Test #3

A client with uncomplicated gonorrhea who is treated with ceftriaxone and doxycycline asks if a follow-up examination and culture will be necessary. The most appropriate response by the nurse is a. "No, because the disease cannot recur." b. "No, because treatment failure with these medications is rare." c. "Yes, because monthly cultures are now recommended." d. "Yes, because reinfection is very probable."

b. "No, because treatment failure with these medications is rare." After therapy for uncomplicated gonorrhea is completed, a follow-up examination and culture ("test of cure") are not necessary. Treatment failure following combined ceftriaxone-doxycycline therapy is rare. This differs from the recommendation to re-test in 3-12 months because of the high rates of STDs seen in people who have been recently treated for them.

In assessing a client with suspected chlamydia, the nurse's actions are guided by the knowledge that this sexually-transmitted disease is: a. Frequently asymptomatic and requires screening. b. Associated with a yellow-green vaginal discharge. c. Accompanied by heavy bleeding and headache. d. Only seen in immunocompromised clients.

a. Frequently asymptomatic and requires screening.

An adolescent has been diagnosed with Chlamydia infection. Which medication should the nurse expect to be prescribed for this condition? a. Ceftriaxone (Rocephin) IM b. Azithromycin (Zithromax) PO c. Acyclovir (Zovirax) PO d. Penicillin G benzathine (Bicillin) IV

b. Azithromycin (Zithromax) PO Azithromycin is used to treat Chlamydia. The patient should be rescreened in 3 to 4 months. Ceftriaxone is used to treat gonorrhea, acyclovir is used to suppress genital herpes simplex virus, and penicillin G benzathine is used to treat syphilis.

An elderly client with pneumonia may appear with which of the following symptoms first? 1. Hemoptysis and dyspnea 2. Pleuritic chest pain and cough 3. Altered mental status and dehydration 4. Fever and chills

3. Altered mental status and dehydration Fever, chills, hemoptysis, dyspnea, cough, and pleuritic chest pain are common symptoms of pneumonia, but elderly clients may first appear with only an altered mental status and dehydration due to a blunted immune response.

Which of the following mental status changes may occur when a client with pneumonia is first experiencing hypoxia? 1. Apathy 2. Depression 3. Coma 4. Irritability

4. Irritability Clients who are experiencing hypoxia characteristically exhibit irritability, restlessness, or anxiety as initial mental status changes. As the hypoxia becomes more pronounced, the client may become confused and combative. Coma is a late clinical manifestation of hypoxia. Apathy and depression are not symptoms of hypoxia.

When assessing the trauma victim, the nurse evaluates the patient for fractured ribs and a scapular fracture. These disorders can lead to A) subluxation of the shoulder. B) possible pulmonary contusion. C) deep vein thrombosis. D) disseminated intravascular coagulation.

B) possible pulmonary contusion.

When a client developed a hemothorax, the physician inserted a chest catheter connected to a drainage system. In the first 2 hours, 900 ml of blood drainage was collected. The nurse would a. clamp the tubing. b. continue observation of the drainage. c. monitor the client's vital signs. d. report this to the physician immediately.

d. report this to the physician immediately Large amounts of drainage (200 ml/hr or more) should be reported the physician immediately

Clients with chronic illnesses are more likely to get pneumonia when which of the following situations is present? 1. Dehydration 2. Group living 3. Malnutrition 4. Severe periodontal disease

2. Group living Clients with chronic illnesses generally have poor immune systems. Often, residing in group living situations increases the chance of disease transmission.

Doxycycline (Vibramycin) has been prescribed for a patient who has gonorrhea. Prior to beginning the medication, the nurse would instruct the patient to: 1. take the medication with food or crackers. 2. take with fruit juice or milk. 3. take the medication on an empty stomach. 4. take with a full glass of water.

4. take with a full glass of water.

A nurse caring for a client with a pulmonary embolism expects to find which diagnostic result A) Patchy infiltrates on chest x-ray B) Metabolic alkalosis on arterial blood gas C) Elevated CO2 level found on end-tidal carbon dioxide monitor D) Tachycardia and nonspecific T-wave changes on

D) Tachycardia and nonspecific T-wave changes on With pulmonary embolism, tachycardia and nonspecific T-wave changes occur on EKG. The client with a pulmonary embolism will likely have respiratory alkalosis from rapid breathing, not metabolic alkalosis. The end-tidal carbon dioxide monitor (EtCO2) will be decreased, not increased, due to rapid breathing.

The nurse assesses a patient for a possible pulmonary embolism. The nurse looks for the most frequent sign of: A. Cough B. Hemoptysis C. Syncope D. Tachypnea.

D. Tachypnea. Tachypnea is the most common sigh to be found among patients with pulmonary embolism. A: Cough is not a sign of pulmonary embolism. B: Hemoptysis is not a sign of pulmonary embolism. C: Syncope is not a sign of pulmonary embolism.

The nurse identifies the diagnosis Potential for Ineffective Gas Exchange as appropriate for a patient with pneumonia. Which independent nursing actions should the nurse plan for this problem? (Select all that apply.) a. Apply oxygen, 2 liters, per nasal cannula. b. Turn and reposition in bed every 2 hours. c. Coach to deep breathe and cough every hour. d. Administer intramuscular antibiotic medication. e. Encourage to drink 240 mL of fluid every 2 hours.

b. Turn and reposition in bed every 2 hours. c. Coach to deep breathe and cough every hour. e. Encourage to drink 240 mL of fluid every 2 hours.

The nurse is providing care to a patient diagnosed with cerebral palsy. The patient requires ventilatory support at night. Based on this knowledge, the nurse understands that the patient may require which of the following types of ventilation? 1. negative pressure ventilation 2. positive pressure ventilation 3. pressure-cycled ventilation 4. volume-cycled ventilation

1. negative pressure ventilation Negative pressure ventilation is a type of ventilation that can be applied for short time intervals—such as overnight. It does not require an artificial airway, it allows for more normal breathing mechanics, and the patient can eat and talk normally. Each of the other types of ventilation requires the use of an artificial airway and would not be practical for nighttime use at home

Which of the following would be an appropriate expected outcome for an elderly client recovering from bacterial pneumonia? 1. A respiratory rate of 25 to 30 breaths per minute 2. Chest pain that is minimized by splinting the ribcage. 3. The ability to perform ADL's without dyspnea 4. A maximum loss of 5 to 10 pounds of body weight

3. The ability to perform ADL's without dyspnea

Which of the following best describes pleural effusion? 1. The collapse of alveoli 2. The fluid in the alveolar space 3. The accumulation of fluid between the linings of the pleural space. 4. The collapse of bronchiole

3. The accumulation of fluid between the linings of the pleural space. The pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries and lymphatics. Any condition that interferes with either the secretion or drainage of this fluid will lead to a pleural effusion.

An 87-year-old client requires long term ventilator therapy. He has a tracheostomy in place and requires frequent suctioning. Which of the following techniques is correct? 1. Using intermittent suction while advancing the catheter. 2. Using continuous suction while advancing the catheter. 3. Using intermittent suction while withdrawing the catheter. 4. Using continuous suction while withdrawing the catheter.

3. Using intermittent suction while withdrawing the catheter. Intermittent suction should be applied during catheter withdrawal. To prevent hypoxia, suctioning shouldn't last more than 10-seconds at a time. Suction shouldn't be applied while the catheter is being advanced.

A client's ABG analysis reveals a pH of 7.18, PaCO2 of 72 mm Hg, PaO2 of 77 mm Hg, and HCO3- of 24 mEq/L. What do these values indicate? 1. Respiratory alkalosis 2. Respiratory acidosis 3. Metabolic acidosis 4. Metabolic alkalosis

2. Respiratory acidosis

The client receives acyclovir (Zovirax) for treatment of genital herpes. What is a priority assessment by the nurse? 1. Auditory and visual hallucinations 2. Increased serum creatinine 3. Respiratory distress 4. Thrombocytopenia

2. Increased serum creatinine Acyclovir (Zovirax) is nephrotoxic, so serum creatinine should be monitored.

A client with pneumonia develops dyspnea with a respiratory rate of 32 breaths/minute and difficulty expelling his secretions. The nurse auscultates his lung fields and hears bronchial sounds in the left lower lobe. The nurse determines that the client requires which of the following treatments first? 1. Bed rest 2. Oxygen 3. Antibiotics 4. Nutritional intake

2. Oxygen The client is having difficulty breathing and is probably becoming hypoxic. As an emergency measure, the nurse can provide oxygen without waiting for a physicians order. Antibiotics may be warranted, but this isn't a nursing decision. The client should be maintained on bedrest if he is dyspneic to minimize his oxygen demands, but providing additional will deal more immediately with his problem. The client will need nutritional support, but while dyspneic, he may be unable to spare the energy needed to eat and at the same time maintain adequate oxygenation.

When the nurse observes the paradoxical movement in a patient with a flail chest who has marked dyspnea, the nurse should prepare for: 1. a thoracotomy. 2. an intubation. 3. a thoracentesis. 4. a body cast.

2. an intubation. A patient with an unstable chest usually requires intubation and mechanical ventilation.

A 24-year-old client comes into the clinic complaining of right-sided chest pain and shortness of breath. He reports that it started suddenly. The assessment should include which of the following interventions? 1. Echocardiogram 2. Electrocardiogram (ECG) 3. Chest x-ray 4. Auscultation of breath sounds

4. Auscultation of breath sounds Because the client is short of breath, listening to breath sounds is a good idea. He may need a chest x-ray and an ECG, but a physician must order these tests. Unless a cardiac source for the client's pain is identified, he won't need an echocardiogram.

A nurse evaluates the blood theophylline level of a client receiving aminophylline (theophylline) by intravenous infusion. The nurse would determine that a therapeutic blood level exists if which of the following were noted in the laboratory report? 1. 5 mcg/mL 2. 30 mcg/mL 3. 15 mcg/mL 4. 25 mcg/mL

3. 15 mcg/mL The therapeutic theophylline blood level range from 10-20 mcg/mL.

The nurse is reviewing clients for risk factors in the development of pneumonia. Which of the following clients would be at the highest risk for developing this disorder? 1. A 48-year-old client experiencing menopause 2. An 18-year-old client with abdominal pain 3. A 23-year-old client diagnosed with sickle-cell anemia and a cough 4. A 3-year-old client with fever

3. A 23-year-old client diagnosed with sickle-cell anemia and a cough High-risk groups for acquiring pneumonia are people with diabetes, infants 6- to 23-months old, and those with a chronic illness such as sickle-cell anemia. Menopause and abdominal pain are not symptoms associated with pneumonia. Fever in a 3-year-old client could be caused by many disorders and not necessarily pneumonia.

If a pleural effusion develops, which of the following actions best describes how the fluid can be removed from the pleural space and proper lung status restored? 1. Inserting a chest tube 2. Allowing the pleural effusion to drain by itself. 3. Performing thoracentesis 4. Performing paracentesis

3. Performing thoracentesis Performing thoracentesis is used to remove excess pleural fluid. The fluid is then analyzed to determine if it's transudative or exudative. Transudates are substances that have passed through a membrane and usually occur in low protein states. Exudates are substances that have escaped from blood vessels. They contain an accumulation of cells and have a high specific gravity and a high lactate dehydrogenase level. Exudates usually occur in response to a malignancy, infection, or inflammatory process. A chest tube is rarely necessary because the amount of fluid typically isn't large enough to warrant such a measure. Pleural effusions can't drain by themselves.

A laboring woman is found to have an active outbreak of genital herpes simplex virus (HSV). The nurse prepares for which treatment intervention? 1. Predelivery skin scrub with an antiseptic cleaner 2. Normal vaginal delivery if possible 3. Treatment with pyrimethamine for the infant starting immediately after birth 4. Cesarean delivery

4. Cesarean delivery Active cases of genital herpes require delivery by cesarean section to avoid contact between the infant and the herpes lesions.

Assessing male clients with sexually-transmitted diseases, a nurse recognizes that both chlamydia and gonorrhea have the same manifestations, which are: a. Painful urination and purulent urethral discharge. b. A single, firm painless open sore on the shaft of the penis. c. Red superficial vesicles on the shaft of the penis. d. A single or a cluster of wart-like growth in the anal-rectal area.

a. Painful urination and purulent urethral discharge.

The client has experienced left-sided chest trauma 3 hours ago, which included simple fractures of three ribs. The nurse now finds the client to have increased dyspnea, pulse oximetry of 86%, and tracheal deviation to the right. What is the nurse's interpretation of these findings? A. Flail chest B. Pulmonary contusion C. Tension pneumothorax D. Acute respiratory distress syndrome

C. Tension pneumothorax Blunt chest trauma can cause an air leak into the thoracic cavity, collapsing the lung on the side with the air leak. More air enters the pleural space with each breath, increasing intrathoracic pressure on the affected side, moving the trachea to the unaffected side, and leading to decreased cardiac output. This condition is life threatening without intervention.

Continuous positive airway pressure (CPAP) can be provided through an oxygen mask to improve oxygenation in hypoxic patients by which of the following methods? 1. The mask provides continuous air that the client can breathe. 2. The mask provides pressurized at the end of expiration to open collapsed alveoli. 3. The mask provides 100% oxygen to the client. 4. The mask provides pressurized oxygen so the client can breathe more easily.

4. The mask provides pressurized oxygen so the client can breathe more easily. The mask provides pressurized oxygen continuously through both inspiration and expiration. The mask can be set to deliver any amount of oxygen needed. By providing the client with pressurized oxygen, the client has less resistance to overcome in taking his next breath, making it easier to breathe. Pressurized oxygen delivered at the end of expiration is positive end-expiratory pressure (PEEP), not continuous positive airway pressure.

A pregnant client is diagnosed with chlamydia. The nurse should ask if the client has an allergy to: 1. Doxycycline. 2. Azithromycin. 3. Penicillin. 4. Erythromycin.

4. Erythromycin. Erythromycin is used to treat chlamydia in the pregnant client, and the nurse assesses for allergy to the drug.

A client with pneumonia has a temperature of 102.6*F (39.2*C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care? 1. Position changes q4h 2. Frequent offering of a bedpan. 3. Nasotracheal suctioning to clear secretions 4. Frequent linen changes

4. Frequent linen changes Frequent linen changes are appropriate for this client because of diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Position changes need to be done every 2 hours. Nasotracheal suctioning is not indicated with the client's productive cough. Frequent offering of a bedpan is not indicated by the data provided in this scenario.

A nurse is presenting a lecture about pneumonia to a group of senior citizens in a community center. The nurse explains that people with which of the following risk factors are at a higher risk of developing the infection? A. Cigarette smoking, alcoholism, and heart failure B. Immunosuppression and hypertension C. Diabetes and gastritis D. Hypertension, diabetes, and heart

A. Cigarette smoking, alcoholism, and heart failure

Isoniazid (INH) and rifampin (Rifadin) have been prescribed for a client with TB. A nurse reviews the medical record of the client. Which of the following, if noted in the client's history, would require physician notification? 1. Hepatitis B 2. Heart disease 3. Allergy to penicillin 4. Rheumatic fever

1. Hepatitis B Isoniazid and rifampin are contraindicated in clients with acute liver disease or a history of hepatic injury.

A patient with syphilis is seen at the clinic and complains of body aches, pustules, fever, and sore throat. The nurse recognizes that these are symptoms of syphilis at which stage? 1. Primary 2. Secondary 3. Latent 4. Late

2. Secondary Symptoms in the secondary stage are body aches, rash, pustules, fever, and sore throat

What are the possible complications in a patient with pulmonary embolism? A. Right ventricular failure B. Cardiogenic shock C. Septic shock D. Both A and B.

D. Both A and B. D: Both right ventricular failure and cardiogenic shock are possible complications in a patient with pulmonary embolism. A: Right ventricular failure is a possible complication in a patient with pulmonary embolism. B: Cardiogenic shock is a possible complication in a patient with pulmonary embolism. C: Septic shock is not a complication in pulmonary embolism.

While evaluating a male client for treatment of gonorrhea, which question is the most important for the nurse to ask? a."Do you have a history of sexually transmitted disease?" b."When was your last sexual encounter?" c."When did your symptoms begin?" d."What are the names of your recent sexual partners?"

d."What are the names of your recent sexual partners?" Sexual partners, as well as the client, should be tested and treated for gonorrhea. Asking about sexually transmitted disease history, last sexual encounter, and onset of symptoms would be helpful with the history taking, but the priority is treating the client's sexual partners to limit the spread of the disease.

While palpating respiratory expansion on a client in the emergency room the nurse notes movement on only one side of the chest. Which of the following conditions may produce this finding? Select all that apply. 1. Atelectasis 2. Chronic bronchitis 3. Lobar pneumonia 4. Pleural effusion 5. Congestive heart failure

1. Atelectasis 3. Lobar pneumonia 4. Pleural effusion Rationale 1: Atelectasis. Atelectasis is a condition in which there is an obstruction of airflow. Lung tissue may collapse from airway obstruction, such as a mucous plug, lack of surfactant, or a compressed chest wall. Atelectasis will result in decreased lung expansion on the client's affected side. Rationale 2: Chronic bronchitis. Chronic inflammation of the tracheobronchial tree leads to increased mucous production and blocked airways. It does not result in decreased lung expansion on one side. Rationale 3: Lobar pneumonia. It is due to an infection that causes fluid, bacteria, and cellular debris to fill the alveoli. It may result in decreased lung expansion on the client's affected side. Rationale 4: Pleural effusion. This condition refers to fluid accumulating in the pleural space. It may result in decreased lung expansion on the client's affected side. Rationale 5: Congestive heart failure. This is when increased pressure in the pulmonary veins causes interstitial edema around the alveoli and may cause edema of the bronchial mucosa. It does not result in decreased lung expansion on one side.

Which of the following treatments would the nurse expect for a client with a spontaneous pneumothorax? 1. Chest tube placement 2. Antibiotics 3. Hyperbaric chamber 4. Bronchodilators

1. Chest tube placement The only way to re-expand the lung is to place a chest tube on the right side so the air in the pleural space can be removed and the lung re-expanded.

Which of the following pathophysiological mechanisms that occurs in the lung parenchyma allows pneumonia to develop? 1. Inflammation 2. Bronchiectasis 3. Atelectasis 4. Effusion

1. Inflammation The common feature of all type of pneumonia is an inflammatory pulmonary response to the offending organism or agent. Atelectasis and bronchiectasis indicate a collapse of a portion of the airway that doesn't occur in pneumonia. An effusion is an accumulation of excess pleural fluid in the pleural space, which may be a secondary response to pneumonia.

A pulse oximetry gives what type of information about the client? 1. Percentage of hemoglobin carrying oxygen 2. Amount of carbon dioxide in the blood 3. Respiratory rate 4. Amount of oxygen in the blood

1. Percentage of hemoglobin carrying oxygen

A client with pneumonia has a temperature ranging between 101* and 102*F and periods of diaphoresis. Based on this information, which of the following nursing interventions would be a priority? 1. Provide fluid intake of 3 L/day 2. Maintain complete bedrest 3. Provide frequent linen changes. 4. Administer oxygen therapy

1. Provide fluid intake of 3 L/day A fluid intake of at least 3 L/day should be provided to replace any fluid loss occurring as a result the fever and diaphoresis; this is a high-priority intervention.

A client with shortness of breath has decreased to absent breath sounds on the right side, from the apex to the base. Which of the following conditions would best explain this? 1. Spontaneous pneumothorax 2. Acute asthma 3. Pneumonia 4. Chronic bronchitis

1. Spontaneous pneumothorax A spontaneous pneumothorax occurs when the client's lung collapses, causing an acute decrease in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath. An asthma attack would show wheezing breath sounds, and bronchitis would have rhonchi. Pneumonia would have bronchial breath sounds over the area of consolidation.

Which of the following methods is the best way to confirm the diagnosis of a pneumothorax? 1. Take a chest x-ray 2. Have the client use an incentive spirometer 3. Auscultate breath sounds 4. Stick a needle in the area of decreased breath sounds

1. Take a chest x-ray A chest x-ray will show the area of collapsed lung if pneumothorax is present as well as the volume of air in the pleural space. Listening to breath sounds won't confirm a diagnosis. An IS is used to encourage deep breathing. A needle thoracostomy is done only in an emergency and only by someone trained to do it.

A patient is in the intensive care unit with a pulmonary contusion sustained from a motor vehicle accident. Which of the following post-traumatic complications should the nurse focus on when providing care to this patient? 1. acute renal failure 2. ARDS 3. abdominal compartment syndrome 4. sepsis

2. ARDS The patient with a thoracic injury is prone to developing the post-traumatic complications of ARDS and DIC. Acute renal failure, sepsis, and abdominal compartment syndrome are more likely seen in the patient with abdominal trauma.

Which evidence based intervention would the nurse use to prevent pneumonia in the patient receiving mechanical ventilation? 1. Aseptic technique when performing oral hygiene 2. Administration of an H2 antagonist to prevent peptic ulcers 3. Elevation of the head of the bed to 15 degrees to prevent aspiration 4. Changing the ventilator circuit daily

2. Administration of an H2 antagonist to prevent peptic ulcers One of the evidence based practices used to prevent ventilator-associated pneumonia includes the use of an H2 antagonist to prevent peptic ulcers.

Which manifestations should the nurse investigate as indicating possible pneumonia in an older patient? Select all that apply. 1. Fever 2. Dyspnea 3. Tachycardia 4. Behavior changes 5. Substernal chest pain

2. Dyspnea 3. Tachycardia 4. Behavior changes 5. Substernal chest pain Fever may be absent in the older patient because many older people have a lower basal temperature and will not exhibit a fever response in the face of infection.

Which of the following statements best explains how opening up collapsed alveoli improves oxygenation? 1. Alveoli have no effect on oxygenation 2. Gaseous exchange occurs in the alveolar membrane. 3. Alveoli need oxygen to live 4. Collapsed alveoli increase oxygen demand

2. Gaseous exchange occurs in the alveolar membrane. Gaseous exchange occurs in the alveolar membrane, so if the alveoli collapse, no exchange occurs, Collapsed alveoli receive oxygen, as well as other nutrients, from the bloodstream. Collapsed alveoli have no effect on oxygen demand, though by decreasing the surface area available for gas exchange, they decrease oxygenation of the blood.

When auscultating the chest of a client with pneumonia, the nurse would expect to hear which of the following sounds over areas of consolidation? 1. Bronchovestibular 2. Vesicular 3. Bronchial 4. Tubular

3. Bronchial Chest auscultation reveals bronchial breath sounds over areas of consolidation. Bronchovesicular are normal over midlobe lung regions, tubular sounds are commonly heard over large airways, and vesicular breath sounds are commonly heard in the bases of the lung fields.

A 79-year-old client is admitted with pneumonia. Which nursing diagnosis should take priority? 1. Acute pain related to lung expansion secondary to lung infection 2. Anxiety related to dyspnea and chest pain. 3. Risk for imbalanced fluid volume related to increased insensible fluid losses secondary to fever. 4. Ineffective airway clearance related to retained secretions.

4. Ineffective airway clearance related to retained secretions. Pneumonia is an acute infection of the lung parenchyma. The inflammatory reaction may cause an outpouring of exudate into the alveolar spaces, leading to an ineffective airway clearance related to retained secretions.

The nurse is caring for a patient who has been diagnosed with genital herpes. When preparing a teaching plan for this patient, what general guidelines should be taught? A) Good hand-washing is essential after touching lesions B) Sunbathing assists in eradicating the virus. C) Lesions should be massaged with ointment. D) Self-infection cannot occur from touching lesions during a breakout.

A) Good hand-washing is essential after touching lesions

A nurse is caring for a 16-year-old patient with primary syphilis who states that she contracted the disease by holding hands with someone who has syphilis. The most appropriate nursing diagnosis for this patient is: A) Knowledge deficit related to modes of transmission B) Noncompliance with treatment regimen related to age C) Fear related to complications D) Alteration in comfort related to impaired skin integrity

A) Knowledge deficit related to modes of transmission Syphilis is spread mainly by sexual contact and may be congenital. This patient displays knowledge deficit about the modes of transmission for syphilis.

A registered nurse working with a student nurse explains problems that can cause ventilator alarms. Which patient problems does the nurse include? (Select all that apply.) A. Asynchronous breathing B. Biting the endotracheal tube C. Copious secretions obstructing the tube D. Coughing and gagging E. Kinking of the ventilator tubes

A. Asynchronous breathing B. Biting the endotracheal tube C. Copious secretions obstructing the tube D. Coughing and gagging Asynchronous breathing, biting the tube, secretions, and coughing and gagging are all patient-related problems that lead to ventilator alarms. Kinked tubing is a ventilator problem

A nurse is assessing a client for possible risk factors for chlamydia and gonorrhea. Which of the following would the nurse identify? A) Asian American ethnicity B) Age under 25 years C) Married D) Consistent use of barrier contraception

B) Age under 25 years High-risk groups for chlamydia and gonorrhea include single women, women younger than 25 years, African American women, women with a history of STIs, those with new or multiple sex partners, those with inconsistent use of barrier contraception, and women living in communities with high infection rates.

A client with pneumonia develops respiratory acidosis. Which medications should the nurse prepare to administer to this client? Select all that apply. A) Furosemide (Lasix) 20 mg by mouth twice a day B) Amoxicillin 1 gram intravenous every 6 hours C) Albuterol inhaler 2 puffs every 4 hours D) Diazepam (Valium) 2 mg by mouth at bedtime for sleep E) Potassium chloride 20 mEq in 100 mL 0.9% normal saline intravenous every day

B) Amoxicillin 1 gram intravenous every 6 hours C) Albuterol inhaler 2 puffs every 4 hours Bronchodilator drugs such as albuterol inhaler may be administered to open the airways and antibiotics such as amoxicillin may be prescribed to treat respiratory infections. Benzodiazepines such as diazepam are central nervous system depressants and would adversely affect this client's respiratory rate, adversely affecting respiratory acidosis. Potassium chloride is indicated in the treatment of metabolic alkalosis.

The nurse is planning care to address pain in the client with genital herpes. Which intervention would be appropriate for this client? A) Increase the intake of cranberry juice. B) Clean lesions 2 or 3 times a day with warm water and soap. C) Dry lesions with a hair dryer turned to the hot setting. D) Wear tight cotton clothing.

B) Clean lesions 2 or 3 times a day with warm water and soap. Measures to reduce the discomfort of herpes lesions include cleansing the lesions two or three times a day with warm water and soap. Lesions should be dried using a hair dryer turned to a cool setting. It is important to wear loose cotton clothing that will not trap moisture. Fluids that increase urine acidity such as cranberry juice should be avoided.

The nurse is caring for a patient who has developed acute respiratory distress syndrome (ARDS) after smoke inhalation. Based on the pathologic changes in ARDS, the nurse expects what outcome during the first several hours? A) Improvement in airway patency with bronchodilator therapy B) Persistent and worsening hypoxia despite mechanical ventilation C) Evidence of hypercarbic respiratory failure with compensation D) General fluid volume deficit from capillary permeability increase

B) Persistent and worsening hypoxia despite mechanical ventilation

A client with acute respiratory distress syndrome (ARDS) is being weaned from ventilatory support. Which nursing actions are appropriate for this client? Select all that apply. A) Increase percentage of oxygen being provided through the ventilator. B) Place in the Fowler position. C) Provide morning care during the weaning procedures. D) Begin weaning procedures in the morning. E) Medicate with morphine for pain as needed.

B) Place in the Fowler position. D) Begin weaning procedures in the morning. Weaning a client from ventilatory support should begin in the morning when the client is well-rested. The client should be in the Fowler or high-Fowler position, as this facilitates lung expansion and reduces the work of breathing. Activities and care should be limited during the weaning process to reduce the demand for oxygen. The client should not be given any medication known to suppress respirations, as this would interfere with the weaning process. Medicating for pain would be appropriate when the client is back on the ventilator after concluding the weaning procedures. The percentage of oxygen is typically reduced during the weaning process.

The nurse is caring for an adolescent diagnosed with gonorrhea. Which medication is the drug of choice for this sexually transmitted infection? A) Griseofulvin B) Rocephin C) Acyclovir D) Penicillin

B) Rocephin

A child with a pneumothorax has a chest tube attached to a water seal system. When assessing the child, the nurse notices that the chest tube has become disconnected from the drainage system. Which of the following would the nurse do first? A) Notify the physician B) Apply an occlusive dressing C) Clamp the chest tube D) Perform a respiratory assessment

C) Clamp the chest tube If a chest tube becomes disconnected from the water seal drainage system, the nurse would first clamp the chest tube to prevent air from entering the child's chest cavity. Then the nurse would perform a respiratory assessment and notify the physician. An occlusive dressing would be applied first if the chest tube became dislodged from the child's chest.

The following are nursing interventions to assist in the prevention of pulmonary embolism in a hospitalized patient include all except: A. A liberal fluid intake. B. Assisting the patient to do leg elevations above the level of the heart. C. Encouraging the patient to dangle his or her legs over the side of the bed for 30 minutes, four times a day. D. The use of elastic stockings, especially when decreased mobility would promote venous stasis.

C. Encouraging the patient to dangle his or her legs over the side of the bed for 30 minutes, four times a day. c. Dangling could get the emboli stuck and may impede blood flow. A: A liberal fluid intake may help dissolve the clot. B: Leg elevations are done to avoid impeding blood flow. D: Elastic stockings could prevent venous stasis.

The client who has experienced blunt trauma to the chest is at risk for developing a hemo-thorax. Which would the nurse expect to find in a client with a hemothorax? A. Hemoptysis B. Paradoxical chest movements C. Percussion dullness on affected side D. Hypertympanic sound on affected side

C. Percussion dullness on affected side A hemothorax involves bleeding into the thoracic cavity (not into the pulmonary tree so hemop-tysis does not occur), decreasing lung inflation on the affected side. As a result of decreased lung inflation, percussion sounds become duller and less resonant.

In developing a plan of care, the nurse caring for a patient with gonorrhea knows that which of the following should be included in the treatment? A) Radiation therapy to destroy cancerous cells B) Avoid use of tampons C) Vaginal smear D) The patient should also be treated for chlamydia

D) The patient should also be treated for chlamydia Because of the high incidence of coinfection, treatment for gonorrhea should include treatment for chlamydia. One cause of cervicitis is chlamydia. A management strategy used in the treatment of chlamydia is cytologic examination of a cervical smear. Avoiding the use of tampons is part of the self-are management of a patient with possible toxic shock syndrome (TSS). Gonorrhea is considered a sexually transmitted disease (STD), not a carcinoma.

The nurse is providing information to a patient who has recently been diagnosed with genital herpes. Which statements indicates the need for further instruction? (Select all that apply.) a. "I am only contagious when I have open sores." b. "The infection is limited to only my genital region." c. "There is no permanent cure for this condition." d. "I will need to contact my physician for antibiotic cream for the open lesions whenever I have an outbreak." e. "Washing my hands is going to be a good method to prevent introduction of bacteria to the area."

a. "I am only contagious when I have open sores." b. "The infection is limited to only my genital region." d. "I will need to contact my physician for antibiotic cream for the open lesions whenever I have an outbreak." The disease may be spread during outbreaks. It is possible to spread the infection with viral shedding between outbreaks. Herpes is a lifelong condition. There is no cure. The condition's treatment can include the administration of antiviral medication. Antibiotics are not typically in-dicated

A client with primary syphilis was treated with an intramuscular injection of benzathine penicillin G. Later, the client reports a hard painful lump at the injection site and aching joints. Which is the nurse's highest priority initial action? a. Assess the client's vital signs. b. Give the client acetaminophen (Tylenol). c. Document the finding in the chart. d. Apply a warm compress to the site.

a. Assess the client's vital signs. A common reaction to penicillin injections for primary syphilis is the Jarisch-Herxheimer reaction, caused by rapid destruction of the causative microorganism and release of intracellular products. This is not usually serious, but it can cause fever and hypotension. The nurse should first assess the client's blood pressure for stability and should take the temperature. Then if the client's condition warrants, the nurse can administer acetaminophen or even fluids if needed. Documentation can be completed after the assessment is done. A warm compress to the site may or may not be helpful.

The nurse is caring for a client on a ventilator when the high-pressure alarm sounds. What actions are most appropriate? (Select all that apply.) a. Assess the tubing for kinks. b. Assess whether the tubing has become disconnected. c. Determine the need for suctioning. d. Call the health care provider. e. Call the Rapid Response Team. f. Auscultate the client's lungs.

a. Assess the tubing for kinks. c. Determine the need for suctioning. f. Auscultate the client's lungs. Reasons for a high-pressure alarm include water or a kink impeding airflow or mucus in the air-way. The nurse first should assess the client and determine whether he or she needs to be suctioned; then the nurse should auscultate the lungs. The nurse also should assess the tubing for kinks. The high-pressure alarm sounding would not be a reason to call the health care provider or the Rapid Response Team. If the tubing became disconnected, the low-pressure alarm would sound.

The nurse is aware that men with gonorrhea are more likely to seek medical attention because their symptoms are more visible than those of women. Which clinical manifestation is most consistent with symptoms of gonorrhea experienced by men? a. Copious purulent discharge from the penis b. Hematuria at the beginning of the urination stream c. Ulcer on the penis d. Scaly lesions on the scrotum

a. Copious purulent discharge from the penis The man can see his sexual organ and evaluate his urine easily. The man with gonorrhea will have a purulent discharge from the penis and scrotal pain. Vaginal discharges in women are not investigated until there are more significant signs such as changes in odor or color of vaginal secretions.

The nurse is aware that the patient is in respiratory failure when the blood gas findings contain which values? a. PaO2 46 mm Hg; PaCO2 52 mm Hg b. PaO2 50 mm Hg; PaCO2 45 mm Hg c. PaO2 52 mm Hg; PaCO2 42 mm Hg d. PaO2 55 mm Hg; PaCO2 58 mm Hg

a. PaO2 46 mm Hg; PaCO2 52 mm Hg Respiratory failure is defined by ABGs: arterial oxygen (PaO2) is below 50 mm Hg and partial pressure

The nurse is caring for a neonate on positive-pressure ventilation. The nurse monitors for which complications of positive-pressure ventilation? (Select all that apply.) a. Pneumothorax b. Pneumomediastinum c. Respiratory distress syndrome d. Meconium aspiration syndrome e. Pulmonary interstitial emphysema

a. Pneumothorax b. Pneumomediastinum e. Pulmonary interstitial emphysema Positive-pressure introduced by mechanical apparatus increases complications such as pulmonary interstitial emphysema, pneumothorax, and pneumomediastinum. Respiratory distress syndrome and meconium aspiration syndrome are not complications of positive-pressure ventilation.

The nurse is caring for several patients who require oxygen therapy. The nurse anticipates an order for noninvasive positive-pressure ventilation (NIPPV) for the patients with which diagnoses? (Select all that apply.) a. Pulmonary edema b. Obstructive sleep apnea c. Stroke with dysphagia d. Congestive heart failure

a. Pulmonary edema b. Obstructive sleep apnea d. Congestive heart failure In the cardiac patient, NIPPV reduces pulmonary edema because the increased alveolar pressure forces interstitial fluid out of the lungs and back into the pulmonary circulation. In patients who retain carbon dioxide, such as with obstructive sleep apnea, NIPPV keeps the airway open and prevents upper airway collapse. In selected patients, such as those with postpolio syndrome and other neuromuscular diseases, congestive heart failure, sleep disorders, and pulmonary diseases, NIPPV is often the treatment of choice in supporting ventilation without the hazards associated with endotracheal intubation. NIPPV is contraindicated in patients at high risk for aspiration, as after a stroke with dysphagia.

A 19-year-old patient begins to cry when she learns that she has genital herpes. The patient tearfully asks about the treatment. The nurse explains that treatment includes a drug that suppresses transmission, which is a. valacyclovir (Valtrex). b. acyclovir (Zovirax). c. famciclovir (Famvir). d. tobramycin (Nebcin).

a. valacyclovir (Valtrex). Valacyclovir, acyclovir, and famciclovir all reduce the likelihood of transmission, but valacyclovir has the best effects. Although acyclovir and famciclovir can reduce the likelihood of transmission of genital herpes, they are not as efficacious as valacyclovir. Tobramycin is not used in the treatment of genital herpes.

A client being treated for syphilis visits the office with a possible allergic reaction to benzathine penicillin G. Which abnormal findings would the nurse expect to document? (Select all that apply.) a.Red rash b.Shortness of breath c.Heart irregularity d.Chest tightness e.Anxiety

a.Red rash b.Shortness of breath d.Chest tightness e.Anxiety The nurse should keep all clients at the office for at least 30 minutes after the administration of benzathine penicillin G. Allergic manifestations consist of rash, shortness of breath, chest tightness, and anxiety, depicting anaphylaxis and serum sickness. Heart irregularity is not seen as an allergic manifestation.

Which of the following lab values would the nurse expect in a patient who has sustained trauma to the lungs and chest wall and is experiencing respiratory failure? a. Electrolyte imbalances b. Elevated PaCO2 c. Low hematocrit d. Elevated pH

b. Elevated PaCO2 In respiratory failure, inadequate gas exchange occurs such that PaO2 ≤ 60 mm Hg or PaCO2 ≥ 50 mm Hg with pH ≤ 7.25. Electrolyte imbalances do not occur, but changes in blood gas values do. Hematocrit may be unaffected. pH will be

A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? a. Administration of 100% oxygen by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of continuous positive pressure ventilation (CPAP)

b. Endotracheal intubation and positive pressure ventilation The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.

A client has secondary syphilis. What precautions are necessary for the nurse to take when caring for this client? a. No precautions in addition to Standard Precautions are necessary. b. Gloves should be worn whenever direct contact with the client's skin is required. c. Handwashing is required before and after contact with the client. d. A mask should be worn by anyone enter-ing the client's room.

b. Gloves should be worn whenever direct contact with the client's skin is required. The secondary stage of syphilis is a systemic disease, with microorganisms present in the client's blood. Skin lesions and rashes are present. These lesions are considered highly contagious and should not be touched without gloves. Handwashing before and after contact is needed but is not sufficient to prevent spread of the disease. Masks are not needed.

The patient is on mechanical ventilation. Which actions by the nurse are appropriate? (Select all that apply.) a. Keep the patient in a supine position. b. Note and mark the level of the endotracheal (ET) tube at the lips or nares. c. Have suction equipment available for immediate use. d. Perform mouth care at least twice daily.

b. Note and mark the level of the endotracheal (ET) tube at the lips or nares. c. Have suction equipment available for immediate use. The patient should be positioned with the head of bed elevated 30 to 45 degrees to reduce gastric reflux, thereby decreasing the risk for aspiration and ventilator-associated pneumonia. Note and mark the level of the ET tube at the lips or nares. This provides a baseline for depth of tube placement and ensures that the tube is not too close to the carina or in the right main stem bronchus. Set up suction equipment, including oral suctioning, to provide airway care and suctioning as needed of the ET or tracheostomy tube, to prevent plugging of the airway, and to reduce the risk for infection. Perform mouth care at least 4 times per 24 hours. Use a toothbrush and a solution such as chlorhexidine, which is effective in reducing oral bacteria and the risk for ventilator-associated pneumonia.

A patient admitted with acute respiratory failure has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action is a priority for the nurse to include in the plan of care? a. Encourage use of the incentive spirometer. b. Offer the patient fluids at frequent intervals. c. Teach the patient the importance of ambulation. d. Titrate oxygen level to keep O2 saturation >93%.

b. Offer the patient fluids at frequent intervals Because the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. Patients should be instructed to use the incentive spirometer on a regular basis (e.g., every hour) in order to facilitate the clearance of the secretions. The other actions may also be helpful in improving the patient's gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.

The nurse is caring for a patient with syphilis. Which manifestation indicates that the syphilis has progressed to the secondary stage? a. Foul-smelling penile discharge b. Positive serology c. Purulent skin rash d. Scrotal swelling

b. Positive serology A positive serology will appear in the secondary stage of syphilis. Penile discharge is not associated with the secondary stage of syphilis. A generalized skin rash, not purulent, may be seen in the secondary stage of syphilis. Scrotal swelling is not associated with syphilis.

Which actions should the nurse initiate to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)? a. Obtain arterial blood gases daily. b. Provide a "sedation holiday" daily. c. Elevate the head of the bed to at least 30°. d. Give prescribed pantoprazole (Protonix). e. Provide oral care with chlorhexidine (0.12%) solution daily.

b. Provide a "sedation holiday" daily. c. Elevate the head of the bed to at least 30°. d. Give prescribed pantoprazole (Protonix). e. Provide oral care with chlorhexidine (0.12%) solution daily. All of these interventions are part of the ventilator bundle that is recommended to prevent VAP. Arterial blood gases may be done daily but are not always necessary and do not help prevent VAP.

The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider? a. Blood urea nitrogen (BUN) level 32 mg/dL b. Red-brown drainage from orogastric tube c. Scattered coarse crackles heard throughout lungs d. Arterial blood gases: pH 7.31, PaCO2 50, PaO2 68

b. Red-brown drainage from orogastric tube The nasogastric drainage indicates possible gastrointestinal bleeding and/or stress ulcer, and should be reported. The pH and PaCO2 are slightly abnormal, but current guidelines advocating for permissive hypercapnia indicate that these would not indicate an immediate need for a change in therapy. The BUN is slightly elevated but does not indicate an immediate need for action. Adventitious breath sounds are commonly heard in patients with ARDS.

A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? a. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. b. The patient has subcutaneous emphysema on the upper thorax. c. The patient has bronchial breath sounds in both the lung fields. d. The patient has a first-degree atrioventricular heart block with a rate of 58.

b. The patient has subcutaneous emphysema on the upper thorax. The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not specific indications that PEEP should be reduced.

The preceptor is working with a new nurse to provide care for a patient with a chest tube to relieve a pneumothorax. Which action by the new nurse indicates need for additional teaching about chest tube care? a.The suction is discontinued when the patient is ambulated to the bathroom. b.The collection device is emptied at the end of the shift and output recorded in the chart. c.The patient's bed is placed in the semi-Fowler's position to facilitate lung re-expansion. d. The patient is encouraged to use his incentive spirometer at least 10 times every hour.

b.The collection device is emptied at the end of the shift and output recorded in the chart. The chest tube collection device is not emptied at the end of the shift. Instead, the amount of drainage present at the end of the shift (or specified time) is marked on the collection device and the amount of drainage entered into the patient's chart.

Which statement by a 24-year-old patient indicates that the nurse's teaching about management of primary genital herpes has been effective? a. "I will use acyclovir ointment on the area to relieve the pain." b. "I will use condoms for intercourse until the medication is all gone." c. "I will take the acyclovir (Zovirax) every 8 hours for the next week." d. "I will need to take all of the medication to be sure the infection is cured."

c. "I will take the acyclovir (Zovirax) every 8 hours for the next week." The treatment regimen for primary genital herpes infections includes acyclovir 400 mg 3 times daily for 7 to 10 days. The patient is taught to abstain from intercourse until the lesions are gone. (Condoms should be used even when the patient is asymptomatic.) Acyclovir ointment is not effective in treating lesions or reducing pain. Herpes infection is chronic and recurrent.

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best? a. "Breathing so rapidly interferes with oxygenation." b. "Maybe the client has respiratory distress syndrome." c. "The blood clot interferes with perfusion in the lungs." d. "The client needs immediate intubation and mechanical ventilation."

c. "The blood clot interferes with perfusion in the lungs." A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

A patient with a pneumothorax has a chest drainage system. The family asks when the chest tube will be removed. Which of the following responses, by the nurse, is best? a. "The tube is removed when serous drainage has stopped collecting in the system." b. "The tube is taken out when the patient is able to cough and deep breathe effectively." c. "When tidaling stops and lung sounds are equal on both sides, the tube can be removed." d. "When the adventitious lung sounds are resolved, it is usually safe to remove the tube."

c. "When tidaling stops and lung sounds are equal on both sides, the tube can be removed." Absence of tidaling and bilateral breath sounds are signs that the lung is reinflated and the chest tube can be safely removed. Drainage will generally have stopped at this time also, but it is not the primary determinant for removal. Coughing and deep breathing and clear lung sounds are not signs that the lung is reinflated.

The ambulatory care nurse is aware that after the appearance of the primary lesions, latent syphilis will begin in approximately a. 1 month. b. 3 to 6 months. c. 1 to 2 years. d. 3 to 5 years

c. 1 to 2 years. Latent syphilis usually occurs 1 to 2 years after the primary lesion and can last as long as 50 years.

A nurse is caring for a child in acute respiratory failure. Which blood gas analysis indicates the child is still in respiratory acidosis a. pH 7.50, CO2 48 b. pH 7.30, CO2 30 c. pH 7.32, CO2 50 d. pH 7.48, CO2 33

c. pH 7.32, CO2 50 Respiratory failure is a process that involves pulmonary dysfunction generally resulting in impaired alveolar gas exchange, which can lead to hypoxemia or hypercapnia. Acidosis indicates the pH is less than 7.35 and the CO2 is greater than 45. If the pH is less than 7.35 but the CO2 is low, it is metabolic acidosis. Alkalosis is when the pH is greater than 7.45. If the pH is high and the CO2 is high, it is metabolic alkalosis. When the pH is high and the CO2 is low, it is respiratory alkalosis.

The nurse notes that each time the mechanical ventilator delivers a breath to a client with acute respiratory distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the nurse's best intervention? a. Suction the client. b. Perform chest physiotherapy. c. Administer an inhaler. d. Assess the airway.

d. Assess the airway. An increase in peak inspiratory pressure (PIP) in the ARDS client is indicative of decreased lung compliance, making it more difficult to ventilate diseased lungs. The nurse first should assess the airway to make sure no sputum is present in the airway and that no kinks are noted in the tubing. The nurse is not able to make changes in the ventilator settings, so an order is needed to increase inspiratory pressure to oxygenate the client. Suctioning or performing chest physical therapy (PT) will not help the client's lung compliance; however, if mucus is impeding the airway, these interventions would be necessary and would be noticed when the airway is assessed. Administering a bronchodilator may help the client; however, an inhaler could not be used by a client on a ventilator.

The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next? a. Activate the rapid response team. b. Provide reassurance to the patient. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen.

d. Manually ventilate the patient with 100% oxygen. The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team are also appropriate after the nurse has stabilized the patient's oxygenation.

The nurse is caring for a patient whose ventilator settings include 15 cm H2O of positive end-expiratory pressure (PEEP). The nurse understands that although beneficial, PEEP may result in: a. fluid overload secondary to decreased venous return. b. high cardiac index secondary to more efficient ventricular function. c. hypoxemia secondary to prolonged positive pressure at expiration. d. low cardiac output secondary to increased intrathoracic pressure

d. low cardiac output secondary to increased intrathoracic pressure Positive end-expiratory pressure, especially at higher levels, can result in a decreased cardiac output and index secondary to increased intrathoracic pressure, which impedes venous return. Fluid overload is not an expected finding. The cardiac index would likely decrease, not increase, along with cardiac output. PEEP is used to treat hypoxemia; it does not cause it.

The high-pressure alarm on a patient's mechanical ventilator is alarming. What actions should the nurse take? Select all that apply 1. Assess if the patient needs to be suctioned. 2. Assess if the patient is biting the tube. 3. Assess if the patient has rolled onto the tube. 4. Assess for a mucous plug. 5. Assess for respiration synchrony with the ventilator.

1. Assess if the patient needs to be suctioned. 2. Assess if the patient is biting the tube. 3. Assess if the patient has rolled onto the tube. 4. Assess for a mucous plug. Rationale 1: High-pressure alarms should signal the nurse to check the patient to determine if suctioning is needed. Rationale 2: High-pressure alarms should signal the nurse to check if the patient is biting the endotracheal tube. Rationale 3: High-pressure alarms should signal the nurse to check if the patient has rolled onto the endotracheal tube. Rationale 4: High-pressure alarms should signal the nurse to assess if the patient is experiencing a mucous plug. Rationale 5: A high-pressure alarm does not indicate asynchronous respirations.

What effect does hemoglobin amount have on oxygenation status? 1. Low hemoglobin levels cause reduces oxygen-carrying capacity 2. Low hemoglobin levels cause increased oxygen-carrying capacity. 3. No effect 4. More hemoglobin reduces the client's respiratory rate

1. Low hemoglobin levels cause reduces oxygen-carrying capacity Hemoglobin carries oxygen to all tissues in the body. If the hemoglobin level is low, the amount of oxygen-carrying capacity is also low. More hemoglobin will increase oxygen-carrying capacity and thus increase the total amount of oxygen available in the blood. If the client has been tachypneic during exertion, or even at rest, because oxygen demand is higher than the available oxygen content, then an increase in hemoglobin may decrease the respiratory rate to normal levels.

The nurse auscultates crackles at the bases of the lungs of a client with adult respiratory distress syndrome (ARDS). The nurse knows that these adventitious lung sounds are due to: 1. fluid in the alveoli. 2. constriction of the airways. 3. hyperinflated alveoli. 4. mucus in the airways

1. fluid in the alveoli. Massive inflammation damages the alveolar capillary membranes, allowing plasma and blood cells to leak into the alveoli.

The nurse is caring for a patient on mechanical ventilation with positive end expiratory pressure (PEEP). When assessing the patient, which finding would indicate the possibility of tension pneumothorax? 1. new onset of absent breath sounds over the right lung 2. blood pressure of 170/80 3. pulse oximetry readings ranging from 94% to 96% 4. crackles and wheezing heard in both lungs

1. new onset of absent breath sounds over the right lung In a tension pneumothorax, air enters the pleural space with each breath but does not exit. Progressive accumulation of air in the pleural space leads to collapse of the lung on the affected side and hypoxia. As a result, the patient would have absent breath sounds on the affected side rather than adventitious sounds (crackles and wheezes). As the pressure in the thorax increases, cardiac output declines and the patient becomes hypotensive. A pulse oximetry reading of 94% demonstrates adequate oxygenation.

The nurse is caring for a patient intubated for acute respiratory distress syndrome (ARDS). Which medications should the nurse expect to be prescribed for this patient? Select all that apply. 1. surfactant 2. antibiotics 3. nitrous oxide 4. anticoagulants 5. cardiac glycosides

1. surfactant 3. nitrous oxide Although there is no definitive drug therapy for ARDS, a number of medications may be used. Inhaled nitric oxide reduces intrapulmonary shunting and improves oxygenation by dilating blood vessels in better-ventilated areas of the lungs. Surfactant therapy may be prescribed. Surfactant reduces the surface tension within the alveoli, helps maintain open alveoli, reduces the work of breathing, improves compliance and gas exchange, and prevents atelectasis. Antibiotics, anticoagulants, and cardiac glycosides are not indicated in the treatment of ARDS.

The nurse is caring for a client diagnosed with pneumonia. Which of the following signs and symptoms would the nurse most likely assess in this client? (Select all that apply.) 1. Abdominal pain 2. Anorexia 3. Cough 4. Dyspnea 5. Fever 6. Frequent wiping of the nose

1. Abdominal pain 2. Anorexia 3. Cough 4. Dyspnea 5. Fever Specific symptoms suggestive of pneumonia include fever, chills or rigor, sweats, new cough (with or without sputum), pleuritic chest pain, and dyspnea. Nonspecific symptoms include malaise, fatigue, abdominal pain, headaches, anorexia, and worsening of an underlying illness. Frequent wiping of the nose is a sign of allergic rhinitis.

Which assessment findings would the nurse evaluate as supporting the diagnosis of flail chest? Select all that apply. 1. An area of the chest wall is depressed when the patient inspires. 2. The patient's cough is weak and causes obvious pain. 3. The patient's chest x-ray reveals a broken rib. 4. The patient's respirations are shallow. 5. The patient has a sucking chest wound.

1. An area of the chest wall is depressed when the patient inspires. 2. The patient's cough is weak and causes obvious pain. 4. The patient's respirations are shallow. Flail chest is characterized by paradoxical chest movement. The instability in the chest wall results in an ineffective cough and pain when coughing.Flail chest results in decreased tidal volume and decreased vital capacity.

Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply. 1. Auscultation of breath sounds 2. Auscultation of bowel sounds 3. Presence of peripheral edema 4. Presence of chest pain. 5. Color of nail beds

1. Auscultation of breath sounds 3. Presence of peripheral edema 5. Color of nail beds A respiratory assessment, which includes auscultating breath sounds and assessing the color of the nail beds, is a priority for clients with pneumonia. Assessing for the presence of chest pain is also an important respiratory assessment as chest pain can interfere with the client's ability to breathe deeply. Auscultating bowel sounds and assessing for peripheral edema may be appropriate assessments, but these are not priority assessments for the patient with pneumonia.

Nursing interventions to prevent atelectasis and pneumonia include which of the following? Select all that apply. 1. Elevating the head of the bed 45 degrees 2. Keeping the patient lying in a prone position 3. Turning from side to side at least every 2 hours 4. Assisting with turning, coughing, and deep breathing once per shift 5. Assisting with the use of an incentive spirometer, taking 10 to 20 breaths per hour

1. Elevating the head of the bed 45 degrees 3. Turning from side to side at least every 2 hours 5. Assisting with the use of an incentive spirometer, taking 10 to 20 breaths per hour

A patient with ARDS is on a mechanical ventilator and is becoming increasingly restless with a heart rate of 128. The SaO2 is 88% and the ventilator settings are FiO2 50%; PEEP 8 cm; AC 10 with a total respiratory rate of 30; and a tidal volume of 700 mL. There are coarse rhonchi audible in all lung fields. The appropriate nursing action would be to: 1. Hyperoxygenate with 100% oxygen and suction the patient. 2. Administer the ordered neuromuscular blockade medications. 3. Increase the FiO2 to 60% and tidal volume to 750 mL for 2 minutes. 4. Increase the PEEP to 10 cm and sedate the patient.

1. Hyperoxygenate with 100% oxygen and suction the patient. The patient needs to be suctioned as evidenced by the symptoms of hypoxia-low SaO2 and tachycardia. The presence of rhonchi is most likely obstructing the airway.

The nurse is caring for a patient with acute respiratory distress syndrome who is being mechanically ventilated. What actions will the nurse take to prevent ventilator induced injury? Select all that apply. 1. Keep the tidal volume between 4 and 8 mL/kg. 2. Keep the plateau pressure ≤ 30 cm H2O. 3. Keep FiO2 ≤ 60%. 4. Assess arterial blood gas values for a PaCO2 to be between 60-100. 5. Set PEEP at 5-15 cm H2O.

1. Keep the tidal volume between 4 and 8 mL/kg. 2. Keep the plateau pressure ≤ 30 cm H2O 4. Assess arterial blood gas values for a PaCO2 to be between 60-100. Rationale 1: This ventilator setting will prevent ventilator induced injury. Rationale 2: This ventilator setting will prevent ventilator induced injury. Rationale 3: This ventilator setting will reduce the risk of oxygen toxicity. Rationale 4: Permissive hypercapnea prevents ventilator induced injury. Rationale 5: This ventilator setting will recruit alveoli and improve oxygenation.

The nurse is assessing an older patient's respiratory status. What factors related to aging can predispose this patient to pneumonia? Select all that apply. 1. slower respiratory rate 2. less effective cough 3. immobility 4. increased pain response 5. fixed income

2. less effective cough 3. immobility Skeletal muscle strength is lost in the thorax and diaphragm with aging. This contributes to a less effective cough and the ability to remove respiratory secretions. The secretions can pool in the lungs if the patient is not mobile, providing an environment for pneumonia to develop. Respiratory rate does not contribute to the risk of pneumonia. It is a myth that older adults have an increased pain response, and this would not directly contribute to the development of pneumonia. There is no direct correlation between being on a fixed income and developing pneumonia.

A client is in the emergency department with genital herpes for the third time. In order to reduce the severity of symptoms, the nurse advises the client to take the prescribed medications: 1. for the full course to kill the virus. 2. when the client experiences burning and tingling. 3. when the client develops respiratory symptoms. 4. when the herpes lesions appear.

2. when the client experiences burning and tingling. Burning and tingling are prodromal symptoms signaling the onset of a recurrence of herpes. The client should be taught to restart the medication at that time to reduce the length and severity of the disease.

A patient who was in a motor vehicle accident 1 day ago has been diagnosed with lung contusions. The patient develops increasing respiratory distress. The nurse recognizes that which factor will differentiate a diagnosis of acute lung injury (ALI) from a diagnosis of acute respiratory distress syndrome (ARDS)? 1. ALI patients have fewer injuries than ARDS patients. 2. ARDS patients have a lower respiratory rate than ALI patients. 3. ARDS and ALI differ only in the extent of hypoxemia. 4. ALI patients have more inflammation than ARDS patients.

3. ARDS and ALI differ only in the extent of hypoxemia. The difference between ALI and ARDS is based on the extent of hypoxemia. ALI is a less severe disease process.

A client has been treated with antibiotic therapy for right lower-lobe pneumonia for 10 days and will be discharged today. Which of the following physical findings would lead the nurse to believe it is appropriate to discharge this client? 1. Fever of 102*F 2. Vesicular breath sounds in right base 3. Continued dyspnea 4. Respiratory rate of 32 breaths/minute

2. Vesicular breath sounds in right base If the client still has pneumonia, the breath sounds in the right base will be bronchial, not the normal vesicular breath sounds. If the client still has dyspnea, fever, and increased respiratory rate, he should be examined by the physician before discharge because he may have another source of infection or still have pneumonia.

The nurse is reviewing orders written for a patient with uncomplicated gonorrhea. Which medications should the nurse expect to be prescribed for this patient? Select all that apply. 1. cefoxitin 2. ceftriaxone 3. doxycycline 4. clindamycin 5. azithromycin

2. ceftriaxone 3. doxycycline 5. azithromycin Most patients with uncomplicated gonorrheal infections are treated with a single intramuscular dose of ceftriaxone and an oral course of azithromycin or doxycycline. Because patients with gonorrhea frequently also are infected with C. trachomatis, concurrent treatment with azithromycin or doxycycline is recommended. Cefoxitin and clindamycin are used to treat pelvic inflammatory disease.

A client is diagnosed with genital herpes simplex virus. The nurse know that symptoms of the primary infection occur: 1. 1 to 4 days after exposure. 2. 3 to 7 days after exposure. 3. 5 to 9 days after exposure. 4. 7 to 11 days after exposure.

2. 3 to 7 days after exposure. Symptoms of the primary herpes simplex infection occur 3 to 7 days after exposure. The other choices do not describe the length of time before symptoms of the primary herpes simplex infection occur

Which setting on a ventilator would require a nursing intervention to improve the outcome for a 60 kg patient with acute lung injury (ALI)? 1. FiO2 = 0.30 or 30% 2. Tidal volume (VT) = 900 mL 3. Respiratory rate = 15 per minute, when the CO2 levels are elevated 4. Inspiratory: Expiratory ratio (I:E) = 1:2

2. Tidal volume (VT) = 900 mL Rationale 1: The patient with ALI needs supplemental oxygen to help maintain PaO2. Rationale 2: VT is the volume of gas delivered in one ventilatory cycle. VT is normally 7 mL/kg of body weight or around 500 mL. In mechanical ventilation, the volume is kept at 5-8 mL/kg in order to prevent trauma to lung tissues. In ALI, lower volumes are preferred. The nurse would need to discuss reducing the tidal volume with members of the multidisciplinary team. Rationale 3: No action is needed by the nurse. The rate is increased to allow the blow off of CO2; therefore, a rate 15 per minute is adequate for the patient with ALI. Rationale 4: It would not benefit the patient to alter the I:E ration while the tidal volume for this patient is excessive.

What will the nurse expect to assess in a patient with respiratory failure and hypoxemia? 1. Exertional dyspnea, circumoral cyanosis, distal cyanosis 2. Subcutaneous emphysema, absent breath sounds, sharp chest pain 3. Agitation, disorientation, lethargy, chest pain 4. Rales, distended neck veins, orthostatic hypotension

3. Agitation, disorientation, lethargy, chest pain Due to the hypoxia, the brain receives diminished oxygen and personality, perception, and the levels of consciousness are altered. Decreased respiratory reserves lead to hypoxia of the heart, which also requires higher percentages of oxygen to function. The anginal pain is a result of cardiac hypoxia.

The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following? 1. Inadequate peripheral circulation 2. Pleural effusion 3. Decreased oxygenation of the blood. 4. Decreased cardiac output

3. Decreased oxygenation of the blood. A client with pneumonia has less lung surface available for the diffusion of gases because of the inflammatory pulmonary response that creates lung exudate and results in reduced oxygenation of the blood. The client becomes cyanotic because blood is not adequately oxygenated in the lungs before it enters the peripheral circulation.

A comatose client needs a nasopharyngeal airway for suctioning. After the airway is inserted, he gags and coughs. Which action should the nurse take? 1. Reposition the airway. 2. Leave the airway in place until the client gets used to it. 3. Remove the airway and insert a shorter one. 4. Remove the airway and attempt suctioning without it.

3. Remove the airway and insert a shorter one. If a client gags or coughs after nasopharyngeal airway placement, the tube may be too long. The nurse should remove it and insert a shorter one. Simply repositioning the airway won't solve the problem. The client won't get used to the tube because it's the wrong size. Suctioning without a nasopharyngeal airway causes trauma to the natural airway.

Which of the following organisms most commonly causes community-acquired pneumonia in adults? 1. Klebsiella pneumoniae 2. Staphylococcus aureus 3. Steptococcus pneumoniae 4. Haemiphilus influenzae

3. Steptococcus pneumoniae Pneumococcal or streptococcal pneumonia, caused by streptococcus pneumoniae, is the most common cause of community-acquired pneumonia. H. influenzae is the most common cause of infection in children. Klebsiella species is the most common gram-negative organism found in the hospital setting. Staphylococcus aureus is the most common cause of hospital-acquired pneumonia.

The nurse discovers that the client suddenly has become short of breath. Which of the following assessment findings would increase the nurse's suspicion of a spontaneous pneumothorax of the left lung? Select all that apply. 1. Diminished breath sounds in the bases bilaterally, with rhonchi in the left lower lobe 2. Trachea is at midline. 3. Subcutaneous emphysema palpable on the left side of the chest 4. Absent breath sounds on the left side of the chest 5. Tachycardia and tachypnea

3. Subcutaneous emphysema palpable on the left side of the chest 4. Absent breath sounds on the left side of the chest 5. Tachycardia and tachypnea When the lung deflates due to a pneumothorax, the nurse will hear no breath sounds over the involved site. If air leaks from the lungs into the subcutaneous space, a crackling sensation will be felt—called subcutaneous emphysema—usually in the upper chest on the involved side. Heart rate can increase or decrease, respiratory rate increases, and the client reports suddenly feeling short of breath. A large pneumothorax can cause the trachea to shift to the side of the collapse, as chest organs suddenly have room to shift toward the empty space left by the pneumothorax. Breath sounds are not diminished, they are absent, as air is no longer entering the lobe or lobes of the lungs that are no longer functioning.

The nurse is caring for a patient with an intermediate risk for developing a pulmonary embolism. Which of the following interventions would be indicated for this patient? 1. bedrest 2. intravenous fluids 3. preventative anticoagulant therapy and antiembolism stockings 4. strict measurement of intake and output

3. preventative anticoagulant therapy and antiembolism stockings Prevention of pulmonary embolism is a priority of nursing care in all high-risk patients. Since the major cause of pulmonary embolism is deep vein thrombosis, management should center on interventions to prevent a deep vein thrombosis. Preventive measures include: early ambulation, anticoagulant therapy, antiembolism stockings, compression boots, elevation of injured leg above heart level, and frequent assessment of injured leg for signs of a deep vein thrombosis for early recognition and treatment. Deep vein thrombosis may not have any signs or symptoms; however, when present they may include unilateral leg swelling, pain or tenderness, or cramping. Bedrest would not help prevent the onset of a deep vein thrombosis. Intravenous fluids and strict measurement of intake and output would also not prevent the onset of a deep vein thrombosis

The right forearm of a client who had a purified protein derivative (PPD) test for tuberculosis is reddened and raised about 3mm where the test was given. This PPD would be read as having which of the following results? 1. Needs to be redone 2. Positive 3. Indeterminate 4. Negative

4. Negative This test would be classed as negative. A 5 mm raised area would be a positive result if a client was HIV+ or had recent close contact with someone diagnosed with TB. Indeterminate isn't a term used to describe results of a PPD test. If the PPD is reddened and raised 10mm or more, it's considered positive according to the CDC.

The nurse is teaching a student nurse the use of mechanical ventilators for clients in ventilatory failure. Which of the following is an accurate teaching point regarding this procedure? A) A mechanical ventilator is a machine that can be connected to the client via an ET. B) Mechanical ventilation is used if a client can achieve adequate tissue oxygenation. C) A mechanical ventilator is a machine that forces carbon dioxide into the lungs. D) In all settings, the nurse is responsible for adjusting the settings on the ventilator.

A) A mechanical ventilator is a machine that can be connected to the client via an ET. Mechanical ventilation is necessary when a client is unable to achieve adequate tissue oxygenation or to expire adequate amounts of carbon dioxide with use of supplemental oxygen. A mechanical ventilator is a machine that forces supplemental oxygen, air, or both into the lungs. The ventilator is connected to the client via an ET or a tracheostomy tube. Often, a respiratory therapist maintains or adjusts the settings per medical orders.

A patient is diagnosed with type I hypoxemic failure. The nurse realizes that this type of respiratory failure is linked to: 1. Muscular failure to move the air into and out of the lungs 2. Failure of the neurological system to stimulate respirations 3. Skeletal alterations of the thoracic region that limit air movement 4. Breakdown of oxygen transport from the alveolus to arterial

4. Breakdown of oxygen transport from the alveolus to arterial Type I hypoxemic failure is linked to a breakdown of oxygen transport from the alveolus to arterial flow.

A diagnosis of pneumonia is typically achieved by which of the following diagnostic tests? 1. Blood cultures 2. Chest x-ray 3. ABG analysis 4. Sputum culture and sensitivity

4. Sputum culture and sensitivity Sputum C & S is the best way to identify the organism causing the pneumonia. Chest x-ray will show the area of lung consolidation. ABG analysis will determine the extent of hypoxia present due to the pneumonia, and blood cultures will help determine if the infection is systemic.

A client is diagnosed with a large pneumothorax. The percussion note the nurse would expect to find is: 1. dullness. 2. flatness. 3. resonant. 4. tympany.

4. tympany Air-filled areas have a percussion note of tympany. A resonant note can be elicited by percussing a patient with normal lungs. Flatness is heard over bone and dullness is heard over the organs.

To determine if the client on mechanical ventilation has an improperly placed airway and unilateral lung inflation, the nurse should: A. Auscultate lung sounds B. Monitor the blood pressure C. Measure the respiratory rate D. Check the settings for the ventilator alarm

A. Auscultate lung sounds Auscultation of lung sounds verifies placement of an artificial airway.

The nurse is providing care to a client with pneumonia is has a fever. Which interventions should the nurse use to attain the goal of normal body temperature? Select all that apply. A) Increase the temperature of the room environment to prevent shivering. B) Administer antipyretic medications. C) Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance. D) Use ice packs and a tepid bath every 2 hours. E) Promote frequent rest periods to increase energy reserve

B) Administer antipyretic medications. E) Promote frequent rest periods to increase energy reserve Hyperthermia is an expected consequence of the infectious disease process. Fever can produce mild, short-term effects and, when prolonged, can cause life-threatening effects. The nurse should administer antipyretic medications as indicated for elevated temperatures and enforce frequent rest periods because rest increases energy reserve that is depleted by increased metabolic, heart, and respiratory rates. The nurse should use ice packs, cool/tepid baths, or a hypothermia blanket with caution and only as needed. The nurse should encourage fluid intake rather than restrict fluids because of the risk of electrolyte imbalance.

Which of the following interventions should a nurse implement for a client with pneumonia? A) Institute droplet precautions. B) Place the client in semi-Fowler's position. C) Isolate suspected and confirmed clients. D) Administer antiviral prophylaxis to all clients on an affected

B) Place the client in semi-Fowler's position.

A nurse is providing care for an older, previously healthy adult male who has been diagnosed today with pneumococcal pneumonia. Which of the following signs and symptoms is the nurse most likely to encounter? A) The man will be hypotensive and febrile and may manifest cognitive changes. B) The patient will have a cough producing clear sputum, and he will have faint breath sounds and fine crackles. C) The patient will have copious bloody sputum and diffuse chest pain and may lose his cough reflex. D) The patient will lack lung consolidation and will have little, if any, sputum production

B) The patient will have a cough producing clear sputum, and he will have faint breath sounds and fine crackles. The typical onset of pneumococcal pneumonia involves production of clear sputum, along with faint breath sounds and fine crackles. The patient is less likely to be hypotensive, have copious bloody sputum, or have chest pain. A lack of lung consolidation or sputum production is more closely associated with atypical pneumonias.

The nurse in the intensive care unit (ICU) is caring for a client diagnosed with acute respiratory distress syndrome (ARDS). Vital signs prior to endotracheal intubation: HR 108 bpm, RR 32 bpm, BP 88/58 mmHg, and oxygen saturation 82%. The client is intubated and placed on mechanical ventilation with positive pressure ventilation. Which assessment finding indicates a further decrease of cardiac output secondary to positive pressure ventilation? A) Blood pressure 90/60 mmHg B) Urine output 25mL/hr C) Heart rate 110 bpm D) Oxygen saturation 90%

B) Urine output 25mL/hr Decreased cardiac output is supported with by a decrease of urine output. Expected urine output is at least 30 mL/hr. This client's urine output is decreased; therefore this finding supports the diagnosis of decreased cardiac output. Although hypotension and tachycardia are indicative of a decreased cardiac output, this is not a change from the previous assessment and would not indicate a further decrease in cardiac output due to mechanical ventilation. The oxygen saturation level is within normal limits for this client and improving from the previous assessment

Which intervention should the nurse suggest for the client going home after a pulmonary embolism to reduce the risk for recurrence of a pulmonary embolism? A. "Avoid bending over at the waist." B. "Avoid prolonged sitting or standing." C. "Apply ice immediately to any site of injury." D. "Use an incentive spirometer every 2 hours while awake."

B. "Avoid prolonged sitting or standing." Prolonged sitting or standing contributes to increased venous stasis in the legs, increasing the risk for formation of a thrombus or embolus.

Which of the following is a type of embolism? A. Travelling emboli. B. Fat emboli. C. Burn emboli. D. Diabetic emboli.

B. Fat emboli. B. Fat emboli are one of the types of emboli. A: Travelling emboli is not a type of emboli. C: Burn emboli are not a type of emboli. D: Diabetic emboli are not a type of emboli.

The client sustained an injury to the chest in a motor vehicle crash. Which assessment finding 3 hours later alerts the nurse to a possible pulmonary contusion? A. Dyspnea B. Hemoptysis C. Hyperresonance on percussion D. Increased chest pain with movement

B. Hemoptysis Interstitial hemorrhage accompanies pulmonary contusion. Bleeding may not be evident at the initial injury, but the client develops hemoptysis and decreased breath sounds up to several hours after injury as bleeding into the alveoli

A ventilator alarm shows a decrease in minute ventilation. The nurse should: A. Reposition the client B. Suction excess secretions C. Drain the ventilator tubing D. Assess breath sounds and obtain a sample for arterial blood gas levels

B. Suction excess secretions A decrease in minute ventilation or tidal volume alarm can indicate airway secretions that require

The nurse is caring for a client who has been admitted to the unit with respiratory failure and respiratory acidosis. Which data from the nursing history would the nurse suspect contributed to the client's current state of health? A) Use of ibuprofen for the control of pain B) A recent trip to South America C) Aspiration pneumonia D) Recent recovery from a cold virus

C) Aspiration pneumonia Aspiration of a foreign body and acute pneumonia would put the client at risk for respiratory acidosis. A recent trip to South America would not constitute a respiratory risk factor. Recent recovery from a cold would not likely put the client at risk. Ibuprofen does not pose a threat to the respiratory health of the client.

A patient is prescribed acyclovir (Zovirax) for the treatment of genital herpes. What is the expected outcome of this medication? A) Decreased testosterone production B) Decreased libido C) Decreased viral shedding D) Decreased bacterial replication

C) Decreased viral shedding Acyclovir is used to treat genital herpes, in which it decreases viral shedding and the duration of skin lesions and pain. Acyclovir does not decrease testosterone or libido. Acyclovir is used to treat viral, not bacterial, infections.

The nurse is planning care for a client with a pulmonary embolism. Which intervention would assist with the client's decrease in cardiac output? A) Provide oxygen. B) Keep protamine sulfate at the bedside. C) Monitor pulmonary arterial pressures. D) Assess for bleeding.

C) Monitor pulmonary arterial pressures The client with a pulmonary embolism and decreased cardiac output is at risk for developing right heart failure. The nurse should monitor pulmonary arterial pressures. Assessing for bleeding and keeping protamine sulfate at the bedside would be appropriate for the client with ineffective protection. Oxygen would be appropriate for the client with impaired gas exchange.

The nurse is preparing to discharge a client recovering from a pulmonary embolism. Which topics are appropriate for the nurse to include in the teaching session? Select all that apply. A) Limit the use of over-the-counter medications. B) Diet to include green leafy vegetables C) Symptoms of recurrence D) Anticoagulant administration schedule E) Resume normal activity level.

C) Symptoms of recurrence D) Anticoagulant administration schedule The client being discharged after treatment for a pulmonary embolism needs to be instructed in anticoagulant therapy, avoiding green leafy vegetables because of vitamin K, adhering to the physician's prescribed activity level, and avoiding all over-the-counter medications. The nurse should instruct the client in symptoms of bleeding or recurrence of a pulmonary embolism and the schedule for anticoagulation administration

A patient with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation. The patient's high airway pressure alarm sounds, and the nurse finds asymmetrical chest expansion and absent breath sounds on the right.What is the probable cause of this situation? A) Oversedation B) Need for suctioning C) Impending respiratory arrest D) Acute pneumothorax

D) Acute pneumothorax

A nursing student is writing a care plan for a client hospitalized with pneumonia. Her priority nursing diagnosis is ineffective airway clearance. Which intervention should the nursing student include? A) Administration of the pneumococcal vaccine B) Smoking cessation education C) Limit fluid intake D) Chest percussion

D) Chest percussion

Which of the following statements best conveys an aspect of the respiratory pressures that govern ventilation? A) Intrapleural pressure slightly exceeds that of the inflated lung. B) The chest wall exerts positive pressure on the lungs that contributes to expiration. C) The lungs are prevented from collapsing by constant positive intrapulmonary pressure. D) Negative intrapleural pressure holds the lungs against the chest wall.

D) Negative intrapleural pressure holds the lungs against the chest wall. Negative intrapleural pressure holds the lungs in place against the chest wall and prevents their natural elastic properties from causing them to collapse. Intrapleural pressure is negative in relation to the inflated lung, and the chest wall exerts negative pressure on the lungs that keeps them from contracting and contributes to inspiration. Intrapulmonary pressure oscillates between positive and negative relative to atmospheric pressure with expiration and inspiration.

The nurse is caring for an adolescent diagnosed with syphilis. What is the drug of choice to treat this sexually transmitted infection? A) Griseofulvin B) Rocephin C) Acyclovir D) Penicillin

D) Penicillin

The nurse examines the genital area of a young man with lesions on the penis. The nurse suspects genital warts caused by the human papillomavirus (HPV), because the lesions appear: A) like blisters in clusters. B) singularly as pustules. C) like strawberries. D) like cauliflower growths.

D) like cauliflower growths. Genital warts have a cauliflower growth-like appearance. Option A describes genital herpes. Warts do not look like pustules or strawberries.

The following are diagnostic tests for a patient with pulmonary embolism except: A. Chest x-ray B. ECG C. ABG analysis D. Pulmonary function tests

D. Pulmonary function tests D: Pulmonary function tests are not performed in a patient with pulmonary embolism. A: Chest x-ray is a diagnostic test for patients with pulmonary embolism. B: ECG is a diagnostic test for patients with pulmonary embolism. C: ABG analysis is a diagnostic test for patients with pulmonary embolism.

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin)

a. Alteplase (Activase) Activase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.

The nurse is caring for a patient with genital herpes. Which manifestation alerts the nurse to a potential signal of an impending outbreak? a. Elevation in temperature b. Tingling sensation in the vagina c. Copious vaginal discharge d. Migraine-like headache

b. Tingling sensation in the vagina Many women with herpes can predict an outbreak because of tingling or burning in the vagina. Elevations in temperature, increased vaginal discharge, and headaches are not common precursors of a herpes outbreak.

The nurse is caring for a patient with a suspected pulmonary embolism. Which diagnostic tests or procedures should the nurse expect to be prescribed for this patient? (Select all that apply.) a. D-dimer b. Spirometry c. Angiogram d. Bronchoscopy e. Ventilation-perfusion lung scan f. Spiral computed tomography (CT) scan

a. D-dimer c. Angiogram e. Ventilation-perfusion lung scan f. Spiral computed tomography (CT) scan A spiral CT scan is a new and fast type of CT scan that is noninvasive and can diagnose PE quickly. If this is not available, a lung scan (ventilation-perfusion scan) is done to assess the extent of ventilation of lung tissue and the areas of blood perfusion. A pulmonary angiogram can outline the pulmonary vessels with a radiopaque dye injected via a cardiac catheter. D-dimer is a fibrin fragment that is found in the blood after any thrombus formation. It can be present in a number of disorders, but if it is negative, PE can be eliminated as a possible cause of the patient's symptoms. D. Bronchoscopy is not used to determine PE. B. Spirometry is not a diagnostic test.

The nurse is providing a discharge instruction sheet for a client who has had a pulmonary embolism and is going home on Coumadin therapy. Which of the following are important to review with the client? a. Follow up with the lab at prescribed intervals for PT/PTT levels. b. Use a soft toothbrush to prevent trauma to gums and bleeding. c. Inspect skin daily for bruises and/or petechiae. d. Eat a large amount of leafy, green vegetables a day for good nutrition. e. Continue other aspirin medications for arthritis pain as needed. f. Report nosebleeds, tarry stool, hematuria, or hematemesis to physician. g. Report signs and symptoms of amenorrhea to physician

a. Follow up with the lab at prescribed intervals for PT/PTT levels. b. Use a soft toothbrush to prevent trauma to gums and bleeding. c. Inspect skin daily for bruises and/or petechiae. f. Report nosebleeds, tarry stool, hematuria, or hematemesis to physician. Client teaching for anticoagulant therapy (Coumadin) should stress the importance of follow-up laboratory testing, using a soft toothbrush to prevent trauma to the gums (bleeding), inspecting the skin for bruises or petechiae, using an electric razor to avoid scratching skin, reporting nosebleeds, tarry stool, hematuria, or hematemesis to the physician, eating a consistent amount of green, leafy vegetables daily (differing amounts alter anticoagulant effects), avoiding other medications including aspirin (it has an anticoagulant effect) without approval from physician and in the female client, monitor menstrual flow for excessive amount.

The nurse is caring for an intubated child on mechanical ventilation. What interventions should the nurse implement to prevent ventilator-assisted pneumonia (VAP)? (Select all that apply.) a. Routine oral hygiene b. Appropriate hand hygiene c. Limit oropharyngeal suctioning of secretions d. Elevating the head of the bed 30 to 45 degrees e. Wearing gloves to handle respiratory secretions

a. Routine oral hygiene b. Appropriate hand hygiene d. Elevating the head of the bed 30 to 45 degrees e. Wearing gloves to handle respiratory secretions Critically ill children on mechanical ventilation are at risk for acquisition of VAP. To prevent VAP, recommendations for nurses working with mechanically ventilated patients include appropriate hand hygiene measures; wearing gloves to handle respiratory secretions or contaminated objects; elevating the head of the bed 30 to 45 degrees; and routine oral hygiene, which includes oropharyngeal suctioning of secretions.

A patient asks the nurse what signs and symptoms are associated with chlamydia. How should the nurse respond? a. The first signs that chlamydia presents are frequency and burning upon urination. b. Symptoms of chlamydia usually affect only women. c. Small red blisters appear first and then multiply. d. Dementia results if chlamydia goes untreated too long.

a. The first signs that chlamydia presents are frequency and burning upon urination. Urinary problems and abnormal discharge are often the first signs of chlamydia. Both men and women can experience these symptoms, although it is known as the silent STI because symptoms may not present for a length of time after the disease is contracted. Small red blisters are associated with genital warts and herpes. Chlamydia does not cause dementia.

The nurse is caring for a client with a high risk for pulmonary embolism (PE). Which prevention measures does the nurse add to the client's care plan? (Select all that apply.) a. Use antiembolism stockings. b. Massage calf muscles per client request. c. Maintain supine position with the legs flat. d. Turn every 2 hours if client is in bed. e. Refrain from active range-of-motion ex-ercises.

a. Use antiembolism stockings. d. Turn every 2 hours if client is in bed. Both antiembolism stockings (or sequential pressure devices) and a turning schedule can help prevent venous thromboembolism, which can lead to PE. Massaging the calves is discouraged because this can cause a clot to break loose and travel to the lungs. Legs should be elevated when in bed, and the client should perform active range of motion (ROM) if able. If the client is unable to perform active ROM, the nurse should provide passive ROM.

On physical examination of a client with pneumonia, the nurse would expect a. absence of whispered pectoriloquy over the affected area. b. increased tactile fremitus over the affected area. c. tympanic percussion notes over the affected area. d. vesicular breath sounds over the affected area.

b. increased tactile fremitus over the affected area. Consolidated lung tissue transmits bronchial sound waves to outer lung fields. Crackling sounds and whispered pectoriloquy may be heard over the affected areas. Tactile fremitus is usually increased over areas of pneumonia, whereas percussion notes are dulled.

A patient who has been diagnosed with chlamydia is started on a protocol of doxycycline and is reminded by the nurse that: (Select all that apply.) a. her partner does not need treatment. b. she should use a condom to protect part-ners from disease. c. the disease can develop into pelvic inflammatory disease. d. the entire prescription of antibiotics should be taken. e. the disease can result in an ectopic pregnancy.

b. she should use a condom to protect part-ners from disease. c. the disease can develop into pelvic inflammatory disease. d. the entire prescription of antibiotics should be taken. e. the disease can result in an ectopic pregnancy. The partner should be under treatment as well.

The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation and positive end-expiratory pressure (PEEP). The alarm sounds, indicating decreased pressure in the system. What is the nurse's best action? a. Change the client's position. b. Suction the client. c. Assess lung sounds. d. Turn off the pressure alarm.

c. Assess lung sounds. One of the biggest risks in the client with ARDS on mechanical ventilation with PEEP is tension pneumothorax. The nurse needs to assess lung sounds hourly. The alarms on a ventilator should never be turned off. If the client needed to be suctioned, the high-pressure alarm would sound. Changing the client's position would not change the pressure needed to administer a breath

When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes

c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.

Which medication should the nurse anticipate administering to a patient with a pulmonary embolism? a. Theophylline b. Corticosteroid c. Heparin d. Expectorant

c. Heparin If a thrombolytic agent is not used, treatment is aimed at preventing extension of the clot and the formation of additional clots. Heparin will prevent clot extension. Theophylline is a bronchodilator, corticosteroids are anti-inflammatory, and an expectorant will help raise secretions.

A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is found.

c. Teach the client about factor V Leiden testing. Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder should be referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature.

A client's ventilator alarm begins to ring. The nurse enters the room and notes that the "low expired minute volume" alarm is sounding. After quickly determining that the client is in no acute distress, the nurse would a. add more water to the humidifier. b. look for a kink in the tubing. c. look for a leak or disconnection in the system. d. suction the client's secretions.

c. look for a leak or disconnection in the system. Possible causes of low expired minute volume include low spontaneous client breathing activity, leakage in the cuff, leakage in the client circuit, and improper alarm limit setting. The nurse should check cuff pressure and the client circuit, performing a leakage test if necessary, and check pause time and graphics to verify, while considering more ventilator support for the client.

A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient's a. blood glucose. b. urine osmolality. c. serum creatinine. d. serum potassium.

c. serum creatinine.

The nurse providing care in a women's health care setting must be aware regarding which sexually transmitted infection that can be successfully treated and cured? a. Herpes b. Acquired immunodeficiency syndrome (AIDS) c. Venereal warts d. Chlamydia

d. Chlamydia The usual treatment for infection by the bacterium Chlamydia is doxycycline or azithromycin. Concurrent treatment of all sexual partners is needed to prevent recurrence. There is no known cure for herpes, and treatment focuses on pain relief and preventing secondary infections. Because there is no known cure for AIDS, prevention and early detection are the primary focus of care management. Condylomata acuminata are caused by human papillomavirus. No treatment eradicates the virus.

What action should a nurse implement to prevent complications in a patient with hepatitis who has been prescribed bedrest? a. Raise the knee gatch to prevent the patient from sliding down in bed. b. Provide undisturbed periods of 6 hours to encourage rest. c. Restrict fluids. d. Encourage turning, coughing, and deep breathing every 2 hours.

d. Encourage turning, coughing, and deep breathing every 2 hours. The nurse must encourage measures that will prevent pneumonia and improve impaired skin in-tegrity because of the increased risk factors associated with bedrest.

Which of the following will cause a nurse to suspect that a patient's pulmonary contusion is worsening? a. A pulmonary artery catheter showing a central venous pressure of 6 cm H2O and a wedge pressure of 8 mm Hg b. An increased need for pain medication c. An arterial blood gas value that demonstrates respiratory alkalosis d. Increased peak airway pressures on the ventilator

d. Increased peak airway pressures on the ventilator A contusion manifests initially as a hemorrhage followed by alveolar and interstitial edema. The edema can remain rather localized in the contused area or can spread to other lung areas. Inflammation affects alveolar-capillary units. As more units are affected by inflammation, further pathophysiologic events can occur, including decreased compliance, increased pulmonary vascular resistance, and decreased pulmonary blood flow. These processes result in a ventilation perfusion imbalance that results in progressive hypoxemia and poor ventilation over a 24-48hr period.

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which action will the nurse anticipate taking next? a. Increase the tidal volume and respiratory rate. b. Increase the fraction of inspired oxygen (FIO2). c. Perform endotracheal suctioning more frequently. d. Lower the positive end-expiratory pressure (PEEP).

d. Lower the positive end-expiratory pressure (PEEP). Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for pneumothorax.