UNIT 2 EXAM: Gas exchange exemplars: Pleural effusion, RSV, PE
The nurse is caring for a client who has undergone a total hip replacement. The nurse recognizes which clinical manifestations that indicate a pulmonary embolism? Select all that apply. 1.Sudden chest pain 2.Flushing of the face 3.Elevation of temperature 4.Abrupt onset of shortness of breath 5.Pain rating increase from 2 to 8 in the hip
1,4 Sudden chest pain is caused by decreased oxygenation to pulmonary tissues. Because capillary perfusion is blocked by the pulmonary embolus, oxygen saturation drops and the client experiences shortness of breath, dyspnea, and tachypnea. Flushing of the face and fever are not classic signs of pulmonary embolus. The pain associated with pulmonary embolus generally is sudden in onset, severe, and located in the chest, not the hip.
Hypocapnia causes respiratory alkalosis which causes
hypocalcemia and hypokalemia
A patient reports a tingling sensation in his extremities while experiencing which acid-base imbalance?
hypocapnia--> respiratory alkalosis
Which of the following is a complication from another condition? - Pleural effusion - RSV - Influenza - TB
Pleural effusion
1. Complete bed rest can place the patient at risk for ALL of the following EXCEPT: - Pneumonia - DVT - PE - RSV
RSV
1. Which is the priority intervention for a patient with RSV? - Oxygen via NC - Antibiotics - Suction - IV hydration
Suction
Hypercapnia causes respiratory acidosis which results in
hyperkalemia
What makes RSV especially difficult for young infants? - Obligatory nose breathers - Narrower airway - Inability to expectorate - All of the above
All of the above
A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention? 1.Administering an antiviral agent 2.Clustering care to conserve energy 3.Offering oral fluids to promote hydration 4.Providing an antitussive agent whenever necessary
2 Often the infant will have a decreased pulmonary reserve, and the clustering of care is essential to provide for periods of rest. Antiviral therapy is controversial for this age group and is not given unless complications ensue. Intravenous fluids are given during the acute phase to prevent dehydration. Antitussive agents are not used; nasal secretions are aspirated with the use of a bulb syringe whenever necessary.
A priority nursing intervention for a patient who has just undergone a chemical pleurodesis for recurrent pleural effusion is a. administering ordered analgesia. b. monitoring chest tube drainage. c. sending pleural fluid for laboratory analysis. d. monitoring the patient's level of consciousness
Administering ordered analgesia.
Which of the following creates a perfusion impairment? - RSV - Pleural effusion - PE
PE
A 5-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV) infection. The infant's condition suddenly deteriorates, and a dose of epinephrine is prescribed to relieve bronchospasm. For what side effect of the medication should the nurse assess the infant? 1.Tachycardia 2.Hypotension 3.Respiratory arrest 4.Central nervous system depression
1 Epinephrine stimulates beta- and alpha-receptors; its actions include increasing heart rate and blood pressure and inducing bronchodilation. Increased blood pressure, not hypotension, is a potential side effect. Epinephrine relieves respiratory problems; it does not cause respiratory arrest. Epinephrine stimulates, not depresses, the central nervous system.
An infant with bronchiolitis caused by respiratory syncytial virus (RSV) is admitted to the pediatric unit. What does the nurse expect the prescribed treatment to include? 1.Humidified cool air and adequate hydration 2.Postural drainage and oxygen by hood 3.Bronchodilators and cough suppressants 4.Corticosteroids and broad-spectrum antibiotics
1 Humidified cool air and hydration are essential to facilitating improvement in the child's physical status. Postural drainage is not effective with this disorder; oxygen is used only if the infant has severe dyspnea and hypoxia. Bronchodilators are not used, because the bronchial tree is not in spasm; cough suppressants are ineffective. Corticosteroids are ineffective; antibiotics are also ineffective, because the causative agent is viral.
The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply. 1.Place the infant in a private room. 2.Ensure that the infant's head is in a flexed position. 3.Wear a mask, gown, and gloves when in contact with the infant. 4.Place the infant in a tent that delivers warm humidified air. 5.Position the infant on the side, with the head lower than the chest. 6.Ensure that nurses caring for the infant with RSV do not care for other high-risk children.
1,3,6 Rationale: RSV is a highly communicable disorder and is transmitted via droplets or contact with respiratory secretions. Use of contact, droplet, and standard precautions during care (wearing gloves, mask, and a gown) reduces nosocomial transmission of RSV. In addition, it is important to ensure that nurses caring for a child with RSV do not care for other high-risk children to prevent the transmission of the infection. An infant with RSV should be placed in a private room. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. Cool humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea.
A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) infection is made, and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care? 1.Place in a warm, dry environment. 2.aintain standard and contact precautions. 3.Administer prescribed antibiotic immediately. 4.Allow parents and siblings to room in with the infant
2 RSV is highly contagious. The infant should be isolated or placed with other infants with RSV. Standard and contact precautions are instituted to limit the spread of pathogens to others. The infant should receive cool, humidified oxygen by nasal cannula or mask or in a croup tent. Because RSV is extremely contagious, the number of visitors should be limited. Uninfected children should not be allowed near the infant, and as few personnel as possible should care for the infant. Antibiotics are not effective against RSV, and their use is contraindicated.
The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? 1.Initiate strict enteric precautions. 2.Move the infant to a room with another child with RSV. 3.Leave the infant in the present room because RSV is not contagious. 4.Inform the staff that they must wear a mask, gloves, and a gown when caring for the child.
2 Rationale: RSV is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands. Use of contact and standard precautions during care is necessary. Using good hand-washing technique and wearing gloves and gowns are also necessary. Masks are not required. An infant with RSV is isolated in a single room or placed in a room with another child with RSV. Enteric precautions are unnecessary.
The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? 1.Initiate strict enteric precautions. 2.Move the infant to a private room. 3.Leave the infant in the present room, because RSV is not contagious. 4.Inform the staff that using standard precautions is all that is necessary when caring for the child.
2 Rationale: RSV is a highly communicable disorder and is transmitted via droplets and direct contact with respiratory secretions. Use of contact, droplet, and standard precautions during care is necessary. Using good hand-washing technique and wearing gloves, gown, and a mask should be done to prevent transmission. An infant with RSV should be placed in a private room to prevent transmission. Enteric precautions are unnecessary
A client with a suspected pulmonary embolism is scheduled for a spiral computed tomography scan. Which intervention should the nurse perform when preparing the client for the test? 1.Check the client's blood glucose levels. 2.Obtain informed consent from the client. 3.Assess if the client is allergic to shellfish. 4.Instruct the client to remove his or her dentures.
3 A spiral computed tomography scan may be used to diagnose a pulmonary embolism. Before preparing the client for the test, the nurse should assess if the client is allergic to shellfish since the contrast used in the test is iodine based. The client may be asked to remove his or her dentures while preparing for magnetic resonance imaging. An informed consent may not be needed for the spiral computed tomography; it may be required for endoscopic procedures such as a bronchoscopy. High blood glucose levels may interfere with the positron emission tomography scan; therefore, the nurse should check the blood glucose levels of the client before preparing for this test.
A client is receiving warfarin for a pulmonary embolism. Which drug is often contraindicated when taking warfarin? 1.Atenolol 2.Ferrous sulfate 3.Chlorpromazine 4.Acetylsalicylic acid
4 Acetylsalicylic acid can cause decreased platelet aggregation, increasing the risk for undesired bleeding that may occur with administration of anticoagulants. It should not be administered unless specifically prescribed, usually by a cardiologist or other specialist, to manage serious risks of thrombosis. Ferrous sulfate does not affect warfarin; it is used for red blood cell synthesis. Atenolol is a beta-blocker that reduces blood pressure; it does not affect bleeding. Chlorpromazine is a neuroleptic; it does not affect bleeding.
Which action by the parent of an infant with respiratory syncytial virus infection who is receiving ribavirin would indicate a need for further instruction regarding the management of the disease process? 1.Wearing protective garb when visiting the infant 2.Washing the hands before leaving the infant's room 3.Telling a family member who has asthma that he should not visit the infant 4.Telling the infant's aunt, who is pregnant, that it is acceptable to visit the infant
4 Rationale: When an infant is receiving ribavirin, exposure precautions need to be observed. Anyone entering the infant's room should wear a gown, mask, gloves, and hair covering. Anyone who is pregnant or considering pregnancy and anyone with a history of respiratory problems or airway disease should not care for or visit the infant who is receiving ribavirin. Hand washing is absolutely necessary before leaving the room to prevent the spread of germs
A nurse is providing education to a coworker who is caring for a client who is scheduled to have a thoracentesis for a pleural effusion. Which information will be appropriate for the nurse to include? 1.The thoracentesis procedure uses the principle of positive pressure. 2.It is common for a sclerosing agent to be instilled at the end of the procedure. 3.Clients will have temporary increased dyspnea immediately after the procedure. 4.Rapid removal of large amounts of fluid may precipitate cardiovascular collapse.
4 The mechanism is unclear, but cardiovascular collapse probably is caused by fluid shifts. A thoracentesis uses the principle of negative pressure. Use of a sclerosing agent is not commonly done. Dyspnea should be relieved immediately; if dyspnea increases, a pneumothorax should be suspected.
A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism? 1.An obese client with leg trauma 2.A pregnant client with acute asthma 3.A client with diabetes who has cholecystitis 4.A client with pneumonia who is immunocompromised
1 An obese client with leg trauma has two risk factors for the development of pulmonary embolism: obesity and leg trauma. A pregnant client with acute asthma has one risk factor for the development of pulmonary embolism: pregnancy. A client with diabetes who has cholecystitis has one risk factor for the development of pulmonary embolism: diabetes. A client with pneumonia who is immunocompromised has no risk factors for the development of pulmonary embolism.
A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? 1.A 59-year-old who had a knee replacement 2.A 60-year-old who has bacterial pneumonia 3.A 68-year-old who had emergency dental surgery 4.A 76-year-old who has a history of thrombocytopenia
1 Clients who have had a joint replacement have decreased mobility; they are at risk for developing thrombophlebitis, which may lead to pulmonary embolism if the clot becomes dislodged into the circulation. Bacterial pneumonia and emergency dental surgery are not associated with an increased risk for pulmonary embolism. A history of thrombocytopenia leads to a decreased ability to clot, so it increases the risk of bleeding but decreases the risk of a thrombus or embolus.
What points should be considered when a client with a respiratory disorder undergoes a spiral-computed tomography (CT) scan to diagnose a pulmonary embolism? Select all that apply. 1.The test involves the administration of a contrast medium. 2.Clients should have their hydration levels assessed. 3.Clients are instructed to lie still on a hard table. 4.Clients are served shellfish before the test. 5.A client's serum creatinine level is evaluated after the test
1,2,3 A contrast medium may be given intravenously when performing a spiral-computed tomography (CT). The nurse should make sure that the client is well hydrated before and after the procedure to help flush out the contrast medium. The nurse should instruct the client to lie still on the hard table and that the scanner will revolve around the body with clicking noises. The nurse should assess if the client is allergic to shellfish because the contrast medium used is iodine-based. The nurse should evaluate the client's blood urea nitrogen and serum creatinine before the test to assess renal function.
An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant? Select all that apply. 1.Limiting fluid intake 2.Instilling saline nose drops 3.Maintaining contact precautions 4.Suctioning mucus with a bulb syringe 5.Administering warm humidified oxygen
2,3,4 Saline nose drops help clear the nasal passage, which improves breathing and aids the intake of fluids. RSV is contagious; infants with RSV should be isolated from other children, and the number of people visiting or caring for the infant should be limited. Infants with RSV produce copious amounts of mucus, which hinders breathing and feeding; suctioning before meals and at naptime and bedtime provides relief. Fluid intake should be increased; adequate hydration is essential to counter fluid loss. These infants have difficulty nursing and often vomit their feedings. If measures such as suctioning before feeding and instilling saline nose drops are ineffective, intravenous fluid replacement is instituted. The humidified oxygen should be cool. It relieves the dyspnea and hypoxia that is prevalent in infants with RSV.
After a bronchoscopy because of suspected cancer of the lung, a client develops pleural effusion. What should the nurse conclude is the most likely cause of the pleural effusion? 1.Excessive fluid intake 2.Inadequate chest expansion 3.Extension of cancerous lesions 4.Irritation from the bronchoscopy
3 Cancerous lesions in the pleural space increase the osmotic pressure, causing a shift of fluid to that space. Excessive fluid intake is usually balanced by increased urine output. Inadequate chest expansion results from pleural effusion and is not the cause of it. A bronchoscopy does not involve the pleural space
When assessing a client with pleural effusion, what does the nurse expect to identify? 1.Moist crackles at the posterior of the lungs 2.Deviation of the trachea toward the involved side 3.Reduced or absent breath sounds at the base of the lung 4.Increased resonance with percussion of the involved area
3 Compression of the lung by fluid that accumulates at the base of the lungs reduces lung expansion and air exchange. There is no fluid in the alveoli, so no crackles are produced. If there is tracheal deviation, it is away from the involved side. Dullness is produced on percussion of the involved area.
A nurse caring for a client who has had a hysterectomy is concerned about the client's risk for postoperative thrombosis. The nurse remembers that the majority of pulmonary emboli begin as deep vein thromboses in what area? 1.Calf 2.Thoracic cavity 3.Pelvis and thighs 4.Extremities and abdomen
3 Most pulmonary emboli after surgery of the pelvic floor originate in the deep veins of the pelvis and thighs because of the extensive vascular network in the region. The calf, thoracic cavity, extremities, and abdomen are not where most pulmonary emboli originate after surgery involving the pelvic floor.
A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1.Hot, flushed feeling 2.Sudden chills and fever 3.Chest pain that occurs suddenly 4.Dyspnea when deep breaths are taken
3 Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.
After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client makes which statement? 1."Lately I can only breathe well if I sit up." 2."During the night I sometimes get the chills." 3."I get a sharp, stabbing pain when I take a deep breath." 4."I'm coughing up larger amounts of thicker mucus for the last several days."
3 Tension is placed on the pleura at the height of inspiration and causes pain. The response "Lately I can only breathe well if I sit up" is typical of heart failure. The response "During the night I sometimes get the chills" may indicate a pulmonary infection. The response "I'm coughing up larger amounts of thicker mucus for the last several days" may indicate a pulmonary infection.
A client with a history of pulmonary emboli is taking warfarin daily. The nurse teaches the client about foods that are appropriate to consume when taking this medication. The nurse evaluates that the client needs further teaching when the client makes which statement? 1."Eggs provide a good source of iron, which is needed to prevent anemia." 2."Yellow vegetables are high in vitamin A and should be included in the diet." 3."Milk and other high-calcium dairy products are necessary to counteract bone density loss." 4."Dark green leafy vegetables are high in vitamin K so I should eat them more often."
4 Foods high in vitamin K should be limited to usual amounts eaten by the client when establishing the prothrombin time/international normalized ratio because vitamin K is part of the body's blood-clotting mechanism and will counter the effects of warfarin if eaten in excess. Foods containing protein and iron are permitted because they are unrelated to blood clotting. Foods containing vitamin A are permitted because vitamin A is unrelated to blood clotting. Foods containing calcium are permitted because calcium is unrelated to blood clotting.
What physiologic alteration does the nurse expect when assessing a 6-month-old infant with bronchiolitis (respiratory syncytial virus [RSV])? 1.Decreased heart rate 2.Intercostal retractions 3.Increased breath sounds 4.Prolonged expiratory phase
4 Infectious and mechanical changes narrow the bronchial passages and make it difficult for air to leave the lungs. As a result of increased respiratory effort and decreased oxygen exchange, tachycardia may develop. Intercostal retractions are unlikely because of overinflation of the chest with air and shallow, rapid breathing. Breath sounds may be diminished because of swelling of the bronchiolar mucosa and filling of the lumina with mucus and exudate.
The nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. In which position should the nurse place the infant? 1.Supine, side-lying position with the arms elevated 2.Prone with the head of the bed elevated 15 degrees 3.Trendelenburg's, at a 60-degree angle with pelvis higher than head 4.Head and chest at a 30-degree angle with the neck slightly extended
4 Rationale: The nurse should position the infant with the head and the chest at a 30- to 40-degree angle with the neck slightly extended to maintain an open airway and to decrease pressure of the diaphragm. The positions noted in the remaining options do not achieve these goals.
