MODS info Ch 38

A patient has developed a pulmonary problem that has resulted in decreased lung compliance. How will this affect the patient's respiratory system?

It will increase the patient's work of breathing. Rationale: Because the lung is less compliant or "stiffer," it makes it more difficult to expand, increasing the work required to breathe.

A client's burned arm is erythematous and blistered. Capillary refill is brisk, and the client complains of severe pain. How should the nurse document this burn?

Superficial partial-thickness Rationale: Superficial partial-thickness burns are characterized by areas that are erythematous, blistered, and painful. Capillary refill is brisk.

Which assessment finding is most important for the nurse to monitor during initial fluid resuscitation of a seriously burned client?

Urine output Rationale: Urine output is a good measure of the adequacy of fluid resuscitation, as are vital signs, mentation, capillary refill, and peripheral pulses.

The nurse teaches a client to apply an emollient to healing burn wounds several times a day. Which rationale should the nurse offer for this instruction? (Select all that apply.)

"This will help keep your skin moist." "You do not have as many sebaceous glands as you did before the injury." Rationale: 1. Emollients help to moisten the skin. 2. Burns result in the destruction of subcutaneous structures, including sebaceous glands.

The surgeon has planned tangential excision of eschar on a severely burned client. How would the nurse explain this procedure to the client's family? (Select all that apply.)

- "This procedure can result in blood loss, so we may need to transfuse." - "The cosmetic results of this procedure are better than those of the alternatives." - "This procedure will be done under anesthesia in the operating room." Rationale: 2. Tangential excision can result in significant blood loss. 3. Tangential excision has a better cosmetic result than facial excision. 4. Surgical debridement is done under anesthesia in the OR.

A nurse is developing educational materials on burn prevention. The nurse would discuss which reasons that older adults are prone to burn injury? (Select all that apply.)

1. Older adults often have impaired senses. 3. As people age, their reaction times slow. 5. Risk assessment skills decline with aging. Rationale: 1. With aging, the senses become less acute. Impairments in the sense of smell and hearing can adversely affect the client's ability to detect the presence of fire. 3. Reaction times do slow with aging. Clients who cannot react quickly may not be able to remove themselves quickly enough from a situation in which burns might occur. 5. Older adults tend to incorrectly assess risk and may choose to stay and fight a fire instead of leaving. They may also incorrectly assess the risks of behaviors that could result in fire.

A patient who has developed right middle-lobe pneumonia will experience decreased ventilation in the affected lung areas for which reasons? (Select all that apply.)

1. The pressure gradient is abnormal. 4. Gas follows the path of least resistance. 5. The consolidation in the tissues will increase the pressure. Rationale: Rationale: 1. The normal pressure gradient has been altered by the presence of inflammation and consolidation. 4. Ventilation occurs when gas moves from an area of higher pressure to an area of lower pressure, following the path of least resistance. The pressure is higher in the involved areas due to edema and inflammation, so gas will move to areas of lower pressure. 5. The consolidation in the lung tissues will increase the amount of pressure needed to expand the lung.

An emergency department uses the American Burn Association's criteria for transfer to a burn center. The nurse would anticipate that which client would require transfer?

A client with deep partial-thickness burns over the entire face Rationale: Any burn that involves the entire face puts the client at risk for inhalation burns and injury to eye and other mucous membranes. This client should be treated in a specialty unit.

A client's pressure-adjusted heart rate (PAR) has increased since yesterday's measurement. Which information should the nurse provide to the client's family?

Answer: 1. "Her cardiovascular status has worsened." Rationale: 1. An increasing PAR indicates worsening cardiovascular function.

A client is being prepared for a heart-lung transplant. The nurse is assessing the client and family for risks for nonadherence to the posttransplant drug regimen. Which statements would the nurse interpret as indicating an increased risk? (Select all that apply.)

Answer: 1. "My heart medicines sure make me nauseated." 2. "I hope I can remember how to take all these medicines." 3. "When I'm nervous, I still want a cigarette." Rationale: 1. Adverse side effects of medications can result in nonadherence. 2. The complexity of the posttransplant drug regimen can result in nonadherence. 3. The client who has a history of addictive behavior, such as tobacco use or alcohol abuse, is at higher risk of nonadherence.

A client is in refractory shock. What information should the nurse provide to the family?

Answer: 1. "You should prepare yourself for your loved one's death." Rationale: 1. When the client is in refractory shock, cell destruction is so severe that death is inevitable.

A patient is placed on volume-cycled ventilation. The nurse plans care for this client based on which characteristic of this method of ventilation?

Answer: 1. A set volume will be delivered, which will help overcome the client's airway resistance changes. Rationale: 1. Volume-cycled ventilation delivers a preset volume of gas to the lungs, making volume constant and pressure variable. The ventilator will deliver the volume of gas regardless of the pressure it requires, overcoming the changes in lung compliance and airway resistance

A patient is hospitalized with chronic respiratory insufficiency. The nurse is developing a plan to address the problem of impaired oxygenation and ventilation. Which desired patient outcome most accurately measures progress in addressing this problem?

Answer: 1. ABG within acceptable limits for patient Rationale: 1. ABG within normal limits for the patient is a realistic outcome for patients with chronic respiratory insufficiency.

A client has experienced blunt trauma in a motor vehicle crash. The ED nurse would consider which forces while discussing mechanism of injury with the paramedic team? (Select all that apply.)

Answer: 1. Acceleration 3. Deceleration 5. Shearing Rationale: 1. Acceleration occurs when the vehicle comes to an abrupt stop and the passenger continues moving at a greater speed. As velocity increases, so does tissue damage. 3. Deceleration is the decrease in the rate of velocity of a moving object. In a motor vehicle accident, this force occurs when the passenger who is moving forward after the vehicle stops hits the dashboard. 5. Shearing refers to injury resulting from two structures or two parts of the same structure sliding in opposite directions. In blunt trauma it occurs when a relatively immobile portion of the client (the body) is connected to a relatively mobile section (the head). In this instance, the neck is the point of shearing.

A client is determined to be near death, and the organ procurement organization (OPO) has been notified. Which persons should discuss the possibility of organ donation with the client's family? (Select all that apply.)

Answer: 1. An employee of the OPO 5. A specially trained employee Rationale: 1. According to Medicare conditions of participation, the person discussing organ donation with the family must be an employee of the OPO or have special training. 5. According to Medicare conditions of participation, the person discussing organ donation with the family must be an employee of the OPO or have special training.

A patient who has COPD is in a state of chronic respiratory insufficiency. Which assessment finding would the nurse attribute to that condition?

Answer: 1. BP 145/88 Rationale: 1. Respiratory insufficiency requires compensation of other systems and reflects a chronic state of stress. Hypertension (BP of 145/88) would be a compensatory mechanism.

A patient who has had flu-like symptoms for the last few days presents in the emergency department with increasing shortness of breath. The patient states that the cough "has become worse over the last few hours, and I am coughing up thick stuff." The nurse would ask assessment questions about which manifestations of post-influenza bacterial pneumonia? (Select all that apply.)

Answer: 1. Chills 2. Chest pain Rationale: 1. Chills are often a presenting manifestation of pneumonia. 2. Pleuritic chest pain often occurs with pneumonia.

A patient is at high risk for pulmonary embolus. The nurse would monitor this patient for the development of which common clinical manifestations? (Select all that apply.)

Answer: 1. Dyspnea 2. Chest pain 4. Cough Rationale: 1. Dyspnea is the most common manifestation of pulmonary embolus. 2. Pleuritic chest pain is a common manifestation of pulmonary embolus. 4. Cough is a common manifestation of pulmonary embolus.

A patient who was severely injured in a motor vehicle crash 7 days ago has developed ARDS. The nurse has explained the concept of nonhydrostatic pulmonary edema to the patient's family. Which statement by a family member would indicate understanding of this concept?

Answer: 1. Her disease has injured the membranes in her lung so that fluid is leaking into her lungs from the tiny blood vessels. Rationale: 1. Nonhydrostatic pulmonary edema allows fluid to move from the vascular space into the lung due to injury/disruption of the capillary and alveolar membranes.

What improvements have made cardiac transplantation a highly successful option for today's client and surgeon? (Select all that apply.)

Answer: 1. Improved immunosuppressive therapy 3. Improved tissue typing Rationale: 1. Improved immunosuppressive therapy has reduced the severity of organ rejection and the problems related to the therapy itself. 3. Improvement in tissue typing has reduced problems with rejection.

A client who was admitted to the emergency department after a gunshot wound to the chest is hemorrhaging. What interventions should the nurse anticipate? (Select all that apply.)

Answer: 1. Initiation of IV access with two large-bore catheters 3. Administration of packed red blood cells 4. Rapid administration of IV fluid 5. Open resuscitative thoracotomy Rationale: 1. IV access should be achieved with large-bore catheters to allow for rapid administration of blood or fluid. 3. Blood and blood products will be administered to increase oxygen-carrying capacity. 4. Intravascular fluid volume must be replaced. IV fluids are easily obtainable and can be administered quickly. 5. Open resuscitative thoracotomy may be done as a last resort to manage the bleeding structures within the chest.

A client is successfully weaned off mechanical ventilation using spontaneous breathing (T-piece) trials. The nurse explains to the student nurse that using the T-piece supports weaning in which manner?

Answer: 1. It requires the client to gradually take over the work of breathing. Rationale: 1. Spontaneous breathing or T-piece trials involves removing the client from the ventilator and applying oxygen for increasing amounts of time.

A client admitted in respiratory failure becomes increasingly tachypneic and hypoxic and requires emergent intubation. The nurse can expect which artificial airway to be inserted?

Answer: 1. Oral endotracheal tube Rationale: 1. Oral intubation is most frequently used during emergency situations because direct visualization of the vocal cords ensures proper placement of the endotracheal tube in the lower airway.

Which assessment would alert the nurse to the presence of flail chest?

Answer: 1. Paradoxical chest wall movement Rationale: 1. Paradoxical chest wall movement occurs when a section of the chest wall is no longer attached to the underlying rib structure. This section "floats" and moves in an opposite direction from the remainder of the chest wall. When the chest wall expands, this section retracts. This is a classic finding associated with flail chest.

A client's ventilatory setting is at 10 cm H2O of PEEP. Which assessment findings would the nurse evaluate as indicating a possible negative consequence to this ventilator setting? (Select all that apply.)

Answer: 1. Pneumothorax 3. Decrease in blood pressure Rationale: 1. PEEP increases the pressure and volume within the alveoli, both of which can cause alveoli to burst. 3. The use of PEEP can result in hemodynamic changes. Lower blood pressure can be an effect of increased pressure in the chest and decreased return to the heart as a result of higher levels of PEEP.

A client who had abdominal surgery yesterday is cold, clammy, and confused. Which additional assessment findings would support concern that this client is in shock? (Select all that apply.)

Answer: 1. Pulse rapid and weak 3. Serum lactate level 5.8 mmol/L Rationale: 1. A rapid, weak pulse can indicate that compensatory mechanisms for shock are occurring. The heart rate increases in an attempt to increase cardiac output. A weak pulse can occur either because there is not enough circulating blood volume or because the rapid pulse prevents ventricular filling. 3. A lactate level higher than 5 mmol/L is characteristic of lactic acidosis, which is common in the shock state.

A patient is admitted to the hospital with severe dyspnea and a productive cough. History reveals that the patient has smoked one to two packages of cigarettes daily for the last 45 years and was diagnosed with COPD 10 years ago. A diagnosis of right lower lobe pneumonia is established. Based on this data, the nurse would plan care for a patient who has which type of acute lung disorder?

Answer: 1. Restrictive disease Rationale: 1. Although this patient does have some COPD, the acute disorder is pneumonia, which is a restrictive disease.

It is suspected that a client is developing SIRS. Which assessment findings would the nurse interpret as supporting this suspicion? (Select all that apply.)

Answer: 1. Temperature 35.8°C (96.4°F) 2. Heart rate 108/min 3. PaCO2 28 mmHg 5. Respiratory rate 22/min Rationale: 1. A core temperature higher than 38°C (100.9°F) or lower than 36°C (96.8°F) is a criterion for the diagnosis of SIRS. 2. Tachycardia of over 90 beats/min is a criterion for the diagnosis of SIRS. 3. PaCO2 less than 32 mmHg is a criterion for the diagnosis of SIRS. 5. A respiratory rate over 20/min is a criterion for the diagnosis of SIRS.

A client is receiving intravenous dobutamine, which the nurse is titrating to effect. Which assessment findings would indicate the need to reduce the rate of infusion? (Select all that apply.)

Answer: 1. The client complains of chest pain. 2. The client's heart rate is 110 beats/min. 3. The client begins having ventricular dysrhythmias. 4. The client's blood pressure is 160/110 mmHg. Rationale: 1. Angina may occur as the heart works harder. This indicates the need to reduce the dose. 2. A dose-related effect of dobutamine is tachycardia. 3. One of the dose-related effects of dobutamine is dysrhythmia. 4. Hypertension can occur as a result of dobutamine administration.

The medical team is concerned that a client's gut may be injured. Which assessment findings would the nurse interpret as supporting that concern? (Select all that apply.)

Answer: 1. The client's bowel sounds are greatly diminished. 2. The client has diarrhea. 3. Tube feeding residuals are increasing. Rationale: 1. Diminished bowel sounds may indicate that an ileus is developing. Development of an ileus occurs with gut injury. 2. Diarrhea may result when the gut is injured because of the inability to resorb liquids. 3. An increase in tube feeding residuals would indicate that the client is not absorbing tube feeding. This may result from gut injury.

A patient whose left femur was surgically repaired 7 days ago has been on bedrest since surgery. This morning, the nurse is concerned with an acute change in the patient's pulmonary status. Which factors of Virchow's triad would the nurse identify in this case, putting the patient at risk for development of deep-vein thrombosis? (Select all that apply.)

Answer: 1. Venous stasis 4. Venous injury Rationale: 1. Venous stasis is part of Virchow's triad and occurs with prolonged immobility. In this case, the patient's mobility has been restricted for at least 7 days. 4. Venous or endothelial injury is part of Virchow's triad and is present in this case due to trauma and surgery.

It is suspected that a client has a systemic inflammation. Which findings would the nurse interpret as supporting this suspicion? (Select all that apply.)

Answer: 1. WBC of 14,400/mm3 2. Temperature of 38°C (100.4°F) 4. Decreased urine output 5. General malaise and confusion Rationale: 1. This is an elevated WBC, which is an indicator of infection or inflammation. 2. Temperature elevation is a result of the release of pyrogens associated with inflammation. 4. Clients with systemic inflammation may have decreased urine output. 5. General malaise, or feeling unwell, often accompanies systemic inflammation. Clients often have alteration in LOC.

A client says, "I just had a kidney transplant 2 days ago. Now the doctor says I have to go on dialysis for 2 weeks. I don't understand all of this." How should the nurse respond?

Answer: 2. "Because your transplant was not from a living donor, it may take a while for the kidney to recover." Rationale: 2. When the organ is from a nonliving donor, ischemia may slow the kidney's response. Dialysis allows time for the kidney to recover, which generally takes about 2 weeks.

A hospital has seen an increase in the number of its clients who develop SIRS and MODS. Which statement by the nurse in charge of quality reflects correct initial management of this increase?

Answer: 2. "I will review the admission status of these clients." Rationale: 2. The admission status of clients may indicate that they were at increased risk for development of SIRS and MODS. This data should be compared to similar data from the period when the prevalence of SIRS and MODS was lower.

The nurse explains that a client has multiple organ dysfunction syndrome that likely was caused by widespread inflammation. The client's spouse says, "But the doctor said he didn't have an infection." How should the nurse respond?

Answer: 2. "Inflammation can occur even when there's no infection." Rationale: 2. Inflammation can occur as a result of irritation or tissue injury in the absence of an infection.

A client is scheduled for an allogeneic hematopoietic stem cell transplant. What education should the nurse provide to the client and family? (Select all that apply.)

Answer: 2. A demonstration of how to don protective clothing before visiting 4. Hand hygiene protocol and demonstration 5. The need to avoid bringing flowers in the room Rationale: 2. Visitors must don protective clothing to prevent the introduction of pathogens into the client's environment. 4. Hand hygiene is a very important aspect of infection control and should be explained and demonstrated. 5. Flowers are a potential source of pathogens that should not be introduced into the client's environment.

A patient who has a right upper-lobe pneumothorax has had a chest tube for 2 days. While assessing the chest drainage system, the nurse notes continuous vigorous bubbling in the water-seal chamber. What should the nurse do?

Answer: 2. Check all connections for a leak. Rationale: 2. Continuous bubbling in the water-seal chamber indicates either a very large pleural fistula or a leak in the chest tube system. Such leaks are most common at connection points, so checking all connections is the most appropriate action at this time.

A client has been admitted with multiple trauma injury. What assessments should make the nurse suspect that a posttrauma complication has occurred? (Select all that apply.)

Answer: 2. Decreased urine output 4. Decreased level of consciousness 5. Changing wound drainage characteristics Rationale: 2. Decreased urine output may suggest acute kidney injury related to decreased tissue perfusion. 4. Level of consciousness can decline because of decreased oxygenation or increased metabolic toxins. 5. Changes in the characteristics of wound drainage, such as foul odor or color, suggest infection.

Paramedics report that a client was the restrained driver of a vehicle that struck a bridge abutment. Time of injury was approximately 30 minutes ago. Which assessment findings would alert the nurse to the possibility of a ruptured spleen? (Select all that apply.)

Answer: 2. Hypotension with no obvious hemorrhage 3. Presence of seat belt abrasions 4. Distention of the abdomen Rationale: 2. Hypotension when there is no obvious hemorrhage could indicate internal bleeding. The spleen could have been injured when the seat belt restrained the client. 3. The driver's seat belt would go over the area of the spleen. Sharp deceleration that could cause abrasions could also cause the spleen to rupture. 4. Distention of the abdomen could be from internal hemorrhage.

A nurse is having difficulty clearing secretions from a client's endotracheal tube. What actions should the nurse take? (Select all that apply.)

Answer: 2. Increase the client's fluid intake. 4. Check to see that adequate humidification is delivered via the ventilator. Rationale: 2. Fluid intake will help to thin secretions. 4. The humidification system of the ventilator should be checked for correct function.

A client has hypovolemic shock as a result of massive gastrointestinal bleeding. The client is given fluids and vasopressors. Which outcome indicates to the nurse that these treatments are having the desired effect?

Answer: 2. Lactate levels are decreasing from admission levels. Rationale: 2. Serum lactate levels can be used as an indirect measure of impaired oxygen delivery and indicate the degree of hypoperfusion. Decreasing lactate levels indicate that tissue perfusion and oxygenation are improving.

A client with a long history of chronic obstructive pulmonary disease (COPD) presents to the emergency department in respiratory distress. After assessing absence of lung sounds on the right and tracheal deviation, the nurse notifies the ED physician. What emergency intervention should the nurse anticipate?

Answer: 2. Needle thoracostomy Rationale: 2. This client shows signs of tension pneumothorax. If this proves to be the case, needle thoracostomy

Brain-death testing is being conducted at the bedside of a client critically injured in an explosion. Which results would the nurse interpret as indicating that brain death has occurred? (Select all that apply.)

Answer: 2. No doll's-eye reflex to head rotation 3. No eye movement to cold-water ear irrigations 5. No pupillary response to light Rationale: 2. A criterion of brain death is the absence of the doll's-eye reflex to head rotation. 3. A criterion of brain death is the absence of eye movement to cold-water ear irrigations. 5. A criterion of brain death is the absence of pupillary response to light.

A client having chest pain is being monitored for myocardial infarction. Which finding would the nurse evaluate as indicating the client is at risk for developing cardiogenic shock?

Answer: 2. The client has started having increased premature ventricular contractions. Rationale: 2. Worsening cardiac dysrhythmia indicates a risk of cardiogenic shock. Dysrhythmia is related to irritability of the heart muscle, which can occur when ischemia is present.

A client is received in the emergency department from emergency medical services after sustaining a brain injury in a fall. She is on a spineboard and has a cervical collar in place. She is not moving her lower extremities. What would alert the nurse to the possible development of neurogenic shock?

Answer: 2. The client's heart rate drops from 82 beats/min to 68 beats/min. Rationale: 2. Bradycardia is an indicator that shock is developing. This client's heart rate is dropping, and the nurse should be aware of the potential for developing shock.

A client who received a kidney transplant 2 years ago has been diagnosed with chronic rejection of the graft. If this rejection is not effectively managed, what will happen?

Answer: 2. The kidney will become ischemic and die. Rationale: 2. If treatment is not successful, the kidney will become ischemic and die.

A client is admitted to the emergency department with two gunshot wounds. What can the nurse determine from the presence of these wounds? (Select all that apply.)

Answer: 2. The location of the wounds provides a hint of the trajectory the missile might have taken if the same missile caused both wounds. 5. It will be necessary to inspect both wounds closely for the presence of gunpowder. Rationale: 2. If there are two wounds, noting the location of each gives the clinician a hint of the trajectory only if the same missile caused both wounds. 5. Both wounds will require close inspection for any foreign substances such as gunpowder.

The nurse is reviewing the serial SOFA scores of a client with MODS. What is the benefit of understanding this trend?

Answer: 2. The trend can provide information about the efficacy of interventions. Rationale: 2. SOFA score trending helps the treatment team determine whether interventions are effective.

A client has an oral endotracheal tube and has been on mechanical ventilation for 3 days. Why is it important for the nurse to monitor and maintain cuff pressure at no more than 30 mmHg?

Answer: 2. To prevent necrosis of the trachea Rationale: 2. Decreased or obliterated blood flow to tracheal tissue, leading to tissue necrosis, can be caused by overinflating endotracheal tube cuffs with pressures greater than 30 mmHg.

A client who has developed chronic renal failure says, "I really don't want to wait until I need to go on dialysis. Let's just go ahead and do a transplant now." How should the nurse respond?

Answer: 3. "The primary criterion for transplant is end-stage renal disease, which you have not reached." Rationale: 3. The client must meet certain criteria for transplant. A major criterion is end-stage organ disease.

A client who had a myocardial infarction yesterday was pain free until 15 minutes ago. The client now says the pain is like it was when he originally came to the emergency department. Which assessments should the nurse conduct? (Select all that apply.)

Answer: 3. Auscultate breath sounds. 4. Evaluate cardiac rhythm. Rationale: 3. The nurse should assess respiratory sounds for crackles. 4. Cardiac rhythm changes may occur as the myocardium becomes hypoxic.

A client required a colostomy following a gunshot wound to the abdomen. The nurse would evaluate which assessment finding as indicating development of a common complication of this type of injury?

Answer: 3. Fever Rationale: 3. The intestine contains bacteria that can cause infection if spilled into the abdominal cavity. Because this client required a colostomy, it is likely that disruption of the colon occurred.

The spouse of a client asks why his wife has developed SIRS. The nurse reviews the client's history and discovers the client is 43 years old, is 5 feet 5 inches tall, weighs 200 pounds, has three children who were all born by cesarean section, has never smoked, and drinks wine with dinner three times a week. Which assessment finding would the nurse interpret as a risk factor for the development of SIRS?

Answer: 3. Increased body mass index Rationale: 3. Clients with increased BMI are at higher risk for developing SIRS. Ideally, this client should weigh approximately 125 to 130 pounds.

A client who has developed MODS has had an average blood glucose of 165 mg/dL over the last 3 days. How would the nurse interpret this finding?

Answer: 3. The client's glycemic control is adequate. Rationale: 3. A blood glucose of 165 mg/dL is below the 180 mg/dL desired under new, more moderate glycemic control recommendations.

A client in septic shock has been prescribed a vasopressor medication. Which assessment finding would the nurse evaluate as indicating the need to question this order?

Answer: 3. The client's urine output for the last hour was 10 mL. Rationale: 3. Vasopressor medications are not effective if there is inadequate circulating blood volume. Poor urine output is one measure of insufficient fluid resuscitation.

The sister of a client who needs a kidney transplant says, "I would donate my kidney, but I have type O blood and his blood is type A." How should the nurse respond?

Answer: 4. "The transplant may still be possible." Rationale: 4. A donor with type O blood is a potential match for a recipient with type A blood.

A client in septic shock is given IV insulin therapy. The nurse would increase this infusion if which blood glucose level was measured? (Select all that apply.)

Answer: 4. 184 mg/dL 5. 200 mg/dL Rationale: 4. A blood glucose level of 184 mg/dL is above the recommended parameter of 180 mg/dL. The nurse should titrate the infusion upward. 5. A blood glucose level of 200 mg/dL is above the recommended parameter of 180 mg/dL. The nurse should titrate the infusion upward.

An adult client has been declared brain dead and is being managed until organ donation can occur. The nurse works to maintain at least which mean arterial pressure (MAP) level in this client?

Answer: 4. 60 mmHg Rationale: 4. A 60 mmHg MAP is the minimum pressure desirable to perfuse organs.

A client was admitted after being severely injured in an explosion. How long would the nurse monitor this client for the development of primary MODS?

Answer: 4. 72 hours Rationale: 4. The client should be monitored for the first 72 hours after admission.

Brain natriuretic peptide (BNP) has been drawn to assess whether a patient has heart failure or ARDS. What will the nurse expect the test to reveal if this patient has heart failure rather than ARDS?

Answer: 4. A value greater than 100 pg/mL Rationale: 4. A BNP in excess of 100 pg/mL suggests that the patient's symptoms are due to heart failure rather than ARDS.

A patient is scheduled for chest tube removal today. How should the nurse plan to address pain control for this procedure?

Answer: 4. Administer a PRN IV analgesic so that the drug's peak effect coincides with tube removal. Rationale: 4. Administering IV analgesia and then giving it time to take effect will reduce the pain associated with this procedure.

Before being placed on noninvasive positive pressure ventilation (NIPPV), a client has these ABGs: pH 7.25, PaCO2 66 mmHg, PaO2 90 mmHg, HCO3 23 mmHg. One hour after being placed on NIPPV, the client's ABGs are pH 7.32, PaCO2 46 mmHg, PaO2 92 mmHg, HCO3 24 mmHg. What should the nurse do? (Select all that apply.)

Answer: 4. Check the mask for an air leak. 5. Continue monitoring. Rationale: 4. After 1 hour using NIPPV, more improvement in ABGs would be anticipated. The client's values suggest continued hypoventilation. Hypoventilation is the most common mechanical problem associated with NIPPV, and repositioning the mask to improve the seal may relieve it. 5. The nurse should continue to monitor this client.

A client is placed on a mechanical ventilator at these settings: tidal volume 450 mL, rate 8 breaths per minute, FiO2 50%. The client's PaCO2 has increased from 45 mm Hg to 55 mm Hg. What ventilator setting does the nurse expect to be altered to decrease the PaCO2?

Answer: 4. Increase rate to 12 breaths per minute. Rationale: 4. Minute ventilation is the amount of air that moves in and out of the lungs in 1 minute. Minute ventilation is dependent on rate and tidal volume (minute ventilation = tidal volume × rate). If minute ventilation becomes too low, hypoventilation occurs. In this situation, increasing the respiratory rate will increase minute ventilation and correct the hypoventilation.

A client admitted after a motor vehicle crash is 36 weeks pregnant. After spinal injury has been ruled out, how should the nurse position the client?

Answer: 4. Left lateral decubitus Rationale: 4. The left lateral decubitus position moves the enlarged uterus off the inferior vena cava and increases venous return. This is the position of choice for this client if no other injuries prevent its use.

A client, admitted after falling, is unconscious and has open fractures to both femurs. Initial assessment reveals diminished breath sounds bilaterally despite chest wall movements of breathing. What is the nurse's priority intervention?

Answer: 4. Perform a modified jaw thrust maneuver. Rationale: 4. The nurse should first attempt to open the airway without moving the neck. The modified jaw thrust maneuver is one method to achieve an open airway.

A client on mechanical ventilation has decreasing hemoglobin and hematocrit with dark stools. The nurse should prepare for which intervention?

Answer: 4. Test stools for blood. Rationale: 4. Stress ulcers (also called stress-related mucosal injury [SIMI]) occur in clients receiving mechanical ventilation secondary to gastric hyperacidity or transient visceral hypoxia. Testing stool for blood will help to determine if the client is having an active gastrointestinal bleed. Bleeding may be gross or occult.

A patient is admitted to the emergency department with complaints of shortness of breath, cough, and fever. Which clinical manifestations would the nurse interpret as indicating early respiratory distress? (Select all that apply.)

Answer: 1. Increased respiratory rate 2. Tachycardia 3. Agitation 5. Confusion Rationale: 1. An increased respiratory rate is the body's way of obtaining more oxygen. 2. Tachycardia occurs as the body attempts to distribute oxygen. The stress of respiratory distress also increases the heart rate. 3. Agitation is an early sign that the brain is not receiving sufficient oxygen. 5. Confusion occurs when the brain is not receiving enough oxygen.

A client is admitted to the hospital with a diagnosis of acute respiratory failure and may require mechanical ventilation. The client has a low ventilation-perfusion ratio as a result of pulmonary shunting. Which ABG result would the nurse anticipate in this client?

Answer: 1. PaO2 55mm Hg Rationale: 1. Pulmonary shunting refers to normal perfusion past unventilated alveoli resulting in hypoxemia.

Pulmonary function tests are performed on a patient diagnosed with right middle-lobe pneumonia. The patient's tidal volume and vital capacity are both below normal. The nurse would plan care based on which interpretation of these results?

Answer: 1. The patient has respiratory muscle fatigue. Rationale: 1. Tidal volume and vital capacity monitor respiratory muscle strength. When these values decrease, it is indicative of respiratory muscle fatigue.

A patient is admitted to the hospital with complaints of severe chest pain and dyspnea. The patient has an oral temperature of 38.3°C (101°F). Why is it important for the nurse to obtain a nutritional history from this patient? (Select all that apply.)

Answer: 2. High-carbohydrate diets increase carbon dioxide levels. 4. Poor nutritional status increases susceptibility to infection. Rationale: 2. High-carbohydrate diets increase the carbon dioxide load in the body. 4. Malnutrition is associated with a weakened immune system, placing the patient at risk for developing infection.

A patient has been in the ICU and intubated for 1 week. EtCO2 is attached to the patient's mechanical ventilator circuit to assess for which development?

Answer: 3. Early changes in ventilation Rationale: 3. Low EtCO2 is associated with hyperventilation, whereas increased EtCO2 is associated with hypoventilation.

A patient comes to the emergency department complaining of shortness of breath and chest pain. The ABG results are: pH 7.45, PaCO2 35 mmHg, PaO2 60 mmHg, HCO3 24 mEq/L. What should be the nurse's first intervention?

Answer: 3. Place the patient on oxygen. Rationale: 3. Normal PaO2 is 80-100 mmHg. This patient's value is only 60 mmHg, so supplemental oxygen should be initiated.

A patient with pneumonia develops what is believed to be an absolute pulmonary shunt. Oxygen therapy has been initiated per venti-mask. The nurse would expect which effect on the patient's hypoxemia?

Answer: It will worsen. Rationale: An absolute shunt is the combination of blood that does not take part in gas exchange and the normal flow of blood past unventilated alveoli. Because the alveoli are nonfunctioning, an absolute shunt is refractory to oxygen therapy. Because the patient is continuing to use oxygen, hypoxemia will worsen.

A patient is diagnosed with diabetic ketoacidosis (DKA) after being admitted to the hospital with a serum glucose of 650 mg/dL and positive serum ketones. Blood gases are: pH 7.25, PaCO2 36 mmHg, HCO3 14 mEq/L. This pH is most likely a result of which acid-base disturbance?

Answer: Metabolic acidosis Rationale: The pH below 7.35 and the HCO3 below 22 mEq/L indicate metabolic acidosis.

A patient has the following ABG results: pH 7.50, PaCO2 30 mmHg, HCO3 20 mEq/L, PaO2 88 mmHg, SaO2 98%. How would the nurse interpret these results?

Answer: Partially compensated respiratory alkalosis Rationale: The elevated pH (alkaline) and low PaCO2 indicate metabolic alkalosis. The decreased (acid) HCO3 represents partial compensation, as the pH is not in normal range.

A nurse is advised that a client with multiple blunt trauma is expected to arrive in the emergency department. What preparations should the nurse make?

Answer:Alert radiology staff that x-rays will be required. Rationale: Because the forces of blunt trauma are transferred to the tissues involved, deformation is likely. Radiologic studies are necessary to determine the presence of broken bones and other injuries.

A client has an inhalation injury. The nurse would prepare to assist with which tests specific to this injury?

Arterial blood gases, bronchoscopy Rationale: Arterial blood gases are necessary to determine levels of oxygenation in the client with inhalation injury. A bronchoscopy is often done to determine the amount and level of damage.

A client had an immediate hypermetabolic response to a severe burn and is now experiencing a hypermetabolic hyperdynamic state. Which assessment findings would the nurse anticipate? (Select all that apply.)

Increased heart rate Increased respiratory rate Rationale: The heart rate increases in the hypermetabolic hyperdynamic state. The respiratory rate increases in the hypermetabolic hyperdynamic state.

A severely burned client is in the resuscitative phase of burn care. How can the nurse help to minimize psychological and emotional problems in this client?

Involve the client in self-care activities as soon as medically feasible.

The nurse is working with a physical therapist and an occupational therapist to promote antideformity positioning in a burned client. What criterion should the positions meet?

The position should maintain joint extension. Rationale: Scar formation across a joint causes contractures of flexion. The antideformity position is one of extension.