Critical Care Exam 2 Prep

A client verbalizes fear of infection from a blood transfusion. What is the nurse's best response? -there is no need for testing unless you have a history of a transfusion reaction -every unit of donated blood is typed and tested for antibodies to infections -blood typing is more important than testing for infection -the risk of transmission of HIV is so low, there's no need to worry

"Every unit of donated blood is typed and tested for antibodies to infections." Each blood donation is always tested for antibodies to bloodborne pathogens. Blood typing is equally as important as testing for infections. The risk of HIV transmission has decreased in recent years, but telling the client there's no need to worry discredits the client's fears and is not the best response.

The nurse understands that asystole can be caused by several conditions. Select all that apply. -hypoxia -alkalosis -hypovolemia -hypothermia -acidosis

-hypoxia -hypovolemia -hypothermia -acidosis Ventricular asystole is treated the same as pulseless electrical activity (PEA), focusing on high-quality cardiopulmonary resuscitation (CPR) with minimal interruptions and identifying underlying and contributing factors. The key to successful treatment is a rapid assessment to identify a possible cause, which is known as the "Hs and Ts": hypoxia, hypovolemia, hydrogen ion (acid/base imbalance), hypo- or hyperglycemia, hypo- or hyperkalemia, hyperthermia, trauma, toxins, tamponade (cardiac), tension pneumothorax, or thrombus (coronary or pulmonary).

A client presents to the emergency department after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling of not being able to breathe enough. The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of which respiratory problem? -pneumoconiosis -pleural effusion -acute respiratory failure -pneumonia

Acute respiratory failure Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.

A client arrives in the emergency room with emphysema and has developed an exacerbation of COPD with respiratory acidosis from airway obstruction. What is the highest priority for the nurse? -apply supplemental oxygen as ordered -educate the client about the importance of pursed lip breathing -refer the client to respiratory therapy if breathing becomes labored -assess vital signs every 2 hours, including O2 saturation and ABG results

Apply supplemental oxygen as ordered. When the client arrives in an ED, the first line of treatment is supplemental oxygen therapy and rapid assessment. Oxygen will correct the hypoxemia. Careful observation of the liter flow or the percentage administered and its effect on the patient is important. These clients generally require low-flow oxygen rates of 1-2 L/min. Monitor and titrate to achieve desired PaO2. Periodic arterial blood gases and pulse oximetry help evaluate the adequacy of oxygenation.

The ED nurse is assessing the respiratory function of a client who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive of what condition? -pleurisy -emphysema -pneumonia -asthma

Asthma Wheezes are commonly associated with asthma. They do not normally accompany pleurisy, emphysema, or pneumonia.

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction and that leads to the collapse of alveoli. What complication should the nurse monitor for? -pneumonia -atelectasis -pleurisy -emphysema

Atelectasis In bronchiectasis, the retention of secretions and subsequent obstruction ultimately cause the alveoli distal to the obstruction to collapse (atelectasis).

Which type of chest configuration is typical of a client with COPD? -pigeon chest -funnel chest -flail chest -barrel chest

Barrel chest In clients with COPD who have a primary emphysematous component, chronic hyperinflation leads to the "barrel chest" thorax configuration. This configuration results from a more fixed position of the ribs in the inspiratory position (due to hyperinflation) and from loss of lung elasticity. Pigeon chest results from a displaced sternum. Flail chest results when the ribs are fractured. Funnel chest occurs when there is a depression in the lower portion of the sternum; it is associated with Marfan syndrome or rickets.

Which assessment finding would be most consistent with advanced emphysema? -dependent edema -epigastric pain -aortic bruit -barrel-shaped chest

Barrel-shaped chest Barrel chest occurs as result of overinflation of the lungs. In a client with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge on expiration. The appearance of a such a client with advanced emphysema is easily detected.

Which statement is true about both lung transplant and bullectomy? -both procedures improve the quality of life of a client with COPD -both procedures treat patients with bullous emphysema -both procedures cure COPD -both procedures treat end-stage emphysema

Both procedures improve the overall quality of life of a client with COPD. Treatments for COPD are aimed more at treating the symptoms and preventing complications, thereby improving the overall quality of life of a client with COPD. In fact, there is no cure for COPD. Lung transplant is aimed at treating end-stage emphysema and bullectomy is used to treat clients with bullous emphysema.

The nurse is caring for a client suspected of having acute respiratory distress syndrome (ARDS). What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the client's symptoms from those of a cardiac etiology? -complete blood count -brain natriuretic peptide (BNP) level -carboxyhemoglobin level -C-reactive protein (CRP) level

Brain natriuretic peptide (BNP) level Common diagnostic tests performed for clients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. CRP and CBC levels do not help differentiate from a cardiac problem.

The nurse hears the alarm sound on the telemetry monitor and observes a flat line. The patient is found unresponsive, without a pulse, and no respiratory effort. What is the first action by the nurse? -administer epinephrine 1:10,000 10mL IV push -defibrillate the patient with 360 joules -deliver breaths with a bag-valve mask -call for help and begin chest compressions

Call for help and begin chest compressions. Following the recognition of unresponsiveness, a protocol for basic life support is initiated. This includes activation of the emergency response team for help and performance of high-quality cardiopulmonary resuscitation (CPR), which includes beginning chest compressions.

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism? -hypertension and lack of fever -bradypnea and bradycardia -nonproductive cough and abdominal pain -chest pain and dyspnea

Chest pain and dyspnea As an embolus occludes a pulmonary artery, it blocks the supply of oxygenated blood to the heart, causing chest pain. It also blocks blood flow to the lungs, causing dyspnea. The client with pulmonary embolism typically has a cough that produces blood-tinged sputum (rather than a nonproductive cough) and chest pain (rather than abdominal pain). Hypertension, absence of fever, bradypnea, and bradycardia aren't associated with pulmonary embolism.

The nurse is caring for a client who has had emphysema for 10 years. When performing a fingernail assessment, what does the nurse anticipate the client's nails will be documented as? -clubbing -concave -discolored -brittle

Clubbing Clubbing of the nails is evidenced by an angle greater than 160°, and suggests long-standing cardiopulmonary disease and chronic hypoxic states. Concave or "spooning" may indicate iron-deficiency anemia. Discolored or brittle nails may result from other disorders or smoking.

A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? -Surgery to remove the tonsils and adenoids -medications to assist the patient with sleep at night -Bi-level positive airway pressure (BiPAP) -continuous positive airway pressure (CPAP)

Continuous positive airway pressure (CPAP) CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea.

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia? -cyanosis -clubbing of fingers -restlessness -crackles

Cyanosis Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence or absence of cyanosis is determined by the amount of unoxygenated hemoglobin in the blood. Cyanosis appears when there is at least 5 g/dL of unoxygenated hemoglobin.

Post transfusion, the donor stands up immediately after the needle is withdrawn. The nurse should be alert for which vital sign change? -decreased blood pressure -decreased pulse -elevated temperature -decreased respiratory rate

Decreased blood pressure. Because of the loss of blood volume, hypotension and syncope may occur when the donor assumes an erect position. The most likely vital sign change is decreased blood pressure. The respiratory rate and temperature should not be affected by a change in position. With hypotension and decreased blood volume, the pulse would increase, not decrease.

A client is receiving the first of two prescribed units of PRBCs. Shortly after the initiation of the transfusion, the client reports chills and experiences a sharp increase in temperature. What is the nurse's priority action? -discontinue the transfusion -position the client in high fowler position -obtain a blood specimen from the client -auscultate the client's lungs

Discontinue the transfusion. Stopping the transfusion is the first step in any suspected transfusion reaction. This must precede other assessments and interventions, including repositioning, chest auscultation, and collecting specimens.

A junior-level nursing class has just finished learning about the management of clients with chronic pulmonary diseases. They learned that a new definition of COPD leaves only one type of disorder within its classification. Which of the following is part of that disorder? -cystic fibrosis -asthma -emphysema -bronchiectasis

Emphysema COPD may include diseases that cause airflow obstruction (e.g., emphysema, chronic bronchitis) or any combination of these disorders. Other diseases such as cystic fibrosis, bronchiectasis, and asthma that were previously classified as types of COPD are now classified as chronic pulmonary disorders. Asthma is now considered a distinct, separate disorder and is classified as an abnormal airway condition characterized primarily by reversible inflammation.

High or increased compliance occurs in which disease process?

Emphysema High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, as in emphysema. Conditions associated with decreased compliance include pneumothorax, pleural effusion, and acute respiratory distress syndrome (ARDS).

The nurse is caring for a client who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign or symptom should the nurse monitor? -hypothermia -pain -bradycardia -coffee ground emesis

Hypothermia Temperature should be monitored closely to ensure that rapid fluid resuscitation does not precipitate hypothermia. IV fluids may need to be warmed during the administration of large volumes. The nurse should monitor the client for cardiovascular overload and pulmonary edema when large volumes of IV solution are given. Coffee ground emesis is an indication of a GI bleed, not shock. Pain is related to cardiogenic shock.

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? -initiate oxygen therapy -administer a heparin bolus and begin an infusion at 500 units/hour -perform nasopharyngeal suctioning -administer analgesics as orderes

Initiate oxygen therapy. The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.

A client is receiving a blood transfusion and reports a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? -slow the infusion rate and monitor the client closely -discontinue the transfusion and begin resuscitation -discontinue the transfusion and administer a beta-blocker, as prescribed -pause the transfusionn ad administer a 250 mL bolus of normal saline

Slow the infusion rate and monitor the client closely. The client is showing early signs of hypervolemia; the nurse should slow the infusion rate and assess the client closely for any signs of exacerbation. At this stage, discontinuing the transfusion is not necessary. A bolus would worsen the client's fluid overload.

A client on the medical unit is found to have pulmonary tuberculosis (TB). What is the most appropriate precaution for the staff to take to prevent transmission of this disease? -standard and airborne precautions -droplet precautions -standard and contact precautions -standard precautions only

Standard and airborne precautions Airborne precautions are required for proven or suspected pulmonary TB. Standard precaution techniques are used in conjunction with the transmission-based precautions, regardless of the client's diagnosis. Droplet and contact precautions are insufficient.

For a client with chronic obstructive pulmonary disease, which nursing intervention helps maintain a patent airway? -teaching the client how to perform controlled coughing -enforcing absolute bed rest -administering ordered sedatives regularly and in large amounts -restricting fluid intake to 1000ml/day

Teaching the client how to perform controlled coughing Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the client's ability to maintain a patent airway, causing a high risk of infection from pooled secretions.

A nurse is caring for an older adult with emphysema. Which nursing action demonstrates primary prevention? -comparing the client's peak expiratory flow rate with the baseline measuremet -teaching the client safety preautions on the use of supplemental oxygen -encouraging the client to have periodic chest x-rays for early detections of cancer -teaching the client various methods to help prevent pneumonia

Teaching the client various methods to help prevent pneumonia The only action that is considered primary prevention is teaching the client methods to prevent pneumonia. Primary prevention focuses on health promotion and the prevention of illness. Teaching the client on current medications or oxygen, as well as comparing peaks flows are part of treating established disease states and would not be considered primary prevention. Early detection for cancer is considered secondary prevention, not primary.

Nursing students are reviewing the various infectious diseases that require transmission-based precautions. The students demonstrate understanding of the information when they identify which infectious disease as requiring airborne precautions? -impetigo -tuberculosis -scabies -rubella

Tuberculosis Airborne precautions are used for clients with tuberculosis. Contact precautions would be appropriate for clients with scabies or impetigo. Droplet precautions are appropriate for clients with rubella.

You are caring for a client admitted with chronic bronchitis. The client is having difficulty breathing, and the family asks you what causes this difficulty. What would be your best response? -anytime there is a chronic disease process it is hard for the person to breathe -having a chronic respiratory disease scars the lung and affects the effort it takes to breathe -in this particular case your family member is just overly tired and having problems breathing -conditons such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe

"Conditions such as chronic bronchitis cause thickening of the bronchial mucosa so it makes it harder to breathe." Conditions that may alter bronchial diameter and affect airway resistance include contraction of bronchial smooth muscle (e.g., asthma); thickening of bronchial mucosa (e.g., chronic bronchitis); airway obstruction by mucus, a tumor, or a foreign body; and loss of lung elasticity (e.g., emphysema). Option A is incorrect, not all chronic diseases make it hard to breathe. Option B is incorrect; not all chronic respiratory diseases caused scarring in the lung. Option C is incorrect; this response negates the families question and belittles their concern.

A patient develops gastrointestinal bleeding from a gastric ulcer and requires blood transfusions. The patient states to the nurse, "I am not going to have a transfusion because I don't want to get AIDS." What is the best response by the nurse? -if you don't have the blood transfusion, you may not make it through this episode of bleeding -i understand what you mean, you can never be sure if the blood is tainted -no one has gotten HIV from blood in a long time. You have the transfusion -I understand your concern. The blood is screened very carefully for different viruses as well as HIV

"I understand your concern. The blood is screened very carefully for different viruses as well as HIV." Blood and blood products can transmit HIV to recipients. However, the risk associated with transfusions has been virtually eliminated as a result of voluntary self-deferral, completion of a detailed health history, extensive testing, heat treatment of clotting factor concentrates, and more effective virus inactivation methods. Donated blood is tested for antibodies to HIV-1, human immunodeficiency virus type 2 (HIV-2), and p24 antigen; in addition, since 1999, nucleic acid amplification testing (NAT) has been performed.

A nurse is teaching high school students about transmission of the human immunodeficiency virus (HIV). Which comment by a student warrants clarification by the nurse? -i've heard adout people who got AIDS from blood transfusions -IV drug users can get HIV from sharing needles -a man should wear a latex condom during intumate sexual contact -i won't donate blood because i don't want to get AIDS

"I won't donate blood because I don't want to get AIDS." HIV is transmitted through infected blood, semen, and certain other body fluids. Although a transfusion with infected blood may cause HIV infection in the recipient, a person can't become infected by donating blood. The other options reflect accurate understanding of HIV transmission.

A client newly diagnosed with COPD tells the nurse, "I can't believe I have COPD; I only had a cough. Are there other symptoms I should know about"? Which is the best response by the nurse? -you can also expect to experience a progresive weight gain -there are no other symptoms:however your cough may get worse as the disease progresses -as your COPD worsens, you will frequently develop respiratory infections -other symptoms you may develop are shortness of breath upon exerction and sputum production

"Other symptoms you may develop are shortness of breath upon exertion and sputum production." COPD is characterized by three primary symptoms: cough, sputum production, and dyspnea upon exertion. Clients with COPD are at risk for respiratory insufficiency and respiratory infections, which in turn increase the risk of acute and chronic respiratory failure. Weight loss is common with COPD.

The intensive care nurse is responsible for the care of a client who is in shock. What cardiac signs or symptoms would suggest to the nurse that the client may be experiencing acute organ dysfunction? Select all that apply. -drop in systolic blood pressure of >40mmHg from baselines -hypotension that responds to bolus fluid resuscitation -exaggerated responds to bolus fluid resuscitation -serum lactate >4mmol/L -mean arterial pressure (MAP) of 65mmHg

-drop in systolic blood pressure of >40mmHg from baselines -serum lactate >4mmol/L -Mean arterial pressure (MAP) of 65mmHg

The nurse is caring for a client with hypoxemia of unknown cause. Which of the following oxygen transport considerations does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply. -oxygen is dissolved -high blood pressure disrupts oxygen transport -oxyhemoglobin circulates to the body tissue -all systemic oxygen is available for diffusion -adequate red blood cells are needed for oxygen transport

-oxygen is dissolved -oxyhemoglobin circulates to the body tissue -adequate red blood cells are needed for oxygent transport

The nurse is assessing a client whose respiratory disease is characterized by chronic hyperinflation of the lungs. Which physical characteristic would the nurse most likely observe in this client? -signs of oxygen toxicity -a moon face -long, thin fingers -a barrel chest

A barrel chest In chronic obstructive pulmonary disease (COPD) clients with a primary emphysematous component, chronic hyperinflation leads to the barrel chest thorax configuration. The client with COPD is more likely to have finger clubbing, which is an abnormal rounded appearance of the fingertips, rather than long, thin fingers. Clubbed fingers are the result of chronically low blood levels of oxygen. A moon face is swelling of the face due to increased fat deposits. This may be a sign of Cushing syndrome or a side effect of steroid use. Signs of oxygen toxicity, such as facial pallor or behavioral changes, may be possible but are not the most likely physical findings for this client.

A client is being treated for a pulmonary embolism and the medical nurse is aware that the client suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology? -maintenance of muscle tone in the diaphram -pH balance in the pulmonary veins and arteries -adequate flow of blood through the pulmonary circulation -maintenance of constant osmotic pressure in the alveoli

Adequate flow of blood through the pulmonary circulation. Pulmonary perfusion is the actual blood flow through the pulmonary circulation. Perfusion is not defined in terms of pH balance, muscle tone, or osmotic pressure.

After receiving a dose of penicillin, a client develops dyspnea and hypotension and the nurse suspects the client is experiencing anaphylactic shock. What is the nurse's first action? -Administer epinephrine, as ordered -continue to monitor the client's vital signs -inset an indwelling urinary catheter -page an anesthesiologist immediately

Administer epinephrine, as ordered. To reverse anaphylactic shock, the nurse first should administer epinephrine, a potent bronchodilator, as ordered. The health care provider is likely to order additional medications, such as antihistamines and corticosteroids; if the medications don't relieve the respiratory compromise associated with anaphylaxis. No antidote for penicillin exists; however, the nurse should continue to monitor the client's vital signs. A client who remains hypotensive may need fluid resuscitation and fluid intake and output monitoring with a Foley catheter; however, administering epinephrine is the first priority.

A client newly diagnosed with emphysema asks the nurse to explain all about the disease. The nurse would include the following response when defining emphysema: -increased oxygen diffusion with inflammation of the bronchioles -inflammation of the bronchioles with a normal distention of the air spaces -an abnormal distention of the air spaces with destruction of the alveolar walls -decreaed sputum production with dilation of bronchioles

An abnormal distention of the air spaces with destruction of the alveolar walls Emphysema is a pathologic term that describes an abnormal distention of the air spaces beyond the terminal bronchioles and destruction of the walls of the alveoli. This causes a decrease in oxygen diffusion and an increase in sputum production.

A nurse provides morning care for a client in the intensive care unit (ICU). Suddenly, the bedside monitor shows ventricular fibrillation and the client becomes unresponsive. After calling for assistance, what action should the nurse take next? -administer intravenous epinephrine -begin cardiopulmonary resuscitation (CPR) -prepare for endotracheal intubation -provide electrilca cardioversion

Begin cardiopulmonary resuscitation In the acute care setting, when ventricular fibrillation is noted, the nurse should call for assistance and defibrillate the client as soon as possible. If defibrillation is not readily available, CPR is begun until the client can be defibrillated, followed by advanced cardiovascular life support (ACLS) intervention, which includes endotracheal intubation and administration of epinephrine. Electrical cardioversion is not indicated for a client in ventricular fibrillation.

The nurse in the intensive care unit (ICU) hears an alarm sound in the patient's room. Arriving in the room, the patient is unresponsive, without a pulse, and a flat line on the monitor. What is the first action by the nurse? -administer atropine 0.5mg -begin cardiopulmonary resuscitation (CPR) -defibrillate with 360 joules (monophasic defibrillation) -administer epinephrine

Begin cardiopulmonary resuscitation (CPR) Commonly called flatline, ventricular asystole (Fig. 26-19) is characterized by absent QRS complexes confirmed in two different leads, although P waves may be apparent for a short duration. There is no heartbeat, no palpable pulse, and no respiration. Without immediate treatment, ventricular asystole is fatal. Ventricular asystole is treated the same as PEA, focusing on high-quality CPR with minimal interruptions and identifying underlying and contributing factors.

A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? -bilateral wheezes -shallow respirations -increased anterior-posterior (AP) diameter -bradypnea

Bilateral wheezes The three most common symptoms of asthma are cough, dyspnea, and wheezing. There may be generalized wheezing (the sound of airflow through narrowed airways), first on expiration and then, possibly, during inspiration as well. Respirations are not usually slow and the child's AP diameter does not normally change.

A nurse is developing the teaching portion of a care plan for a client with COPD. What would be the most important component for the nurse to emphasize? -Minor respiratory infections are considred to be self-limited and are not treated with medication -chronic inhalation of indoor toxins can cause lung damage -activities of daily living (ADLs) should be clustered in the early morning hours -smoking up to three cigarettes weekly is generally allowable

Chronic inhalation of indoor toxins can cause lung damage. Environmental risk factors for COPD include prolonged and intense exposure to occupational dusts and chemicals, indoor air pollution, and outdoor air pollution. Smoking cessation should be taught to all clients who are currently smoking. Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of the person with emphysema. ADLs should be paced throughout the day to permit clients to perform these without excessive distress.

Which is the most important risk factor for development of chronic obstructive pulmonary disease (COPD)? -air pollution -occupational exposure -genetic abnormalities -cigarette smoking

Cigarette smoking Pipe, cigar, and other types of tobacco smoking are also risk factors for COPD. Although risk factors, neither occupational exposure nor air pollution is the most important risk factor for development of COPD. Genetic abnormalities are also a risk factor, but again, not the most important one.

The nurse knows that what condition is associated with increased compliance of the lungs? -pneumothorax -pleural effusion -emphysema -ARDS

Emphysema Compliance is normal if the lungs and the thorax easily stretch and distend. Increased compliance occurs if the lungs have lost their elastic recoil and become overdistended as in emphysema. Decreased compliance occurs if the lungs and the thorax are "stiff." Conditions associated with decreased compliance include morbid obesity, pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and acute respiratory distress syndrome (ARDS). This causes airway collapse during expiration, dyspnea, and eventually cyanosis.

A nurse finds a client with absent breathing and prepares to begin one-person cardiopulmonary resuscitation. What will the nurse do first? -open the airways -assess the client for a carotid pulse -call for help -establish unresponsiveness

Establish unresponsiveness. The correct sequence begins with establishing unresponsiveness. The nurse should then call for help, assess the client for breathing while opening the airway, deliver two breaths, and check for a carotid pulse.

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? -type 1 diametes mellitus -myasthenia gravis -opioid overodse -extreme anxiety

Extreme anxiety Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

What is the treatment of choice for ventricular fibrillation? -atropine -immediate bystander CPR -pacemaker -implanted defibrillator

Immediate bystander CPR The treatment of choice for ventricular fibrillation is immediate bystander cardiopulmonary resuscitation (CPR), defibrillation as soon as possible, and activation of emergency services.

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? -promote the client's ability to take in oxygen -improve oxygen transport; induce a slow, deep breathing patter; and assist the client to control breathing -promote more efficient and controlled ventilation and to decrease the work of breathing -promote the strengthening of the clients diaphram

Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.

A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. What is the priority nursing concern with this client? -activity intolerance -acute pain -ineffective breathing pattern -excess fluid volume

Ineffective breathing pattern Ineffective breathing pattern takes priority for a client with a pulmonary contusion with a pulmonary embolism. The objective of immediate management is to restore and maintain cardiopulmonary function. After an adequate airway is ensured and ventilation is established, examination for shock and intrathoracic and intra-abdominal injuries is necessary. Fluid volume, pain, and activity intolerance are not priority concerns.

The staff educator is teaching a class in arrhythmias. What statement is correct for defibrillation? -it is used to eliminate ventricular arryhthmias -it uses less electrilca energy than cardioversion -the client is sedated before the procedure -it is a scheduled procedure 1-10 days in advance

It is used to eliminate ventricular arrhythmias. The only treatment for a life-threatening ventricular arrhythmia is immediate defibrillation, which has the exact same effect as cardioversion, except that defibrillation is used when there is no functional ventricular contraction. It is an emergency procedure performed during resuscitation. The client is not sedated but is unresponsive. Defibrillation uses more electrical energy (200 to 360 joules) than cardioversion.

The nurse is aware that a religious group that refuses blood transfusions for religious reasons is: -jews -catholics -jehovah's witnesses -methodists

Jehovah's Witnesses Jehovah's Witnesses decline blood transfusions for religious reasons.

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? -lungs and kidney -kidney and liver -pancreas and stomach -heart and lungs

Lungs and kidney The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving CO2 by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? -oxygen analyzer -manual resusciation bag -water-seal chest drainage set-up -tracheostomy cleaning kit

Manual resuscitation bag The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.

Which nursing intervention must a nurse perform when administering prescribed vasopressors to a client with a cardiac dysrhythmia? -keep the client flat for one hour after administration -document heart rate before and after administration -administer every five minutes during cardiac resusciation -monitor vital signs and cardiac rhythm

Monitor vital signs and cardiac rhythm The nurse should monitor the client's vital signs and cardiac rhythm for effectiveness of the medication and for side effects and should always have emergency life support equipment available when caring for an acutely ill client. The side effects of vasopressor drugs are hypertension, dysrhythmias, pallor, and oliguria. It is not necessary to place a client flat during or after vasopressor administration. When administering cholinergic antagonists, documentation of the heart rate is necessary.

Hyperresonance is audible when which area is percussed? -liver -air-filled stomach -thigh -overinflated lung tissue

Overinflated lung tissue Hyperresonance is audible when overinflated lung tissue is percussed, such as in a client with emphysema. Percussion over the liver produces a dull sound. Percussion of the thigh produces a flat sound. Tympany is the drum-like sound produced by percussing an air-filled stomach.

The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what condition? -pneumothorax -aspiration -cardiac ischemia -acute bronchitis

Pneumothorax If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The client is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the client's recent trauma they are inconsistent with cardiac ischemia, bronchitis, or aspiration.

The nurse is caring for a client who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear external pneumatic compression stockings. The nurse should explain that refusing to wear external pneumatic compression stockings increases the risk of which postsurgical complication? -infections -sepsis -hematoma -pulmonary embolism

Pulmonary embolism Clients who have surgery that limits mobility are at an increased risk for pulmonary embolism secondary to deep vein thrombosis. The use of external pneumatic compression stockings significantly reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection or sepsis would not be affected by external pneumatic compression stockings. A hematoma or bruise would not be affected by external pneumatic compression stockings unless the stockings were placed directly over the hematoma.

A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? -dilated and reactive pupils -respiratory rate of 22 breaths/minute -urine output of 40ml/hour -heart rate of 100 beats/minute

Respiratory rate of 22 breaths/minute In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect.

When a disease infects a host a portal of entry is needed for an organism to gain access. What has been identified as the usual portal of entry for tuberculosis? -urinary system -respiratory system -gastrointestinal system -integumentary system

Respiratory system The portal of entry for M. tuberculosis is through the respiratory tract.

The nurse began transfusing the first unit of packed red blood cells (PRBCs) fifteen minutes ago. The client reports shortness of breath, nausea, and is restless. What is the nurse's priority action? -discontinue the intravenous line -stop the infusion -flush the blood tubing with normal saline -notify the primary health care provider

Stop the infusion. The client's symptoms are consistent with a possible blood transfusion reaction. The infusion should be stopped immediately, then the primary health care provider should be notified. The intravenous line should not be discontinued in case the client needs any emergency intravenous medications. Flushing the blood tubing with normal saline would allow the blood in the tubing to be infused; the IV line should be maintained with normal saline through brand new tubing.

The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and reports severe chest tightness. What is the most appropriate initial action for the nurse to take? -remove the client's IV access -assess the client's chest sounds and vital signs -notify the client's health care provider -stop the transfusion immediately

Stop the transfusion immediately. Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the client's vital signs, and notify the health care provider. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The client's IV access should not be removed.

A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure? -insidous onset of lung impairment in a client who had compromised lung function -sudden onset of lung impairment in a client who has comprimised lung function -insidous onset of lung impairment in a client who had normal function -sudden onset of lung impairment in a client who had normal lung function

Sudden onset of lung impairment in a client who had normal lung function In acute respiratory failure, the ventilation or perfusion mechanisms in the lung are impaired. Acute respiratory failure occurs suddenly in a client who previously had normal lung function.

A nurse who works in an oncology practice prepares patients for the side effects of adjuvant hormonal therapy to treat breast cancer. Which of the following is the hormonal agent that has an increased risk of pulmonary embolism and deep vein thrombosis? -anastrozole -tamoxifen -letrozole -exemestane

Tamoxifen Deep vein thrombosis, pulmonary embolism, and superficial phlebitis are all thromboembolic events that are adverse reactions to tamoxifen.

A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus? -wear tight-fitting clothing -begin estrogen replacement -tense and relax muscles in the lower extremities -consume the majority of daily fluid intake prior to bed

Tense and relax muscles in the lower extremities. Clients are encouraged to perform passive or active exercises, as tolerated, to prevent a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism.

A 18-year-old client presents to the emergency department with a severe open fracture of the lower extremity. The health care provider tells the client that the client will need a blood transfusion. The client refuses, despite the advise of the health care provider. What does the nurse understand is the legal implication of the scenario? -the client can only refuse the transfusiong if the consent form has not been signed -the health care providor may first call the client's parents if the client refuses -the client has a right to refuse the transfusion -the health care providor may ask for a court order if the client refuses

The client has a right to refuse the transfusion. An 18-year-old client may refuse transfusion if the client is of sound mind and has been provided education on the risks and benefits of the transfusion. An 18-year-old client is considered an adult and does not require the consent of his or her parent.

A client has tested positive for tuberculosis (TB). While providing client teaching, which information should the nurse prioritize? -TB being self-limiting but taking up to 2 years to resolve -the need to work closely with the occupational and physical therapists -the disease being a lifelong chronic condition that will affect activites of daily living -the importance of adhering to the prescribed medication regimen

The importance of adhering closely to the prescribed medication regimen Successful treatment of TB is highly dependent on careful adherence to the medication regimen. The disease is not self-limiting; occupational and physical therapy are not necessarily indicated. TB is curable.

The nurse is assisting in the care of a client who is receiving cardiopulmonary resuscitation (CPR). For which reason will the client be prescribed to receive amiodarone during the resuscitation efforts? -correct metabolic acidosis -treat pulseless ventricular tachycardia -reduce the development of torsade de pointes -prevent the development of hypotension

Treat pulseless ventricular tachycardia. During CPR, the medications provided will depend upon the client's condition and response to therapy. Amiodarone is used to treat pulseless ventricular tachycardia. Sodium bicarbonate is used to correct metabolic acidosis. Norepinephrine and dopamine are used to prevent the development of hypotension. Magnesium sulfate is used for the client with torsade de pointes.

A client is in the hospital with a bleeding gastric ulcer and requires a blood transfusion. He has been typed and crossmatched for 2 units of packed red blood cells and found to have type O blood. What type of blood will the nurse administer to this client? -type O -type AB -type B -type A

Type O Those with type O blood can only receive type O blood. Clients with all other blood types can receive type O blood provided the Rh factor is compatible.

A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the client's PaCO2 has been between 56 and 64 mm Hg for several months. Why should the nurse be cautious administering oxygen? -the clients calcium will rise dramatically due to the pituitary stimulation -oxygen will increase the clients intracranial pressure and create confusion -oxygen may cause the clients to hyperventilate and become acidotic -using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia

Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia. When PaCO2 chronically exceeds 50 mm Hg, it creates insensitivity to CO2 in the respiratory medulla, and the use of oxygen may result in the client developing carbon dioxide narcosis and hypoxemia. No information indicates the client's calcium will rise dramatically due to pituitary stimulation. No feedback system that oxygen stimulates would create an increase in the client's intracranial pressure and create confusion. Increasing the oxygen would not stimulate the client to hyperventilate and become acidotic; rather, it would cause hypoventilation and acidosis.

A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does this mean for the patient? -ventilation excedes perfusion -ventilation matches perfusion -there is an absense of perfusion and ventilation -perfusion excedes ventilation

Ventilation exceeds perfusion. A high ventilation-perfusion rate means that ventilation exceeds perfusion, causing dead space. The alveoli do not have an adequate blood supply for gas exchange to occur. This is characteristic of a variety of disorders, including pulmonary emboli, pulmonary infarction, and cardiogenic shock.

A client is placed in isolation for suspected tuberculosis. Which action should the nurse take when entering the client's room? -minimize verbal interactions -leave the door open when in the room -wear an N95 respiratory -Apply a face mask with an eye shield

Wear an N95 respirator. Tuberculosis is acquired via airborne transmission. With airborne precautions, the door of a negative-pressure room must remain shut to ensure effectiveness. All personnel entering the room should wear an N-95 respirator or similarly approved respirator. A simple face mask with an eye shield is not an effective barrier to stop transmission. There is no need to minimize verbal interactions with a client with tuberculosis.

Which statement describes emphysema? -a disease of the airways characterized by destruction of the walls of overdistened alveoli -a diseases that results in reversible airflor obstruction, a common clinical outcome -chronc dilation of a bronchus or bronchi -presences of cough and sputm production for at least a combined total of 2-3 months in each of two consecutive years

a disease of the airways characterized by destruction of the walls of overdistended alveoli Emphysema is a category of COPD. Asthma has a clinical outcome of airflow obstruction. Bronchitis includes the presence of cough and sputum production for at least a combined total of 2 to 3 months in each of two consecutive years. Bronchiectasis is a condition of chronic dilatation of a bronchus or bronchi.

A client with emphysema is at a greater risk for developing which acid-base imbalance? -metabolic acidosis -respiratory alkalosis -chronic respiratory acidosis -metabolic alkalosis

chronic respiratory acidosis Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis.

A client with severe anemia is prescribed 2 units of packed red blood cells. The client refuses to sign the consent form for blood administration because to do so conflicts with the client's Jehovah's Witness faith. What did the nurse fail to assess prior to witnessing consent? -emotional readiness -learning environment -learning readiness -cultural belief

cultural beliefs Clients may not accept health treatments if those treatments conflict with the values of their culture. The nurse was not aware of the client's cultural values as a Jehovah's Witness, which include prohibition of the transfusion of blood, prior to attempting to gain consent for the prescribed treatment.

A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation: -is breathing air in and out of the lungs -helps people who cannot breathe on their own -is when the body changes oxygen into CO2 -provides a blood supply to the lungs

is breathing air in and out of the lungs. Ventilation is the actual movement of air in and out of the respiratory tract. Diffusion is the exchange of oxygen and CO2 through the alveolar-capillary membrane. Pulmonary perfusion refers to the provision of blood supply to the lungs. A mechanical ventilator assists patients who are unable to breathe on their own.

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? -pH 7.28, PaO2 50mmHg -pH 7.46, PaO2 80mmHg -pH 7.35 PaCO2 48mmHg -pH 7.36 PaCO2 32mmHg

pH 7.28, PaO2 50 mm Hg ARF is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.

A nurse is discussing asthma complications with a client and family. What complications should the nurse include in the teaching? Select all that apply. -status asthmaticus -respiratory failure -pertussis -atelectasis -thoracentesis

status asthmaticus respiratory failure atelectasis