MS3 Test 3 practice

Using the "rule of nines," calculate the percent of injury in an adult who was injured as follows: the patient sustained partial and full-thickness burns to half of his left arm, his entire left leg, and his perineum. a. 28% b. 23.5% c. 45.5% d. 16%

ANS: B The arm represents 4.5%, the leg 18%, and the perineum 1%, totaling 23.5%.

2. A patient in cardiogenic shock is being treated in the critical care unit. Which findings would the nurse expect to note in the patient to support this diagnosis? (Select all that apply.) a. Warm, dry skin b. Heart rate greater than 100 beats/min c. Weak, thready pulse d. Increased right atrial pressure e. Decreased pulmonary artery occlusion pressure

ANS: B, C, D Clinical manifestations of cardiogenic shock include heart rate greater than 100 beats/min; cool, pale, moist skin; weak, thready pulse; and increased right atrial pressure and pulmonary artery occlusion pressure. PTS: 1 DIF: Cognitive Level: Applying REF: p. 809|Box 34-7 OBJ: Nursing Process Step: Planning TOP: Shock MSC: NCLEX: Physiologic Integrity

23. A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. Which laboratory value would the nurse expect to note to support this diagnosis? a. Decreased fibrinogen degradation products b. Decreased D-dimer concentrations c. Decreased platelet counts d. Increased serum glucose levels

ANS: C Low platelet counts and elevated D-dimer concentrations and fibrinogen degradation products are clinical indicators of disseminated intravascular coagulation (DIC). DIC does not affect serum glucose levels. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 833 OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

A patient is admitted to the burn unit after an electrocution. The patient sustained extensive burns. The nurse should have a high degree of suspicion for what complication associated with this type of burn injury? a. Rhabdomyolysis b. Stress ulcers c. Pneumothorax d. Venous thromboembolism

ANS: C The electrical burn process can result in a profound alteration in acid-base balance and rhabdomyolysis, resulting in myoglobinuria, which poses a serious threat to renal function. Myoglobin is a normal constituent of muscle. With extensive muscle destruction, it is released into the circulatory system and filtered by the kidneys. It can be highly toxic and can lead to intrinsic renal failure.

5. The nurse is caring for a patient in cardiogenic shock. Which hemodynamic parameters would the nurse expect to note to support this diagnosis? a. Increased right atrial pressure b. Decreased pulmonary artery wedge pressure c. Increased cardiac output d. Decreased cardiac index

ANS: D Assessment of the hemodynamic parameter of patients in cardiogenic shock reveals a decreased cardiac output and a cardiac index less than 2.2 L/min/m2. PTS: 1 DIF: Cognitive Level: Applying REF: p. 810 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

10. Which oxygen delivery device is considered a low-flow system? a. Nasal cannula b. Simple face mask c. Reservoir cannula d. Air-entrainment nebulizer

ANS: A A low-flow oxygen delivery system provides supplemental oxygen directly into the patient's airway at a flow of 8 L/min or less. Because this flow is insufficient to meet the patient's inspiratory volume requirements, it results in a variable FiO2 as the supplemental oxygen is mixed with room air. A nasal cannula is a low-flow oxygen delivery system.

21. Which route for endotracheal (ET) tube placement is usually used in an emergency intubation? a. Orotracheal b. Nasotracheal c. Nasopharyngeal d. Trachea

ANS: A An endotracheal tube (ETT) may be placed through the orotracheal or the nasotracheal route. In most situations involving emergency placement, the orotracheal route is used because it is simpler and allows the use of a larger diameter ETT. Nasotracheal intubation provides greater patient comfort over time and is preferred in patients with a jaw fracture

12. Which statement describes the assist-control mode of ventilation? a. It delivers gas at preset volume, at a set rate, and in response to the patient's inspiratory efforts. b. It delivers gas at a preset volume, allowing the patient to breathe spontaneously at his or her own volume. c. It applies positive pressure during both ventilator breaths and spontaneous breaths. d. It delivers gas at preset rate and tidal volume regardless of the patient's inspiratory efforts.

ANS: A Continuous mandatory (volume or pressure) ventilation (CMV), also known as assist-control (AC) ventilation, delivers gas at preset tidal volume or pressure (depending on selected cycling variable) in response to patient's inspiratory efforts and initiates breath if patient fails to do so within preset time.

6. When assessing an intubated patient, the nurse notes normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest. What problem should the nurse suspect? a. Right mainstem intubation b. Left pneumothorax c. Right hemothorax d. Gastric intubation

ANS: A The finding of normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest in a newly intubated patient is probably caused by a right mainstem intubation

2. Which oxygen administration device can deliver oxygen concentrations of 90%? a. Nonrebreathing mask b. Nasal cannula c. Partial rebreathing mask d. Simple mask

ANS: A With an FiO2 of 55% to 70%, a nonrebreathing mask with a tight seal over the face can deliver 90% to 100% oxygen. It is used in emergencies and short-term therapy requiring moderate to high FiO2.

2. Which interventions minimize the complications associated with suctioning an artificial airway? (Select all that apply.) a. Hyperoxygenate the patient prior to the start of the procedure b. Hyperoxygenate the patient after each pass of the suction catheter c. Limit the duration of each suction pass to 20 seconds d. Instill 5 to 10 mL of normal saline to facilitate secretion removal e. Use intermittent suction to avoid damaging tracheal tissue

ANS: A, B Hyperoxygenation and limiting the number of passes help avoid desaturation. There is no evidence to suggest that intermittent suction reduces damage, and saline instillation can actually increase the risk for infection

1. Which of the following are complications of endotracheal tubes? (Select all that apply.) a. Tracheoesophageal fistula b. Cricoid abscess c. Tracheal stenosis d. Tube obstruction e. Hemorrhage

ANS: A, B, C, D Complications of endotracheal tubes include tube obstruction, tube displacement, sinusitis and nasal injury, tracheoesophageal fistula, mucosal lesions, laryngeal or tracheal stenosis, and cricoid abscess. Hemorrhage is a complication of tracheostomy tubes.

4. What are the clinical manifestations associated with oxygen toxicity? (Select all that apply.) a. Substernal chest pain that increases with deep breathing b. Moist cough and tracheal irritation c. Pleuritic pain occurring on inhalation, followed by dyspnea d. Increasing CO2 e. Sore throat and eye and ear discomfort

ANS: A, C, E A number of clinical manifestations are associated with oxygen toxicity. The first symptom is substernal chest pain that is exacerbated by deep breathing. A dry cough and tracheal irritation follow. Eventually, definite pleuritic pain occurs on inhalation followed by dyspnea. Upper airway changes may include a sensation of nasal stuffiness, sore throat, and eye and ear discomforts.

18. A patient was admitted with acute lung failure. The patient has been on a ventilator for 3 days and is being considered for weaning. Which criteria would indicate that the patient is ready to be weaned? a. FiO2 greater than 50% b. Rapid shallow breathing index less than 105 c. Minute ventilation greater than 10 L/min d. Vital capacity/kg greater than or equal to 15 mL

ANS: B The rapid shallow breathing index (RSBI) has been shown to be predictive of weaning success. To calculate the RSBI, the patient's respiratory rate and minute ventilation are measured for 1 minute during spontaneous breathing. The measured respiratory rate is then divided by the tidal volume (expressed in liters). An RSBI less than 105 is considered predictive of weaning success. If the patient meets criteria for weaning readiness and has an RSBI less than 105, a spontaneous breathing trial can be performed.

8. Which statement is correct concerning endotracheal tube cuff management? a. The cuff should be deflated every hour to minimize pressure on the trachea. b. A small leak should be heard on inspiration if the cuff has been inflated using the minimal leak technique. c. Cuff pressures should be kept between 20 to 30 mm Hg to ensure an adequate seal. d. Cuff pressure monitoring should be done once every 24 hours.

ANS: B Cuff pressures are monitored at a minimum of every shift and are maintained within 20 to 30 mm Hg because greater pressures decrease blood flow to the capillaries in the tracheal wall and lesser pressures increase the risk of aspiration. Pressures greater than 30 mm Hg (41 cm H2O) should be reported to the physician. Cuffs are not routinely deflated because this increases the risk of aspiration. The minimal leak technique is no longer recommended

16. A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. When entering the room, the ventilator inoperative alarm sounds. What action should the nurse take FIRST? a. Troubleshoot the ventilator until the problem is found. b. Take the patient off the ventilator and manually ventilate. c. Call the respiratory therapist for help. d. Silence the ventilator alarms until the problem is resolved.

ANS: B Ensure emergency equipment is at bedside at all times (eg, manual resuscitation bag connected to oxygen, masks, suction equipment or supplies), including preparations for power failures. If the ventilator malfunctions, the patient should be removed from the ventilator and ventilated manually with a manual resuscitation bag.

23. A patient was taken to surgery for a left lung resection. The patient returned to the unit 30 minutes ago. Upon completion of the assessment, the nurse notices that the chest tube has drained 150 mL of red fluid in the past 30 minutes. The nurse contacts the physician and suspects that the patient has developed what complication? a. Pulmonary edema b. Hemorrhage c. Acute lung failure d. Bronchopleural fistula

ANS: B Hemorrhage is an early, life-threatening complication that can occur after a lung resection. It can result from bronchial or intercostal artery bleeding or disruption of a suture or clip around a pulmonary vessel. Excessive chest tube drainage can signal excessive bleeding. During the immediate postoperative period, chest tube drainage should be measured every 15 minutes; this frequency should be decreased as the patient stabilizes. If chest tube loss is greater than 100 mL/h, fresh blood is noted, or a sudden increase in drainage occurs, hemorrhage should be suspected.

17. A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure limit alarm keeps alarming. What would cause this problem? a. A leak in the patient's endotracheal (ET) tube cuff b. A kink in the ventilator tubing c. The patient is disconnected from the ventilator d. A faulty oxygen filter

ANS: B High-pressure alarms will sound because of improper alarm setting; airway obstruction resulting from patient fighting ventilator (holding breath as ventilator delivers Vt); patient circuit collapse; kinked tubing; the endotracheal tube in the right mainstem bronchus or against the carina; cuff herniation; increased airway resistance resulting from bronchospasm, airway secretions, plugs, and coughing; water from the humidifier in the ventilator tubing; and decreased lung compliance resulting from tension pneumothorax, change in patient position, acute respiratory distress syndrome, pulmonary edema, atelectasis, pneumonia, or abdominal distention.

24. Which medication can cause bronchospasms and should be administered with a bronchodilator? a. Beta-2 agonist b. Mucloytics c. Anticholinergic agents d. Xanthines

ANS: B Mucolytics may be administered with a bronchodilator because it can cause bronchospasms and inhibit ciliary function. Treatment is considered effective when bronchorrhea develops and coughing occurs. Beta-2 agonists are used to relax bronchial smooth muscle and dilate airways to prevent bronchospasms. Anticholinergic agents are used to block the constriction of bronchial smooth muscle and reduce mucus production. Xanthines are used to dilate bronchial smooth muscle and reverse diaphragmatic muscle fatigue.

15. What nursing interventions should be included in the nursing management of the patient receiving a neuromuscular blocking agent? a. Withholding all sedation and narcotics b. Protecting the patient from the environment c. Keeping the patient supine d. Speaking to the patient only when necessary

ANS: B Patient safety is a major concern for the patient receiving a neuromuscular blocking agent because these patients are unable to protect themselves from the environment. Special precautions should be taken to protect the patient at all times.

20. Patient safety precautions when working with oxygen include which action? a. Observing for signs of oxygen-associated hyperventilation b. Ensuring the oxygen device is properly positioned c. Removal of all oxygen devices when eating d. Administration of oxygen at the nurse's discretion

ANS: B Patient safety precautions when working with oxygen involve administration of oxygen and monitoring of its effectiveness. Activities include restricting smoking, administering supplemental oxygen as ordered, observing for signs of oxygen-induced hypoventilation, monitoring the patient's ability to tolerate removal of oxygen while eating, and changing the oxygen delivery device from a mask to nasal prongs during meals as tolerated

11. Which ventilator phase variable initiates the change from exhalation to inspiration? a. Cycle b. Trigger c. Flow d. Pressure

ANS: B The phase variable that initiates the change from exhalation to inspiration is called the trigger. Breaths may be pressure triggered or flow triggered based on the sensitivity setting of the ventilator and the patient's inspiratory effort or time triggered based on the rate setting of the ventilator.

26. What is the therapeutic blood level for theophylline (Xanthines)? a. 5 to 10 mg/dL b. 10 to 20 mg/dL c. 20 to 30 mg/dL d. 35 to 45 mg/dL

ANS: B Therapeutic blood level for theophylline is 10 to 20 mg/dL.

3. Which statements regarding rotation therapies are accurate? (Select all that apply.) a. Continuous lateral rotation therapy (CLRT) can be effective for improving oxygenation if used for at least 18 hours/day. b. Kinetic therapy can decrease the incidence of ventilator-acquired pneumonia in neurologic and postoperative patients. c. Use of rotational therapy eliminates the need for other pressure ulcer prevention strategies. d. CLRT helps avoid hemodynamic instability secondary to the continuous, gentle turning of the patient. e. CLRT has minimal pulmonary benefits for critically ill patients.

ANS: B, E Studies have found that to achieve benefits with rotation therapy, rotation must be aggressive, and the patient must be at least 40 degrees per side, with a total arc of at least 80 degrees for at least 18 hours a day. Kinetic therapy has been shown to decrease the incidence of ventilator-acquired pneumonia, particularly in neurologic and postoperative patients. Complications of the procedure include dislodgment or obstruction of tubes, drains, and lines; hemodynamic instability; and pressure ulcers. Lateral rotation does not replace manual repositioning to prevent pressure ulcers. Continuous lateral rotation therapy (CLRT) has been shown to be of minimal pulmonary benefit for the critically ill patients.

25. What is an indication for a pneumonectomy? a. Peripheral granulomas b. Bronchiectasis c. Unilateral tuberculosis d. Single lung abscess

ANS: C A pneumonectomy is the removal of entire lung with or without resection of the mediastinal lymph nodes. Indications include malignant lesions, unilateral tuberculosis, extensive unilateral bronchiectasis, multiple lung abscesses, massive hemoptysis, and bronchopleural fistula.

7. Which airway would be the most appropriate for a patient requiring intubation longer than 21 days? a. Oropharyngeal airway b. Esophageal obturator airway c. Tracheostomy tube d. Endotracheal intubation

ANS: C Although no ideal time to perform the procedure has been identified, it is commonly accepted that if a patient has been intubated or is anticipated to be intubated for longer than 7 to 10 days, a tracheostomy should be performed.

3. Which oxygen therapy device should is used in a patient requiring the delivery of a precise low FiO2? a. Simple mask b. Nasal cannula c. Air-entrainment mask d. Partial rebreathing mask

ANS: C An air-entrainment mask is used in patients requiring the delivery of a precise low FiO2. A simple mask, partial rebreathing mask, and nasal cannula are not able to provide as precise level of oxygen as an air-entrainment mask.

4. Use of oxygen therapy in the patient who is hypercapnic may result in which situation? a. Oxygen toxicity b. Absorption atelectasis c. Carbon dioxide retention d. Pneumothorax

ANS: C Deoxygenated hemoglobin carries more CO2 compared with oxygenated hemoglobin. Administration of oxygen increases the proportion of oxygenated hemoglobin, which causes increased release of CO2 at the lung level. Because of the risk of CO2 accumulation, all patients who are chronically hypercapnic require careful low-flow oxygen administration.

9. What nursing intervention can minimize the complications of suctioning? a. Inserting the suction catheter no more than 5 inches b. Premedicating the patient with atropine c. Hyperoxygenating the patient with 100% oxygen d. Increasing the suction to 150 mm Hg

ANS: C Hypoxemia can be minimized by giving the patient three hyperoxygenation breaths (breaths at 100% FiO2) with the ventilator before the procedure and again after each pass of the suction catheter.

22. The Passy-Muir valve is contraindicated in which patient? a. A patient who is trying to relearn normal breathing patterns b. A patient who has minimal secretions c. A patient with laryngeal or pharyngeal dysfunction d. A patient who wants to speak while on the ventilator

ANS: C The Passy-Muir valve is contraindicated in patients with laryngeal or pharyngeal dysfunction, excessive secretions, or poor lung compliance.

19. A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. Which criteria would indicate that the patient is not tolerating weaning? a. A decrease in heart rate from 92 to 80 beats/min b. An SpO2 of 92% c. An increase in respiratory rate from 22 to 38 breaths/min d. Spontaneous tidal volumes of 300 to 350 mL

ANS: C Weaning intolerance indicators include (1) a decrease in level of consciousness; (2) a systolic blood pressure increased or decreased by 20 mm Hg; (3) a diastolic blood pressure greater than 100 mm Hg; (4) a heart rate increased by 20 beats/min; (5) premature ventricular contractions greater than 6/min, couplets, or runs of ventricular tachycardia; (6) changes in ST segment (usually elevation); (7) a respiratory rate greater than 30 breaths/min or less than 10 breaths/min; (8) a respiratory rate increased by 10 breaths/min; (9) a spontaneous tidal volume less than 250 mL; (10) a PaCO2 increased by 5 to 8 mm Hg or pH less than 7.30; (11) an SpO2 less than 90%; (12) use of accessory muscles of ventilation; (13) complaints of dyspnea, fatigue, or pain; (14) paradoxical chest wall motion or chest abdominal asynchrony; (15) diaphoresis; and (16) severe agitation or anxiety unrelieved with reassurance

5. To select the correct size of an oropharyngeal airway, the nurse should ensure the airway extends from which area to which area? a. Tip of the nose to the ear lobe b. Middle of the mouth to the ear lobe c. Tip of the nose to the middle of the trachea d. Corner of the mouth to the angle of the jaw

ANS: D An oropharyngeal airway's proper size is selected by holding the airway against the side of the patient's face and ensuring that it extends from the corner of the mouth to the angle of the jaw. If the airway is improperly sized, it will occlude the airway. Nasopharyngeal airways are measured by holding the tube against the side of the patient's face and ensuring that it extends from the tip of the nose to the ear lobe.

14. Which statement best describes the effects of positive-pressure ventilation on cardiac output? a. Positive-pressure ventilation increases intrathoracic pressure, which increases venous return and cardiac output. b. Positive-pressure ventilation decreases venous return, which increases preload and cardiac output. c. Positive-pressure ventilation increases venous return, which decreases preload and cardiac output. d. Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return and cardiac output.

ANS: D Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return to the right side of the heart. Impaired venous return decreases preload, which results in a decrease in cardiac output.

13. What is the preset positive pressure used to augment the patient's inspiratory effort known as? a. Positive end-expiratory pressure (PEEP) b. Continuous positive airway pressure (CPAP) c. Pressure control ventilation (PCV) d. Pressure support ventilation (PSV)

ANS: D Preset positive pressure used to augment the patient's inspiratory efforts is known as pressure support ventilation. With continuous positive airway pressure, positive pressure is applied during spontaneous breaths; the patient controls rate, inspiratory flow, and tidal volume. Positive end-expiratory pressure is positive pressure applied at the end of expiration of ventilator breaths.

1. Which arterial blood gas (ABG) values would indicate a need for oxygen therapy? a. PaO2 of 80 mm Hg b. PaCO2 of 35 mm Hg c. HCO of 24 mEq d. SaO2 of 87%

ANS: D The amount of oxygen administered depends on the pathophysiologic mechanisms affecting the patient's oxygenation status. In most cases, the amount required should provide an arterial partial pressure of oxygen (PaO2) of greater than 60 mm Hg or an arterial hemoglobin saturation (SaO2) of greater than 90% during both rest and exercise.

What condition develops when air enters the pleural space from the lung on inhalation and cannot exit on exhalation? a. Tension pneumothorax b. Sucking chest wound c. Open pneumothorax d. Pulmonary interstitial empyema

ANS: A A tension pneumothorax develops when air enters the pleural space from either the lung or the chest wall on inhalation and cannot escape on exhalation. Open pneumothorax is a laceration in the parietal pleura that allows atmospheric air to enter the pleural space; it occurs as a result of penetrating chest trauma. Pulmonary interstitial emphysema is air in the pulmonary interstitial space.

After a pancreatic transplant with bladder exocrine drainage, the nurse would anticipate which order? a.Continuous bladder irrigation b.Intermittent insulin injections c.Removal of the nasogastric tube as soon as the patient is alert d.Daily hematocrit and hemoglobin levels

ANS: A An increased potential for urinary catheter occlusion exists for pancreas recipients who have undergone a urinary diversion procedure. The exocrine pancreatic enzymes make the urine more viscous, and they irritate the anastomosis site on the bladder, causing an increased risk of bleeding. Continuous bladder irrigation may be necessary to keep the catheter patent.

A patient who was an unrestrained driver in a high-speed, head-on motor vehicle collision presents with dyspnea, tachycardia, hypotension, jugular venous distention, tracheal deviation to the left, and decreased breath sounds on the right side. The nurse suspects these findings are indicative of which disorder? a. Tension pneumothorax b. Cardiac tamponade c. Simple pneumothorax d. Ruptured diaphragm

ANS: A Clinical manifestations of a tension pneumothorax include dyspnea, tachycardia, hypotension, and sudden chest pain extending to the shoulders. Patients with cardiac tamponade will not have unilateral decreased breath sounds. Neither a simple pneumothorax nor a ruptured diaphragm will result in hypotension, jugular venous distention, or tracheal deviation unless it goes untreated.

A patient was admitted following an aspiration event on the medical-surgical floor. The patient is receiving 40% oxygen via a simple facemask. The patient has become increasingly agitated and confused. The patient's oxygen saturation has dropped from 92% to 84%. The nurse notifies the practitioner about the change in the patient's condition. What interventions should the nurse anticipate? a. Intubation and mechanical ventilation b. Change in antibiotics orders c. Suction and reposition the patient d. Orders for a sedativE

ANS: A Given the significant drop in oxygen saturation, increasing agitation and confusion, the nurse should anticipate the patient will need to be intubated and mechanically ventilated. Administering antibiotics, suctioning and repositioning, and administering a sedative would not address the development of severe hypoxemia.

A patient is admitted with acute abdominal trauma. The patient has a positive Focused Assessment with Sonography for Trauma (FAST scan) and is hemodynamically unstable. What procedure should the nurse anticipate next? a. Emergency surgery b. Diagnostic peritoneal lavage (DPL) c. Computed tomography scan d. Intraabdominal pressure monitoring

ANS: A Hemodynamically unstable patients with a positive Focused Assessment with Sonography for Trauma (FAST) scan generally undergo emergency surgery to achieve hemostasis. Diagnostic peritoneal lavage (DPL) is undertaken less frequently in many trauma centers. Computed tomography (CT) scanning is the mainstay of diagnostic evaluation in the hemodynamically stable patient with abdominal trauma; however, when the patient is hemodynamically unstable, the patient is taken to surgery. Intraabdominal pressure monitoring is done in the presence of intraabdominal hypertension.

25. An elderly patient is admitted with pneumonia. This morning the patient is febrile, tachycardic, tachypneic, and confused. The nurse suspects the patient may be developing what problem? a. Sepsis b. Delirium c. Adult respiratory distress syndrome d. Acute kidney injury

ANS: A Increased heart rate, change in sensorium, increased temperature, and increased respiratory rate are all signs of sepsis in the presence of an existing infection. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 821 OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

15. A patient is being admitted with cardiogenic shock secondary to acute heart failure. In addition to a diuretic, which medication would the nurse anticipate the practitioner ordering for the patient? a. Epinephrine b. Nitroprusside c. Dobutamine d. Nitroglycerine

ANS: A Inotropic agents are used to increase contractility and maintain adequate blood pressure and tissue perfusion. Dobutamine is the inotrope of choice. A vasopressor, preferably norepinephrine (not Epinephrine), may be necessary to maintain blood pressure when hypotension is severe. Diuretics may be used for preload reduction. Vasodilating agents (Nitroglycerine and Nitroprusside) are used for preload and afterload reduction only in specific situations in conjunction with an inotrope or when the patient is no longer in shock. PTS: 1 DIF: Cognitive Level: Applying REF: p. 810 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

A patient with a Le Fort III facial fracture has been admitted to the critical care unit. Which statements is true regarding this type of facial fracture? a. It is frequently associated with cerebrospinal fluid leaks. b. It is not as severe as Le Forte I and II injuries. c. The patient's airway is not usually compromised. d. It is associated with a low risk for hemorrhagic shock.

ANS: A Le Fort III fractures are associated with craniofacial disruption. Cerebrospinal fluid frequently leaks with Le Fort II and III fractures because there is frequently communication between the cranial base and the cribriform plate. Patients are at risk of airway occlusion from the tongue, hemorrhage, broken teeth, emesis, or bone fragments. Significant blood loss can occur with these injuries because of the extensive soft tissue and vascular damage that results.

3. A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the administration of large volumes of fluid? a. Inserting a large-diameter peripheral intravenous catheter b. Positioning the patient in the Trendelenburg position c. Encouraging the patient to drink at least 240 mL of fluid each hour d. Administering intravenous fluids under pressure with a pressure bag

ANS: A Measures to facilitate the administration of volume replacement include insertion of large-bore peripheral intravenous catheters; rapid administration of prescribed fluids; and positioning the patient with the legs elevated, trunk flat, and head and shoulders above the chest. PTS: 1 DIF: Cognitive Level: Applying REF: p. 807 OBJ: Nursing Process Step: Intervention TOP: Shock MSC: NCLEX: Physiologic Integrity

A nurse is caring for a patient who is receiving sirolimus. The nurse knows to monitor the patient for what side effect? a.Bleeding b.Diarrhea c.Rigors d.Hypotension

ANS: A Other primary side effects of this medication include hyperlipidemia and myelosuppression. Most of the myelosuppressive effect is directed at platelets, and severe thrombocytopenia can result, making it necessary to discontinue the medication.

What two pathogens are most frequently associated with ventilator-associated pneumonia? a. Staphylococcus aureus and Pseudomonas aeruginosa b. Escherichia coli and Haemophilus influenzae c. Acinetobacter baumannii and Haemophilus influenzae d. Klebsiella spp. and Enterobacter spp.

ANS: A Pathogens that can cause hospital-associated pneumonia (HAP) include Escherichia coli, H. influenzae, methicillin-sensitive S. aureus, S. pneumoniae, P. aeruginosa, Acinetobacter baumannii, methicillin-resistant S. aureus (MRSA), Klebsiella spp., and Enterobacter spp. Two of the pathogens most frequently associated with ventilator-associated pneumonia (VAP) are S. aureus and P. aeruginosa.

A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. Total body surface area (TBSA) burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The patient's weight is estimated at 85 kg. What is the initial plan for fluid replacement? a. 5950 mL of Lactated Ringer (LR) solution for the first 8 hours; then 5950 mL of LR over the next 16 hours b. 2868 mL of normal saline (NS) for the first 8 hours; then 5737 mL of hypertonic NS over the next 16 hours c. 11,900 mL of dextran evenly divided over the first 24 hours d. 11,475 mL of LR evenly divided over the first 24 hours

ANS: A Per the Parkland formula, you would administer 5950 mL of Lactated Ringer (LR) solution for the first 8 hours and 5950 mL of LR over the next 16 hours (4 mL ´ 85 kg ´ 45% = 15,300 mL in first 24 hours).

7. A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the decrease in the patient's cardiac output is the result of which mechanism? a. Peripheral vasodilation b. Increased venous return c. Increased alveolar ventilation d. Decreased myocardial contractility

ANS: A Peripheral vasodilation results in decreased venous return. This decreases intravascular volume and the development of relative hypovolemia. Decreased venous return results in decreased stroke volume and a fall in cardiac output. PTS: 1 DIF: Cognitive Level: Applying REF: p. 811|p. 813|Box 34-10 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

Which nursing intervention should be used to optimize oxygenation and ventilation in the patient with acute lung failure? a. Provide adequate rest and recovery time between procedures. b. Position the patient with the good lung up. c. Suction the patient every hour. d. Avoid hyperventilating the patient.

ANS: A Providing adequate rest and recovery time between various procedures prevents desaturation and optimizes oxygenation. In acute lung failure, the goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Hyperventilate the patient before suctioning; suction patients as needed.

During assessment of a new trauma patient, the nurse observes perianal ecchymosis. The nurse suspects the patient has what problem? a. Pelvic fracture b. Bladder trauma c. Rectal laceration d. Spleen laceration

ANS: A Signs of pelvic fracture include swelling, tenderness, and/or bruising to the pubis, iliac bones, hips, or sacrum. Perianal ecchymosis (scrotum or vulva), indicating extravasation of urine or blood, may be present.

A patient was thrown 30 feet from an open-top Jeep and straddled a row of mailboxes before landing on the ground. The patient has an open pelvic fracture. What characteristics of this injury are important for the nurse to understand? a. Aggressive fluid and blood replacement will probably be needed. b. The patient will probably be able to walk as soon as the patient is stable. c. The patient will probably not need surgery to stabilize her fracture. d. There is little likelihood of damage to the genitourinary or gastrointestinal tracts.

ANS: A The mortality rate for these injuries is high because, unlike closed pelvic fractures that bleed into the peritoneum, open pelvic fractures result in external exsanguinations.

What are the most common presenting signs and symptoms associated with a pulmonary embolism (PE)? a. Tachycardia and tachypnea b. Hemoptysis and evidence of deep vein thromboses c. Apprehension and dyspnea d. Right ventricular failure and fever

ANS: A The patient with a pulmonary embolism may have any number of presenting signs and symptoms, with the most common being tachycardia and tachypnea. Additional signs and symptoms that may be present include dyspnea, apprehension, increased pulmonic component of the second heart sound (P1), fever, crackles, pleuritic chest pain, cough, evidence of deep vein thrombosis, and hemoptysis. Syncope and hemodynamic instability can occur as a result of right ventricular failure.

A patient with multisystem trauma has been in the intensive care unit (ICU) for 6 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The patient's vital signs include blood pressure (BP), 92/66 mm Hg; heart rate (HR), 118 beats/min; temperature (T), 38.7° C; and central venous pressure (CVP), 5 mm Hg. What is the most likely cause of this hemodynamic picture? a. Septic shock b. Hemorrhagic shock c. Cardiogenic shock d. Neurogenic shock

ANS: A The patient with multiple injuries is at risk for overwhelming infections and sepsis. The source of sepsis in the trauma patient can be invasive therapeutic and diagnostic catheters or wound contamination with exogenous or endogenous bacteria. The source of the septic nidus must be promptly evaluated. Gram stain and cultures of blood, urine, sputum, invasive catheters, and wounds are obtained.

What are the goals of the rehabilitation phase of burn management? a. Recuperation and healing physically and emotionally b. Hydrotherapy and splinting c. Reverse wound isolation and surgical grafting d. Bed rest and splinting

ANS: A The rehabilitation phase is one of recuperation and healing physically and emotionally.

A patient developed a hemothorax after a blunt chest trauma. The practitioner inserted a chest tube on the left side, and 1800 mL of blood was evacuated from the chest. The nurse expects that the patient will be taken to surgery for what procedure? a. Thoracotomy b. Pericardiocentesis c. Splenectomy d. Pneumonectomy

ANS: A Thoracotomy may be necessary for patients who require persistent blood transfusions or who have significant bleeding (200 mL/h for 2 to 4 hours or more than 1500 mL on initial tube insertion) or when there are injuries to major cardiovascular structures.

The nurse is caring for a patient with blunt abdominal trauma. The nurse understands that patient is at risk for abdominal compartment syndrome. Which findings would the nurse expect to note as evidence of this complication? (Select all that apply.) a. Decreased cardiac output b. Increased peak pulmonary pressures c. Decreased urine output d. Hypoxemia e. Bradycardia

ANS: A, B, C, D Clinical manifestations of abdominal compartment syndrome include decreased cardiac output, decreased tidal volumes, increased peak pulmonary pressures, decreased urine output, and hypoxemia.

What psychologic factors contribute to long-term mechanical ventilation dependence? (Select all that apply.) a. Fear b. Delirium c. Lack of confidence d. Depression e. Trust in the stuff

ANS: A, B, C, D Psychologic factors contributing to long-term mechanical ventilation dependence include a loss of breathing pattern control (anxiety, fear, dyspnea, pain, ventilator asynchrony, lack of confidence in ability to breathe), lack of motivation and confidence (inadequate trust in staff, depersonalization, hopelessness, powerlessness, depression, inadequate communication), and delirium (sensory overload, sensory deprivation, sleep deprivation, pain medications).

Medical management of a patient with status asthmaticus includes which treatments? (Select all that apply.) a. Oxygen therapy b. Bronchodilators c. Corticosteroids d. Antibiotics e. Intubation and mechanical ventilation

ANS: A, B, C, E Medical management of a patient with status asthmaticus is directed toward supporting oxygenation and ventilation. Bronchodilators, corticosteroids, oxygen therapy, and intubation and mechanical ventilation are the mainstays of therapy.

Nursing management of the patient with acute lung failure includes which interventions? (Select all that apply.) a. Positioning the patient with the least affected side up b. Providing adequate rest between treatments c. Performing percussion and postural drainage every 4 hours d. Controlling fever e. Pharmaceutical medications to control anxiety

ANS: A, B, D, E The goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Patients with diffuse lung disease may benefit from being positioned with the right lung down because it is larger and more vascular than the left lung. For patients with alveolar hypoventilation, the goal of positioning is to facilitate ventilation. These patients benefit from nonrecumbent positions such as sitting or a semierect position. In addition, semirecumbency has been shown to decrease the risk of aspiration and inhibit the development of hospital-associated pneumonia. Frequent repositioning (at least every 2 hours) is beneficial in optimizing the patient's ventilatory pattern and ventilation/perfusion matching. These include performing procedures only as needed, hyperoxygenating the patient before suctioning, providing adequate rest and recovery time between various procedures, and minimizing oxygen consumption. Interventions to minimize oxygen consumption include limiting the patient's physical activity, administering sedation to control anxiety, and providing measures to control fever.

A patient has been admitted with muscle trauma and crush injuries. The nurse understands that this patient is at high risk for the development of acute kidney injury secondary to rhabdomyolysis. Which findings would suggest the patient is developing this complication? (Select all that apply.) a. Dark tea-colored urine b. Decreased urine output c. Hypoxemia d. Diminished pulses e. Increased serum creatine kinase level

ANS: A, B, E Circulating myoglobin can lead to the development of kidney failure by three mechanisms: decreased renal perfusion, cast formation with tubular obstruction, and direct toxic effects of myoglobin in the kidney tubules. Dark tea-colored urine suggests myoglobinuria. The most rapid screening test is a serum creatine kinase level. Urine output and serial creatine kinase levels should be monitored. Hypoxemia and diminished pulses are not associated with rhabdomyolysis.

Potential recipients are matched with donors based on what factors? (Select all that apply.) a.Blood type b.Human leukocyte antigen c.Race d.Socioeconomic status e.Severity of illness f.Location of recipient g.Waiting time on the list

ANS: A, B, E, F, G Potential recipients are matched with the donor based on blood type, height, weight, human leukocyte antigen, distance from the donor, waiting time on the list, and severity of illness. The national system in place for organ allocation is fair and equitable for those requiring a transplant. The list does not reference race, gender, or socioeconomic status.

Patients immobilized because of spinal trauma are at a high risk for contractures. The nursing management plan for these patients should include which preventive measures? (Select all that apply.) a. Consultation by physical therapist (PT) and occupational therapist (OT) early in the treatment of the patient. b. Turning and repositioning the patient every 2 hours as ordered by the physician. c. Range of motion exercises 1 month after the spine has been stabilized. d. Removal of splints every 4 hours and at bedtime. e. Hand splints for patients with paraplegia. f. Hand and foot splints for patients with quadriplegia.

ANS: A, B, F Physical therapy and occupational therapy personnel should be consulted early in the patient's course. Range-of-motion exercises are initiated as soon as the spine has been stabilized. Footdrop splints should be applied on admission to prevent contractures and prevent skin breakdown of the heels. Hand splints should be applied for patients with quadriplegia. Hand and foot splints should be removed every 2 hours.

The nurse is caring for a patient with extensive trauma to the lower extremities. The nurse understands that patient is at risk for compartment syndrome. Which findings would the nurse expect to note as evidence of this complication? (Select all that apply.) a. Paresthesia b. Decreased pulses c. Pain in the affected extremity d. Swelling in the affected extremity e. Decreases capillary refill

ANS: A, C, D Clinical manifestations of compartment syndrome include obvious swelling and tightness of an extremity, paresis, and pain of the affected extremity. Diminished pulses and decreased capillary refill do not reliably identify compartment syndrome because they may be intact until after irreversible changes have occurred. Elevated intracompartmental pressures confirm the diagnosis.

Major trauma patients are at high risk of developing deep venous thrombosis and pulmonary embolism. The nurse understands that trauma patients are at risk due to which factors? (Select all that apply.) a. Blood stasis b. Hypernatremia c. Injury to the intimal surface of the vessel d. Hyperosmolarity e. Hypercoagulopathy f. Immobility

ANS: A, C, E, F The factors that form the basis of venous thromboembolism (VTE) pathophysiology are blood stasis, injury to the intimal surface of the vessel, and hypercoagulopathy. Trauma patients are at risk for VTE because of endothelial injury, coagulopathy, and immobility. Hypernatremia and hyperosmolarity are associated with acute kidney injury.

The nurse is caring for a patient who has had a recent heart transplant. Which signs and symptoms would alert the nurse that the patient is rejecting the transplant? (Select all that apply.) a.Shortness of breath b.Tolerance of exercise c.Disturbance in mood d.Decreased weight e.Pulmonary crackles f.Onset of hypertension g.Sudden onset of edema

ANS: A, C, E, G Signs and symptoms of heart transplant rejections include intolerance to exercise, increased weight, and onset of hypotension.

A patient is admitted after being burned while lighting the barbecue. The injuries appear moist and red with some blister formation and the patient states they are very painful. What kind of burn would the nurse document in the patient's record? a. Superficial, first-degree burn b. Partial-thickness, second-degree burn c. Deep dermal partial-thickness, second-degree burn d. Full-thickness, third-degree burn

ANS: B A light to bright red or mottled appearance characterizes superficial second-degree burns. These wounds may appear wet and weeping, may contain bullae, and are extremely painful and sensitive to air currents. The microvessels that perfuse this area are injured, and permeability is increased, resulting in leakage of large amounts of plasma into the interstitium. This fluid, in turn, lifts off the thin damaged epidermis, causing blister formation. Despite the loss of the entire basal layer of the epidermis, a burn of this depth will heal in 7 to 21 days.

A patient has a partial-thickness burn wound that is being treated with porcine xenograft (pigskin). The nurse knows that pigskin usually dissolves in 5 to 7 days because of what reason? a. Infection b. Lack of blood supply c. Lack of lymphatic drainage d. Contamination

ANS: B After the pigskin is in place, it may be dressed with antibacterial-impregnated dressings or other forms of dressings. Pigskin usually is removed or dissolves because of a lack of blood supply in 5 to 7 days. The pigskin is packaged in a variety of ways and in various sizes. It can be treated with silver sulfadiazine and can be meshed or nonmeshed. Pigskin can be used for temporary coverage of full- and partial-thickness wounds, burn wounds, and donor sites.

A trauma patient's condition has deteriorated. The nurse notes changes in patient's condition, including trachea shift, absence of breath sounds on the left side, and hypotension. The nurse suspects that the patient has developed what complication? a. Cardiac tamponade b. Hemothorax c. Open pneumothorax d. Ruptured diaphragm

ANS: B Assessment findings for patients with a hemothorax include hypovolemic shock. Breath sounds may be diminished or absent over the affected lung. With hemothorax, the neck veins are collapsed, and the trachea is at midline. Massive hemothorax can be diagnosed on the basis of clinical manifestations of hypotension associated with the absence of breath sounds or dullness to percussion on one side of the chest.

A patient was admitted after a motor vehicle crash (MVC). The nurse knows that this type of injury is the greatest cause of what type of trauma? a. Spinal shock b. Blunt thoracic trauma c. Maxillofacial injuries d. Penetrating thoracic injuries

ANS: B Blunt trauma to the chest most often is caused by motor vehicle crashes (MVCs) or falls. Spinal shock is a condition that can occur shortly after traumatic injury to the spinal cord. Maxillofacial injury results from blunt or penetrating trauma. Blunt trauma may occur from motor vehicle, industrial, or athletic injuries; violent blows to the head; or falls. The penetrating object involved determines the damage sustained from penetrating thoracic trauma. Low-velocity weapons (eg, 22-caliber gun, knife) usually damage only what is in the weapon's direct path.

For which situation does a patient with acute lung failure require a bronchodilator? a. Excessive secretions b. Bronchospasms c. Thick secretions d. Fighting the ventilator

ANS: B Bronchodilators aid in smooth muscle relaxation and are of particular benefit to patients with airflow limitations. Mucolytics and expectorants are no longer used because they have been found to be of no benefit in this patient population.

Using the Parkland formula for fluid resuscitation and your knowledge of injury calculations using the "rule of nines," calculate the estimated fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns to the anterior chest, perineum, and entire right leg. a. 2775 mL b. 5550 mL c. 8325 mL d. 11,100 mL

ANS: B In a 75-kg person with a 37% burn injury (based on a rule of nines calculation: 18%—chest, 1%—perineum, 18%—right leg = 37% total body surface area [TBSA] burn), the Parkland formula estimates fluid resuscitation needs at 4 mL ´ 37 ´ 75 = 11,100 mL. In the first 8 hours after injury, half of the calculated amount of fluid is administered. This amount equals 5550 mL.

A patient was admitted with acute lung failure secondary to pneumonia. What is the single most important measure to prevent the spread of infection between staff and patients? a. Place the patient in respiratory isolation. b. Ensure everyone is using proper hand hygiene. c. Use personal protective equipment. d. Initiate prompt administration of antibiotics.

ANS: B Proper hand hygiene is the single most important measure available to prevent the spread of bacteria from person to person.

Which diagnostic criteria is indicative of mild adult respiratory distress syndrome (ARDS)? a. Radiologic evidence of bibasilar atelectasis b. PaO2/FiO2 ratio less than or equal to 200 mm Hg c. Pulmonary artery wedge pressure greater than 18 mm Hg d. Increase in static and dynamic compliance

ANS: B The Berlin Definition of ARDS is as follows: timing—within 1 week of known clinical insult or new or worsening respiratory symptoms; chest imaging—bilateral opacities not fully explained by effusions, lobar or lung collapse, or nodules; origin of edema—respiratory failure not fully explained by cardiac failure or fluid overload; need objective assessment to exclude hydrostatic edema if no risk factor present; oxygenation—mild (200 mg Hg less than PaO2/FiO2 less than or equal to 300 mm Hg with positive end-respiratory airway pressure (PEEP) or constant positive airway pressure greater than or equal to 5 cm H2O), moderate (100 mg Hg less than PaO2/FiO2 less than or equal to 200 mm Hg with PEEP greater than or equal to 5 cm H2O), or severe (PaO2/FiO2 less than or equal to 100 mm Hg with PEEP greater than or equal to 5 cm H2O). The mortality rate for ARDS is estimated to be 34% to 58%.

A patient is admitted to the intensive care unit (ICU) for observation of his grade II splenic laceration. Which signs and symptoms suggest that the patient has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock? a. Blood pressure (BP), 110/70 mm Hg; HR, 120 beats/min; Hct, 42 mg/dL; UO, 40 mL/h; skin that is pink, warm, and dry, with capillary refill of 3 seconds b. BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/h; pale, cool, clammy skin; confused c. BP, 100/60 mm Hg; HR, 100 beats/min; Hct, 35 mg/dL; UO, 30 mL/h; pale, cool, dry skin; alert and oriented d. BP, 110/60 mm Hg; HR, 118 beats/min; Hct, 38 mg/dL; UO, 60 mL/h; flushed, warm, diaphoretic skin; agitated and confused

ANS: B The first set of vital signs is normal. Patients who are in hemorrhagic shock are significantly tachycardic with a narrowed pulse pressure and oliguric, and their skin is pale, cool, and clammy. They also have a low hematocrit and are confused. Hemodynamically stable patients may be monitored in the critical care unit by means of serial hematocrit values and vital signs. Progressive deterioration may indicate the need for operative management.

What is the major hemodynamic consequence of a massive pulmonary embolus? a. Increased systemic vascular resistance leading to left heart failure b. Pulmonary hypertension leading to right heart failure c. Portal vein blockage leading to ascites d. Embolism to the internal carotids leading to a stroke

ANS: B The major hemodynamic consequence of a pulmonary embolus is the development of pulmonary hypertension, which is part of the effect of a mechanical obstruction when more than 50% of the vascular bed is occluded. In addition, the mediators released at the injury site and the development of hypoxia cause pulmonary vasoconstriction, which further exacerbates pulmonary hypertension.

A trauma victim has sustained right rib fractures and pulmonary contusions. Auscultation reveals decreased breath sounds on the right side. Bulging intercostal muscles are noted on the right side. Heart rate (HR) is 130 beats/min, respiratory rate (RR) is 32 breaths/min, and breathing is labored. In addition to oxygen administration, what procedure should the nurse anticipate? a. Thoracentesis b. Chest tube insertion c. Pericardiocentesis d. Emergent intubation

ANS: B The patient is experiencing a pneumothorax and will need immediate chest tube insertion. Chest tubes are inserted into the pleural space to remove fluid or air, reinstate the negative intrapleural pressure, and re-expand a collapsed lung.

A patient is admitted with a blunt cardiac injury (BCI) with no evidence of rupture. The nursing management plan should include which intervention? a. Administer nitroglycerine for chest pain as needed. b. Monitor the patient for new onset dysrhythmias. c. Monitor serial biomarkers for evidence of further damage. d. Do not administer antidysrhythmic medications, as they are ineffective.

ANS: B The patient should be monitored for new onset of dysrhythmias. The patient may complain of chest pain that is similar to anginal pain, but it is not typically relieved with nitroglycerin. Chest pain is usually caused by associated injuries. Use of biomarkers, such as troponin, offers very little diagnostic help for blunt cardiac injury (BCI). Medical management is aimed at preventing and treating complications. This approach includes hemodynamic monitoring in a critical care unit and possible administration of antidysrhythmic medications.

The organ procurement organization coordinator writes orders to initiate standard donor care. Which interventions are parts of standard donor care? (Select all that apply.) a.Continue administration of osmotic agents and diuretics. b.Maintain head of bed at 30 to 40 degrees elevation. c.Continue routine pulmonary suctioning and side-to-side body positioning. d.Warming blanket to maintain body temperature above 36.5° C. e.Maintain mean arterial pressure less than 70 mm Hg.

ANS: B, C, D Standard donor care includes: maintain head of bed at 30 to 40 degrees elevation, continue routine pulmonary suctioning and side-to-side body positioning, and warming blanket to maintain body temperature above 36.5° C. Osmotic agents and diuretics should be discontinued. Mean arterial pressure should be maintained above 70 mm Hg.

The nurse is caring for a patient with respiratory failure. The nurse notes the patient's diaphragmatic excursing is 8 cm. What coexisting conditions could account for this finding? a. Asthma and emphysema b. Hepatomegaly and ascites c. Atelectasis and pleural effusion d. Pneumonia and pneumothorax

ANS: C Normal diaphragmatic excursion is 3 to 5 cm and is part of the percussion component of the physical examination. Diaphragmatic excursion is increased in pleural effusion, and disorders that elevate the diaphragm, such as atelectasis or paralysis. Diaphragmatic excursion is decreased in disorders such as ascites, pregnancy, hepatomegaly, and emphysema.

Which finding confirms the diagnosis of a pulmonary embolism (PE)? a. Low-probability ventilation-perfusion (V/Q) scan b. Negative pulmonary angiogram c. High-probability V/Q scan d. Absence of vascular markings on the chest radiograph

ANS: C A definitive diagnosis of a pulmonary embolism requires confirmation by a high-probability ventilation-perfusion (V/Q) scan, an abnormal pulmonary angiogram or computed tomography scan, or strong clinical suspicion coupled with abnormal findings on lower extremity deep venous thrombosis studies.

What is the medical treatment for a pneumothorax greater than 15%? a. Systemic antibiotics to treat the inflammatory response b. An occlusive dressing to equalize lung pressures c. Interventions to evacuate the air from the pleural space d. Mechanical ventilation to assist with re-expansion of the collapsed lung

ANS: C A pneumothorax greater than 15% requires intervention to evacuate the air from the pleural space and facilitate re-expansion of the collapsed lung. Interventions include aspiration of the air with a needle and placement of a small-bore (12 to 20 Fr) or large-bore (24 to 40 Fr) chest tube.

A patient was admitted in acute lung failure. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. Which test would the nurse expect the practitioner to order to identify the infectious pathogen? a. CBC with differential b. Wound culture of surgical site c. Sputum Gram stain and culture d. Urine specimen

ANS: C A sputum Gram stain and culture are done to facilitate the identification of the infectious pathogen. In 50% of cases, though, a causative agent is not identified. A diagnostic bronchoscopy may be needed, particularly if the diagnosis is unclear or current therapy is not working. In addition, a complete blood count (CBC) with differential, chemistry panel, blood cultures, and arterial blood gas analysis is obtained.

21. A patient has developed septic shock. The nurse knows that the clinical manifestations of ischemic hepatitis show up 1 to 2 days after the insult. Which finding would the nurse expect to note to support this diagnosis? a. Elevated serum creatinine b. Decreased bilirubin c. Jaundice d. Decreased serum transaminase

ANS: C Clinical manifestations of hepatic insufficiency are evident 1 to 2 days after the insult. Jaundice and transient elevations in serum transaminase and bilirubin levels occur. Hyperbilirubinemia results from hepatocyte anoxic injury and an increased production of bilirubin from hemoglobin catabolism. PTS: 1 DIF: Cognitive Level: Applying REF: p. 832 OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

The nurse is caring for a patient with extensive burns. Which intervention should be included in the nursing management plan to prevent cross-contamination and decrease the risk of infection in the burn-injured patient? a. Gloves are the only personal protective equipment worn when changing dressings that are in direct contact of body fluids. b. Family members only have to wear a gown when visiting a patient because masks will increase anxiety in the patient. c. Changing gloves and handwashing should be done when moving from area to area on the same patient. d. Sharing of equipment between patients in the same room does not show evidence of cross-contamination.

ANS: C Cross-contamination by direct contact is a significant source of infection and a subsequent cause of sepsis. Effective handwashing technique cannot be overemphasized. Nurses must wash their hands and change gloves when moving from area to area on the same patient. For example, after changing the chest dressing, which may be contaminated with sputum from the tracheostomy, hands must be washed and gloves changed before the nurse moves to the legs. Gowns, gloves, and masks should be worn whenever contact with body fluids occurs. These garments also must be changed and hands washed before caring for a different patient. Maintaining patient-specific dressings and topical agents is recommended. Equipment such as thermometers, intravenous pumps, and stethoscopes should be designated for each patient or, when shared, should be cleaned with appropriate bactericidal cleansers between patients.

A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. What adjustment, if any, needs to be made to the fluid resuscitation plan? a. Continue as planned; everything looks good. b. IV rate should be decreased and colloids started. c. IV rate should be increased and fluid status closely watched. d. Fluids should be switched to packed red blood cells.

ANS: C Desired clinical responses to fluid resuscitation include a urinary output of 0.5 to 1 mL/kg/h; a pulse rate lower than 120 beats/min; blood pressure in normal to high ranges; a central venous pressure less than 12 cm H2O or a pulmonary artery occlusion pressure less than 18 mm Hg; clear lung sounds; clear sensorium; and the absence of intestinal events, such as nausea and paralytic ileus.

The nurse understands that certain trauma patients are at risk for developing fat embolism syndrome. Which group of patients is a high risk for this complication? a. Patients with liver trauma b. Patients with burns c. Patients with orthopedic trauma d. Patients with spleen trauma

ANS: C Fat embolism syndrome can occur as a complication of orthopedic trauma.

Which cause of hypoxemia is the result of blood passing through unventilated portions of the lungs? a. Alveolar hypoventilation b. Dead space ventilation c. Intrapulmonary shunting d. Physiologic shunting

ANS: C Hypoxemia is the result of impaired gas exchange and is the hallmark of acute respiratory failure. Hypercapnia may be present, depending on the underlying cause of the problem. The main causes of hypoxemia are alveolar hypoventilation, ventilation-perfusion (V/Q) mismatching, and intrapulmonary shunting. Intrapulmonary shunting occurs when blood passes through a portion of a lung that is not ventilated. Physiologic shunting is normal and not a cause of hypoxemia.

The nurse is working on an organization-wide falls prevention project. The nurse understands that the majority of falls accounting for traumatic injury occur in what population? a. Construction workers b. Adolescents c. Older adults d. Young adults

ANS: C Older persons experience most of the falls that result in injuries, and these falls are likely to occur from level surfaces or steps. Because many of the falls may be caused by an underlying medical condition (eg, syncope, myocardial infarction, dysrhythmias), management of an older patient who has fallen must include an evaluation of events and conditions immediately preceding the fall.

Depending on the patient's risk for the recurrence of pulmonary embolism (PE), how long may a patient remain on warfarin once they are discharged from the hospital? a. 1 to 3 months b. 3 to 6 months c. 3 to 12 months d. 12 to 36 months

ANS: C The patient should remain on warfarin for 3 to 12 months depending on his or her risk for thromboembolic disease.

A nurse is caring for a patient who was burned 2 weeks ago. The nurse knows the patient has entered the next phase of healing, which is characterized by rapid synthesis of collagen. What phase is the patient in? a. Wound phase b. Inflammatory phase c. Proliferative phase d. Maturation phase

ANS: C The proliferative phase of healing occurs approximately 4 to 20 days after injury. The key cell in this phase of healing, the fibroblast, rapidly synthesizes collagen. Collagen synthesis provides the needed strength for a healing wound. The inflammatory phase begins immediately after injury. Vascular changes and cellular activity characterize this period. Changes in the severed vessels occur in an attempt to wall off the wound from the external environment. The maturation phase, or remodeling phase, of healing occurs from approximately 20 days after injury to longer than 1 year after injury. During this period, the wound develops tensile strength as collagen deposits form scar tissue.

Which therapeutic measure would be the most effective in treating hypoxemia in the presence of intrapulmonary shunting associated with acute respiratory distress syndrome (ARDS)? a. Sedating the patient to blunt noxious stimuli b. Increasing the FiO2 on the ventilator c. Administering positive-end expiratory pressure (PEEP) d. Restricting fluids to 500 mL per shift

ANS: C The purpose of using positive-end expiratory pressure (PEEP) in a patient with acute respiratory distress syndrome is to improve oxygenation while reducing FiO2 to less toxic levels. PEEP has several positive effects on the lungs, including opening collapsed alveoli, stabilizing flooded alveoli, and increasing functional residual capacity. Thus, PEEP decreases intrapulmonary shunting and increases compliance.

A patient with multisystem trauma has been in the critical care unit for 2 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The nurse understands that immobility places the patient at risk for developing which complication? a. Pneumonia b. Infection c. Venous thromboembolism d. Fat embolism syndrome

ANS: C Trauma patients are at risk for infection because of contaminated wounds, invasive therapeutic and diagnostic catheters, intubation and mechanical ventilation, host susceptibility, and the critical care environment. Nursing management must include interventions to decrease and eliminate the trauma patient's risk of infection.

The nurse and a new graduate nurse are caring for a patient with extensive burns. They are discussing skin grafts. Which statement indicates the new graduate understood the information? a. Autografts are procured from both live and deceased donors. b. Autografts can placed at the bedside or in the operating room. c. Autografts can transmit disease and be rejected. d. Autografts provide permanent coverage and are the least expensive.

ANS: D An autograft is a skin graft harvested from a healthy, uninjured donor site on the burn patient and then placed over the patient's burn wound to provide permanent coverage of the wound. Autografts must be done in the operating room and are the least expensive. Homografts can transmit disease and be rejected.

A patient has been admitted with the diagnosis of acute respiratory distress syndrome (ARDS). Arterial blood gasses (ABGs) revealed an elevated pH and decreased PaCO2. The patient is becoming fatigued, and the practitioner orders a repeat ABG. Which set of results would be indicative of the patient's current condition? a. Elevated pH and decreased PaCO2 b. Elevated pH and elevated PaCO2 c. Decreased pH and decreased PaCO2 d. Decreased pH and elevated PaCO2

ANS: D Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen administration (refractory hypoxemia). Initially, the PaCO2 is low as a result of hyperventilation, but eventually the PaCO2 increases as the patient fatigues. The pH is high initially but decreases as respiratory acidosis develops.

A nurse and a new graduate nurse are discussing the secondary survey of the trauma patient. The nurse asks the new graduate to identify the most important aspect of a secondary survey. Which response would indicate the new graduate nurse understood the information? a. Check circulatory status. b. Check electrolyte profile. c. Insert a urinary catheter. d. Obtain patient history.

ANS: D During the secondary survey, a head-to-toe approach is used to thoroughly examine each body region. The history is one of the most important aspects of the secondary survey. Additional interventions during the resuscitation phase involve placement of urinary and gastric catheters. During resuscitation from traumatic hemorrhagic shock, normalization of standard clinical parameters such as blood pressure, heart rate, and urine output are not adequate. Circulatory status is part of the primary survey.

8. A patient with a known penicillin allergy develops anaphylactic shock after a dose of ampicillin was given in error. Which medication would the nurse administer first? a. Methylprednisolone b. Gentamicin c. Atropine d. Epinephrine

ANS: D Epinephrine is given in anaphylactic shock to promote bronchodilation and vasoconstriction and inhibit further release of biochemical mediators. PTS: 1 DIF: Cognitive Level: Applying REF: p. 814 OBJ: Nursing Process Step: Intervention TOP: Shock MSC: NCLEX: Physiologic Integrity

Rejection that occurs within hours after the transplantation and results in immediate graft failure is referred to as what type of rejection? a.Acute b.Intermediate c.Chronic d.Hyperacute

ANS: D Hyperacute rejection is a humoral-mediated response, which occurs within hours after transplantation and results in immediate graft failure. Acute rejection tends to occur weeks to months after transplantation but can occur at any time. Chronic rejection occurs at varying times after transplantation and progresses for years until it leads to ultimate failure of the transplanted organ.

Older trauma patients have a higher mortality than younger trauma patients. The nurse understands that this fact is probably related to what physiologic change? a. Deterioration of cerebral and motor skills b. Poor vision and hearing c. Diminished pain perception d. Limited physiologic reserve

ANS: D Older adults have limited ability to increase their heart rate in response to blood loss, obscuring one of the earliest signs of hypovolemia—tachycardia. Loss of physiologic reserve and the presence of preexisting medical conditions are likely to produce further conflicting hemodynamic data. An older patient's lack of physiologic reserve makes it imperative that early nutritional support is initiated.

Patients with left-sided pneumonia may benefit from placing them in which position? a. Reverse Trendelenburg b. Supine c. On the left side d. On the right side

ANS: D Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Because gravity normally facilitates preferential ventilation and perfusion to the dependent areas of the lungs, the best gas exchange would take place in the dependent areas of the lungs. Thus, the goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position.

A patient with severe traumatic brain injury has been admitted to the critical care unit. What is one intervention to minimize secondary brain injury? a. Hyperventilate the patient to keep PCO2 less than 30. b. Restrict fluids to keep central venous pressure less than 6 cm H2O. c. Maintain the patient's body temperature more than 37.5° C. d. Administer fluids to keep the systolic blood pressure greater than 90 mm Hg.

ANS: D Secondary injury can be caused by ischemia, hypercapnia, hypotension, cerebral edema, sustained hypertension, calcium toxicity, or metabolic derangements. Hypoxia or hypotension, the best-known culprits for secondary injury, typically are the result of extracranial trauma. Extreme vasodilation of the cerebral vasculature occurs in an attempt to supply oxygen to the cerebral tissue. This increase in blood volume increases intracranial volume and raises intracranial pressure.

What nursing intervention can facilitate the prevention of aspiration? a. Observing the amount given in the tube feeding b. Assessing the patient's level of consciousness c. Encouraging the patient to cough and to breathe deeply d. Positioning a patient in a semirecumbent position

ANS: D Semirecumbency has been shown to decrease the risk of aspiration and inhibit the development of hospital-associated pneumonia.

Supplemental oxygen administration is usually effective in treating hypoxemia related which situation? a. Physiologic shunting b. Dead space ventilation c. Alveolar hyperventilation d. Ventilation-perfusion mismatching

ANS: D Supplemental oxygen administration is effective in treating hypoxemia related to alveolar hypoventilation and ventilation-perfusion mismatching. When intrapulmonary shunting exists, supplemental oxygen alone is ineffective. In this situation, positive pressure is necessary to open collapsed alveoli and facilitate their participation in gas exchange. Positive pressure is delivered via invasive and noninvasive mechanical ventilation.

A nurse and a nursing student are discussing management of the trauma patient. The nurse asks the student what the AVPU method is used for during the primary survey. Which response would indicate the new graduate nurse understood the information? a. Used to assess respiratory status b. Used to assess circulatory status c. Used to assess pain status d. Used to assess level of consciousness

ANS: D The AVPU method can be used to quickly describe the patient's level of consciousness: A: alert, V: responds to verbal stimuli, P: responds to painful stimuli, and U: unresponsive

Roughly 80% of burns in children are classified as what type of burn? a. Radiation b. Chemical c. Electrical d. Thermal

ANS: D The most common type of burn is a thermal burn caused by steam, scalds, contact with heat, and fire injuries. About 80% of burns in children are caused by scalds (ie, contact with hot objects or liquids).

A patient is admitted with a massive head trauma. The patient is unresponsive and on mechanical ventilation. The electroencephalogram is negative for brain waves. The family has agreed to organ donation. How would the nurse check for the absence of cerebral motor reflexes? a.Performing a sternal rub b.Applying needle pricks to fingers and toes c.Clapping hands near the ears d.Applying pressure to the nail beds or supraorbital ridge

ANS: D These motor responses can be stimulated by the application of pressure to the nail beds or supraorbital ridge.

A patient was admitted after a left pneumonectomy. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. What action should the nurse take next? a. Lavage the airway with normal saline. b. Place the patient supine in a semi-Fowler position. c. Manually ventilate the patient. d. Suction the airway.

ANS: D When aspiration is witnessed, emergency treatment should be instituted to secure the airway and minimize pulmonary damage. The patient's head should be turned to the side, and the oral cavity and upper airway should be suctioned immediately to remove the gastric contents.

How does the patient history assist the nurse in developing the management plan? (Select all that apply.) a. Provides direction for the rest of the assessment b. Exposes key clinical manifestations. c. Aids in developing the plan of care d. The degree of the patient's distress determines the extent of the interview. e. Determines length of stay in the hospital setting.

Answer: A, B, C, D Rationale: The initial presentation of the patient determines the rapidity and direction of the interview. For a patient in acute distress, the history should be curtailed to just a few questions about the patient's chief complaint and precipitating events.

What risk factors need to be considered when preparing a patient for a thoracentesis? (Select all that apply.) a. Coagulation defects b. Unstable hemodynamics c. Pleural effusion d. Uncooperative patient e. Empyema

Answer: A, B, D Rationale: No absolute contraindications to thoracentesis exist, although some risks may contraindicate the procedure in all but emergency situations. These risk factors include unstable hemodynamics, coagulation defects, mechanical ventilation, the presence of an intraaortic balloon pump, and patients who are uncooperative. It is used most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema.

Which conditions will commonly reveal breath sounds with inspiration greater than expiration on assessment? (Select all that apply.) a. Normal lung. b. Bronchiectasis. c. Emphysema. d. Acute bronchitis. e. Diffuse pulmonary fibrosis.

Answer: A, B, D Rationale: The normal lung, bronchiectasis, and acute bronchitis will commonly present with an inspiration greater than expiration ratio. Acute bronchitis can also have inspiration that equals expiration ratio as also seen with emphysema, diffuse pulmonary fibrosis, and consolidating pneumonia. Noting that many conditions present with the same findings affirms the need for further assessment and evaluation.

Deviation of the trachea occurs in which conditions? (Select all that apply.) a. Pneumothorax. b. Pulmonary fibrosis. c. Chronic obstructive pulmonary disease. d. Emphysema e. Pleural effusion

Answer: A, B, E Rationale: Assessment of tracheal position assists in the diagnosis of pneumothorax, unilateral pneumonia, pulmonary fibrosis, and pleural effusion.

Muscles of exhalation include which of the following? (Select all that apply.) a. Abdominal. b. Diaphragm. c. External intercostals. d. Internal intercostals. e. Scalene.

Answer: A, D. Rationale: Exhalation occurs when the diaphragm relaxes and moves back up toward the lungs. The intrinsic elastic recoil of the lungs assists with exhalation. Because exhalation is a passive act, there are no true muscles of exhalation other than the internal intercostal muscles, which assist the inward movement of the ribs.

The lymphatic system plays which of the following important roles? (Select all that apply.) a. Ridding lung tissue of excess CO2. b. Connecting the thebesian veins to the coronary circulation. c. Removing fluid from the lungs. d. Producing immune responses e. Removing cell debris from the lungs.

Answer: C, D, E. Rationale: The lymphatic system in the lungs serves two purposes. As part of the immune system, it is responsible for removing foreign particles and cell debris from the lungs and for producing both antibody and cell-mediated immune responses. It also is responsible for removing fluid from the lungs and for keeping the alveoli clear.

Which range would be considered normal for pulmonary artery systolic pressures? a. 15 to 30 mm Hg b. 4 to 12 mm Hg c. 25 to 35 mm Hg d. 1 to 11 mm Hg

Answer: a. 15 to 30 mm Hg Rationale: Pulmonary artery systolic pressure ranges from 15 to 30 mm Hg, pulmonary artery diastolic pressure ranges from 4 to 12 mm Hg, and pulmonary artery mean pressure ranges from 9 to 18 mm Hg. Pulmonary hypertensions is defined as pulmonary artery systolic pressure of greater than 35 mm Hg.

A patient just involved in a motor vehicle accident has sustained blunt chest trauma as part of his injuries. The nurse notes absent breath sounds on the left side. A left-sided pneumothorax is suspected and is further validated when assessment of the trachea reveals what finding?term-26 a. A shift to the right. b. A shift to the left. c. No deviation d. Subcutaneous emphysema.

Answer: a. A shift to the right. Rationale: With a pneumothorax, the trachea shifts to the opposite side of the problem; with atelectasis, the trachea shifts to the same side as the problem. Subcutaneous emphysema is more commonly related to a pneumomediastinum and is not specifically related to the trachea but to air trapped in the mediastinum and general neck area.

Atelectasis can cause a shunt-producing ventilation-perfusion mismatch. Which pathophysiologic mechanism explains how this occurs? a. An alveolus that is receiving perfusion exceeding ventilation. b. An alveolus that is receiving ventilation exceeding perfusion. c. An alveolus that is receiving ventilation but not perfusion. d. An alveolus that is not receiving perfusion or ventilation.

Answer: a. An alveolus that is receiving perfusion exceeding ventilation. Rationale: A shunt-producing ventilation-perfusion mismatch is one in which perfusion exceeds ventilation. Whereas situations in which ventilation exceeds perfusion V/Q greater than 0.8 are considered to be dead space producing, situations in which perfusion exceeds ventilation V/Q less than 0.8 are considered to be shunt producing.

A patient presents with absent lung sounds in the left lower lung fields, moderate shortness of breath, and dyspnea. The nurse suspects pneumothorax and notifies the practitioner. Orders for a STAT chest radiography and reading are obtained. Which finding best supports the nurse's suspicions? a. Blackness in the left lower lung area. b. Whiteness in the left lower lung area. c. Blunted costophrenic angles. d. Elevated left hemidiaphragm.

Answer: a. Blackness in the left lower lung area. Rationale: With a pneumothorax, the pleural edges become evident as one looks through and between the images of the ribs on the film. A thin line appears just parallel to the chest wall, indicating where the lung markings have pulled away from the chest wall. In addition, the collapsed lung will be manifested as an area of increased density separated by an area of radiolucency (blackness).

Trauma to which vertebrae will cause ventilation dysfunction? a. C3 to C5. b. C5 to T3. c. T4 to T6. d. T7 to T10.

Answer: a. C3 to C5. Rationale: The phrenic nerve arises from the cervical plexus through the fourth cervical nerve, with secondary contributions by the third and fifth cervical nerves. For this reason and because the diaphragm does most of the work of inhalation, trauma involving levels C3 to C5 causes ventilation dysfunction.

A patient is admitted with acute lung failure secondary to pneumonia. Arterial blood gas (ABG) values on the current ventilator settings are pH, 7.37; PaCO2, 50 mm Hg; and HCO3¯, 27 mEq/L. What is the correct interpretation of the patient's ABG values? a. Compensated respiratory acidosis. b. Compensated metabolic alkalosis. c. Uncompensated respiratory alkalosis. d. Uncompensated metabolic acidosis.

Answer: a. Compensated respiratory acidosis. Rationale: The ABG values reflect a compensated respiratory acidosis. Values include a pH of 7.35 to 7.39, PaCO2 above 45 mm Hg, and HCO3¯above 26 mEq/L. Uncompensated respiratory alkalosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and HCO3¯of 22 to 26 mEq/L. Compensated metabolic alkalosis values include a pH of 7.41 to 7.45, PaCO2 above 45 mm Hg, and HCO3¯above 26 mEq/L. Uncompensated metabolic acidosis values include a pH above 7.35, PaCO2 of 35 to 45 mm Hg, and HCO3¯ below 22 mEq/L.

Which pulmonary alteration increases the work of breathing in the patient with emphysema? a. Decreased lung recoil. b. Decreased chest wall compliance. c. Increased lung compliance. d. Increased airway resistance.

Answer: a. Decreased lung recoil. Rationale: Emphysema results in destruction and enlargement of the alveoli, leading to decreased lung recoil and increased work of breathing. Emphysema results in decreased lung compliance not increased compliance. Emphysema does not affect chest wall compliance or airway resistance.

A patient has the following arterial blood gas (ABG) values: pH, 7.20; PaO2, 106 mm Hg; pCO2, 35 mm Hg; and HC03- , 11 mEq/L. What symptom would be most consistent with the ABG values? a. Diarrhea. b. Shortness of breath. c. Central cyanosis. d. Peripheral cyanosis.

Answer: a. Diarrhea. Rationale: Diarrhea is one mechanism by which the body can lose large amounts of HC03-. The other choices are indications of hypoxia, which is not indicated with a PaO2 of 106 mm Hg.

What are the primary functions of the pulmonary system? a. Gas exchange and the movement of air in and out of the lungs. b. Gas exchange and the transfer of oxygen to the tissues. c. The movement of blood in and out of the lungs and the removal of waste products. d. Gas exchange and the prevention of infections.

Answer: a. Gas exchange and the movement of air in and out of the lungs. Rationale: The primary functions of the pulmonary system are ventilation and respiration. Ventilation is the movement of air in and out of the lungs. Respiration is the process of gas exchange, that is, the movement of oxygen from the atmosphere into the bloodstream and the movement of carbon dioxide from the bloodstream into the atmosphere.

The nurse performs inspection of the oral cavity as part of a focused pulmonary assessment to check for evidence of what condition? a. Hypoxia b. Dyspnea c. Dehydration d. Malnutrition

Answer: a. Hypoxia Rationale: Severe hypoxia will be manifested by central cyanosis, which is evident in the oral and circumoral areas. Although dehydration and nutritional status can both be partially assessed by oral cavity inspection, this information is not as vital as determining hypoxia. Dyspnea means difficulty breathing.

Normally, the central chemoreceptors responsible for triggering ventilation changes respond to which of the following? a. Increased PaCO2. b. Increased HCO3¯. c. Decreased PaO2. d. Increased PaO2.

Answer: a. Increased PaCO2. Rationale: Ventilation increases when the hydrogen ion concentration increases and decreases when the hydrogen ion concentration decreases. An increase in the partial pressure of carbon dioxide (PaCO2) causes the movement of carbon dioxide across the blood-brain barrier into the cerebrospinal fluid, stimulating the movement of hydrogen ions into the brain's extracellular fluid. Peripheral chemoreceptors respond to changes in PaO2 levels.

The nurse is performing a pulmonary assessment on a patient with a pleural effusion. Which finding is unexpected? a. Increased diaphragmatic excursion. b. Decreased tactile fremitus. c. Dull percussion tones. d. Pleural friction rub.

Answer: a. Increased diaphragmatic excursion. Rationale: Assessment findings associated with pleural effusion include dullness on percussion, decreased tactile fremitus, pleural friction rub, and decreased diaphragmatic excursion. Increased diaphragmatic excursion is not associated with acute bronchitis.

On admission, a patient presents with a respiratory rate of 28 breaths/min, heart rate of 108 beats/min in sinus tachycardia, and a blood pressure of 140/72 mm Hg. The patient's arterial blood gas (ABG) values on room air are PaO2, 60 mm Hg; pH, 7.32; PaCO2, 45 mm Hg; and HC03- , 26 mEq/L. What action should the nurse anticipate for this patient? a. Initiate oxygen therapy. b. Prepare for emergency intubation. c. Administer 1 ampule of sodium bicarbonate. d. Initiate capnography.

Answer: a. Initiate oxygen therapy. Rationale: The patient is hypoxemic and oxygen therapy should be initiated at this time. The patient's arterial blood gas (ABG) values do not warrant intubation at this time. Sodium bicarbonate is not indicated because this patient has a normal bicarbonate level. Capnography would not be indicated at this time as the patient's CO2 is normal. A repeat ABG may be ordered to assess the patient's ongoing respiratory status.

When assessing a patient, the use of observation is referred to as what technique? a. Inspection b. Palpation c. Percussion d. Auscultation

Answer: a. Inspection Rationale: Inspection is the process of looking intently at the patient. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

In what condition are bronchophony, egophony, and whispering pectoriloquy increased? a. Pneumonia with consolidation b. Pneumothorax c. Asthma d. Bronchiectasis

Answer: a. Pneumonia with consolidation Rationale: Voice sounds are increased in pneumonia with consolidation because there is increased vibration through material. Bronchophony and whispering pectoriloquy are heard as clear transmission of sounds on auscultation; egophony is heard as an "a" sound when the patient is saying "e."

Ventilation-perfusion (V/Q) scans are ordered to evaluate the possibility of which of the following? a. Pulmonary emboli. b. Acute myocardial infarction. c. Emphysema. d. Acute respiratory distress syndrome.

Answer: a. Pulmonary emboli. Rationale: This test is ordered for the evaluation of pulmonary emboli. Electrocardiography or cardiac enzymes are ordered to evaluate for myocardial infarction; arterial blood gas analysis, chest radiography, and pulmonary function tests are ordered to evaluate for emphysema. Chest radiography and hemodynamic monitoring are ordered for evaluation of acute respiratory distress syndrome.

Severe coughing and shortness of breath during a thoracentesis are indicative of what complication? a. Re-expansion pulmonary edema b. Pleural infection c. Pneumothorax d. Hemothorax

Answer: a. Re-expansion pulmonary edema. Rationale: Re-expansion pulmonary edema can occur when a large amount of effusion fluid (~1000 to 1500 mL) is removed from the pleural space. Removal of the fluid increases the negative intrapleural pressure, which can lead to edema when the lung does not re-expand to fill the space. The patient experiences severe coughing and shortness of breath. The onset of these symptoms is an indication to discontinue the thoracentesis.

A patient is admitted with diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetric chest movement. These findings are indicative of which disorder? a. Tension pneumothorax b. Pneumonia c. Pulmonary fibrosis d. Atelectasis

Answer: a. Tension pneumothorax Rationale: Diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetric chest movement are indicative of tension pneumothorax.

What is the most important function of type I alveolar epithelial cells? a. They comprise 90% of total alveolar surface in the lungs for gas exchange. b. The ability to produce, store, and secrete pulmonary surfactant. c. The ability to trap foreign particles for auto digestion. d. The maintenance, repair, and restoration of the mucociliary escalator.

Answer: a. They comprise 90% of total alveolar surface in the lungs for gas exchange. Rationale: Type I alveolar epithelial cells comprise approximately 90% of the total alveolar surface within the lungs. The most important function of the type II cells is their ability to produce, store, and secrete pulmonary surfactant.

What is the movement of air into and out of the lungs termed? a. Ventilation b. Respiration c. Diffusion d. Perfusion

Answer: a. Ventilation Rationale: Ventilation is the movement of air into and out of the lungs and is distinct from respiration, which refers to gas exchange, not movement by air. Respiration is the process of gas exchange by means of movement of oxygen from the atmosphere into the bloodstream and movement of carbon dioxide from the bloodstream into the atmosphere. Diffusion moves molecules from an area of high concentration to an area of low concentration. The distribution of perfusion through the lungs is related to gravity and intra-alveolar pressures.

Place the steps for analyzing arterial blood gases in the proper order. 1. Assess HCO3¯ level for metabolic abnormalities. 2. Assess PaO2 for hypoxemia. 3. Examine PaCO2 for acidosis or alkalosis. 4. Re-examine pH to determine level of compensation. 5. Examine pH for acidemia or alkalemia. a. 5, 1, 2, 4, 3 b. 2, 5, 3, 1, 4 c. 1, 2, 4, 3, 5 d. 1, 3, 4, 5, 2

Answer: b. 2, 5, 3, 1, 4 Rationale: A methodic approach when assessing arterial blood gases allows the nurse to detect subtle changes. A methodic approach includes look at the PaO2 level, look at the pH level, look at the PaCO2 level, look at the HCO3¯, and look again at the pH level.

Which patient would be considered hypoxemic? a. A 70-year-old man with a PaO2 of 72. b. A 50-year-old woman with a PaO2 of 65. c. An 84-year-old man with a PaO2 of 96. d. A 68-year-old woman with a PaO2 of 80.

Answer: b. A 50-year-old woman with a PaO2 of 65. Rationale: Normal PaO2 is 80 to 100 mm Hg in persons younger than 60 years. The formula for determining PaO2 for a person older than 60 years of age is 80 mm Hg minus 1 mm Hg for every year of age above 60 years of age, for example, 70 years old = 80 mm Hg - 10 mm Hg = 70 mm Hg; 84 years old = 80 mm Hg - 20 mm Hg = 60 mm Hg; and 68 years old = 80 mm Hg - 8 mm Hg = 72 mm Hg.

A patient's pulse oximeter alarm goes off. The monitor reads 82%. What is the first action the nurse should perform? a. Prepare to intubate. b. Assess the patient's condition. c. Turn off the alarm and reapply the oximeter sensor. d. Increase O2 level to 4L/NC.

Answer: b. Assess the patient's condition. Rationale: The first nursing action would be to assess the patient to see if there is a change in his or her condition. If the patient is stable, then the nurse would turn off the alarm and reapply the oximeter sensor. The pulse oximeter cannot differentiate between normal and abnormal hemoglobin. Elevated levels of abnormal hemoglobin falsely elevate the SpO2. The ability of a pulse oximeter to detect hypoventilation is accurate only when the patient is breathing room air. Because most critically ill patients require some form of oxygen therapy, pulse oximetry is not a reliable method of detecting hypercapnia and should not be used for this purpose.

Which statement describes the relationship between the pulmonary circulation and the pulmonary vascular bed? a. The pulmonary circulation is a high-pressure system with normal pressures averaging 100/60 to 120/70 mm Hg. b. Because of the low pulmonary arterial pressures, the right ventricular wall thickness needs to be only one-third that of the left ventricle. c. Pulmonary hypertension is defined as increased pulmonary artery systolic pressure above 20 mm Hg. d. The most common cause of pulmonary hypertension is right-sided heart failure.

Answer: b. Because of the low pulmonary arterial pressures, the right ventricular wall thickness needs to be only one-third that of the left ventricle. Rationale: Because of low pulmonary artery pressures, right ventricular wall thickness needs to be only approximately one-third of left ventricular wall thickness. Pulmonary hypertension is defined as increased pressure (pulmonary artery systolic greater than 35 mm Hg and pulmonary artery mean less than 25 mm Hg at rest or less than 30 mm Hg with exertion) within the pulmonary arterial system. Pulmonary hypertension increases the afterload of the right ventricle and, when chronic, can result in right ventricular hypertrophy (cor pulmonale) and failure.

The nurse is performing a pulmonary assessment on a patient with acute bronchitis. Which finding is unexpected? a. Rasping productive cough. b. Decreased tactile fremitus. c. Resonant percussion tones. d. Crackles and wheezes.

Answer: b. Decreased tactile fremitus. Rationale: Assessment findings associated with acute bronchitis include rasping productive cough, resonance on percussion, crackles and wheezes, and normal to increased tactile fremitus. Decreased tactile fremitus is not associated with acute bronchitis.

A patient with chronic obstructive pulmonary disease (COPD) requires intubation. After the practitioner intubates the patient, the nurse auscultates for breath sounds. Breath sounds are questionable in this patient. Which action would best assist in determining endotracheal tube placement in this patient? a. Stat chest radiographic examination. b. End-tidal CO2 monitor. c. Ventilation-perfusion (V/Q) scan. d. Pulmonary artery catheter insertion.

Answer: b. End-tidal CO2 monitor. Rationale: Although a stat chest radiography examination would be helpful, it has a long turnaround time, and the patient's respiratory status can deteriorate quickly. An end-tidal CO2 monitor gives an immediate response, and the tube can then be reinserted without delay if incorrectly placed. The other tests are not for endotracheal tube placement.

A patient is admitted with acute lung failure secondary to emphysema. Percussion of the lung fields will predictably exhibit which tone? a. Resonance b. Hyperresonance c. Tympany d. Dullness

Answer: b. Hyperresonance Rationale: The percussion tone of hyperresonance is heard with emphysema related to overinflation of the lung. Resonance can be found in normal lungs or with the diagnosis of bronchitis. Tympany occurs with the diagnosis of large pneumothorax and emphysematous blebs. Dullness occurs with the diagnosis of atelectasis, pleural effusion, pulmonary edema, pneumonia, and a lung mass.

Which factor will result in a shift of the oxyhemoglobin dissociation curve to the left? a. Increased PaCO2. b. Increased pH. c. Increased temperature. d. Increased 2,3-DPG.

Answer: b. Increased pH. Rationale: Factors shifting the curve to the left are increased pH, decreased PaCO2, decreased temperature, and decreased 2,3-DPG.

A bronchoscopy is indicated for a patient with what condition? a. Pulmonary edema. b. Ineffective clearance of secretions. c. Upper gastrointestinal bleed. d. Instillation of surfactant.

Answer: b. Ineffective clearance of secretions. Rationale: Bronchoscopy visualizes the bronchial tree. If secretions are present, they can be removed by suctioning and sent for culture to help adjust antibiotic therapy.

When assessing a patient, the use of touch to judge the character of the body surface and underlying organs is known as what technique? a. Inspection b. Palpation c. Percussion d. Auscultation

Answer: b. Palpation Rationale: Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

Which nerve stimulates movement of the diaphragm? a. Musculocutaneous nerve. b. Phrenic nerve. c. Median nerve. d. Axillary nerve.

Answer: b. Phrenic nerve. Rationale: The phrenic nerve arises from the cervical plexus through the fourth cervical nerve, with secondary contributions by the third and fifth cervical nerves. The other nerves control use and feeling of the arms.

What chest radiography finding is consistent with a left pneumothorax? a. Flattening of the diaphragm. b. Shifting of the mediastinum to the right. c. Presence of a gastric air bubble. d. Increased radiolucency of the left lung field.

Answer: b. Shifting of the mediastinum to the right. Rationale: Shifting of the mediastinal structures away from the area of involvement is a sign of a pneumothorax.

While conducting a physical assessment on a patient with chronic obstructive pulmonary disease (COPD), the nurse notes that the patient's breathing is rapid and shallow. What is this type of breathing pattern called? a. Hyperventilation. b. Tachypnea. c. Obstructive breathing. d. Bradypnea.

Answer: b. Tachypnea. Rationale: Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation. Hyperventilation is manifested by an increase in both the rate and depth of ventilation. Obstructive breathing is characterized by progressively shallower breathing until the patient actively and forcefully exhales. Bradypnea is a slow respiratory rate characterized as less than 12 breaths/min in an adult.

A patient presents with the following arterial blood gas (ABG) values: pH, 7.20; PaO2, 106 mm Hg; PaCO2, 35 mm Hg; and HC03-, 11 mEq/L. What is the interpretation of the patient's ABG? a. Uncompensated respiratory acidosis. b. Uncompensated metabolic acidosis. c. Uncompensated metabolic alkalosis. d. Uncompensated respiratory alkalosis.

Answer: b. Uncompensated metabolic acidosis. Rationale: The pH indicates acidosis, and the HC03- is markedly decreased, indicating a metabolic disorder. Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and HC03- below 22 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and HC03- of 22 to 26 mEq/L. Uncompensated respiratory alkalosis values include a pH above 7.45, PaCO2 below 35 mm Hg, and HC03- of 22 to 26 mEq/L. Uncompensated metabolic alkalosis values include a pH above 7.45, PaCO2 of 35 to 45 mm Hg, and HC03- above 26 mEq/L

The patient's arterial blood gas (ABG) values on room air are PaO2, 40 mm Hg; pH, 7.10; PaCO2, 44 mm Hg; and HC03- , 16 mEq/L. What is the interpretation of the patient's ABG? a. Uncompensated respiratory acidosis. b. Uncompensated metabolic acidosis. c. Compensated metabolic acidosis. d. Compensated respiratory acidosis.

Answer: b. Uncompensated metabolic acidosis. Rationale: The pH is below normal range (7.35 to7.45), so this is uncompensated acidosis. The PaCO2 normal and the HC03- is markedly low. This indicates uncompensated metabolic acidosis. Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and HC03- below 22 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and HC03- 22 to 26 mEq/L. Compensated metabolic acidosis values include a pH of 7.35 to 7.39, PaCO2 below 35 mm Hg, and HC03- below 22 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.35, PaCO2 above 45 mm Hg, and HC03- above 26 mEq/L.

The patient's arterial blood gas (ABG) values on room air are PaO2, 70 mm Hg; pH, 7.31; PaCO2, 52 mm Hg; and HC03-, 24 mEq/L. What is the interpretation of the patient's ABG? a. Uncompensated metabolic alkalosis. b. Uncompensated respiratory acidosis. c. Compensated respiratory acidosis. d. Compensated respiratory alkalosis.

Answer: b. Uncompensated respiratory acidosis. Rationale: The pH is closer to the acidic level, so the primary disorder is acidosis. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and HC03- of 22 to 26 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.39, PaCO2 greater than 45 mm Hg, and HC03- greater than 26 mEq/L. Compensated respiratory alkalosis values include a pH of 7.41 to 7.45, PaCO2 below 35 mm Hg, and HC03- below 22 mEq/L. Uncompensated metabolic alkalosis values include a pH above 7.45, PaCO2 of 35 to 45 mm Hg, and HC03- above 26 mEq/L.

Which V/Q ratio would most suggest intrapulmonary shunting? a. 0.8 b. 2.2 c. 0.4 d. V/Q ratios are not related to shunting.

Answer: c. 0.4 Rationale: A V/Q ratio of 4:5 or 0.8 is considered normal. A V/Q less than 0.8 is considered shunt producing, and a V/Q greater than 0.8 is considered dead space producing.

The lobes are divided into 18 segments. How many are on the right lung? a. 3 b. 8 c. 10 d. 15

Answer: c. 10 Rationale: The lobes are divided into 18 segments, each of which has its own bronchus branching immediately off a lobar bronchus. Ten segments are located in the right lung and eight in the left lung.

While palpating a patient's lungs the nurse notes fremitus over the patient's trachea but not the lung periphery. What do these findings indicate? a. Bilateral pleural effusion. b. Bronchial obstruction. c. A normal finding. d. Apical pneumothorax.

Answer: c. A normal finding. Rationale: Fremitus is described as normal, decreased, or increased. With normal fremitus, vibrations can be felt over the trachea but are barely palpable over the periphery. With decreased fremitus, there is interference with the transmission of vibrations. Examples of disorders that decrease fremitus include pleural effusion, pneumothorax, bronchial obstruction, pleural thickening, and emphysema.

What does an intrapulmonary shunting value of 35% indicate? a. Normal gas exchange of venous blood. b. An abnormal finding indicative of a shunt-producing disorder. c. A serious and potentially life-threatening condition. d. Metabolic alkalosis.

Answer: c. A serious and potentially life-threatening condition. Rationale: A shunt greater than 10% is considered abnormal and indicative of a shunt-producing disorder. A shunt greater than 30% is a serious and potentially life-threatening condition that requires pulmonary intervention.

A patient presents with chest trauma from a motor vehicle accident. Upon assessment, the nurse documents that the patient is complaining of dyspnea, shortness of breath, tachypnea, and tracheal deviation to the right. In addition, the patient's tongue is blue-gray. Based on this assessment data, what additional assessment findings would the nurse expect to find? a. Kussmaul breathing pattern. b. Absent breath sounds in the right lower lung fields. c. Absent breath sounds in the left lung fields. d. Diminished breath sounds in the right upper lung fields.

Answer: c. Absent breath sounds in the left lung fields. Rationale: The clinical picture described is most consistent with left pneumothorax. This would cause the trachea to deviate to the right, away from the increasing pressure of the left. A pneumothorax this severe would completely collapse the left lung, thus causing absent breath sounds in that lung. The right lung fields would not be affected. Kussmaul breathing pattern is rapid, deep and labored.

A patient in diabetic ketoacidosis would exhibit what alteration to the pulmonary system? a. Breathe faster to increase pH. b. Breathe slower to increase pH. c. Breathe faster to decrease pH. d. Breathe slower to decrease pH.

Answer: c. Breathe faster to decrease pH. Rationale: Breathing faster increases the expiration of CO2, which results in less acid in the bloodstream and a decreased pH.

What medication may be included in the preprocedural medications for a diagnostic bronchoscopy? a. Aspirin for anticoagulation. b. Vecuronium to inhibit breathing. c. Codeine to decrease the cough reflex. d. Cimetidine to decrease hydrochloric acid secretion.

Answer: c. Codeine to decrease the cough reflex. Rationale: Preprocedural medications for a diagnostic bronchoscopy may include atropine and intramuscular codeine. Whereas atropine lessens the vasovagal response and reduces the secretions, codeine decreases the cough reflex. When a bronchoscopy is performed therapeutically to remove secretions, decreased cough and gag reflexes are present, which may impair secretion clearance.

A patient is admitted in respiratory distress secondary to pneumonia. The nurse knows that obtaining a history is very important. What is the appropriate intervention at this time for obtaining this data? a. Collect an overview of past medical history, present history, and current health status. b. Do not obtain any history at this time. c. Curtail the history to just a few questions about the patient's chief complaint and precipitating events. d. Complete the history and then provide measures to assist the patient to breathe easier.

Answer: c. Curtail the history to just a few questions about the patient's chief complaint and precipitating events. Rationale: The initial presentation of the patient determines the rapidity and direction for the interview. For a patient in acute distress, the history should be curtailed to just a few questions about the patient's chief complaint and the precipitating events.

A patient is intubated, and sputum for culture and sensitivity is ordered. Which of the following is important for obtaining the best specimen? a. After the specimen is in the container, dilute thick secretions with sterile water. b. Apply suction when the catheter is advanced to obtain secretions from within the endotracheal tube. c. Do not apply suction while the catheter is being withdrawn because this can contaminate the sample with sputum left in the endotracheal tube. d. Do not clear the endotracheal tube of all local secretions before obtaining the specimen.

Answer: c. Do not apply suction while the catheter is being withdrawn because this can contaminate the sample with sputum left in the endotracheal tube. Rationale: To prevent contamination of secretions in the upper portion of the endotracheal tube, do not apply suction while the catheter is being withdrawn. Clear the endotracheal or tracheostomy tube for all local secretions, avoiding deep airway penetration. This will prevent contamination with upper airway flora. Do not dilute thick secretions with sterile water. This will compromise the specimen.

Based on the oxyhemoglobin dissociation curve, respiratory acidosis will have which effect? a. A shifting of the curve to the left. b. Increased oxygen saturation. c. Enhanced oxygen delivery at the tissue level. d. Hypothermia.

Answer: c. Enhanced oxygen delivery at the tissue level. Rationale: When the curve is shifted to the right, as occurs in acidosis, although the saturation is lower than expected, a right shift enhances oxygen delivery at the tissue level because hemoglobin unloads more readily.

Which physiologic mechanism is a passive event in a spontaneously breathing patient? a. Coughing b. Inhalation c. Exhalation d. Yawning

Answer: c. Exhalation Rationale: Inhalation involves the contraction of the diaphragm, an active event, as do yawning and coughing. Exhalation in the healthy lung is a passive event requiring very little energy.

The nurse is performing a pulmonary assessment on a patient with pulmonary fibrosis. Which finding is unexpected? a. Diminished thoracic expansion. b. Tracheal deviation to the most affected side. c. Hyperresonant percussion tones. d. Decreased breath sounds.

Answer: c. Hyperresonant percussion tones. Rationale: Assessment findings associated with pulmonary fibrosis include diminished thoracic expansion, tracheal deviation to the most affected side, decreased or absent breath sounds, and resonance or dullness on percussion. Hyperresonance is not an expected finding in pulmonary fibrosis.

A patient is admitted with community-associated pneumonia. Respirations are 32 breaths/min. Temperature is 102° F (38.6° C). Based on the readings the nurse would expect the oxyhemoglobin dissociation curve to shift. What other factors would cause the curve to shift in the same direction? a. Decreased 2,3-DPG b. Increased pH c. Increased CO2 d. Increased O2

Answer: c. Increased CO2 Rationale: The oxyhemoglobin dissociation curve will shift to the right as a result of the patient's temperature. Other factors that cause the curve to shift to the right are decreased pH, increased CO2, and increased 2,3-DPG. Increased O2 will not shift the curve either right or left.

A patient is admitted with an exacerbation of chronic obstructive pulmonary disease (COPD). The nurses notes that the patient has difficulty getting breath out. Which phrase best describes the patient's breathing pattern? a. Deep sighing breaths without pauses. b. Rapid, shallow breaths. c. Normal breathing pattern interspersed with forced expirations. d. Irregular breathing pattern with both deep and shallow breaths.

Answer: c. Normal breathing pattern interspersed with forced expirations. Rationale: Difficulty getting breath out is indicative of air trapping. Air trapping is described as a normal breathing pattern interspersed with forced expirations. As the patient breathes, air becomes trapped in the lungs, and ventilations become progressively shallower until the patient actively and forcefully exhales.

What assessment technique uses the creation of sound waves across the body surface to determine abnormal densities? a. Inspection b. Palpation c. Percussion d. Auscultation

Answer: c. Percussion Rationale: Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

A patient is admitted with acute lung failure secondary to chronic obstructive pulmonary disease (COPD). Upon inspection of the patient, the nurse observes that the patient's fingers appear discolored. What does this finding indicate the presence of? a. Clubbing. b. Central cyanosis. c. Peripheral cyanosis d. Chronic tuberculosis.

Answer: c. Peripheral cyanosis Rationale: Discoloration of the fingers is an indication of peripheral cyanosis. Central cyanosis occurs when the unsaturated hemoglobin of arterial blood exceeds 5 g/dL and is considered a life-threatening situation. Clubbing refers to an abnormality of the fingers caused by chronically low blood levels of oxygen often related to a heart or lung disease.

Which statement best describes the left bronchus? a. The left bronchus has a slight angle of 20 to 30 degrees from the midline. b. The two mainstem bronchi are structurally and functionally similar. c. The left bronchus is slightly narrower. d. The bronchi are the end units of the bronchial tree.

Answer: c. The left bronchus is slightly narrower. Rationale: The two mainstem bronchi are structurally different. The right bronchus is wider and angles at 20 to 30 degrees from the midline. The right mainstem bronchus is the most common site of aspiration of foreign objects. The left bronchus is slightly narrower than the right, and because of its position above the heart, the left bronchus angles directly toward the left lung at approximately 45 to 55 degrees from the midline.

The nurse is observing a new graduate listen to a patient's lungs. Which action by the new graduate indicates a need to review auscultation skills? a. The nurse starts at the apices and moves to the bases. b. The nurse compares breath sounds from side to side. c. The nurse listens during inspiration. d. The nurse listens posteriorly, laterally, and anteriorly.

Answer: c. The nurse listens during inspiration. Rationale: Breath sounds are assessed during both inspiration and expiration. Auscultation is done in a systematic sequence: side-to-side, top-to-bottom, posteriorly, laterally, and anteriorly.

Patients who have aspiration pneumonitis often present with right lower lobe involvement more than left lower lobe involvement. Why does this occur? a. The left mainstem bronchus angles down more than the right. b. More people are right-side dominant. c. The right mainstem bronchus angles down more than the left. d. The right mainstem bronchus is narrower than the left.

Answer: c. The right mainstem bronchus angles down more than the left. Rationale: The right bronchus is wider than the left and angles at 20 to 30 degrees from the midline. Because of this angulation and the forces of gravity, the most common site of aspiration of foreign objects is through the right mainstem bronchus into the lower lobe of the right lung.

What anatomic regions are considered physiologic dead space? a. Respiratory bronchiole and unperfused alveoli. b. Trachea and perfused alveoli. c. Trachea and unperfused alveoli. d. Trachea and mainstem bronchi.

Answer: c. Trachea and unperfused alveoli. Rationale: Respiratory bronchioles participate in gas exchange. The areas in the lungs that are ventilated but in which no gas exchange occurs are known as dead space regions (trachea and mainstem bronchi). These unperfused alveoli are known as alveolar dead space. Anatomic dead space plus alveolar dead space is called physiologic dead space.

Oxygen saturation of left atrial blood is normally between 96% and 99%. What is the explanation for less than 100% saturation? a. As blood passes to the alveolar-capillary membrane, a predicted percentage of hemoglobin will not bind with oxygen. b. During normal respiration, the majority of alveoli are not expanded. c. Venous blood from the bronchial circulation is returned to the left atrium. d. A small amount of blood leaks from the right atrium to the left atrium with each ventricular contraction.

Answer: c. Venous blood from the bronchial circulation is returned to the left atrium. Rationale: Venous blood from the bronchial circulation returns directly into the left atrium. The mixing of venous blood decreases the saturation of left atrial blood to a range between 96% and 99%.

Which arterial blood gas (ABG) values represent uncompensated metabolic acidosis? a. pH, 7.29; PaCO2, 57 mm Hg; HCO3¯, 22 mEq/L. b. pH, 7.36; PaCO2, 33 mm Hg; HCO3¯ , 18 mEq/L. c. pH, 7.22; PaCO2, 42 mm Hg; , HCO3¯, 18 mEq/L. d. pH, 7.52; PaCO2, 38 mm Hg; HCO3¯, 29 mEq/L.

Answer: c. pH, 7.22; PaCO2, 42 mm Hg; , HCO3¯, 18 mEq/L. Rationale: A pH of 7.22 is below normal, reflecting acidosis. The metabolic component (HCO3¯) is low, indicating that the acidosis is metabolic in origin. Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and HCO3¯ below 22 mEq/L.

How much of the basal oxygen consumption is required by the pulmonary system during normal quiet breathing? a. 10% to 20% b. 5% to 10% c. 3% to 5% d. 1% to 2%

Answer: d. 1% to 2% Rationale: During normal quiet ventilation, only 1% to 2% of basal oxygen consumption is required by the pulmonary system.

What is the portion of total ventilation that participates in gas exchange termed? a. Alveolar dead space. b. Anatomic dead space. c. Physiologic dead space. d. Alveolar ventilation.

Answer: d. Alveolar ventilation. Rationale: The portion of total ventilation that participates in gas exchange is known as alveolar ventilation. The areas in the lungs that are ventilated but in which no gas exchange occurs are known as dead space regions. The conducting airways are referred to as anatomic dead space because they are ventilated but not perfused and therefore not able to participate in gas exchange. These unperfused alveoli are known as alveolar dead space. Anatomic dead space plus alveolar dead space is called physiologic dead space.

What assessment technique involves having the patient breathe in and out slowly with an open mouth? a. Inspection b. Palpation c. Percussion d. Auscultation

Answer: d. Auscultation Rationale: Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

On admission, a patient presents with a respiratory rate of 24 breaths/min, pursed-lip breathing, heart rate of 96 beats/min in sinus tachycardia, and a blood pressure of 110/68 mm Hg. The patient's arterial blood gas (ABG) values on room air are PaO2, 70 mm Hg; pH, 7.38; PaCO2, 52 mm Hg; and HC03- , 34 mEq/L. What diagnoses would be most consistent with the above arterial blood gas values? a. Acute pulmonary embolism. b. Acute myocardial infarction. c. Congestive heart failure. d. Chronic obstructive pulmonary disease.

Answer: d. Chronic obstructive pulmonary disease. Rationale: The fact that the HC03- level has increased enough to compensate for the increased pCO2 level indicates that this is not an acute condition because the kidneys can take several days to adjust. The other choices would present with a lower HC03- level. The values indicate respiratory acidosis, and one of the potential causes is chronic obstructive pulmonary disease. Potential causes for respiratory alkalosis are pulmonary embolism, acute myocardial infarction, and congestive heart failure.

If a patient sustained an injury to the apneustic center in the lower pons area, in which area should the nurse most expect the patient to exhibit problems? a. Respiratory rate. b. Triggering exhalation. c. Respiratory rhythm. d. Depth of respiration.

Answer: d. Depth of respiration. Rationale: The apneustic center in the lower pons is thought to work with the pneumotaxic center to regulate the depth of inspiration. The pneumotaxic center in the pons is responsible for limiting inhalation and triggering exhalation. This response also facilitates control of the rate and pattern of respiration. The ventral respiratory group, located in the medulla, is responsible for inspiration and expiration during periods of increased ventilation.

In a patient who is hemodynamically stable, which procedure can be used to estimate the PaCO2 levels? a. PaO2/FiO2 ratio. b. A-a gradient. c. Residual volume (RV). d. End-tidal CO2.

Answer: d. End-tidal CO2. Rationale: Capnography is the measurement of exhaled carbon dioxide (CO2) gas; it is also known as end-tidal CO2 monitoring. Normally, alveolar and arterial CO2 concentrations are equal in the presence of normal ventilation-perfusion (V/Q) relationships. In a patient who is hemodynamically stable, the end-tidal CO2 (PetCO2) can be used to estimate the PaCO2. Normally, the PaO2/FiO2 ratio is greater than 286; the lower the value, the worse the lung function. The A-a gradient is normally less than 20 mm Hg on room air for patients younger than 61 years. This estimate of intrapulmonary shunting is the least reliable clinically, but it is used often in clinical decision making. Residual volume is the amount of air left in the lung after maximal exhalation. A normal value is 1200 to 1300 mL.

Which lung sounds would be most likely heard in a patient experiencing an asthma attack? a. Coarse rales. b. Pleural friction rub. c. Fine crackles. d. Expiratory wheezes.

Answer: d. Expiratory wheezes. Rationale: Wheezes are high-pitched, squeaking, whistling sounds produced by airflow through narrowed small airways. They are heard mainly on expiration but may also be heard throughout the ventilatory cycle. Depending on their severity, wheezes can be further classified as mild, moderate, or severe. Rales are crackling sounds produced by fluid in the small airways or alveoli or by the snapping open of collapsed airways during inspiration. A pleural friction rub is a dry, coarse sound produced by irritated pleural surfaces rubbing together and is caused by inflammation of the pleura.

Which blood gas parameter is the acid-base component that reflects kidney function? a. pH b. PaO2 c. PaCO2 d. HCO3¯

Answer: d. HCO3¯ Rationale: The bicarbonate (HC03- ) is the acid-base component that reflects kidney function. The bicarbonate is reduced or increased in the plasma by renal mechanisms. The normal range is 22 to 26 mEq/L. pH measures the hydrogen ion concentration of plasma. PaO2 measures partial pressure of oxygen dissolved in arterial blood plasma. PaCO2 measures the partial pressure of carbon dioxide dissolved in arterial blood plasma.

Determination of oxygenation status by oxygen saturation alone is inadequate. What other value must be known? a. pH b. PaCO2 c. HCO3¯ d. Hemoglobin (Hgb)

Answer: d. Hemoglobin (Hgb) Rationale: Proper evaluation of the oxygen saturation level is vital. For example, an SaO2 of 97% means that 97% of the available hemoglobin is bound with oxygen. The word available is essential to evaluating the SaO2 level because the hemoglobin level is not always within normal limits and oxygen can bind only with what is available.

Which physiologic alteration will stimulate the central chemoreceptors? a. Decreased PaO2. b. Increased PaO2. c. Decreased SaO2. d. Increased PaCO2.

Answer: d. Increased PaCO2. Rationale: The central chemoreceptors respond to changes in the hydrogen ion concentration of that fluid. Ventilation is increased when the hydrogen ion concentration increases, as evidenced by a rise in the plasma arterial PaCO2.

A patient is admitted with an acute exacerbation of asthma. Respirations are 28 breaths/min. Blood gases reveal an uncompensated respiratory acidosis. The patient's work effort for breathing is increased due to which pathophysiologic mechanism? a. Increased lung compliance. b. Decreased lung recoil. c. Increased chest wall compliance. d. Increased airway resistance.

Answer: d. Increased airway resistance. Rationale: Pulmonary diseases that decrease lung compliance (eg, atelectasis, pulmonary edema), decrease chest wall compliance (eg, kyphoscoliosis), increase airway resistance (eg, bronchitis, asthma), or decrease lung recoil (eg, emphysema) can increase the work of breathing so much that one-third or more of the total body energy is used for ventilation.

At what anatomic site does the trachea divide into the right and left mainstem bronchi? a. Posterior larynx b. Cricoid cartilage c. Epiglottis d. Major carina

Answer: d. Major carina Rationale: The trachea is a hollow tube approximately 11 cm in length and 2.5 cm in diameter. It begins at the cricoid cartilage and ends at the bifurcation (the major carina) from which the two mainstem bronchi arise.

A patient is admitted with acute respiratory failure secondary to pneumonia. Upon auscultation, the nurse hears creaking, leathery, coarse breath sounds in the lower anterolateral chest area during inspiration and expiration. This finding is indicative of what condition? a. Emphysema. b. Atelectasis. c. Pulmonary fibrosis. d. Pleural effusion.

Answer: d. Pleural effusion. Rationale: A pleural friction rub is the result of irritated pleural surfaces rubbing together and is characterized by a leathery, dry, loud, coarse sound. A pleural friction rub is seen with pleural effusions or pleurisy and is not indicative of emphysema, atelectasis, or pulmonary fibrosis.

Which condition is an example of a disorder with increased tactile fremitus? a. Emphysema b. Pleural effusion c. Pneumothorax d. Pneumonia

Answer: d. Pneumonia Rationale: Examples of disorders that increase tactile fremitus include pneumonia, lung cancer, and pulmonary fibrosis. Emphysema, pleural effusion, and pneumothorax are disorders that decrease fremitus.

What is the main function of the conducting airways? a. Gas exchange. b. Cool the inhaled air. c. Remove moisture from inhaled air. d. Prevent the entry of foreign material.

Answer: d. Prevent the entry of foreign material. Rationale: The conducting airways consist of the upper airways, the trachea, and the bronchial tree. Their major functions are to warm and humidify the inhaled air, prevent the entrance of foreign matter into the gas exchange areas, and serve as a passageway for air entering and leaving the gas exchange regions of the lungs.

Which artery(s) have the lowest oxygen saturation? a. Aorta b. Subclavian c. Carotid d. Pulmonary

Answer: d. Pulmonary Rationale: The pulmonary artery delivers blood from the right ventricle to the lungs, where they receive oxygen from the alveoli. The aorta, subclavian artery, and carotid artery are all supplied from the left ventricle, where the oxygen concentration is highest.

A 75-kg patient is on a ventilator and may be ready for extubation. A respiratory therapist assesses the patient's rapid shallow breathing index (RSBI). Which result best suggests that the patient is ready for a spontaneous breathing trial? a. RSBI = 150 b. RSBI = 125 c. RSBI = 110 d. RSBI = 90

Answer: d. RSBI = 90 Rationale: The rapid, shallow breathing index (RSBI) can predict weaning success. An RSBI of less than 105 is considered predictive of weaning success. If the patient is receiving sedation, the medication is discontinued at least 1 hour before the RSBI is measured. If the patient meets criteria for weaning readiness and has an RSBI of less than 105, a spontaneous breathing trial can be performed.

What is the sequence for auscultation of the anterior chest? a. Right side, top to bottom, then left side, top to bottom. b. Left side, top to bottom, then right side, top to bottom. c. Side to side, bottom to top. d. Side to side, top to bottom.

Answer: d. Side to side, top to bottom. Rationale: Auscultation should be done in a systematic sequence: side to side, top to bottom, posteriorly, laterally, and anteriorly.

What substance do Alveolar type II cells secrete? a. Trypsin b. Chyme c. Amylase d. Surfactant

Answer: d. Surfactant Rationale: The most important function of the type II cells is their ability to produce, store, and secrete pulmonary surfactant. Trypsin and amylase are proteins used for digestion. Chyme is a semifluid mass of partly digested food that is expelled by the stomach into the duodenum.

A patient is admitted with signs and symptoms of a pulmonary embolus (PE). What diagnostic test most conclusive to determine this diagnosis? a. ABG b. Bronchoscopy c. Pulmonary function test d. V/Q scan

Answer: d. V/Q scan Rationale: A ventilation-perfusion (V/Q) scan is the most conclusive test for a pulmonary embolus. Arterial blood gas (ABG) analysis tests oxygen levels in the blood, bronchoscopy is to used view the bronchi, and pulmonary function tests are used to measure lung volume.

Which ABG values reflect compensation? a. pH, 7.26; PaCO2, 55 mm Hg; HCO3¯, 24 mEq/L. b. pH, 7.30; PaCO2, 32 mm Hg; HCO3¯, 18 mEq/L. c. pH, 7.48; PaCO2, 30 mm Hg;HCO3¯, 22 mEq/L. d. pH, 7.38; PaCO2, 58 mm Hg; HCO3¯, 30 mEq/L.

Answer: d. pH, 7.38; PaCO2, 58 mm Hg; HCO3¯, 30 mEq/L. Rationale: The pH is within normal limits, and both the PaCO2 and the values are abnormal. Compensated respiratory acidosis values include a pH of 7.35 to 7.39, PaCO2 above 45 mm Hg, and above 26 mEq/L.

A patient is admitted with a massive head trauma. The patient is unresponsive and on mechanical ventilation. The electroencephalogram (EEG) is negative for brain waves. The family has agreed to organ donation. How would this organ donor be classified? a.Brain-dead donor b.Donation after cardiac death c.Living related donor d.Living unrelated donor

ANS: A A brain-dead donor is a donor declared dead by neurologic criteria for brain death. Donation after cardiac death is when the donor is declared dead by circulatory criteria for death. A living related donor is a family member related by blood who donates a kidney, portion of the liver, pancreas, intestine, or lung to another family member. A living unrelated donor (directed or nondirected) is a living individual not related to a patient requiring a transplant who donates a kidney, portion of the liver, pancreas, intestine, or lung to that patient. The donor may be anonymous or altruistic.

A patient who has received a transplant is being taught about azathioprine. Which statement made by the patient would indicate the teaching was effective? a."I will notify my health care provider if my gums start to bleed." b."I will make sure to increase the amount of fiber in my diet." c."I realize I may have an increase in hair growth." d."I know the flulike symptoms will go away as I get used to the drug."

ANS: A A common adverse effect is the suppression of other rapidly proliferating cells, resulting in leukopenia, thrombocytopenia, and anemia. The dose of the drug is adjusted to keep the white blood cell (WBC) count between 3000 and 5000 cells/mm3, thus protecting the patient from an increased risk of infection.

2. The nurse is caring for a patient in hypovolemic shock secondary to cirrhosis of the liver. The nurse understands that this type of shock results from shifting of fluid into the abdominal cavity. What is the resulting hypovolemia called? a. Absolute hypovolemia b. Distributive hypovolemia c. Relative hypovolemia d. Compensatory hypovolemia

ANS: A Absolute hypovolemia occurs when there is a loss of fluid from the intravascular space. This can result from an external loss of fluid from the body or from internal shifting of fluid from the intravascular space to the extravascular space. Fluid shifts can result from a loss of intravascular integrity, increased capillary membrane permeability, or decreased colloidal osmotic pressure. Relative hypovolemia occurs when vasodilation produces an increase in vascular capacitance relative to circulating volume. PTS: 1 DIF: Cognitive Level: Applying REF: p. 805 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

A patient has had a kidney transplant. The nurse knows that monitoring of which parameter would have the highest priority? a.Fluid volume b.Electrolytes c.Complete blood count d.Temperature

ANS: A Adequate hydration is an absolute necessity for continued graft function in the immediate postoperative period. Hypovolemia can lead to compromised blood flow to the kidney, acute tubular necrosis, and possible graft failure. The new kidney will produce large amounts of urine, and replacement fluids, usually maintained at a ratio of 1:1 mL, must be sustained.

An unresponsive trauma patient has been admitted to the emergency department. Which statement regarding opening the airway is accurate? a. Airway assessment must incorporate cervical spine immobilization. b. Hyperextension of the neck is the only acceptable technique. c. Flexion of the neck protects the patient from further injury. d. Airway patency takes priority over cervical spine immobilization.

ANS: A Airway assessment must incorporate cervical spine immobilization. The patient's head should not be rotated, hyper-flexed, or hyperextended to establish and maintain an airway. The cervical spine must be immobilized in all trauma patients until a cervical spinal cord injury has been definitively ruled out.

The nurse is caring for a patient after a heart transplant. Which finding would the nurse anticipate after cardiac transplantation? a.Two P waves on the electrocardiogram (ECG) b.High cardiac output c.Anginal pain d.Resting heart rate of 60 to 70 beats/min

ANS: A An electrocardiogram (ECG) abnormality unique to a transplanted heart is the presence of a second P wave generated by the native sinoatrial (SA) node left in the atrial cuff. Because this impulse does not cross the suture line, it is capable of conducting only through the remnant of the native recipient atria. However, this is not seen in hearts transplanted using the bicaval technique because the native right atrium and therefore the SA node is removed.

A patient is admitted to the burn unit after a house fire. The patient sustained extensive burns to the chest, back, left arm, right arm, right upper leg, and areas on the face. The nurse is unable to obtain a palpable pulse or a Doppler pulse in the right arm. What procedure should the nurse anticipate next? a. Escharotomy b. Silver sulfadiazine application c. Splint application d. Xenograft application

ANS: A An escharotomy may be required to restore arterial circulation and to allow for further swelling. The escharotomy can be performed at the bedside with a sterile field and scalpel.

4. The nurse is caring for a patient in cardiogenic shock. The nurse recognizes that the patient's signs and symptoms are the result of what problem? a. Inability of the heart to pump blood forward b. Loss of circulating volume and subsequent decreased venous return c. Disruption of the conduction system when reentry phenomenon occurs d. Suppression of the sympathetic nervous system

ANS: A Cardiogenic shock is the result of failure of the heart to effectively pump blood forward. It can occur with dysfunction of the right or the left ventricle or both. The lack of adequate pumping function leads to decreased tissue perfusion and circulatory failure. PTS: 1 DIF: Cognitive Level: Applying REF: p. 807 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

Who determines the medical suitability of the patient for organ donation? a.The organ procurement organization (OPO) coordinator b.The patient's family c.The admitting health care provider d.The transplant team

ANS: A Determining medical suitability is solely the responsibility of the organ procurement organization (OPO). Speaking to the family about donation is also the responsibility of the OPO unless designated requestors at the hospital have been trained to do so.

A patient has sustained an epidural hematoma after a 10-foot fall from a roof. The nurse understands that an epidural hematoma is a condition that has which characteristic? a. Usually arterial in nature b. Worse mortality rate than subdural hematomas c. Associated with a permanent loss of consciousness d. Signs and symptoms include bilateral pupil dilation

ANS: A Epidural hematoma (EDH) is a collection of blood between the inner table of the skull and the outermost layer of the dura. EDHs are most often associated with skull fractures and middle meningeal artery lacerations (two thirds of patients). A blow to the head that causes a linear skull fracture on the lateral surface of the head may tear the middle meningeal artery. As the artery bleeds, it pulls the dura away from the skull, creating a pouch that expands into the intracranial space.

Identify in the correct order the five layers of the skin from the surface inward. 1. Stratum granulosum 2. Stratum corneum 3. Stratum germinativum 4. Stratum lucidum 5. Stratum spinosum a. 2, 4, 1, 5, 3 b. 2, 4, 5, 1, 3 c. 4, 2, 5, 1, 3 d. 4, 5, 1, 3, 2

ANS: A From the surface inward, its five layers are the (2) stratum corneum, (4) stratum lucidum, (1) stratum granulosum, (5) stratum spinosum, and (3) stratum germinativum.

Which nursing problem would be appropriate for a patient who has received a kidney transplant? a.Deficient fluid volume b.Excess fluid volume c.Urinary retention d.Decreased cardiac output

ANS: A Hypovolemia can lead to compromised blood flow to the kidney, acute kidney injury, and possible graft failure. The new kidney will be producing large amounts of urine, and fluid replacement, usually maintained in a 1:1 ratio, must be sustained.

10. A patient has been admitted with septic shock due to urinary sepsis. The practitioner inserts a pulmonary artery (PA) catheter. Which hemodynamic value would the nurse expect to note to support this diagnosis? a. Cardiac output (CO) of 8 L/min b. Right atrial pressure (RAP) of 17 mm Hg c. Pulmonary artery occlusion pressure (PAOP) of 23 mm Hg d. Systemic vascular resistance (SVR) of 1100 dyne/s/cm-5

ANS: A Increased cardiac output and decreased systemic vascular resistance are classic signs of septic shock. PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 821|Box 34-17 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

A nurse is preparing a patient for a liver transplant. The patient asks which stage of the procedure is the longest and most difficult. What would the nurse tell the patient? a.Stage 1—recipient hepatectomy b.Stage 2—vascular anastomoses c.Stage 3—biliary anastomosis d.Stage 4—induction therapy

ANS: A Liver transplant surgery can be divided into three stages: (1) recipient hepatectomy (the longest and most difficult part of the surgery), (2) vascular anastomoses with donor liver, and (3) biliary anastomosis. Induction therapy, which refers to the first in any series of therapeutic measures taken to treat a disease, would be administered after the transplant and is not part of the procedure.

27. A patient is admitted with a brain and spinal cord injury secondary to a motor vehicle crash. The nurse is monitoring the patient for signs of neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process? a. Loss of sympathetic nervous system innervation b. Parasympathetic nervous system stimulation c. Injury to the hypothalamus d. Focal injury to cerebral hemispheres

ANS: A Neurogenic shock can be caused by anything that disrupts the sympathetic nervous system (SNS). The problem can occur as the result of interrupted impulse transmission or blockage of sympathetic outflow from the vasomotor center in the brain. The most common cause is spinal cord injury (SCI). PTS: 1 DIF: Cognitive Level: Understanding REF: p. 815 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

A patient is brought to the emergency department with extensive burns after a house fire. What is an important nursing intervention for this patient during the resuscitation phase? a. Intravenous opiates and assessment of pulses in both arms b. Oral antiinflammatory drugs and preparation for insertion of an arterial line c. Measurement of sedimentation rate and systemic antibiotics d. Application of splints and initiation of total parenteral nutrition

ANS: A Pain management in burn injuries must be addressed early and frequently reassessed to determine the adequacy of interventions. Intravenous opiates, such as morphine sulfate, are indicated and titrated to effect. Edema formation may cause neurovascular compromise to the extremities; assessments are necessary to evaluate pulses, skin color, capillary refill, and sensation.

The nurse is caring for a patient with a pancreas transplant. Which statement made by the patient indicates the need for further teaching? a."I no longer need to monitor my blood glucose levels." b."I will need to have periodic pancreas biopsies." c."I may feel the urge to urinate frequently." d."I will give urine samples to monitor for rejection."

ANS: A Patients with functional pancreas grafts continue to need glucose monitoring at home but often forget to continue this practice after they no longer require insulin. Continued monitoring with frequent clinic visits is required for several months after pancreas transplantation.

Contracture development leading to impaired physical mobility can occur after a major burn injury. Splints are applied to prevent or correct contractures. Priority nursing interventions concerning this therapy include which action? a. Daily assessment for proper fit and effectiveness b. Removal of splints during showers and dressing changes c. Allowing for frequent breaks from splint use d. Passive and active range of motion may be used instead of splints.

ANS: A Splints can be used to prevent or correct contracture or to immobilize joints after grafting. If splints are used, they must be checked daily for proper fit and effectiveness. Splints that are used to immobilize body parts after grafting must be left on at all times, except to assess the graft site for pressure points during every shift. Splints to correct severe contracture may be off for 2 hours per shift to allow burn care and range-of-motion exercises

The Model for End-Stage Liver Disease (MELD) formula is used to calculate risk of 3-month mortality in patients 12 years old or older. What criteria is part of the MELD formula? a.Whether the patient has undergone hemodialysis at least twice in the past 2 weeks b.The number of organs in which metastasis has occurred following hepatocellular carcinoma c.The presence or absence of intractable pruritus d.The number of hours the patient is expected to live without a transplant

ANS: A The Model for End-Stage Liver Disease (MELD) formula is used in all U.S. transplant centers to calculate the risk of 3-month mortality in patients 12 years old or older. The MELD objective criteria include serum total bilirubin, serum creatinine, prothrombin time, international normalized ratio, and whether the patient has undergone hemodialysis at least twice in the past 2 weeks. Patients who have hepatocellular carcinoma that meet specific tumor criteria are automatically given a MELD score of 22 because the risk of metastasis outside the liver within 3 months is high. Once metastasis occurs, the patient is no longer deemed a transplant candidate. Intractable pruritus and number of hours to live are not part of the MELD formula.

The nurse is caring for a patient with extensive burns. Which zone of injury is the site of the most severe damage? a. Zone of coagulation b. Peripheral zone c. Zone of stasis d. Zone of hyperemia

ANS: A The central zone, or zone of coagulation, is the site of most severe damage, and the peripheral zone is the least. The central zone is usually the site of greatest heat transfer, leading to irreversible skin death.

11. A nurse is caring for a patient in septic shock due to urinary sepsis. Which pathophysiologic mechanism results in septic shock? a. Bacterial toxins lead to vasodilation. b. White blood cells are released to fight invading bacteria. c. Microorganisms invade organs such as the kidneys and heart. d. Decreased red blood cell production and fluid loss

ANS: A The syndrome encompassing severe sepsis and septic shock is a complex systemic response that is initiated when a microorganism enters the body and stimulates the inflammatory or immune system. Shed protein fragments and the release of toxins and other substances from the microorganism activate the plasma enzyme cascades (complement, kinin and kallikrein, coagulation, and fibrinolytic factors), as well as platelets, neutrophils, monocytes, and macrophages. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 817 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

Which statement would indicate that a patient who has received an organ transplant understands the teaching about immunosuppressive medications? a."My drug dosages will be lower because the medications enhance each other." b."I will be less prone to side effects because I will be taking more than one drug." c."Lower doses of these medications put me at greater risk for infection." d."Taking more than one medication will put me at risk for developing allergies."

ANS: A These "triple-drug" regimens are designed to prevent rejection while reducing the toxicity of the individual medications.

A patient is admitted after a lung transplant. The nurse knows the patient is at risk for developing pneumonia. What parameter would be a priority for the nurse to monitor? a.Oxygen saturation b.Chest tube output c.Intake and output d.Blood pressure

ANS: A These patients are at risk for developing pneumonia. Aggressive postoperative pulmonary toilet is essential to promote airway clearance because surgical denervation of the lungs diminishes the cough reflex after surgery. Thus it is important to monitor oxygen saturation levels.

The nurse is caring for a patient after a lung transplant. Which intervention would be a priority for the nurse? a.Wean the patient from the ventilator. b.Maintain hypotensive levels. c.Start corticosteroid therapy. d.Initiate pulmonary function studies.

ANS: A Ventilation settings are determined partially by the underlying disease process and patient progression. Regular suctioning of secretions is crucial to maintain airway clearance. Extubation is performed after satisfactory gas exchange and lung mechanics are accomplished, and most patients are extubated within 24 to 48 hours. Evaluation for graft dysfunction, reperfusion injury, gas trapping, and phrenic nerve injury is ongoing. Early mobilization after extubation is essential for improved pulmonary toilet and helps prevent reintubation.

MULTIPLE RESPONSE 1. A patient is being admitted with septic shock. The nurse appreciates that the key to treatment is finding the cause of the infection. Which cultures would the nurse obtain before initiating antibiotic therapy? (Select all that apply.) a. Blood cultures 2 b. Wound cultures c. Urine cultures d. Sputum cultures e. Complete blood count (CBC) with differential

ANS: A, B, C, D A key measure in the treatment of septic shock is finding and eradicating the cause of the infection. At least two blood cultures plus urine, sputum, and wound cultures should be obtained to find the location of the infection before antibiotic therapy is initiated. Antibiotic therapy should be started within 1 hour of recognition of severe sepsis without delay for cultures. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 822 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

Which federal laws regulate the medical and surgical therapy involved with organ transplantation? (Select all that apply.) a.Omnibus Budget Reconciliation Act b.Uniform Anatomical Gift Act c.Hospital Conditions of Participation-Organ Donations d.Medical Examiner Laws e.Uniform Determination of Death Act

ANS: A, C The Uniform Anatomical Gift Act, Uniform Determination of Death Act, and Medical Examiner Laws Restricting Ability of Medical Examiner or Coroner to deny organ donation are all state laws.

3. The nurse is caring for a patient in septic shock due secondary to pneumonia. The nurse knows that evidence-based guidelines for the treatment of septic shock include which interventions? (Select all that apply.) a. Administer norepinephrine to maintain mean arterial pressure of 65 mm Hg. b. Administer low-dose dopamine to maintain urine output greater than 30 mL/h. c. Start enteral nutrition within the first 48 hours after diagnosis of septic shock. d. Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal to 4 mmol/L. e. Perform an adrenocorticotropic hormone (ACTH) stimulation test to identify patients who need hydrocortisone

ANS: A, C, D There is no evidence to support the use of low-dose dopamine to maintain urine output. An adrenocorticotropic hormone (ACTH) stimulation test should not be used to identify patients who need hydrocortisone. PTS: 1 DIF: Cognitive Level: Applying REF: p. 804|p. 821|Box 34-17 OBJ: Nursing Process Step: Planning TOP:

16. The nurse is caring for a patient who what just admitted with septic shock. The nurse knows that certain interventions should be completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of a practitioner's order? a. Administer fresh frozen plasma b. Obtain a serum lactate level c. Administer epinephrine d. Measure central venous pressure

ANS: B According to the Surviving Sepsis Campaign Bundles, the following interventions should be completed within 3 hours of time of presentation 1. Measure lactate level. 2. Obtain blood cultures prior to administration of antibiotics. 3. Administer broad spectrum antibiotics. 4. Administer 30 mL/kg crystalloid for hypotension or lactate 4 mmol/L. PTS: 1 DIF: Cognitive Level: Applying REF: p. 821|Box 34-17 OBJ: Nursing Process Step: Intervention TOP: Shock MSC: NCLEX: Physiologic Integrity

The nursing management plan for a patient with full-thickness burns includes which intervention? a. Daily replacement of autografts b. Daily wound care with premedication c. Weekly wound care until all eschar is debrided d. Surgical skin grafting within 8 hours of admission

ANS: B Daily cleansing and inspection of the wound and unburned skin are performed to assess for signs of healing and local infection. Generally, this therapy is performed once or twice daily. Pain management and measures to reduce hypothermia are used. Patients should receive adequate premedication with analgesics and sedatives.

22. A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. The nurse knows that DIC is known to occur in patients with retained placental fragments. What is the pathophysiologic consequence of DIC? a. Hypersensitivity response to an antigen b. Excessive thrombosis and fibrinolysis c. Profound vasodilatation d. Loss of intravascular volume

ANS: B Disseminated intravascular coagulation (DIC) results simultaneously in microvascular clotting and hemorrhage in organ systems, leading to thrombosis and fibrinolysis in life-threatening proportions. Clotting factor derangement leads to further inflammation and further thrombosis. Microvascular damage leads to further organ injury. Cell injury and damage to the endothelium activate the intrinsic or extrinsic coagulation pathways. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 833 OBJ: Nursing Process Step: Diagnosis TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

12. A patient has been admitted with septic shock related to tissue necrosis. The nurse knows the initial goal for medical management for this patient is which intervention? a. Limiting fluids to minimize the possibility of heart failure b. Finding and eradicating the cause of infection c. Discontinuing invasive monitoring as a possible cause of sepsis d. Administering vasodilator substances to increase blood flow to vital organs

ANS: B Effective treatment of severe sepsis and septic shock depends on timely recognition. The diagnosis of severe sepsis is based on the identification of three conditions: known or suspected infection, two or more of the clinical indications of the systemic inflammatory response, and evidence of at least one organ dysfunction. Clinical indications of systemic inflammatory response and sepsis were included in the original American College of Chest Physicians/Society of Critical Care Medicine consensus definitions. PTS: 1 DIF: Cognitive Level: Applying REF: p. 822 OBJ: Nursing Process Step: Intervention TOP: Shock MSC: NCLEX: Physiologic Integrity

26. The nurse is caring for a patient with multiple-organ dysfunction syndrome (MODS). The nurse understands that earlier nutritional support is critical for the patient to prevent profound weight loss. Why does this occur in patient MODS? a. Patient experiences hypometabolism. b. Patient experiences hypermetabolism. c. Patient experiences anorexia. d. Patient has gut dysfunction.

ANS: B Hypermetabolism in systemic inflammatory response syndrome (SIRS) or multiple-organ dysfunction syndrome (MODS) results in profound weight loss, cachexia, and loss of organ function. The goal of nutritional support is the preservation of organ structure and function. Although nutritional support may not definitely alter the course of organ dysfunction, it prevents generalized nutritional deficiencies and preserves gut integrity. Enteral nutrition may exert a physiologic effect that downregulates the systemic immune response and reduces oxidate stress. PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 834 OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

Which statement made by a patient who has received an organ transplant indicates that the teaching was effective? a."I will finally be able to eat a regular diet." b."I will establish a routine for checking any skin changes." c."I will check my blood pressure regularly to make sure it's not too high." d."After my drug regimen is established, I won't have to worry about rejection."

ANS: B Immunosuppressed patients are at greater risk for developing skin cancer. After transplantation, such a patient needs to monitor for hypotension and eat a diet that is low in sodium, fat, and cholesterol.

A patient is brought to the emergency department after a house fire. The patient sustained an inhalation injury. The nurse is aware that this injury predisposes the patient to the development of what complication? a. Tension pneumothorax b. Adult respiratory distress syndrome (ARDS) c. Asthma d. Lung cancer

ANS: B Inhalation injury predisposes the patient to the development of pneumonia and acute respiratory distress syndrome (ARDS). Management of ARDS necessitates mechanical ventilatory support and, in extreme cases, high-frequency oscillatory ventilation or extracorporeal membrane oxygenation.

A patient is admitted with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. Nursing care for the patient includes which intervention? a. Keep the room cool, dark, and quiet. b. Maintain mean arterial pressure (MAP) at 85 to 95 mm Hg. c. Elevate the head of the bed 45 degrees. d. Resuscitate low blood pressure by only using intravenous fluid

ANS: B Management of acute cervical spinal cord injury (SCI) involves close hemodynamic monitoring. Current guidelines for the management of acute cervical SCI cite that hypotension (systolic blood pressure less than 90 mm Hg) should be avoided or corrected as soon as possible after acute SCI. It is also considered an option to maintain the mean arterial pressure (MAP) at 85 to 90 mm Hg for the first 5 to 7 days after acute SCI to improve spinal cord perfusion. The room should be kept warm to avoid hypothermia. Elevating the head of the bed will often cause hypotension and is contraindicated until additional spinal cord injuries have been ruled out. Because of the profound vasodilation found with neurogenic shock, patients should be resuscitated with both intravenous fluids and vasopressors to restore intravascular volume as well as vascular tone.

18. A nursing instructor is discussing the difference between primary and secondary multiple-organ dysfunction syndrome (MODS) with a nursing student. Which statement indicates the student understood the information? a. Primary MODS is the result of inflammation in organs not involved in the initial insult. b. Primary MODS is the result of a direct organ injury. c. Primary MODS is due to a disorganization of the inflammatory immune system response. d. Primary MODS is due to disruption of the coagulation system.

ANS: B Organ dysfunction may be the direct consequence of an initial insult (primary multiple-organ dysfunction syndrome [MODS]) or can manifest latently and involve organs not directly affected in the initial insult (secondary MODS). Patients can experience both primary and secondary MODS. Primary MODS results from a well-defined insult in which organ dysfunction occurs early and is directly attributed to the insult itself. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 823 OBJ: Nursing Process Step: Diagnosis TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

What is a leading cause of death in the hospitalized burn patient? a. Smoke inhalation b. Infection c. Burn shock d. Renal failure

ANS: B Preventing infection in burn patients is a true challenge and involves complex decision making. Considerable debate has been going on about the infection control precautions to use with burn patients. The burn wound is the most common source of infection in burn patients.

1. A nurse is discussing the concept of shock with a new graduate nurse. Which statement indicates the new graduate nurse understood the information? a. Shock is a physiologic state resulting in hypotension and tachycardia. b. Shock is an acute, widespread process of inadequate tissue perfusion. c. Shock is a degenerative condition leading to organ failure and death. d. Shock is a condition occurring with hypovolemia that results in hypotension.

ANS: B Shock is an acute, widespread process of impaired tissue perfusion that results in cellular, metabolic, and hemodynamic alterations. It is a complex pathophysiologic process that often results in multiple-organ dysfunction syndrome and death. All types of shock eventually result in ineffective tissue perfusion and the development of acute circulatory failure. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 801 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

13. A patient has been admitted with hypovolemic shock due to blood loss. Which finding would the nurse expect to note to support this diagnosis? a. Distended neck veins b. Decreased level of consciousness c. Bounding radial and pedal pulses d. Widening pulse pressure

ANS: B Signs of hypovolemia include flattened neck veins, a decreased level of consciousness, weak and thready peripheral pulses, and a narrowed pulse pressure. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 805 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

24. The nurse is caring for a patient in shock with an elevated lactate level. Which order should the nurse question in the management of this patient? a. Start an insulin drip for blood sugar greater than 180 mg/dL. b. Administer sodium bicarbonate to keep arterial pH greater than 7.20. c. Start a norepinephrine drip to keep mean arterial blood pressure greater than 65 mm Hg. d. Administer crystalloid fluids.

ANS: B Sodium bicarbonate is not recommended in the treatment of shock-related lactic acidosis. Glucose control to a target level of 140 to 180 mg/dL is recommended for all critically ill patients. Vasoconstrictor agents are used to increase afterload by increasing the systemic vascular resistance and improving the patient's blood pressure level. Crystalloids are balanced electrolyte solutions that may be hypotonic, isotonic, or hypertonic. Examples of crystalloid solutions used in shock situations are normal saline and lactated Ringer solution. PTS: 1 DIF: Cognitive Level: Applying REF: p. 804 OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. What is the nurse's first priority? a. Clean the wounds and remove blisters. b. Assess the airway and provide 100% oxygen. c. Place a urinary drainage catheter and assess for myoglobin. d. Place a central intravenous access and provide antibiotics.

ANS: B The first priority of emergency burn care is to secure and protect the airway. All patients with major burns or suspected inhalation injury are initially administered 100% oxygen.

9. A patient has been admitted with a neurologic disorder. With which disorder should the nurse be the most vigilant for the development of neurogenic shock? a. Ischemic stroke b. Spinal cord injury c. Guillain-Barré syndrome d. Brain tumor

ANS: B The most common cause is spinal cord injury (SCI). Neurogenic shock may mistakenly be referred to as spinal shock. The latter condition refers to loss of neurologic activity below the level of SCI, but it does not necessarily involve ineffective tissue perfusion. PTS: 1 DIF: Cognitive Level: Applying REF: p. 815 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

Many barriers exist to increasing the number of organ donors to meet today's growing need. Which barriers are related to hospital factors? (Select all that apply.) a.Limited resources b.Lack of interest c.Failure to approve protocols d.Nurses' attitudes e.Delay in termination of life support

ANS: B, C, D, E A recent study of hospital donation practices and their impact on organ donation outcomes revealed gaps in knowledge of organ donation; brain death; referral criteria; and at times, a poor relationship between the hospital and the organ procurement organization. It is important that nurses are knowledgeable about the organ donation process. Nurses must assess their own beliefs that pertain to organ donation because the attitude of the nurse and care given to the family can impact the outcome of the donation.

Not every patient with end-stage liver disease is a candidate for receiving a transplant. Which conditions are contraindications to a kidney transplant? (Select all that apply.) a.Malignancy during the past 5 years b.Active infectious process c.Advanced cardiopulmonary disease d.Recreational drug use e.Nonadherence to current medical regimen

ANS: B, C, D, E Contraindications to kidney transplantation include malignancy during the past 3 years, active infectious process, advanced cardiopulmonary disease, high risk for surgery, nonadherence to current medical regimen, recreational drug use, and other serious contributing disease processes.

According to the American College of Surgeons, burns to which body surfaces are best treated in a burn center? (Select all that apply.) a. Arms b. Perineum c. Chest d. Genitalia e. Face

ANS: B, D, E According to triage criteria from the American College of Surgeons, burns on the face, hands, feet, genitalia, major joints, and perineum are best treated in a burn center.

The nurse is caring for a patient after a liver transplant. Which finding would be of most concern to the nurse? a.Increased serum glucose b.Low aspartate aminotransferase (AST) and alanine aminotransferase (ALT) c.Elevated prothrombin time d.Decreased blood urea nitrogen and creatinine

ANS: C A patient with suspected primary nonfunction of a liver graft demonstrates (1) hemodynamic instability, (2) progressive deterioration of kidney function, (3) coagulopathies and abnormal serum liver function laboratory test results, (4) hypoglycemia, (5) continued ventilatory dependence, and (6) an inability to awaken from anesthesia.

A patient is admitted with massive head trauma. The patient is unresponsive and on mechanical ventilation. The electroencephalogram (EEG) is negative for brain waves. The family has agreed to organ donation. Which organs would not be considered for transplant? a.Heart b.Lung c.Liver d.Kidney

ANS: C Brain death is an absolute contraindication for a liver transplant.

The nurse is teaching a patient about antiviral medications. The patient asks what is the most common viral infection in transplant recipients. What should the nurse tell the patient? a.Influenza b.Respiratory syncytial virus c.Cytomegalovirus (CMV) d.Parainfluenza

ANS: C Cytomegalovirus (CMV) is the most common viral infection in transplant recipients. CMV may occur within the first few months after transplantation and may occur later on. Other common viruses after transplant include respiratory syncytial virus, influenza, adenovirus, human metapneumovirus, and parainfluenza. These are not treated prophylactically but as they occur.

A patient is admitted after being burned in a car fire. The wound surface is red with patchy white areas that blanch with pressure but no blister formation. What kind of burn would the nurse document in the patient's record? a. Superficial partial-thickness burn b. Moderate partial-thickness burn c. Deep dermal partial-thickness burn d. Full-thickness burn

ANS: C Deep-dermal partial-thickness (second-degree) burns involve the entire epidermal layer and deeper layers of the dermis. A deep-dermal partial-thickness burn usually is not characterized by blister formation. Only a modest plasma surface leakage occurs because of severe impairment in blood supply. The wound surface usually is red with patchy white areas that blanch with pressure.

6. A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the patient is probably having an immunoglobulin E (IgE)-mediated response as a result of what physiologic mechanism? a. Direct activation of mast cells and basophils b. Nonimmunologic stimulation of biochemical mediators c. Repeat exposure to an antigen in the presence of preformed IgE antibodies d. Activation of the systemic inflammatory response

ANS: C Immunoglobulin E (IgE) is an antibody that is formed as part of the immune response. The first time an antigen enters the body, an antibody IgE, specific for the antigen, is formed. The antigen-specific IgE antibody is then stored by attachment to mast cells and basophils. This initial contact with the antigen is known as a primary immune response. The next time the antigen enters the body, the preformed IgE antibody reacts with it, and a secondary immune response occurs. PTS: 1 DIF: Cognitive Level: Applying REF: p. 811 OBJ: Nursing Process Step: Assessment TOP: Shock MSC: NCLEX: Physiologic Integrity

14. A patient is being admitted from the emergency department (ED) with cardiogenic shock secondary to unstable angina unresponsive to medications. The patient was intubated and ventilated in the ED. Which intervention should the nurse prepare to initiate when the practitioner arrives in the unit? a. Administration of sodium bicarbonate b. Rapid infusion of crystalloids c. Insertion of an intraaortic balloon pump (IABP) d. Insertion of dialysis catheters for continuous renal replacement therapy (CRRT)

ANS: C Mechanical circulatory assist devices are used if adequate tissue perfusion cannot be immediately restored. Options include an intraaortic balloon pump (IABP), a percutaneous ventricular assist device (VAD), or an extracorporeal membrane oxygenator. The IABP is used to decrease myocardial workload by improving myocardial supply and decreasing myocardial demand. It achieves this goal by improving coronary artery perfusion and reducing left ventricular afterload. Sodium bicarbonate, fluids, and dialysis are not indicated in this situation. PTS: 1 DIF: Cognitive Level: Applying REF: p. 810 OBJ: Nursing Process Step: Intervention TOP: Shock MSC: NCLEX: Physiologic Integrity

What physiologic process can result in excessive burn edema and shock in a patient with injuries totaling more than 50% total body surface area (TBSA) burn? a. The heat from the burn leads to immediate vascular wall destruction and extravasation of intravascular fluid. b. A positive interstitial hydrostatic pressure occurs in the dermis leading to burn wound edema. c. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space. d. Capillary permeability decreases in burned and unburned tissue, leading to hypovolemia.

ANS: C Negative interstitial hydrostatic pressure represents an edema-generating mechanism and occurs for approximately 2 hours after injury. Additionally, plasma colloid osmotic pressure is decreased as a result of protein leakage into the extravascular space. Plasma is then further diluted with fluid resuscitation. Thus osmotic pressure is decreased and further fluid extravasation can occur.

A patient is admitted with massive head trauma. The patient is unresponsive and on mechanical ventilation. The electroencephalogram (EEG) is negative for brain waves. The family has agreed to organ donation. When the nurse turns the patient's head quickly from side to side, the patient's eyes do not move. The nurse knows this is the result of the loss of what reflex? a.Oculovestibular b.Corneal c.Oculocephalic d.Pupillary

ANS: C Oculocephalic reflex: Ocular movements are lost with brain death. The oculocephalic reflex, also described as doll's eyes, involves fast turning of the head to both sides. In brain death, this should not generate any eye movements. Oculovestibular reflex: Because the oculovestibular reflex is tested using iced water or normal saline, it is sometimes called cold calorics. The head of the bed is elevated 30 degrees, and approximately 50 mL of ice water or normal saline is injected into the ear; no movement of the eye toward the side of the stimulus should be present. It is recommended that the patient be observed for up to 1 minute after each ear irrigation, and 5 minutes should be allowed before testing the opposite ear. Corneal and jaw reflexes: Facial sensory and motor responses are elicited by testing for corneal and jaw reflexes. Stroking a cotton-tipped swab gently across the cornea tests the corneal reflexes. Pupillary reflexes: Pupillary signs are evaluated by absence of the light reflex, which is consistent with brain death. Most often the pupils are round, oval, or irregularly shaped, although dilated pupils may remain even after brain death has occurred.

A patient is admitted with a severe diffuse axonal injury (DAI) secondary to a motor vehicle crash. The patient's plan of care would involve which nursing action? a. Perform neurologic assessments once a shift. b. Obtain a computed tomography (CT) scan every day. c. Monitor blood pressure and temperature every hour. d. Initiate warming measures to keep temperature greater than 37.5°C

ANS: C Severe diffuse axonal injury (DAI) usually manifests as a prolonged, deep coma with periods of hypertension, hyperthermia, and excessive sweating. Treatment of DAI includes support of vital functions. The outcome after severe DAI is poor because of the extensive dysfunction of cerebral pathways. Neurologic assessment is performed every hours. DAI may not be visible on computed tomography (CT) scan. Warming measures are generally not needed, but cooling measure may be needed.

1. What happens to patients that meet criteria for imminent death? a.They are placed on life support and referred to the organ procurement organizations. b.They are referred to the organ procurement organizations at the time of their death. c.They are referred to the organ procurement organizations in a timely manner. d.They are referred to a practitioner to make the decision if they are candidates for organ donation.

ANS: C The Centers for Medicare and Medicaid Services guidelines, the Joint Commission standards, and hospital policies require that patients meeting criteria for imminent death and cardiac death be referred to an organ procurement organization in a timely manner.

A patient has been admitted with a flail chest. What findings would the nurse expect to note supporting this diagnosis? a. Tracheal deviation toward the unaffected side b. Jugular venous distention c. Paradoxical respiratory movement d. Respiratory alkalosis

ANS: C Tracheal deviation and jugular venous distention are findings associated with tension pneumothorax. Respiratory acidosis is usually present because of the ineffective breathing pattern. In a flail chest, a free-floating segment of the chest wall moves independently from the rest of the thorax and results in paradoxical chest wall movement during the respiratory cycle. During inspiration, the intact portion of the chest wall expands while the injured part is sucked in. During expiration, the chest wall moves in, and the flail segment moves out.

19. The nurse is caring for a patient with sepsis due to necrotic tissue. The nurse knows that necrotic tissue can stimulate the inflammatory immune response. Which biochemical mediator is secreted in response to endotoxin or tissue injury? a. Arachidonic acid metabolite b. Platelet-activating factor c. Tumor necrosis factor d. Interleukin

ANS: C Tumor necrosis factor-á (TNF-á, also known as cachectin) is a polypeptide that is released from macrophages and lymphocytes in response to endotoxin, tissue injury, viral agents, and interleukins. When present in excessive amounts, TNF-á causes widespread destruction in most organ systems and is responsible for the pathophysiologic changes in systemic inflammatory response syndrome (SIRS) and septic shock, including fever, hypotension, decreased organ perfusion, and increased capillary permeability. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 830 OBJ: Nursing Process Step: Diagnosis TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

17. The nurse is caring for a patient with systemic inflammatory response syndrome (SIRS) due to pneumonia. What is SIRS due to infection called? a. Infectivity b. Anaphylaxis c. Sepsis d. Acute respiratory distress syndrome (ARDS)

ANS: C When systemic inflammatory response syndrome (SIRS) is the result of infection, it is referred to as sepsis. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 824 OBJ: Nursing Process Step: Diagnosis TOP: Shock MSC: NCLEX: Physiologic Integrity

20. A patient has developed septic shock. The nurse knows that the patient is at risk for gastrointestinal dysfunction. What happens to the gastrointestinal tract in the patient with septic shock? a. Anorexia leads to loss of gastric enzymes b. Lack of food ingestion leads to intestinal hypomotility c. Hypoperfusion results in loss of gut barrier function d. Low cardiac output causes decreased hydrochloric acid secretion

ANS: C With microcirculatory failure to the gastrointestinal tract, the gut's barrier function may be lost, which leads to bacterial translocation, sustained inflammation, endogenous endotoxemia, and multiple-organ dysfunction syndrome (MODS). PTS: 1 DIF: Cognitive Level: Understanding REF: p. 830 OBJ: Nursing Process Step: Diagnosis TOP: SIRS/MODS MSC: NCLEX: Physiologic Integrity

A patient has been admitted with a flail chest and pulmonary contusion. Which finding will cause a nurse to suspect that the patient's condition is deteriorating? a. Increased bruising on the chest wall b. Increased need for pain medication c. The development of respiratory alkalosis d. Increased work of breathing

ANS: D A contusion manifests initially as a hemorrhage followed by alveolar and interstitial edema. Patients with severe contusions may continue to show decompensation, such as respiratory acidosis and increased work of breathing, despite aggressive nursing management. Increased bruising and the need for pain medication are not signs of deterioration.

A patient is admitted after being burned in a house fire. The nurse feels that the patient should be transferred to a burn center. Which factor is most important when determining whether or not to refer a patient to a burn center? a. The size and depth of burn injury and the burning agent b. The age and present medical history of the patient c. The depth of the burn injury and the presence of soot in the sputum d. The medical history of the patient and the size and depth of the burn injury

ANS: D Burns are classified primarily according to the size and depth of injury. However, the type and location of the burn and the patient's age and medical history are also significant considerations. Recognition of the magnitude of burn injury, which is based on the above-mentioned factors, is of crucial importance in the overall plan of care and in decisions concerning patient management and appropriate referral to a burn center.

A patient is admitted with a C5-C6 subluxation fracture. He is able to move his legs better than he can move his arms. The nurse suspects the patient may have which type of injury? a. Posterior cord syndrome b. Brown-Séquard syndrome c. Diffuse axonal injury d. Central cord syndrome

ANS: D Central cord syndrome is associated with cervical hyperextension/flexion injury and hematoma formation in the center of the cervical cord. This injury produces a motor and sensory deficit more pronounced in the upper extremities than in the lower extremities. Posterior cord syndrome is associated with cervical hyperextension injury with damage to the posterior column. This results in the loss of position sense, pressure, and vibration below the level of injury. Brown-Séquard syndrome is associated with damage to only one side of the cord. This produces loss of voluntary motor movement on the same side as the injury, with loss of pain, temperature, and sensation on the opposite side. Diffuse axonal injury (DAI) is a term used to describe prolonged posttraumatic coma that is not caused by a mass lesion, although DAI with mass lesions has been reported.

Less than 24 hours ago a patient sustained full-thickness burns, to his face, chest, back, and bilateral upper arms, in a house fire. He also sustained an inhalation injury. The patient was intubated and ventilated and is now showing signs of increasing agitation and rising peak airway pressures. The nurse suspects the patient's change in condition is due to which problem? a. Uncontrolled pain b. Hypovolemia c. Worsening hypoxemia d. Decreased pulmonary compliance

ANS: D Circumferential full-thickness burns to the chest wall can lead to restriction of chest wall expansion and decreased compliance. Decreased compliance requires higher ventilatory pressures to provide the patient with adequate tidal volumes

A patient with extensive burns is undergoing skin grafting. The nurse understands pain control is best achieved with what strategies during the early phase of recovery? a. Large doses of opioids given intramuscularly b. Intravenous opioids used in combination with oral antidepressants c. Large doses of opioids given subcutaneously d. Small doses of intravenous opioids titrated to effect

ANS: D Initially after burn injury, narcotics are administered intravenously in small doses and titrated to effect. The constant background pain may be addressed with the use of a patient-controlled analgesia device. When hemodynamic stability has occurred and gastrointestinal function has returned, oral narcotics can be useful. Intramuscular or subcutaneous injections must not be administered because absorption by these routes is unpredictable because of the fluid shifts that occur with burn injury.

A patient with liver failure manifested by portal hypertension and ascites is hospitalized and waiting for a liver transplant. Which order should the nurse question? a.Low-sodium diet b.Low-protein diet c.ABO typing d.Human leukocyte antigen tissue typing

ANS: D Liver failure is managed with a low-protein diet to decrease the risk of hepatic encephalopathy. A low-sodium diet is ordered to help manage the ascites. Blood type and body size are used to match a liver donor, not human leukocyte antigen tissue testing.

Which topical antimicrobial agent is commonly used as a broad-spectrum and fights against gram-positive and -negative bacteria? a. Pure silver b. Bacitracin c. Mafenide acetate cream d. Silver sulfadiazine

ANS: D Silver sulfadiazine (SSD; Silvadene cream) is a broad-spectrum antimicrobial agent with bactericidal action against many gram-negative and -positive bacteria associated with burn wound infection. Mafenide acetate cream penetrates through burn eschar and is bacteriostatic against many gram-negative and -positive organisms. Its use is limited because the application is uncomfortable for the patient because it creates a burning sensation, and it is rapidly absorbed, requiring dressing changes two or three times daily. It is used routinely for coverage of small wounds. Bacitracin ointment is a topical agent applied to superficial burns and facial burns. Bacitracin is effective against gram-positive organisms but not against gram-negative organisms or fungal organisms. Silver has long been used for the treatment of wounds because of its broad-spectrum bacteriostatic properties. The wound moisture activates the silver and releases it into the wound. An advantage of silver dressings is that the dressing does not need to be changed daily because of the sustained release of silver. Silver dressings should be used judiciously and limited to 4 to 6 weeks despite the current absence of negative systemic or local consequences.

A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. The nurse knows that the patient's symptoms are most likely attributable to what cause? a. Blood loss associated with burns and pain b. Hemodynamic stability related to adequate fluid resuscitation. c. Overresuscitation related to overestimation of the burn area involved d. Underresuscitation because of probable wound conversion

ANS: D The rate of fluid administration is adjusted according to the individual's response, which is determined by monitoring urine output, heart rate, blood pressure, and level of consciousness. Meticulous attention to the patient's intake and output is imperative to ensure that he or she is appropriately resuscitated. Underresuscitation may result in inadequate cardiac output, leading to inadequate organ perfusion and the potential for wound conversion from a partial-thickness to full-thickness injury. Overresuscitation may lead to moderate to severe pulmonary edema; to excessive wound edema causing a decrease in perfusion of unburned tissue in the distal portions of the extremities; or to edema-inhibiting perfusion of the zone of stasis, resulting in wound conversion.

A patient involved in a house fire is brought by ambulance to the emergency department. The patient is breathing spontaneously but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide and probably has carbon monoxide (CO) poisoning. What action should the nurse take next? a. Ask the practitioner to order a STAT chest radiograph. b. Apply a pulse oximeter to one of his unburned fingers. c. Call the local hyperbaric chamber to check on its availability. d. Administer 100% high-flow oxygen via a nonrebreathing mask.

ANS: D The treatment of choice for carbon monoxide (CO) poisoning is high-flow oxygen administered at 100% through a tight-fitting nonrebreathing mask or endotracheal intubation. The half-life of CO in the body is 4 hours at room air (21% oxygen), 2 hours at 40% oxygen, and 40 to 60 minutes at 100% oxygen. The half-life of CO is 30 minutes in a hyperbaric oxygen chamber at three times the atmospheric pressure. Currently, the use of hyperbaric oxygen is of controversial benefit in care of burn patients.

A patient who has received a transplant is being taught about cyclosporine. Which statement made by the patient would indicate the teaching was effective? a."I know this drug prevents my immune system from working." b."If I find the capsules are hard to swallow, I'll take the liquid." c."I will need to watch for bruising." d."I will need to monitor my blood pressure."

ANS: D This drug can cause hypertension. Capsules and liquid form are not interchangeable. The immune system still has some ability to work. Cyclosporine does not affect the bone marrow.