Med Surg 2 Final
The nurse monitors the client receiving treatment for acute decompensated heart failure with the knowledge that marked hypotension is most likely to occur with the IV administration of which medication? Nitroprusside Furosemide Milrinone Nitroglycerin
Nitroprusside Although all of these drugs may cause hypotension, nitroprusside is a potent dilator of both arteries and veins and may cause such marked hypotension that an inotropic agent (e.g. dobutamine) administration may be necessary to maintain BP during its administration. Furosemide may cause hypotension because of diuretic-induced depletion of intravascular volume. Milrinone has a positive inotropic effect in addition to peripheral vasodilation. Nitroglycerin is a vasodilator and can decrease BP but not as severely as nitroprusside. It primarily dilates veins and increases myocardial oxygen supply.
A client with acute pericarditis has a nursing diagnosis of pain related to pericardial inflammation. What is the best nursing intervention for the client? Position the client in Fowler's position with a padded over-the-bed table for the client to lean on. Administer opioids as prescribed on an around-the-clock schedule. Promote progressive relaxation exercises with the use of deep, slow breathing. Position the client on the right side with the head of the bed elevated 15 degrees.
Position the client in Fowler's position with a padded over-the-bed table for the client to lean on. Relief from pericardial pain is often obtained by sitting up and leaning forward. Pain is increased by lying flat. Anti-inflammatory medications may also be used to help control pain, but opioids are not usually indicated. The pain has a sharp, pleuritic quality that changes with respiration, and clients take shallow breaths.
When mechanical ventilation is used for the client with ARDS, what is the reason for applying positive end-expiratory pressure (PEEP)? Prevent alveolar collapse and open collapsed alveoli Permit smaller tidal volumes with permissive hypercapnia Permit extracorporeal oxygenation and carbon dioxide removal outside the body Promote complete emptying of the lungs during exhalation
Prevent alveolar collapse and open collapsed alveoli Positive end-expiratory pressure (PEEP) used with mechanical ventilation applies positive pressure to the airway and lungs at the end of exhalation, keeping the lung partially expanded and preventing collapse of the alveoli and helping open collapsed alveoli. Permissive hypercapnia is allowed when the client with ARDS is ventilated with smaller tidal volumes to prevent barotrauma. Extracorporeal membrane oxygenation and extracorporeal CO2 removal involve passing blood across a gas-exchanging membrane outside the body and then returning oxygenated blood to the body.
What is the most important role of the nurse in preventing rheumatic fever? Promote the early diagnosis and immediate treatment of group A streptococcal pharyngitis Teach clients with infective endocarditis to adhere to antibiotic prophylaxis. Encourage the use of antibiotics for treatment of all infections involving sore throat. Identify clients with valvular heart disease who are at risk for rheumatic fever.
Promote the early diagnosis and immediate treatment of group A streptococcal pharyngitis Initial attacks of rheumatic fever and the development of rheumatic heart disease can be prevented by adequate treatment of group A streptococcal pharyngitis. Because streptococcal infection accounts for only about 20% of acute pharyngitis, cultures should be done to identify the organism and direct antibiotic therapy. Viral infections should not be treated with antibiotics. Prophylactic therapy is indicated in those who have valvular heart disease or have had rheumatic heart disease.
When obtaining a nursing history for a client with myocarditis, what should the nurse specifically question the client about? A history of coronary artery disease with or without an MI A recent streptococcal infection requiring treatment with penicillin Recent symptoms of a viral illness, such as fever and malaise Prior use of digoxin for treatment of cardiac problems
Recent symptoms of a viral illness, such as fever and malaise Viruses are the most common cause of myocarditis in the United States, and early manifestations of myocarditis are often those of systemic viral infections. Myocarditis may also be associated with autoimmune disorders as well as with other microorganisms, drugs, or toxins. The client with myocarditis is predisposed to drug-related dysrhythmias and toxicity with digoxin, so it is used very cautiously, if at all, in the treatment of the condition, but digoxin does not lead to myocarditis. A streptococcal infection is more likely to lead to rheumatic fever.
A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially? Metabolic acidosis Respiratory alkalosis Metabolic alkalosis Respiratory acidosis
Respiratory acidosis Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion of it, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation from anesthetics or opioids.
A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? Respiratory acidosis Metabolic acidosis Respiratory alkalosis Metabolic alkalosis
Respiratory acidosis With uncompensated respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg.
The client is brought to the emergency department with acute coronary syndrome. What changes should the nurse expect to see on the ECG if only myocardial injury has occurred? Absent P wave Tall, peaked T wave A wide QT interval ST-segment elevation
ST-segment elevation ST segment elevation is seen in myocardial injury. An absent or buried P wave can occur with PVCs, ventricular tachycardia, or ventricular fibrillation. A wide pathologic QT interval affects repolarization and is caused by drugs and electrolyte imbalances. Tall, peaked T waves may be seen with electrolyte imbalances.
A preoperative client reveals that an uncle died during surgery because of a fever and cardiac arrest. Knowing the client is at risk for malignant hyperthermia, the perioperative nurse alerts the surgical team. What is likely to happen next? The surgery will have to be canceled. Specific precautions can be taken to safely anesthetize the client. Dantrolene must be given to prevent hyperthermia during surgery. The client should be placed on a cooling blanket during the surgical procedure.
Specific precautions can be taken to safely anesthetize the client. Although malignant hyperthermia can result in cardiac arrest and death, if the client is known or suspected to be at risk for the disorder, appropriate precautions taken by the anesthesia care provider can provide for safe anesthesia for the client. Because preventative measures are possible if the risk is known, it is critical that preoperative assessment include a careful family history of surgical events. The definitive treatment of malignant hyperthermia is prompt administration of dantrolene. The cooling blanket would have no effect.
A client receiving mechanical ventilation is very anxious and agitated, and neuromuscular blocking agents are used to promote ventilation. What should the nurse recognize about the care of this client? The client should always be addressed and explanations of care given. Caregivers should be encouraged to provide stimulation and diversion. The client will be too sedated to be aware of the details of care. Communication will not be possible with the use of neuromuscular blocking agents.
The client should always be addressed and explanations of care given. Neuromuscular blocking agents produce a paralysis that facilitates ventilation, but they do not sedate the client. It is important for the nurse to remember that the client can hear, see, feel, and think and should be addressed and given explanations accordingly. Communication with the client is possible, especially from the nurse, but visitors for an anxious and agitated client should provide a calming, restful effect on the client.
A client has an oral ET tube inserted to relieve an upper airway obstruction and to facilitate secretion removal. Place the following nursing responsibilities following the placement of the tube in priority order. First Place an end tidal CO2 detector on the ET tube. Assess for bilateral breath sounds and symmetric chest movement. Secure the ET tube to the face. Obtain x-ray confirmation of the ET tube placement. Suction the tube to remove secretions. Last
The first action of the nurse is to use an end tidal CO2 detector. If no CO2 is detected, the tube is in the esophagus. The second action by the nurse following ET intubation is the auscultate the chest to confirm bilateral breath sounds and observe to confirm bilateral chest expansion. If this evidence is present, the tube is secured and connected to an O2 source. Then the placement is confirmed immediately with x-ray, and the tube is marked where it exits the mouth. the client should then be suctioned as needed.
When instructing the client with angina about taking sublingual NTG tablets, what should the nurse teach the client? To take the tablet with a large amount of water so that it will dissolve right away. That if the tablet causes dizziness and a headache, stop the medication and call the doctor or go to the hospital. To lie or sit and place one tablet under the tongue when chest pain occurs. That if one tablet does not relieve the pain in 15 minutes, the client should go to the hospital.
To lie or sit and place one tablet under the tongue when chest pain occurs. A common complication of nitrates is dizziness caused by orthostatic hypotension, so the client should sit or lie down and place the tablet under the tongue. The tablet should be allowed to dissolve under the tongue. To prevent the tablet from being swallowed, water should not be taken with it. The recommended dose for the client whom NTG has been prescribed is one tablet taken sublingually for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the client should contact the emergency response system before taking additional NTG. If symptoms are significantly improved by one dose of NTG, instruct the client or caregiver to repeat NTG every 5 minutes for a maximum of three doses and contact ERS if symptoms have not resolved completely. Headache is also a common complication of nitrates but usually resolves with continued use of nitrates and may be controlled with mild analgesics.
To detect and treat the most common complications of MI, what should the nurse do? Auscultate the chest for crackles Take vital signs every 2 hours for the first 8 hours Use continuous cardiac monitoring Measure hourly urine output.
Use continuous cardiac monitoring The most common complication of MI is cardiac dysrhythmias. Continuous cardiac monitoring allows identification and treatment of dysrhythmias that may cause further deterioration of the cardiovascular status or death. Measurement of hourly urine output and vital signs is indicated to detect symptoms of the complication of cardiogenic shock. Crackles, dyspnea, and tachycardia may indicate the onset of heart failure.
A nurse in the intensive care unit is providing teaching for a client prior to removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching? "A nurse will monitor your vital signs every 15 minutes in the first hour after the tube is removed." "Use the incentive spirometer every 4 hr after the tube is removed." "Rest in a side-lying position after the tube is removed." "Avoid speaking for long periods."
"Avoid speaking for long periods." The client should avoid speaking for long periods to promote gas exchange.
The client progressed from acute lung injury to acute respiratory distress syndrome (ARDS). He is on the ventilator and receiving propofol for sedation and fentanyl to decrease anxiety, agitation, and pain to decrease his work of breathing, O2 consumption, carbon dioxide production, and risk of injury. What intervention may be recommended in caring for this client? A sedation holiday Repositioning him every 4 hours to decrease agitation Monitoring for hypermetabolism Keeping his legs still to avoid dislodging the airway
A sedation holiday A sedation holiday is needed to assess the client's condition and readiness to extubate. A hypermetabolic state occurs with critical illness. Enteral or parenteral nutrition is started within 24 to 48 hours. With these medications, the client will be assessed for cardiopulmonary depression. Venous thromboembolism prophylaxis will be used, but there is no reason to keep the legs still. Repositioning the patient every 2 hours may help decrease discomfort and agitation.
A nurse in the emergency department is caring for a client who has pulmonary edema, reports dyspnea, and appears anxious. The client's blood pressure is 108/79 and his apical pulse is 112. Which of the following interventions is the nurse's priority? Reassure the client. Give the client sublingual nitroglycerin. Place the client in high-Fowler's position with legs dependent. Administer high-flow oxygen at 5 L/min by facemask to the client.
Administer high-flow oxygen at 5 L/min by facemask to the client. A client who has pulmonary edema is critically ill and is hypoxic. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to administer high-flow oxygen at 5 L/min by facemask to the client.
A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? Administer oxygen therapy. Give morphine IV. Start an IV infusion of lactated Ringer's. Initiate cardiac monitoring.
Administer oxygen therapy. The greatest risk to the safety of a client who has a pulmonary embolism is hypoxemia with respiratory distress and cyanosis. Oxygen therapy should be applied by the nurse using a nasal cannula or mask. Pulse oximetry should be initiated to monitor oxygen saturation.
A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? Assess for indications of pulmonary embolism. Prepare for mechanical ventilation. Prepare to administer a sedative. Administer oxygen via face mask.
Administer oxygen via face mask. The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are involved, so the client has respiratory alkalosis. The client's oxygen saturation is low, so one priority is to administer oxygen via mask attempting to achieve an oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus the priority is to restore oxygenation.
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? Hypotension Dysphagia Agitation Nausea
Agitation The nurse should expect agitation due to neurological changes from poor oxygen exchange.
A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care? Preventing musculoskeletal disability Stabilizing cardiac arrhythmias Decreasing intracranial pressure Airway protection
Airway Protection When assessing and treating a client who has trauma, a systematic approach is taken during the primary survey. It begins with the assessment and interventions necessary to ensure a patent airway.
Which drugs would the nurse expect to be included in those prescribed for clients with a mechanical valve replacement? Oral nitrates Anticoagulants Atrial antidysrhythmic Beta-adrenergic blocking agents
Anticoagulants Clients with mechanical valves have an increased risk for thromboembolism and require long-term anticoagulation to prevent systemic or pulmonary embolization. Nitrates are contraindicated for the client with aortic stenosis because an adequate preload is necessary to open the stiffened aortic valve. Antidysrhythmic are used only if dysrhythmias occur and beta-adrenergic blocking drugs may be used to control the heart rate if needed.
A client on the cardiac telemetry unit goes into ventricular fibrillation and is unresponsive. Following initiation of the emergency call system (Code Blue), what is the next priority for the nurse caring for this client? Administer amiodarone IV Defibrillate with 360 joules Begin CPR Get the crash cart
Begin CPR Until the defibrillator is available, the client needs CPR. Defibrillation is needed as soon as possible, so someone should bring the crash cart to the room. Amiodarone is an antidysrhythmic that is part of the advanced cardiac life support (ACLS) protocol for ventricular fibrillation. Defibrillation would be with 360 joules for monophasic defibrillators and 120-200 joules for biphasic defibrillators.
In a client with a positive Chvostek's sign, the nurse would anticipate the IV administration of which medication? Loop diuretics Calcium gluconate Vitamin D Calcitonin
Calcium gluconate Chvostek's sign is a contraction of facial muscles in response to a tap over the facial nerve. This indicates the neuromuscular irritability of low calcium levels, and IV calcium is the treatment used to prevent laryngeal spasms and respiratory arrest. Calcitonin is indicated for treatment of hypercalcemia, and look diuretics may be used to decrease calcium levels. Oral vitamin D supplements are part of the treatment for hypocalcemia but not for impending tetany.
A client's tracheostomy tube becomes dislodged with vigorous coughing. What should be the nurse's first action? Ventilate the client with a manual resuscitation bag until the health care provider arrives. Place the client in high Fowler's position. Notify the health care provider. Call for help and attempt to replace the tube.
Call for help and attempt to replace the tube. If a tracheostomy tube is dislodged, after calling for help, the nurse should immediately attempt to replace the tube by using hemostats to spread the opening. The obturator is inserted in the replacement tube, water-soluble lubricant is applied to the tip, and the tube is inserted in the stoma at a 45-degree angle to the neck. The obturator is immediately removed to provide an airway. If the tube cannot be reinserted, the HCP should be notified and the client should be assessed for the level of respiratory distress, positioned in semi-Fowler's position, and ventilated with a manual resuscitation bag (MRB) only if necessary, until assistance arrives.
A client's rhythm strip indicates a normal HR and rhythm with normal P waves and QRS complexes, but the PR interval is 0.26 second. What is the most appropriate action by the nurse? Prepare the client for placement of a temporary pacemaker Administer atropine per protocol Prepare the client for synchronized cardioversion Continue to assess the client
Continue to assess the client A rhythm pattern that is normal except for a prolonged PR interval is characteristic of a first-degree heart block. First-degree heart blocks are not treated but are observed for progression to higher degrees of heart block. Atropine is administered for bradycardia. Synchronized cardioversion is used for atrial fibrillation with rapid ventricular response or paroxysmal supraventricular tachycardia (PSVT). Pacemakers are used for higher-degree heart blocks.
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? Continue to monitor the client's respiratory status. Clamp the chest tube. Check the suction control outlet on the wall. Check the tubing connections for leaks.
Continue to monitor the client's respiratory status. Slow, steady bubbling in the suction control chamber is an expected finding. Therefore, the nurse should continue to monitor the client's respiratory status.
A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? Continue to monitor the client. Clamp the chest tube near the water seal. Reposition the client toward the left side. Immediately notify the provider
Continue to monitor the client. The fluid in the water seal chamber rises 2 to 4 inches during inhalation and falls during exhalation. This is a process called tidaling. An absence of tidaling might indicate a fully expanded lung or an obstruction in the chest tube.
A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication? Constant bubbling in the suction-control chamber Continuous bubbling in the water-seal chamber Occasional bubbling in the water-seal chamber Fluctuations in the fluid level in the water-seal chamber
Continuous bubbling in the water-seal chamber Excessive and continuous bubbling in the water-seal chamber indicates an air leak in the drainage system.
A patient in acute respiratory failure is receiving ACV with a positive end-expiratory pressure (PEEP) of 10 cm H2O. What sign alerts the nurse to undesirable effects of increased airway and thoracic pressure? Decreased partial pressure of oxygen in arterial blood (PaO2) Decreased spontaneous respirations Increased crackles Decreased BP
Decreased BP Positive pressure ventilation, especially with positive end-expiratory pressure (PEEP), increases intrathoracic pressure with compression of thoracic vessels, resulting in decreased venous return to the heart, decreased left ventricular end-diastolic volume (preload), decreased CO, and lowered BP. None of the other factors is related to increased intrathoracic pressure.
What is a compensatory mechanism for metabolic alkalosis? Deep, rapid respirations (Kussmaul respirations) to increase CO2 excretion Decreased respiratory rate and depth to retain CO2 and kidney excretion of bicarbonate Shifting of bicarbonate into cells in exchange for chloride Kidney conservation of bicarbonate and excretion of hydrogen ions
Decreased respiratory rate and depth to retain CO2 and kidney excretion of bicarbonate Decreased respiratory rate and kidney excretion of HCO3 compensates for metabolic alkalosis. Shifting of bicarbonate for Cl may buffer acute respiratory alkalosis. The kidney conserves bicarbonate and excretes hydrogen to compensate for respiratory acidosis. Kussmaul respirations occur with metabolic acidosis to compensate.
A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention? Chest tube eyelets not visible Presence of tidal fluctuation in the water seal chamber Development of subcutaneous emphysema Continuous bubbling in the suction control chamber
Development of subcutaneous emphysema Subcutaneous emphysema is an indication that air is trapped in and under the skin, which be the result of a pneumothorax and should be reported to the provider.
To provide free water and intracellular fluid hydration for a client with acute gastroenteritis who is NPO, the nurse would expect administration of which infusion? Dextrose 10% in water Dextrose 5% in water Dextrose 5% in normal saline (0.9%) Lactated Ringer's solution
Dextrose 5% in water Fluids such as 5% dextrose in water allow water to move from the extracellular fluid to the intracellular fluid. Although D5W is physiologically isotonic, the dextrose is rapidly metabolized, leaving free water to shift into the cells.
A common collaborative problem related to both hyperkalemia and hypokalemia is which potential complication? Dysrhythmias Paralysis Acute kidney injury Seizures
Dysrhythmias Potassium maintains normal cardiac rhythm, transmission and conduction of nerve impulses, and contraction of muscles. Cardiac cells demonstrate the most clinically significant changes with potassium imbalances because of changes in cardiac conduction. Although paralysis may occur with severe potassium imbalances, cardiac changes are seen earlier and much more commonly.
A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? Perform range-of-motion exercises Encourage the use of an incentive spirometer Administer an expectorant Place suction equipment at the bedside
Encourage the use of an incentive spirometer Incentive spirometry expands the lungs and promotes gas exchange after surgery which can help prevent pulmonary complications.
The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first? Check pupillary response to light. Assess the capillary refill. Evaluate chest expansion. Check client's response to questions about place and time.
Evaluate chest expansion. When using the airway, breathing, circulation approach to client care, the nurse should plan on evaluating the client's respiratory effort and function. This involves listening to breath sounds, evaluating chest expansion, and assessing the client for chest trauma or abnormalities that would compromise breathing.
A client admitted to the hospital for evaluation of chest pain has no abnormal serum cardiac markers 4 hours after the onset of pain. What noninvasive diagnostic test can be used to differentiate angina from other types of chest pain? Transesophageal echocardiogram Exercise stress test Coronary angiogram 12-lead ECG
Exercise stress test An exercise stress test will reveal ECG changes that indicate impaired coronary circulation when the oxygen demand of he heart is increased. A single ECG is not conclusive for CAD, and negative findings do not rule out CAD. Coronary angiography can detect narrowing of coronary arteries but is an invasive procedure. Echocardiograms of various types may identify abnormalities of myocardial wall motion under stress but are indirect measures of CAD.
A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? Furosemide Atropine Dexamethasone Heparin
Heparin A pulmonary emboli is a condition in which the pulmonary blood flow is obstructed, resulting in hypoxia and possible death. Most often caused by a blood clot, treatment such as heparin, an anticoagulant, is used to prevent the enlargement of the existing clot or formation of new clots.
A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately? Decreased temperature Serosanguineous drainage from the puncture site Increased heart rate Discomfort at the puncture site
Increased heart rate Clients are at risk for developing pulmonary edema or cardiovascular distress due mediastinal content shift after the aspiration of a large amount of fluid from the client's pleural space. Therefore, the client may experience an increase in heart and respiratory rate, along with coughing with blood-tinged frothy sputum, and tightness in the chest. These findings require notification of the provider immediately.
A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? Increased heart rate from 68 to 72/min. Increased respiratory rate from 18 to 44/min. Increased blood pressure from 112/68 to 120/72 mm Hg. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F)
Increased respiratory rate from 18 to 44/min. No feedback but obvious
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? Disconnect the chest tube from the drainage system during transport. Empty the collection chamber prior to transport. Clamp the chest tube prior to transferring the client to a wheelchair Keep the drainage system below the level of the client's chest at all times.
Keep the drainage system below the level of the client's chest at all times. During transport, the drainage system should be kept below the level of the client's chest to prevent air and drainage fluid from re-entering the thoracic cavity.
During a preoperative physical examination, the nurse is alerted to the possibility of compromised respiratory function during or after surgery in a client with which problem? Decreased peripheral pulses Dehydration Obesity Enlarged liver
Obesity Obesity, as well as spinal, chest, and airway deformities, may compromise respiratory function during and after surgery. Dehydration may require preoperative fluid therapy. An enlarged liver may indicate hepatic dysfunction that will increase perioperative risk related to glucose control, coagulation, and drug interactions. Weak peripheral pulses may reflect circulatory problems that could affect healing.
A client with a massive hemothorax and pneumothorax has absent breath sounds in the right lung. To promote improved V/Q matching, how should the nurse position the client? In a reclining chair bed On the right side On the left side Supine with the head of the bed elevated
On the left side When there is impaired function of 1 lung, the client should be positioned with the unaffected lung in the dependent position to promote perfusion to the functioning tissue. If the diseased lung is positioned dependently, more V/Q mismatch occurs. The head of the bed may be elevated or a reclining chair may be used, with the client positioned on the unaffected side, to maximize thoracic expansion if the client has increased work of breathing.
During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. To care for the tracheostomy appropriately, what should the nurse do? Remove the inner cannula if the patient shows signs of airway obstruction. Deflate the cuff, then remove and suction the inner cannula. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube. Remove the inner cannula and replace it per institutional guidelines
Remove the inner cannula and replace it per institutional guidelines An inner cannula is a second tubing that fits inside the outer tracheostomy tube. Disposable inner cannulas are frequently used, but nondisposable ones can be removed and cleaned of mucus that has accumulated on the inside of the tube. Many tracheostomy tubes do not have inner cannulas because when humidification is adequate, accumulation of mucus should not occur. Cuff deflation is no longer recommended. When signs of airway obstruction occur, suction is needed.
A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take? Strip the client's chest tube. Reposition the client. Clamp the client's chest tube. Increase the client's wall suction.
Reposition the client. The nurse repositioning the client is an appropriate action to relieve chest burning from the chest tube.
A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. First Open the airway using a jaw-thrust maneuver. Determine effectiveness of ventilator efforts. Establish IV access. Perform a Glasgow Coma Scale assessment. Remove clothing for a thorough assessment. Last
The priority of actions should follow ABCs. A = airway - Open the airway using a jaw-thrust maneuver. B = breathing - Determine effectiveness of ventilator efforts. C = circulation - Establish IV access. Follow ABCs with focused assessments - Perform a Glasgow Coma Scale assessment. Then thorough head-to-toe assessment - Remove clothing for a thorough assessment.
Upon admission of a client to the PACU, the nurse's priority assessment is surgical site vital signs respiratory adequacy level of consciousness
respiratory adequacy Physiologic status of the client is always prioritized with regard to airway, breathing, and circulation, and respiratory adequacy is the first assessment priority of the client on admission to the PACU from the operating room. Following assessment of respiratory function, cardiovascular neurologic, and renal function should be assessed as well as the surgical site.
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? Remove the dressing to inspect the wound. Raise the foot of the bed to a 90° angle. Prepare to insert a central line. Administer oxygen via nasal cannula.
Administer oxygen via nasal cannula. The client has an increased respiratory rate and heart rate, indicating that she is having respiratory difficulty. The sucking chest wound indicates the client has a pneumothorax and/or a hemothorax. Administering oxygen will increase the oxygen exchange in the lungs and the oxygen available to the tissues.
Which findings would lead the nurse to suspect the early stage of ARDS in a seriously ill client? Has diffuse crackles and wheezing Develops respiratory acidosis Exhibits dyspnea and restlessness Has a decreased PaO2 and an increased PaCO2
Exhibits dyspnea and restlessness Early signs of ARDS are insidious and difficult to detect, but the nurse should be alert for any early signs of hypoxemia, such as dyspnea, tachypnea, cough, and restlessness in clients at risk for ARDS. Later, tachycardia, diaphoresis, mental status changes, cyanosis, and pallor may be present. Abnormal findings on physical examination or diagnostic studies, such as worsened lung sounds and respiratory distress, respiratory alkalosis, or decreasing PaO2, are usually indications that ARDS has progressed beyond the initial stages.
In caring for the client with ARDS, what is the most characteristic sign the nurse would expect the client to exhibit? Increased pulmonary artery wedge pressure (PAWP) Bronchial breath sounds Progressive hypercapnia Refractory hypoxemia
Refractory hypoxemia Refractory hypoxemia, hypoxemia that does not respond to increasing concentrations of oxygenation by any route, is a hallmark of ARDS and is always present. Bronchial breath sounds may be associated with the progression of ARDS. PaCO2 levels may be normal until the patient is no longer able to compensate in response to the hypoxemia. Pulmonary artery wedge pressure (PAWP) that is normally increased in cardiogenic pulmonary edema is normal in the pulmonary edema of ARDS.
When should the nurse check for leaks in the chest tube and pleural drainage system? Fluid in the water-seal chamber fluctuates with the patient's breathing. There is constant bubbling of water in the suction control chamber. There is continuous bubbling in the water-seal chamber. The water levels in the water-seal and suction control chambers are decreased.
There is continuous bubbling in the water-seal chamber. The water-seal chamber should bubble intermittently as air leaves the lung with exhalation in a spontaneously breathing patient. Continuous bubbling indicates a leak. The water in the suction control chamber will bubble continuously and the fluid in the water-seal chamber fluctuates (tidaling) with the patient's breathing. Water in the suction control chamber, and perhaps in the water-seal chamber, evaporates and may have to be replaced periodically.
Which descriptions are characteristic of hypoxemic respiratory failure (select all that apply)? Exists when partial pressure of oxygen in arterial blood (PaO2) is less than 60 mm Hg, even when O2 is given at 60% or more Body is unable to compensate for acidemia of increased partial pressure of carbon dioxide in arterial blood (PaCO2) Most often caused by ventilation-perfusion (V/Q) mismatch and shunt Referred to as ventilatory failure Risk of inadequate O2 saturation of hemoglobin exists Main problem is inadequate O2 transfer
1,3,5,6 The main problem in hypoxemic respiratory failure is inadequate oxygen transfer. There is a risk of inadequate oxygen saturation of hemoglobin. It is often caused by ventilation-perfusion (V/Q) mismatch and shunt. It exists when the partial pressure of oxygen in arterial blood (PaO2) is 60 mm Hg or less, even though oxygen is given at 60% or more. Ventilatory failure is hypercapnic respiratory failure. Hypercapnic respiratory failure results from an imbalance between ventilatory supply and ventilatory demand and the body is unable to compensate for the acidemia of increased partial pressure of carbon dioxide in arterial blood (PaCO2).
What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction? A tracheostomy is safer to perform in an emergency. A tracheostomy tube allows for more comfort and mobility. An ET tube is more likely to lead to lower respiratory tract infection. An ET tube has a higher risk of tracheal pressure necrosis.
A tracheostomy tube allows for more comfort and mobility. With a tracheostomy (versus an endotracheal [ET] tube), patient comfort is increased because there is no tube in the mouth. Because the tube is more secure, mobility is improved. The ET tube is more easily inserted in an emergency situation. It is preferable to perform a tracheostomy in the operating room because it requires careful dissection, but it can be performed with local anesthetic in the intensive care unit (ICU) or in an emergency. With a cuff, tracheal pressure necrosis is as much a risk with a tracheostomy tube as with an ET tube, and infection is also as likely to occur because the defenses of the upper airway are bypassed.
A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? No fluctuations in the water seal chamber No reports of pleuritic chest pain Occasional bubbling in the water-seal chamber Oxygen saturation of 95%
No fluctuations in the water seal chamber Fluctuation stops when the lung has re-expanded, but the nurse should check for other indications of re-expansion, such as equal breath sounds bilaterally, because fluctuation can also stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or the suction source is not functioning.
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan? Place in a prone position. Encourage oral intake of at least 3,000 mL of fluids per day. Administer low-flow oxygen continuously via nasal cannula. Offer high-protein and high-carbohydrate foods frequently.
Place in a prone position. Oxygenation in clients who have ARDS is improved when placed in the prone position. Frequent and consistent turning of the client is also beneficial and can be accomplished by the use of specialty beds.
The best client response to treatment of ARDS occurs when initial management includes what? Treatment of the underlying condition Endotracheal intubation and mechanical ventilation Administration of prophylactic antibiotics Treatment with diuretics and mild fluid restriction
Treatment of the underlying condition Because ARDS is precipitated by a physiologic insult, a critical factor in its prevention and early management is treatment of the underlying condition. Prophylactic antibiotics, treatment with diuretics and fluid restriction, and mechanical ventilation are used as ARDS progresses.
A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect? Decreasing respiratory rate Friction rub Increasing dyspnea Facial flushing
Increasing dyspnea The postoperative client is at increased risk for developing atelectasis because of a blunted cough reflex or shallow breathing due to anesthesia, opioids or pain medication. Common manifestations include shortness of breath and pleural pain.
A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to? Chest tube drainage Pain level Arterial blood gases Urinary output
Arterial blood gases According to the ABC priority-setting framework, the postoperative surgical client may need supplemental oxygen in order to maintain normal blood oxygen levels. The effectiveness of oxygenation is monitored using pulse oximetry and arterial blood gases.
