NUS 211-Test 2

A home care nurse is visiting a left-handed client who has an implantable cardioverter-defibrillator (ICD) implanted in the left chest. The client is planning to go rifle hunting. How should the nurse respond? "You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site." "Being that close to a rifle might make your ICD fire." "You'll need to take an extra dose of your antiarrhythmic before you shoot." "Enjoy your hunting trip."

"You can't shoot a rifle left-handed because the rifle's recoil will traumatize the ICD site."

A nurse is caring for a client with ARDS. Which of the following clinical indicators would signify that this client is in respiratory failure? Select all that apply. A PaO2 level below 60 mmHg Pulse oximetry of 94% on room air A pCO2 level over 50 mmHg An ABG pH level of 7.35 A respiratory rate greater than 16 breaths per minute

A PaO2 level below 60 mmHg A pCO2 level over 50 mmHg

A nurse is using a non-rebreather mask to administer oxygen to an adult client who is in respiratory distress. Which nursing intervention should the nurse employ when using this type of oxygen delivery device? Slowly increase the amount of oxygen administered over the first hour Avoid administering solid food and only give liquids with this type of mask Assess the client's skin and hair every 4 hours Ensure that the mask fits well over the mouth and nose

Ensure that the mask fits well over the mouth and nose

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily?

Intubate the client and control breathing with mechanical ventilation

A nurse must position the client prone after a diagnosis of acute respiratory distress syndrome (ARDS). Which of the following is a benefit of using this position? Select all that apply. Decreased pleural pressure Reduced need for endotracheal intubation Increased response to corticosteroid therapy Mobilization of secretions Decreased atelectasis

Mobilization of secretions Decreased atelectasis Decreased pleural pressure

To evaluate a client's atrial depolarization, the nurse observes which part of the electrocardiogram waveform? P wave QRS complex PR interval T wave

P wave

A client suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. Which intervention may improve oxygenation and provide comfort for the client?

Position the client in the prone position

Which ECG waveform characterizes conduction of an electrical impulse through the left ventricle? P wave PR interval QT interval QRS complex

QRS complex

The nurse is preparing to perform the care of a patient's tracheostomy tube. Which of the following actions should the nurse perform during this procedure?

Remove the soiled twill tape after new tape has been put in place.

Which ventilation-perfusion ratio is exhibited by acute respiratory distress syndrome (ARDS)?

Silent unit

While caring for a patient with an endotracheal tube the nurse recognizes that suctioning is required:

When adventitious breath sounds are auscultated

Which of the following is true of positive-pressure ventilators?

expiration occurs passively

A monitor technician on the telemetry unit asks a charge nurse why every client whose monitor shows atrial fibrillation is receiving warfarin. Which response by the charge nurse is best? "Warfarin prevents clot formation in the atria of clients with atrial fibrillation." "Warfarin controls heart rate in the client with atrial fibrillation." "It's just a coincidence; most clients with atrial fibrillation don't receive warfarin." "Warfarin prevents atrial fibrillation from progressing to a lethal arrhythmia."

"Warfarin prevents clot formation in the atria of clients with atrial fibrillation."

A client is admitted to the emergency department reporting chest pain and shortness of breath. The nurse notes an irregular rhythm on the bedside electrocardiograph monitor. The nurse counts 9 RR intervals on the client's 6-second rhythm tracing. The nurse correctly identifies the client's heart rate as 80 bpm. 70 bpm. 100 bpm. 90 bpm.

90 bpm.

A nurse is caring for a client who's experiencing sinus bradycardia with a pulse rate of 40 beats/minute. The client's blood pressure is 80/50 mm Hg and the client reports dizziness. Which medication does the nurse anticipate administering to treat bradycardia? Atropine Lidocaine Amiodarone Dobutamine

Atropine

The nurse is caring for a client who has just been intubated and started on mechanical ventilation in the intensive care unit. The nurse recognizes that it is possible to inadvertently intubate the right lung only. What nursing assessment and monitoring is required to determine if this complication has occurred? Select all that apply. Auscultate both sides of the chest Mark the endotracheal tube at the corner of the mouth and nose Monitor for both high and low pressure alarms Apply suctioning to clear the airway Re-set the ventilator rate as needed

Auscultate both sides of the chest Mark the endotracheal tube at the corner of the mouth and nose Monitor for both high and low pressure alarms

A client appears to be breathing faster than during the last assessment. Which of the following actions should the nurse perform? Assess the radial pulse. Count the rate of respirations. Assist the client to lie down. Inquire if there have been any stressful visitors.

Count the rate of respirations.

Which ventilation-perfusion ratio is exhibited in a client diagnosed with a pulmonary embolus?

Dead space

An older adult patient has experienced a severe exacerbation of chronic obstructive pulmonary disease and requires mechanical ventilation. Which of the following settings will be specified by the primary care provider? Select all that apply. Fraction of inspired oxygen Respiratory rate Tidal volume Positive end expiratory pressure CO2 saturation level

Fraction of inspired oxygen Respiratory rate Tidal volume Positive end expiratory pressure

A patient receiving plasma develops transfusion-related acute lung injury (TRALI) 4 hours after the transfusion. What type of aggressive therapy does the nurse anticipate the patient will receive to prevent death from the injury? (Select all that apply.) Serial chest x-rays Oxygen Fluid support Intubation and mechanical ventilation Intra-aortic balloon pump

Oxygen Fluid support Intubation and mechanical ventilation

The nurse is caring for a ventilated client after coronary artery bypass graft surgery. What are the criterions for extubation for the client? Select all that apply. adequate cough and gag reflexes inability to speak acceptable arterial blood gas values labile vital signs breathing without assistance of the ventilator

adequate cough and gag reflexes acceptable arterial blood gas values breathing without assistance of the ventilator

A critical care nurse is providing care to a client being mechanically ventilated. The low pressure alarm sounds. The nurse would assess for which situation?

disconnection from the ventilator

A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea?

Call for a chest x-ray.

The intensive care unit nurse is caring for a client who has severe brain injury with no neurological drive to breathe. This client would receive which type of mechanical ventilation?

Controlled mandatory ventilation (CMV)

While teaching a CPR class, a student in the class asks what the difference is between cardioversion and defibrillation. What would be the nurse's best response? "Cardioversion is done on a beating heart; defibrillation is not." "Cardioversion is always attempted before defibrillation because it is not as dangerous." "The difference is the timing of the delivery of the electric current." "Defibrillation is synchronized with the electrical activity of the heart; cardioversion is not."

"The difference is the timing of the delivery of the electric current."

A client had a tracheostomy two hours ago. The nurse assesses the client and finds the client's breathing is shallow, with a respiratory rate of 30. The nurse notes increased mucus production around the tracheostomy and on the dressing. What are the priority nursing concern(s)? Select all that apply. Ineffective airway clearance Infection risk Knowledge deficiency Impaired gas exchange Altered body image perception

Ineffective airway clearance Impaired gas exchange

The staff educator is presenting a class on cardiac dysrhythmias. How would the educator describe the characteristic pattern of the atrial waves in atrial flutter? Sawtooth Square Sinusoidal Triangular

Sawtooth

You're providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the patient is developing acute respiratory distress syndrome (ARDS)? A. The patient is experiencing bradypnea. B. The patient is tired and confused. C. The patient's PaO2 remains at 45 mmHg. D. The patient's blood pressure is 180/96.

The answer is C. A hallmark sign and symptom found in ARDS is refractory hypoxemia. This is where that although the patient is receiving a high amount of oxygen (here a 100% non-rebreather mask) the patient is STILL hypoxic. Option C is the answer because it states the patient's arterial oxygen level is remaining at 45 mmHg (a normal is 80 mmHg but when treating patients with ARDS a goal is at least 60 mmHg). Yes, the patient can be tired and confused from a low oxygen level BUT this question wants to know the HALLMARK sign and symptom.

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether:

she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube

A client's Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats/minute. What type of dysrhythmia would the cardiologist likely diagnose? supraventricular bradycardia sinus bradycardia supraventricular tachycardia sinus tachycardia

sinus tachycardia

A nurse is caring for a client who has had an automatic cardiac defibrillator implanted. What instructions should the nurse provide to the client? Avoid devices with a magnetic field. Avoid driving for at least 3 months. Avoid using microwave ovens. Use digital cellular telephones.

Avoid devices with a magnetic field.

A patient has had several episodes of recurrent tachydysrhythmias over the last 5 months and medication therapy has not been effective. What procedure should the nurse prepare the patient for? Insertion of an ICD Catheter ablation therapy Maze procedure Insertion of a permanent pacemaker

Catheter ablation therapy

The nurse explains to the patient with PACs that there are many causes, some of which are modifiable. Select all that apply. Alcohol Atrial ischemia Hypoxemia Hyperkalemia Hypovolemia Anxiety

Hypoxemia Atrial ischemia Alcohol Anxiety

A patient is recovering from a motor vehicle accident, which has necessitated mechanical ventilation in the intensive care unit (ICU). The ICU nurse is aware that multiple nursing diagnoses are associated with mechanical ventilation. Which of the following nursing diagnoses is a consequence of mechanical ventilation? Risk for Imbalanced Body Temperature Acute Confusion Moral Distress Impaired Verbal Communication

Impaired Verbal Communication

A nurse is caring for a client who is in respiratory distress because of ARDS. Which of the following conditions would most likely be present in this client? Lack of tissue perfusion Problems with thermoregulation Disturbed personal identity Anuria

Lack of tissue perfusion

A nurse should obtain serum levels of which electrolytes in a client with frequent episodes of ventricular tachycardia? Magnesium and potassium Calcium and magnesium Potassium and calcium Potassium and sodium

Magnesium and potassium

The emergency department nurse is caring for a patient who has gone into cardiac arrest. The nurse is performing external defibrillation. Which of the following is a vital step in the procedure? Continue to ventilate the patient via endotracheal tube during the procedure. Second shock cannot be administered for 1 minute to allow recharging. Gel pads are placed anteriorly, over the apex, and posteriorly for better conduction. No one is to be touching the patient at the time shock is delivered.

No one is to be touching the patient at the time shock is delivered.

A nurse is caring for a client who was brought into the ED complaining of chest pain and difficulty breathing. Which of the following vital sign measurements most likely indicate that the client is struggling with dyspnea? Respiratory rate greater than 25/min Oxygen saturation of 95% Dry, hot skin Concave abdomen

Respiratory rate greater than 25/min

As the nurse you know that acute respiratory distress syndrome (ARDS) can be caused by direct or indirect lung injury. Select below all the INDIRECT causes of ARDS:* A. Drowning B. Aspiration C. Sepsis D. Blood transfusion E. Pneumonia F. Pancreatitis

The answers are: C, D, F Indirect causes are processes that can cause inflammation OUTSIDE of the lungs....so the issue arises somewhere outside the lungs. Therefore, sepsis (infection...as long as it is outside the lungs), blood transfusion, and pancreatitis are INDIRECT causes. Drowning, aspiration, and pneumonia are issues that arise in the lungs (therefore, they are DIRECT causes of lung injury).

The nursing student learning on a cardiac unit asks the instructor why loss of the "atrial kick" causes a decrease in cardiac output, because the ventricles are still contracting. What is the nursing instructor's best response? "The atrial kick is only helpful if the ventricles are failing." "Loss of the atrial kick does not affect cardiac output; cardiac output remains the same, with or without it." "The atrial contraction fills the ventricles and accounts for nearly one-third of the volume ejected during ventricular contraction." "The atrial kick is never lost; there is always some atrial kick present."

The atrial contraction fills the ventricles and accounts for nearly one-third of the volume ejected during ventricular contraction."

The nurse checks the synchronizer switch before using a defibrillator to terminate ventricular fibrillation for what important reason? The defibrillator won't deliver a shock if the synchronizer switch is turned off. The shock must be synchronized with the client's T wave. The delivered shock must be synchronized with the client's QRS complex. The defibrillator won't deliver a shock if the synchronizer switch is turned on.

The defibrillator won't deliver a shock if the synchronizer switch is turned on.

The nurse is mentoring a new graduate nurse and the two are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. Which complication(s) would the nurse identify for the new nurse? Select all that apply. Absence of secretions Aspiration Infection Injury to the laryngeal nerve Penetration of the anterior tracheal wall

Aspiration Infection Injury to the laryngeal nerve

Which postimplantation instruction must a nurse provide to a client with a permanent pacemaker? Keep the arm on the side of the pacemaker higher than the head Avoid sources of electrical interference Keep moving the arm on the side where the pacemaker is inserted Delay activities such as swimming and bowling for at least 3 weeks

Avoid sources of electrical interference

The nurse cares for a client following the insertion of a permanent pacemaker. What discharge instruction(s) should the nurse review with the client? Select all that apply. Check pulse daily, reporting sudden slowing or increase Avoid handheld screening devices in airports Refrain from walking through antitheft devices Avoid the usage of microwave ovens and electronic tools Wear a medical alert, noting the presence of a pacemaker

Check pulse daily, reporting sudden slowing or increase Avoid handheld screening devices in airports Refrain from walking through antitheft devices Wear a medical alert, noting the presence of a pacemaker

Elective cardioversion is similar to defibrillation except that the electrical stimulation waits to discharge until an R wave appears. The nurse knows elective cardioversion prevents what? Disrupting the heart during the critical period of atrial repolarization. Disrupting the heart during the critical period of ventricular repolarization. Disrupting the heart during the critical period of ventricular depolarization. Disrupting the heart during the critical period of atrial depolarization.

Disrupting the heart during the critical period of ventricular repolarization.

The nurse and student nurse are observing a cardioversion procedure completed by a physician. At which time is the nurse most correct to identify to the student when the electrical current will be initiated? During ventricular depolarization During repolarization of the heart During stimulation of the SA node During the QRS complex

During ventricular depolarization

A client receives a pacemaker to treat a recurring arrhythmia. When monitoring the cardiac rhythm strip, the nurse observes extra pacemaker spikes that don't precede a beat. Which condition should the nurse suspect? Failure to capture Failure to sense Asystole Failure to pace

Failure to capture

What is the treatment of choice for ventricular fibrillation? Atropine Immediate bystander CPR Pacemaker Implanted defibrillator

Immediate bystander CPR

The nurse enters the client's room and finds the client pulseless and unresponsive. What would be the treatment of choice for this client? Immediate defibrillation Chemical cardioversion IV lidocaine Electric cardioversion

Immediate defibrillation

A patient is recovering from a motor vehicle accident, which has necessitated mechanical ventilation in the intensive care unit (ICU). The ICU nurse is aware that multiple nursing diagnoses are associated with mechanical ventilation. Which of the following nursing diagnoses is a consequence of mechanical ventilation?

Impaired Verbal Communication

A critical care nurse is aware of the high incidence and prevalence of ventilator-associated pneumonia (VAP) in high-acuity settings. In order to reduce patients' risks of developing VAP, what intervention should the nurse prioritize?

Provide frequent, thorough mouth care.

You're providing care to a patient who was just transferred to your unit for the treatment of ARDS. The patient is in the exudative phase. The patient is ordered arterial blood gases. The results are back. Which results are expected during this early phase of acute respiratory distress syndrome that correlates with this diagnosis?* A. PaO2 40, pH 7.59, PaCO2 30, HCO3 23 B. PaO2 85, pH 7.42, PaCO2 37, HCO3 26 C. PaO2 50, pH 7.20, PaCO2 48, HCO3 29 D. PaO2 55, pH 7.26, PaCO2 58, HCO3 19

The answer is A. This option demonstrates respiratory alkalosis. In the early stages of ARDS (exudative) the patient will start to enter in respiratory alkalosis. The patient starts to have tachypnea (the body's way of trying to increase the oxygen level but it can't). They will have a very low PaO2 level (normal PaO2 is 80 mmHg), the blood pH will become high (normal is 7.35-7.45) (alkalotic). In the late stage, the patient can enter into respiratory acidosis.

A patient is on mechanical ventilation with PEEP (positive end-expiratory pressure). Which finding below indicates the patient is developing a complication related to their therapy and requires immediate treatment?* A. HCO3 26 mmHg B. Blood pressure 70/45 C. PaO2 80 mmHg D. PaCO2 38 mmHg

The answer is B. Mechanical ventilation with PEEP can cause issues with intrathoracic pressure and decrease the cardiac output (watch out for a low blood pressure) along with hyperinflation of the lungs (possible pneumothorax or subq emphysema which is air that escapes into the skin because the lungs are leaking air).

During the exudative phase of acute respiratory distress syndrome (ARDS), the patient's lung cells that produce surfactant have become damaged. As the nurse you know this will lead to?* A. bronchoconstriction B. atelectasis C. upper airway blockage D. pulmonary edema

The answer is B. Surfactant decreases surface tension in the lungs. Therefore, the alveoli sacs will stay stable when a person exhales (hence the sac won't collapse). If there is a decrease in surfactant production this creates an unpredictable alveoli sac that can easily collapse, hence a condition called ATELETASIS will occur (collapse of the lung tissue) when there is a decrease production in surfactant.

1.) You're providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the patient is developing acute respiratory distress syndrome (ARDS)? A. The patient is experiencing bradypnea. B. The patient is tired and confused. C. The patient's PaO2 remains at 45 mmHg. D. The patient's blood pressure is 180/96.

The answer is C. A hallmark sign and symptom found in ARDS is refractory hypoxemia. This is where that although the patient is receiving a high amount of oxygen (here a 100% non-rebreather mask) the patient is STILL hypoxic. Option C is the answer because it states the patient's arterial oxygen level is remaining at 45 mmHg (a normal is 80 mmHg but when treating patients with ARDS a goal is at least 60 mmHg). Yes, the patient can be tired and confused from a low oxygen level BUT this question wants to know the HALLMARK sign and symptom.

Which patient below is at MOST risk for developing ARDS and has the worst prognosis?* A. A 52-year-old male patient with a pneumothorax. B. A 48-year-old male being treated for diabetic ketoacidosis. C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection. D. A 30-year-old female with cystic fibrosis.

The answer is C. Sepsis is the MOST common cause of ARDS because of systemic inflammation experienced. This is also true if the cause of the sepsis is a gram-negative bacterium (this also makes the infection harder to treat...hence poor prognosis). With sepsis, the immune cells that are present with the inflammation travel to the lungs and damage the alveolar capillary membrane leading to fluid to leak in the alveolar sacs.

10. A patient is experiencing respiratory failure due to pulmonary edema. The physician suspects ARDS but wants to rule out a cardiac cause. A pulmonary artery wedge pressure is obtained. As the nurse you know that what measurement reading obtained indicates that this type of respiratory failure is NOT cardiac related?* A. >25 mmHg B. <10 mmHg C. >50 mmHg D. <18 mmHg

The answer is D. A pulmonary artery wedge pressure measures the left atrial pressure. A pulmonary catheter is "wedged" with a balloon in the pulmonary arterial branch to measure the pressure. If the reading is less than 18 mmHg it indicates this is NOT a cardiac issue but most likely ARDS. Therefore, the pulmonary edema is due to damage to the alveolar capillary membrane leaking fluid into the alveolar sac....NOT a heart problem ex: heart failure.

You're teaching a class on critical care concepts to a group of new nurses. You're discussing the topic of acute respiratory distress syndrome (ARDS). At the beginning of the lecture, you assess the new nurses understanding about this condition. Which statement by a new nurse demonstrates he understands the condition?* A. "This condition develops because the exocrine glands start to work incorrectly leading to thick, copious mucous to collect in the alveoli sacs." B. "ARDS is a pulmonary disease that gradually causes chronic obstruction of airflow from the lungs." C. "Acute respiratory distress syndrome occurs due to the collapsing of a lung because air has accumulated in the pleural space." D. "This condition develops because alveolar capillary membrane permeability has changed leading to fluid collecting in the alveoli sacs."

The answer is D. ARDS is a type of respiratory failure that occurs when the capillary membrane that surrounds the alveoli sac becomes damaged, which causes fluid to leak into the alveoli sac. Option A describes cystic fibrosis, option B describes COPD, and option C describes a pneumothorax.

. You're precepting a nursing student who is assisting you care for a patient on mechanical ventilation with PEEP for treatment of ARDS. The student asks you why the PEEP setting is at 10 mmHg. Your response is:* A. "This pressure setting assists the patient with breathing in and out and helps improve air flow." B. "This pressure setting will help prevent a decrease in cardiac output and hyperinflation of the lungs." C. "This pressure setting helps prevent fluid from filling the alveoli sacs." D. "This pressure setting helps open the alveoli sacs that are collapsed during exhalation."

The answer is D. This setting of PEEP (it can range between 10 to 20 mmHg of water) and it helps to open the alveoli sacs that are collapsed, especially during exhalation.

You are caring for a patient with acute respiratory distress syndrome. As the nurse you know that prone positioning can be beneficial for some patients with this condition. Which findings below indicate this type of positioning was beneficial for your patient with ARDS?* A. Improvement in lung sounds B. Development of a V/Q mismatch C. PaO2 increased from 59 mmHg to 82 mmHg D. PEEP needs to be titrated to 15 mmHg of water

The answers are A and C. Prone positioning helps improve PaO2 (82 mmHg is a good finding) without actually giving the patient high concentrations of oxygen. It helps improves perfusion and ventilation (hence correcting the V/Q mismatch). In this position, the heart is no longer laying against the posterior part of the lungs (improves air flow...hence improvement of lung sounds) and it helps move secretions from other areas that were fluid filled and couldn't move in the supine position, hence helping improve atelectasis.

A 25-year-old client in the ICU is being treated for acute respiratory distress syndrome (ARDS). The client is on a ventilator and requires 80 percent FiO2. Which information would the nurse most likely need to report about the client to the respiratory therapist assigned to this case? The client needs more oxygen because of O2 saturations The client needs endotracheal suctioning The client needs an arterial blood gas drawn The client needs a hemoglobin level drawn

The client needs an arterial blood gas drawn

When no atrial impulse is conducted through the AV node into the ventricles, the client is said to be experiencing which type of AV block? Third degree Second degree, type II Second degree, type I First degree

Third degree

The nurse is caring for a client who has been on a mechanical ventilator since admission to the intensive care unit 4 days ago. Upon assessment, the nurse notes the client has tachycardia, a temperature of 102.2°F (39°C) and purulent secretions upon suctioning. Chest auscultation reveals crackles in the right lower lung lobe. The nurse should suspect which respiratory complication? Pneumothorax Gastrointestinal bleed Ventilator associated pneumonia (VAP) Pulmonary embolism (PE)

Ventilator associated pneumonia (VAP)

The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?

Sudden restlessness

A patient has been hospitalized in the ICU for a near drowning event. The patient's respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS?* A. infiltrates only on the upper lobes B. enlargement of the heart with bilateral lower lobe infiltrates C. white-out infiltrates bilaterally D. normal chest x-ray

The answer is C. This is a finding found in ARDS....pronounce white-out infiltrates bilaterally.