MS exam 4 practice q
A nurse is planning care for a patient with a 30% body surface area burn injury. Which statement regarding the nutritional status of this patient is true? Maintaining a hypermetabolic state reduces the patient's risk for infection. Decreased protein intake will decrease the chance of renal complications. Controlling the temperature of the environment reduces caloric requirements. A hypermetabolic state results in poor healing and increased protein and lipid needs.
A hypermetabolic state results in poor healing and increased protein and lipid needs.
A client with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, what should the nurse do? A. Hyperoxygenate with 100% oxygen before and after suctioning B. Suction two or three times in quick succession to remove secretions C. Use the technique of short, pushing movements when applying suction D. Apply suction for no more than 10 seconds while inserting the catheter
A. Hyperoxygenate with 100% oxygen before and after suctioning
The nurse expects to see what oxygenation and ABG changes for a patinet when their ARDS begins to resolve? New-onset respiratory alkalosis An increasing P a O2/F I O2 ratio A decreasing P a O2/F I O2 ratio Resolving metabolic alkalosis
An increasing P a O2/F I O2 ratio (progression from respiratory alkalosis to metabolic acidosis is seen as oxygenation deteriorates and the patient moves to anaerobic metabolism—Respiratory alkalosis is seen in early ARDS due to the tachypnea seen in an effort to increase oxygen levels. Metabolic alkalosis is not common in ARDS A decreasing ratio indicates a worsening in oxygenation status. n increase in the PaO2/FIO2 ratio indicating improvements in oxygenation.would expect to see a_
A patient is receiving mechanical ventilation after having a stroke. The nurse determines that the ventilator settings are based on which patient status? Ideal body weight, vital signs, and family preference Ethics committee results, current physiologic state, and ideal body weight Respiratory muscle strength, ethics committee results, and family preference Arterial blood gases (ABGs), current physiologic state, and respiratory muscle strength
Arterial blood gases (ABGs), current physiologic state, and respiratory muscle strength
The nurse is caring for a patient who has just been orally intubated. Which action should the nurse takefirst? Assess for symmetrical chest rise and fall with ventilation Assess the need for nutritional support by an oral /nasogastric tube Provide a communication board for the patient and family Provide mouth care to ensure a clean oral cavity
Assess for symmetrical chest rise and fall with ventilation
he nurse is providing care for a patient requiring mechanical ventilation. When the nurse enters the room at the beginning of the shift, the patient's monitor displays a heart rate of 64 and oxygen saturation of 88%. Which nursing action is the priority? Removing the patient from the ventilator and hyperoxygenating the patient Checking ventilator settings Assessing the patient for airway obstruction Increasing the oxygen concentration
Assessing the patient for airway obstruction
The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy?A. Vital signs B. Urine output C. Mental status D.Peripheral pulses
B. Urine output
The low-pressure alarm sounds on a ventilator. A nurse assess the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initial action? A. Checks the client's vital signs. B. Ventilates the client manually. C. Administers oxygen. D. Starts cardiopulmonary resuscitation.
B. Ventilates the client manually.
The nurse is caring for a patient receiving mechanical ventilation with high levels of positive end-expiratory pressure (PEEP). What complication should the nurse monitor for in this patient? Barotrauma Oxygen toxicity Pneumoperitoneum Ventilator-associated pneumonia (VAP)
Barotrauma
What complication can a high peak airway pressure used in the mechanical ventilation of a patient with acute respiratory distress syndrome (ARDS) cause? Volutrauma Barotrauma Stress ulcers Ventilator-assisted pneumonia (VAP)
Barotrauma
A patient has developed acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. Which respiratory complications would the nurse assess for in this patient? Select all that apply. Barotrauma Pneumothorax Pulmonary hemorrhage Decreased cardiac output Ventilator-associated pneumonia
Barotrauma Pneumothorax Ventilator-associated pneumonia
A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider (HCP) and anticipates which prescription? A. Transfusing 1 unit of packed red blood cells B. Administering a diuretic to increase urine output C. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour D. Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water
C. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour
The nurse recognizes that the alarm of a mechanical ventilator is displaying a high-pressure limit. What causes should the nurse assess for in this situation? Select all that apply. Loss of airway Compressed tubing Condensate in tubing Ventilator asynchrony Total ventilator disconnect
Compressed tubing Condensate in tubing Ventilator asynchrony
A patient is being mechanically ventilated. A high-pressure ventilation alarm sounds. The nurse should assess for what cause of this type of alarm? Power failure Insufficient gas flow Condensate in tubing Tracheotomy cuff leak
Condensate in tubing
The nurse should intervene when a patient who is being admitted to the unit with the diagnosis of COPD is noted to have which clinical manifestation? Confusion Cough Depression Fatigue
Confusion (Patients experiencing hypoxia usually have signs of irritability, restlessness, anxiety, and confusion. As the brain cells receive less oxygen, thepatient becomes more confused)
An older adult patient reports having used an "iron lung" after contracting polio as a child. The nurse knows this patient is referring to which type of mechanical ventilation? Positive pressure Negative pressure Volume ventilation Pressure ventilation
Negative pressure
A nurse is attending a patient with acute respiratory distress syndrome (ARDS). Which position will provide the best outcome for this patient? Prone Sitting Supine Lateral
Prone
A patient who is tachypneic for an extended period of time will demonstrate which of the following arterial blood gas results? Respiratory alkalosis with hypocapnia Respiratory alkalosis with hypercapnia No changes in the results due to metabolic compensation Respiratory acidosis will a rising pH
Respiratory alkalosis with hypocapnia
the nurse identifies it is most important to observe for hyperventilation in a client receiving which mode of mechanical ventilation a. control mechanical ventilation (CMV) b. assist control ventilation (AC) c. synchronized intermittent mandatory ventilation (SIMV) d. continuous positive airway pressure (CPAP)
b. assist control ventilation (AC)
A client's chest X-ray reveals bilateral white-outs, indicating acute respiratory distress syndrome (ARDS). Which pathological process does the nurse recognize is the underlying cause of this condition? a) decreased blood flow to pulmonary vessels b) decreased compliance of lungs c) increased pulmonary capillary permeability d) increased retentino of serum carbon dioxide
c) increased pulmonary capillary permeability.
a nurse cares for a client suspected of having a PE. which sign does the nurse recognize supports this diagnosis? select all bradypnea dyspnea headache hemoptysis tachycardia
dyspnea hemoptysis tachycardia
the client requires respiratory support with synchronized intermittent mandatory ventilation (SIMV). which does the nurse understand to be the primary mechanism of action of SIMV a. the delivery of breaths is synchronized with the R wave of the client b. a set tidal volume is delivered at a set rate regardless of the breathing efforts of the client c. positive pressure is intermittently exerted at the end of ventilator breaths d. ventilator breaths are correlated w client breathing and client can breathe naturally in between
d. ventilator breaths are correlated w client breathing and client can breathe naturally in between
The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate? continue to suction notify the HCP immediately stop the procedure and reoxygenate the pt ensure that the suction is limited to 15 seconds
stop the procedure and reoxygenate the pt
Which information should a nurse provide to the family of a patient who is using an endotracheal tube in an emergency department? "The tube allows for patient movement." "The patient can eat with an endotracheal tube." "An endotracheal tube is used to aspirate the trachea of the patient." "An endotracheal tube is used to manage proper ventilation initially."
"An endotracheal tube is used to manage proper ventilation initially."
A patient with severe respiratory failure requires endotracheal intubation. Which parameter does the nurse monitor to ensure tube placement? Oxygen status Hemodynamics Arterial blood gases End-tidal carbon dioxide
End-tidal carbon dioxide
A patient who is receiving mechanical ventilation is at risk for which complications? Hypotension, infection, and barotrauma Anxiety, hypertension, and fatigue VAP, atelectasis, and hypothermia Dyspnea, hypoxia, and normothermia
Hypotension, infection, and barotrauma (Hypotension: Secondary to changes in the pressure in the chest cavity. This increased pressure in the chest causes a decrease in venous return and can ultimately decrease CO. Infection: Because the normal defense of the upper and lowerairways are bypassed. The ETT leads directly into the lungs and can introduce infection. Barotrauma: Due to the increased positive pressure that cancause alveolar rupture)
The nurse maintains the head of the bed elevated for a patient on mechanical ventilation. What neurologic disorder is the nurse attempting to reduce the risk of? Guillain-Barré Multiple sclerosis (MS) Traumatic brain injury (TBI) Increased intracranial pressure (ICP)
Increased intracranial pressure (ICP)
What therapy is provided to a patient with acute respiratory distress syndrome (ARDS)? Mechanical ventilation Oxygen via a Venturi mask Oxygen via a non-rebreather mask Small volume nebulizer treatments
Mechanical ventilation
The nurse is caring for a patient with lung injury that has increased capillary permeability. What findings does the nurse anticipate in this patient? Pulmonary edema Pulmonary fibrosis Pulmonary embolus Pulmonary barotrauma
Pulmonary edema
When managing hypoxemia in a patient with multiple organ dysfunction syndrome, what appropriate interventions should the nurse use to decrease oxygen demand? Select all that apply. Sedate the patient. Administer analgesics. Catheterize the patient. Initiate mechanical ventilation. Assist the patient to move around.
Sedate the patient. Administer analgesics. Initiate mechanical ventilation.
A patient on mechanical ventilation is given esomeprazole via a gastric tube. The nurse knows that this prophylactic treatment is important because of which associated risks? Select all that apply. Sedation Immobility Decreased peristalsis Decreased air swallowing Increased acid production
Sedation Immobility Decreased peristalsis Increased acid production
The nurse is caring for a patient with a tracheostomy on mechanical ventilation when the alarm displays low tidal volume and low-pressure limit. What does the nurse infer from this finding? Total extubation Insufficient gas flow Tracheotomy cuff leak Change in patient's respiratory rate
Tracheotomy cuff leak
the client arriving at the emergency department has experienced frostbite to the R hand. which finding would the nurse note on assessmnet of the pts hand? a. pink edematous hand b. fiery red skin w edema in nail beds c. black fingertips surrounded by erythematous rash d. white color to skin which is insensitive to touch
d. white color to skin which is insensitive to touch
A patient's family member asks the nurse what SIMV means on the settings of the mechanical ventilator attached to the patient. Which statement is the best response by the nurse? "SIMV is a mode that allows the ventilator to totally control your father's breathing. It will prevent him from hyperventilating or hypoventilating, thus ensuring the best oxygenation." "SIMV provides additional inspiratory pressure so that your father does not have to work as hard to breathe, thus enabling better oxygenation and a quicker recovery with fewer complications." "SIMV is a mode that allows your father to breathe on his own, but the ventilator will control how deep a breath he will receive. The ventilator can sense when he wants a breath and it will deliver it." "SIMV is a mode that allows your father to breathe on his own while receiving a preset number of breaths from the ventilator. He can breathe as much or as little as he wants beyond what the ventilator will breathe for him."
"SIMV is a mode that allows your father to breathe on his own while receiving a preset number of breaths from the ventilator. He can breathe as much or as little as he wants beyond what the ventilator will breathe for him."`
The family of a patient being treated for multiple organ dysfunction syndrome (MODS) asks the nurse why the patient is being sedated and placed on mechanical ventilation. Which explanation by the nurse provides the best explanation for the anticipated outcomes secondary to these interventions? "This allows the gastrointestinal system to rest which helps prevent hyperglycemia." "All patients with MODS are sedated and placed on mechanical ventilation as a preventive measure." "Sedation and mechanical ventilation help to decrease oxygen demands and increase oxygen delivery to organs." "Sedation and mechanical ventilation help keep the patient from having a heart attack, which is common with MODS."
"Sedation and mechanical ventilation help to decrease oxygen demands and increase oxygen delivery to organs."
A health care provider (HCP) writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The registered nurse determines that the new graduate nurse understands this modality of weaning if which statement is made? 1."The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance." 2."A T-piece will be attached to the ventilator and provide supplemental oxygen at a concentration that is 10% higher than the ventilator setting." 3."It will provide pressure support to decrease the workload of breathing and increase the client's ability to initiate spontaneous breathing efforts." 4."It involves removing the ventilator from the client and closely monitoring the client's ability to breathe spontaneously for a predetermined amount of time."
1."The respiratory rate is decreased gradually until the client can assume the work of breathing without ventilatory assistance."
The nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high-pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which complication? 1.A kink in the ventilator circuit 2.A leak in the endotracheal tube cuff 3.Displacement of the endotracheal tube 4.A disconnection of the ventilator tubing
1.A kink in the ventilator circuit
The nurse is reviewing the ventilator settings on a client with an endotracheal tube attached to mechanical ventilation. The nurse notes that the tidal volume is set at 700 mL. How does the nurse interpret this setting? 1.It is the amount of air delivered with each set breath. 2.It is a breath that has a greater volume than the preset tidal volume. 3.It is the number of breaths that the client will receive per minute by the ventilator. 4.It is the fraction of inspired oxygen (FiO2) that is delivered to the client through the ventilator.
1.It is the amount of air delivered with each set breath.
The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. 1.Water or a kink in the tubing 2.Biting on the endotracheal tube 3.Increased secretions in the airway 4.Disconnection or leak in the system 5.The client ceasing spontaneous breathing
1.Water or a kink in the tubing 2.Biting on the endotracheal tube 3.Increased secretions in the airway
The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? 5 seconds 10 seconds 30 seconds 60 seconds
10 seconds
Fluid resuscitation is an important intervention in burn patients. The nurse recognizes that what fluid is recommended for the first 24 hours after a burn? 1 to 2 mL lactated Ringer's/kg/%TBSA burned 2 to 4 mL lactated Ringer's/kg/%TBSA burned 6 to 8 mL lactated Ringer's/kg/%TBSA burned 8 to 10 mL lactated Ringer's/kg/%TBSA burned
2 to 4 mL lactated Ringer's/kg/%TBSA burned
A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? SELECT ALL THAT APPLY 1. restrict fluids 2. Assess for airway patency. 3. Administer oxygen as prescribed. 4. Place a cooling blanket on the client. 5. Elevate extremities if no fractures are present. 6. Prepare to give oral pain medication as prescribed.
2. Assess for airway patency. 3. Administer oxygen as prescribed. 5. Elevate extremities if no fractures are present.
A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? 18% 22.5% 27% 36%
22.5%
An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which percentage?
22.5%
The nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding? 1.A tubing obstruction or kink 2.The accumulation of secretions 3.Disconnection of the ventilator tubing 4.Condensation of water in the ventilator tubing
3.Disconnection of the ventilator tubing
An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury percentage wise ?
36%
The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm sounds. The nurse assesses the client and attempts to determine the cause of the alarm. Which initial nursing action would be appropriate if the nurse is unable to determine the cause of ventilator alarm? 1.Shut the alarm off and call for help. 2.Call the respiratory therapy department to fix the problem. 3.Call the health care provider (HCP) for further instructions. 4.Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device.
4.Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device.
when caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate? A. Remove secretions by suctioning. B. Lower the setting of the tidal volume. C. Check that tubing connections are secure. D. Obtain a specimen for arterial blood gases (ABGs).
A. Remove secretions by suctioning.
A nurse is attending to a patient with partial-thickness burns on the hands and legs. What actions should the nurse perform as a part of the wound care for the emergent phase of treatment? Select all that apply. Avoid using topical antibiotics. Administer a tetanus antitoxin. Perform debridement as required. Avoid using antimicrobial dressings. Assess the extent and depth of the burns.
Administer a tetanus antitoxin. Perform debridement as required. Assess the extent and depth of the burns.
A patient who was on mechanical ventilation through an endotracheal tube develops inspiratory stridor and sternal retraction upon removal of the endotracheal tube. How should the nurse manage this patient and ensure oxygenation? Select all that apply. Suction the airway. Administer oxygen therapy. Administer muscle relaxants. Tilt the head and thrust the jaw.
Administer oxygen therapy. Administer muscle relaxants. (laryngospasm associated w removing WT tube)
A patient sustains burns covering 35% of the body surface area. The patient weighs 100 kg. Which action is most appropriate for the nurse to take during the early course of the patient's care? Administering 3500 mL of colloid IV fluids over the 8 hours after injury Administering 140 mL/hr of colloid IV fluids for the 24 hours after injury Administering 7000 mL of crystalloid IV fluids over the 8 hours after injury Administering 14,000 mL of crystalloid IV fluids over the 12 hours after injury
Administering 7000 mL of crystalloid IV fluids over the 8 hours after injury
A patient has been admitted to the emergency department after ingesting an entire bottle of chewable multivitamins in a suicide attempt. The nurse should anticipate which intervention? Induced vomiting Whole bowel irrigation Administration of activated charcoal Administration of fresh frozen plasma
Administration of activated charcoal
The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? A. Decreased heart rate B. Increased urinary output C. Increased blood pressure D. Elevated hematocrit levels
D. Elevated hematocrit levels
The nurse is caring for a patient that sustained a head injury in a motor vehicle crash that is presently being mechanically ventilated with positive pressure ventilation. Which neurologic complication should the nurse monitor the patient for? Decrease in venous return Compression of jugular vein Reduction of cerebral volume Reduction of intracranial pressure
Decrease in venous return (PEEP increases intrathoracic pressure which decreases venous return)
The nurse understands that the rationale for the administration of sedative and analgesic medications to at patient while on mechanical ventilation is which of the following? (Select all that apply.) Decrease oxygen consumption Increase mobilization Improve respiratory effort Increase patient-ventilator synchrony Reduce the pain/ increase comfort
Decrease oxygen consumption Increase patient-ventilator synchrony Reduce the pain/ increase comfort
When caring for a critically ill patient who is being mechanically ventilated, the nurse will astutely monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)? Increased serum albumin Decreased respiratory compliance Increased gastrointestinal (GI) motility Decreased blood urea nitrogen (BUN)/creatinine ratio
Decreased respiratory compliance
The nurse is providing care to a patient who is intubated and receiving mechanical ventilation. Which nursing actions are appropriate when providing care to this patient? Select all that apply Select all that apply Assessing the patient without speaking Contacting a translator prior to providing patient care Explaining each task to the patient prior to performing it Providing a notepad for the patient to write down questions or comments Using hand gestures when providing care to the patient when appropriate
Explaining each task to the patient prior to performing it Providing a notepad for the patient to write down questions or comments Using hand gestures when providing care to the patient when appropriate
A patient with acute pancreatitis is at risk of developing ventilator-associated pneumonia (VAP). What nursing actions are essential for the prevention of VAP? Select all that apply. Frequent hand washing Ventilation in smaller tidal volumes Correction of predisposing conditions Frequent mouth care and oral hygiene Sterile technique during endotracheal suctioning
Frequent hand washing Frequent mouth care and oral hygiene Sterile technique during endotracheal suctioning
The pulmonary edema associated with ARDS is caused by: Left ventricular failure due to poor oxygenation Right ventricular failure with pulmonary hypertension Increased permeability of the (ACM) alveolar-capillary membrane Fluid overload related to resuscitation in the first phase
Increased permeability of the (ACM) alveolar-capillary membrane (The pulmonary edema is non-cardiogenic, caused by the leak of plasma out of the vascular space and into the alveoli and interstitial spaces of the lungs. Fluid overload can complicate the picture, worsening the fluid leakage that is occurring due tothe damaged ACM.)
The nurse assesses for which physiologic response as compensation for metabolic acidosis? Decreasing the respiratory rate Increasing urine output Increasing the respiratory rate Decreasing urine output
Increasing the respiratory rate
The nurse assesses a patient who is tachypneic and notes a PaO 2 of 56%, a PaCO 2 of 50%, and diminished mental status. The patient's medical history reveals a 40-year history of smoking. Which nursing action is the highest priority? Obtaining a detailed history of prior hospitalizations Implementing a plan to teach the patient diaphragmatic and pursed-lip breathing Initiating postural drainage and chest percussion and vibration to remove secretions Initiating the administration of oxygen and continuous pulse oximetry monitoring
Initiating the administration of oxygen and continuous pulse oximetry monitoring
The nurse understands that J.T.'s initial "refractory hypoxemia" indicates what about the adequacy of his supplemental oxygen support? It has caused alveolar collapse It is sufficient, and the FIO2 can be reduced. It fails to maintain adequate oxygen saturation. It has caused signs of oxygen toxicity.
It fails to maintain adequate oxygen saturation. (Refractory means that in spite of increases of oxygen levels the patient's oxygenation status does not improve. This indicates a worsening ventilation perfusion mismatch or shunt requiring more than supplemental oxygen for treatment. Oxygen does not cause alveolar collapse—that is caused by excessive secretions or pressure.)
The nurse is maintaining a propofol drip in the intensive care unit for a patient on a mechanical ventilator. What does the nurse inform the family about the benefit of the drug regarding managing anxiety and agitation? It reduces blood pressure in the body. It causes fluid replacement effectively. It maintains electrolyte balance effectively. It has a short half-life and rapid onset of action.
It has a short half-life and rapid onset of action.
A patient with acute respiratory distress syndrome (ARDS) has been put on a ventilator. What nursing measures decrease the risk of development of pneumonia secondary to ventilator use? Select all that apply. Using invasive monitoring devices Maintaining proper hygiene of the patient Keeping the patient on prolonged ventilation Using the enteral route for feeding the patient Using aseptic techniques when suctioning the patient
Maintaining proper hygiene of the patient Using aseptic techniques when suctioning the patient
After assessing a patient with acute respiratory distress (ARDS) on a ventilator, the nurse notes that the respiratory therapist has written that the patient is at high risk for volutrauma. Which action should the nurse implement immediately? Call the health care provider. Make sure the V T is set to 8 mL/kg. Set the pressure support to 17 H 2O. Prepare the family for the patient's imminent demise.
Make sure the V T is set to 8 mL/kg.
The nurse is caring for a patient in the intensive care unit that is intubated and receiving mechanical ventilation. The health care provider prescribes positive end-expiratory pressure (PEEP) therapy. What does the nurse recognize the patient has developed? Hypovolemia Pulmonary edema Low cardiac output Unilateral lung disease
Pulmonary edema
The nurse is caring for a patient with a shunt due to acute respiratory distress syndrome (ARDS). Which nursing intervention is associated with better symptomatic relief for this patient? Mechanical ventilation only Mechanical ventilation and high FIO 2 Bronchodilators along with corticosteroids High fraction of inspired oxygen (FIO 2) only
Mechanical ventilation and high FIO 2
Which precautions should the nurse take when suctioning a tracheostomy? Limit suction time to 30 seconds. Rinse the catheter with clean water between suction passes. Monitor oxygen saturation and lung sounds after suctioning. Apply suction when inserting the catheter into the tracheostomy.
Monitor oxygen saturation and lung sounds after suctioning.
When caring for a patient diagnosed with respiratory acidosis, the nurse includes which nursing interventions? (Select all that apply.) Monitor sedation medication usage. Monitor the patient's ABGs. Administer supplemental oxygen Encourage the patient to use slow breathing. Have the patient breathe into a paper bag. Encourage the patient to use an incentive spirometer.
Monitor sedation medication usage. Monitor the patient's ABGs. Administer supplemental oxygen Encourage the patient to use an incentive spirometer.
Air enters the lungs due to: Negative intrathoracic pressure (pressure lower than atmospheric pressure) and contraction of the diaphragm (inspiration) Positive intrathoracic pressure and relaxation of the diaphragm (exhalation) sympathetic nervous system response to stress,which will increase the respiratory rate Chemoreceptors which are sensitive to the level of carbon dioxide in the blood which will stimulate the brain to control the respiratory rate
Negative intrathoracic pressure (pressure lower than atmospheric pressure) and contraction of the diaphragm (inspiration)
The nurse is caring for a patient who is on mechanical ventilation. What findings suggest that the patient has ventilator-associated pneumonia? Select all that apply. Hypothermia Odorous sputum Crackles on auscultation Reduced white blood cell count Pulmonary infiltrates on chest x-ray
Odorous sputum Crackles on auscultation Pulmonary infiltrates on chest x-ray
When taking care of a patient diagnosed with respiratory failure on a mechanical ventilator, the nurse hears the apnea alarm beeping. What assessment data should be gathered to determine the cause of the alarm? Pain or anxiety Partial ventilator disconnect Secretions, coughing, or gagging Oversedation with opioid analgesics
Oversedation with opioid analgesics
A patient diagnosed with acute respiratory distress syndrome is being mechanically ventilated with 12 cm of positive end-expiratory pressure (PEEP). Upon assessment, the nurse notes deterioration of vital signs and absent breath sounds in the right lung field. What is the mostlikely cause for this finding? Pneumothorax Decreased cardiac output Deterioration of the disease Obstructed endotracheal tube
Pneumothorax
The nurse anticipates which of the following in the initial care of a patient with ARDS? Anticoagulants Positive-pressure ventilation Inotropic agents fresh frozen plasma (FFP)
Positive-pressure ventilation (The first step in caring for any patient with ARDS is to treat the refractory hypoxemia with positive pressure ventilation in an effort to open the alveoli and improve gas exchange. Inotropic agents may be necessary if the patient experiences hemodynamic instability. Anticoagulation is not indicated inthe treatment of ARDS unless there is a complication of immobility resulting in clotting or DVT. FFP may be indicated if there is a problem with excessive bleeding)
When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect? Increased inflation of the lungs Prevention of barotrauma to the lung tissue Prevention of alveolar collapse during expiration Increased fraction of inspired oxygen concentration (FIO 2) administration
Prevention of alveolar collapse during expiration
The nurse is taking care of a patient who is intubated and being mechanically ventilated. In order to prevent ventilator-associated pneumonia (VAP), what nursing action is appropriate? Promoting early exercise and mobility Performing hand washing during suctioning Draining collected ventilator tubing water toward the patient Maintaining the head of the bed at a minimum of 20 degrees
Promoting early exercise and mobility
The intensive care unit nurse is caring for a patient who is ventilated mechanically. To prevent sepsis in this patient, which nursing intervention does the nurse include in the plan of care? Provide oral care every two to four hours. Turn patient from side to side every eight hours. Position patient in a supine position every two hours. Use clean gloves when suctioning the endotracheal tube.
Provide oral care every two to four hours.
A nurse is caring for a patient diagnosed with septic shock. The patient develops dyspnea, tachycardia, and bilateral lung crackles. The nurse suspects the patient has developed acute respiratory distress syndrome (ARDS). Which intervention is the nurse's priority? Repeat chest radiograph Draw arterial blood gasses Start broad spectrum antibiotics Pulmonary management with mechanical ventilation
Pulmonary management with mechanical ventilation
The nurse is caring for a patient on mechanical ventilation. What are the nursing interventions that prevent the development of volutrauma in a patient on a ventilator? Select all that apply. Sterile techniques Strict hand washing Smaller tidal volumes Pressure-control ventilation Mouth care and oral hygiene
Smaller tidal volumes Pressure-control ventilation
A patient experiencing severe wheezing arrives in the emergency department and is diagnosed with severe exacerbation of asthma. During the admission assessment, the nurse on the inpatient unit notes that the patient continues to struggle with breathing; however, there is an absence of wheezing. How should the nurse interpret the assessment findings? The patient is hypoxic and needs oxygen therapy. The patient has improved because there is no wheezing. The patient has respiratory failure and needs mechanical ventilation. The patient has retained secretions and needs chest physiotherapy.
The patient has respiratory failure and needs mechanical ventilation.
A patient arrives at the burn unit with large burns on the chest and abdomen. While assessing the patient, the nurse suspects full-thickness burns. What findings are likely to be found in the patient with full-thickness burns? Select all that apply. The patient is shivering. The burned areas have blisters. The burned areas are very painful. The patient has low blood pressure. The patient has absence of bowel sounds.
The patient is shivering. The patient has low blood pressure. The patient has absence of bowel sounds.
The nurse working in the intensive care unit (ICU) is taking care of a patient on a mechanical ventilator who had a motor vehicle accident two weeks ago. What does the nurse know about this situation? The patient has severe hypoxia due to acute respiratory failure. The ventilator will support the patient until he or she can breathe on his or her own. The patient suffered from a chronic pulmonary disease before the accident. The patient will be on long-term ventilation until the family decides to withdraw ventilator support.
The ventilator will support the patient until he or she can breathe on his or her own.
A patient is brought to the emergency department (ED) with severe burns on the legs and feet. Which factors lead the nurse to believe the patient may have full-thickness burns? Select all that apply. Touch sensation is impaired. Blanching with pressure is observed. Lack of blanching with pressure is observed. Wounds appear mottled white, pink to cherry-red. Wounds appear waxy white, dark brown, or charred.
Touch sensation is impaired. Lack of blanching with pressure is observed. Wounds appear waxy white, dark brown, or charred.
The nurse working in a critical care unit understands that tidal volume is an important setting in a mechanical ventilator. Which statement appropriately describes tidal volume? Number of breaths the ventilator delivers per minute Volume of gas delivered to patient during each ventilator breath Positive pressure used to augment patient's inspiratory pressure Positive pressure applied at the end of expiration of ventilator breaths
Volume of gas delivered to patient during each ventilator breath
Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? a. return of distal pulses b. brisk bleeding from the site c. decreasing edema formation d. formation of granulation tissue
a. return of distal pulses
the nurse prepares to suction the ET tube of a pt on a mechanical vent. which vent setting is adjusted by the nurse before and after this procedure a. tidal volume b. respiratory rate c. fraction of inspired oxygen (FIO2) d. flow
c. fraction of inspired oxygen (FIO2) (hyper oxygenate)
A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? hot, flushed feeling sudden chills and fever chest pain that occurs suddenly dyspnea when deep breaths are taken
chest pain that occurs suddenly
a nurse is caring for a client who is intubated and mechanically ventilated. which assessment findings lead the nurse to perform endotracheal suction ? select all coarse rhonchi bilaterally high peak inspiratory pressure increased incidence of coughing increased o2 requirements pulse of 62bpm
coarse rhonchi bilaterally high peak inspiratory pressure increased incidence of coughing increased o2 requirements
the nurse expects which mode of mechanical ventilation will be prescribed for a pt w severe guillain barre syndrome controlled mechanical ventilation (CMV) assist control ventilation (AC) synchronized intermittent mandatory ventilation (SIMV) continuous positive airway pressure (CPAP)
controlled mechanical ventilation (CMV)
a nurse cares for a client who is orally intubated and mechanically ventilated. which interventions does the nurse perform in order to reduce the risk of pneumonia? select all administer prophylactic antibiotics elevate HOB perform oral care every 4h reposition client every 2h restrict the clients fluid
elevate HOB perform oral care every 4h reposition client every 2h
the nurse assesses a client admitted to the hospital after sustaining multiple burns. the clients arm is white leathery and does not blanch or cause pain. which depth of injury does the nurse describe to the HCP deep partial thickness full thickness superficial superficial partial thickness
full thickness
The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? bilateral wheezing inspiratory crackles intercostal retractions increased resp rate
increased resp rate
a nurse treats a client admitted w severe frostbite. which assesssmnet finding does the nurse expct to make excessive exudate increased perfusion loss of sensation sensitive skin
loss of sensation
a client sustains majjor burns on the anterior thorax, head and bilateral upper extremities following a house fire. whats the inital treatment goal for this clieint? maintain patent airway prevent infection restore hemodynamic stability resuscitate intravascular fluid
maintain patent airway
In assessing a patient's arterial blood gases, who is diagnosed with earlystage acute respiratory failure, the nurse would expect to see which of thefollowing results? pH 7.48, PaCO2 44mm Hg, HCO3 30mm Hg,PaO2 70mm Hg, SaO2 94% pH 7.34, PaCO2 40mm Hg, HCO3 18mm Hg,PaO2 74mm Hg, SaO2 98% pH 7.48, PaCO2 30mm Hg, HCO3 26mm Hg,PaO2 52mm Hg, SaO2 90% pH 7.38, PaCO2 48mm Hg, HCO3 24mm Hg,PaO2 88mm Hg, SaO2 96%
pH 7.48, PaCO2 44mm Hg, HCO3 30mm Hg,PaO2 70mm Hg, SaO2 94% (In the early stages of acute respiratory failure the nurse would anticipate that the client's respiratory rate is elevated and oxygenation would be decreased, resulting in a respiratory alkalosis with hypoxemia.)
A nurse is monitoring a patient with spinal cord injury. The nurse reviews the arterial blood gas (ABG) reports and notifies the health care provider that the patient may need mechanical ventilation. Which blood gas abnormality would have led the nurse to this opinion? Select all that apply. pH = 7.27 PaO 2 = 80 mm Hg PaCO 2= 55 mm Hg PaHCO 3 = 26 mm Hg
pH = 7.27 PaCO 2= 55 mm Hg
the nurse knows it is essential to have which piece of equiptment at the bedside of a pt receiving mechanical ventilation resuscitation bag incentive spirometer particulate respirator patient controlled analgesia
resuscitation bag
a client w a circumferencial full thickness burn to the chest reports chest tightness. the nurse assesses for which desired outcome of an escharotomy debrided infected tissue reduced arm edema reduced scarring return of circulation distal to the burn
return of circulation distal to the burn
the triage nurse assess a client w burns on the R arm and leg, the client is crying w pain, the skin is red and large wet blisters are present. which depth of injury does hte nurse suspect deep partial thickness full thickness superficial superficial partial thickness
superficial partial thickness