 26 breaths/min, blood pressure 158/92 mmHg, and PaC02 62 mmHg. The nurse would
Prepare to assist with reintubation.
A client was brought to the emergency department after sustaining injuries in a severe car crash. Assessment of the client's... paradoxical abnormal movement with respirations, oxygen saturation is 82%, and the client is dyspneic and cyanotic. What is the priority?
Prepare to assist with stat intubation.
The nurse explains that the definitive laboratory finding confirming the diagnosis of sickle cell anemia is:
Presence of hemoglobin S (Hgb S)
A patient is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?
Provide frequent oral care protocol.
The nurse caring for mechanically ventilated patients uses best practices to prevent ventilator associated pneumonia. What actions are included in this practice? (SATA)
Providing oral care per protocol, Elevating the HOB, Adherence to proper hand hygiene, Administering antiulcer medication.
The nurse monitoring a client with early onset adult respiratory distress syndrome (ARDS) would closely assess for
Pulmonary Edema
When a client developed a hemothorax, the physician inserted a chest catheter connected to a drainage system. In the first 2 hours, 900 ml of blood drainage was collected. The nurse would?
Report this to the physician immediately.
The nurse caring for a client with cystic fibrosis would select as the highest priority the nursing diagnosis of?
Risk for ineffective airway clearance.
A pt with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit. The nurse assesses the pt and finds the abdominal dressing saturated with blood. Which action is most important?
Taking a set of vital signs and notifying the surgeon.
A patient with cystic fibrosis (CF) has fasting blood glucose levels that are consistently between 200 to 250 mg/dL Which nursing action will the nurse plan to implement?
Teach the patient about administration of insulin.
The nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end- expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced?
The patient has subcutaneous emphysema to the upper thorax.
The nurse is caring for a 33 y/o patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action?
The patient's PaC02 is 45 mmHg.
The nurse explains that the medication essential for a client with pernicious anemia:
Vitamin B12
The nurse assessing a female client with a hemoglobin level of 11 g/dL would expect the client to report:
no significant manifestations.
The nurse working in a critical care unit is caring for a client that experiences respiratory arrest. In what order will the nurse respond? All options must be used.
Call for emergency help, Begin emergency resuscitation, Document resuscitation, Complete an incident report, Alert the family to the event, Restock the room with emergency equipment.
While performing an admission assessment on a moderately anemic client, the nurse would expect to find a history of?
Cardiac palpitations
A nurse caring for a patient with sickle cell disease (SCD) reviews the patient's laboratory work. Which finding should the nurse report to provider?
Creatinine: 2.9 mg/dL (256mcmol/L)
