403 Exam 3 Questions
A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (SATA) A. encourage the client to cough & deep breath B. check for continuous bubbling in the suction chamber C. strip the drainage tubing every 4 hr D. clamp the tube once a day E. obtain a CXR
A, B, E
A nurse is caring for a client who has a prescription for heparin therapy. Which of the following statements by the client should indicate concern for the nurse? A. "I am allergic to morphine" B. "I take antacids several times a day for my ulcer" C. I had a blood clot in my leg several years ago" D. "It hurts to take a deep breath"
B - risk of bleeding from peptic ulcer, should notify provider
A nurse is assessment a client who has a PE. Which of the following should the nurse suspect? A. bradypnea B. pleural friction rub C. hypertension D. petechiae E. tachycardia
B, D, E *tachypnea, hypotension
A client with a cerebral embolus is receiving recombinant tissue-type plasminogen activator (tPA). The nurse should evaluate the client for which expected therapeutic outcomes of this drug? A. improved cerebral perfusion B. decreased vascular permeability C. dissolved emboli D. prevention of cerebral hemorrhage
C
What are possible causes for high pressure alarm?
bronchospasm, secretions, water in tubing, biting the endotracheal tube, and the fighting ventilator
Match the cause with either Hypoxemic (Oxygenation) Failure or Hypercapnic (Ventilation) Failure: 1. Acute respiratory distress syndrome 2. COPD 3. Pneumonia 4. Sedative and opioid overdose 5. Spinal cord injury 6. Pulmonary emboli 7. Cardiogenic pulmonary edema 8. Toxic inhalation 9. Asthma 10. Pain 11. Severe head injury 12. Severe obesity
1. O 2. V 3. O 4. V 5. V 6. O 7. O 8. O 9. V 10. V 11. V 12. V *Hypoxemic respiratory failure is commonly defined as a PaO2 less than 60 mm Hg when the patient is receiving an inspired O2 concentration of greater than or equal to 60%. Hypercapnic respiratory failure is commonly defined as a PaCO2 greater than 45 mm Hg in combination with acidemia (arterial pH less than 7.35). Clinical manifestations are variable and may develop suddenly or gradually, depending on the cause. Frequently, the first indication of acute respiratory failure is a change in the patient's mental status.
Which condition contributes to secondary pulmonary arterial hypertension by causing pulmonary capillary and alveolar damage? a. COPD b. Sarcoidosis c. Pulmonary fibrosis d. Pulmonary embolism
A - COPD & scleroderma *PE obstructs pulmonary blood flow but would not alone cause SPAH
A nurse is preparing to care for a client following chest tube placement. Which of the following should be available in the clients room? (SATA) A. oxygen B. sterile water C. enclosed hemostat clamps D. indwelling catheter E. occlusive dressing
A, B, C, E
Which of the following clients are at risk for developing ARDS? (SATA) A. client who experienced near drowning incident B. client following CABG surgery C. client who has hemoglobin of 15.1 D. client who has dysphagia E. client who has experienced acute drug toxicity
A, B, D, E *low hemoglobin is a risk
A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect pneumothorax? (SATA) A. tachypnea B. deviation of trachea C. bradycardia D. decreased use of accessory muscles E. pleuritic pain
A, B, E *tachycardia related to resp distress & pain, increased use of accessory muscles
A nurse is caring for a group of clients. Which of the following are at risk for PE? A. client with BMI of 30 B. female client who is postmenopausal C. client who has fractured femur D. client who is a marathon runner E. client who has chronic afib
A, C, E *postmenopause causes decreased estrogen & increased estrogen causes risk for PE, client who is marathon runner has increased blood flow & circulation which decreases risk for developing PE
A client with acute respiratory distress syndrome is showing signs of increased dyspnea. The nurse reviews a report of blood gas values: pH 7.35 PaCO2 25 mm Hg HCO3 22mEq/L PaO2 95 mm Hg Which finding is abnormal?
B
When caring for a patient with acute respiratory distress syndrome (ARDS), which finding indicates therapy is appropriate? A. Arterial pH is 7.32. B. PaO2 is greater than or equal to 60 mm Hg. C. PEEP increased to 20 cm H2O caused BP to fall to 80/40 D. No change in PaO2 when patient is turned from supine to prone position.
B
A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has ARDS. Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. the medication is used to treat infection B. the medication is used to facilitate ventilation C. the medication is used to decrease inflammation D. the medication is used to decrease anxiety
B - neuromuscular blocking agent given to facilitate ventilation & decrease oxygen consumption
What are clinical manifestations of barotrauma? A. Hypocapnia B. Subcutaneous emphysema C. Increase in rhonchi and/or crackles D. Unilateral decreased or absent breath sounds E. Bradypnea F. Tachycardia
B, D, F *hypercapnia & hypoemia
A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (SATA) A. confusion B. pale skin C. bradycardia D. hypotension E. elevated BP
B, E *others are late signs
A nurse is assisting a provider with the removal of a chest tube. Which of the following actions should the nurse take? A. instruct the client to lie prone with arms by side B. complete surgical checklist with client C. remind the client that there is minimal discomfort during the removal process D. place an occlusive dressing over the site once the tube is removed
D
A nurse is caring for a client receiving mechanical ventilation via ET tube. Which of the following actions should the nurse take? A. apply vest restraint if self extubation is attempted B. monitor vent settings every 8 hr C. document tube placement in cm at angle of jaw D. assess breath sounds every 4 hr
D *if self extubation, soft wrist restraints should be applied; settings should be monitored hourly; document tube placement in cm at teeth or lips
A nurse is reviewing discharge instructions for a client who has COPD and experienced a pneumothorax. Which of the following statements should the nurse include? A. notify your provider if you experience weakness B. you should be able to return to work in 1 week C. you need to wear a mask when in crowded areas D. notify your provider if you experience a productive cough
D - indicative of respiratory infection *weakness is expected, should expect lengthy recovery, not necessary to wear mask unless conditions with immunosuppression
A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first? A. Elevate the head of the bed 30 to 45 degrees. B. Encourage the client to cough and deep breathe. C. Auscultate the lungs to detect abnormal breath sounds. D. Contact the health care provider (HCP).
A
The nurse is caring for a patient who has developed acute respiratory failure. Which medication is used to decrease patient pulmonary congestion and agitation? A. Morphine B. Albuterol C. Azithromycin D. Methylprednisolone
A *Albuterol is used to reduce bronchospasm. Azithromycin is used for pulmonary infections. Methylprednisolone is used to reduce airway inflammation and edema.
A patient with acute respiratory distress syndrome (ARDS) is on positive pressure ventilation (PPV). The patient's cardiac index is 1.4 L/min and pulmonary artery wedge pressure is 8 mm Hg. What order by the provider would the nurse to question? A. Increase PEEP from 10 to 15 cm H2O. B. Start a dobutamine infusion at 3 mcg/kg/min. C. Give 1 unit of packed RBCs over the next 2 hours. D. Change the maintenance IV rate from 75 to 125 mL/hr.
A - High levels of PEEP increase intrathoracic pressure and cause decreased venous return which results in decreased CO
The patient with pulmonary fibrosis has hypoxemia during exercise but not at rest. To plan patient care, the nurse identifies the patient is experiencing which physiologic mechanism of respiratory failure? A. Diffusion limitation B. Intrapulmonary shunt C. Alveolar hypoventilation D. Ventilation-perfusion mismatch
A - The patient with pulmonary fibrosis has a thickened alveolar-capillary interface that slows gas transport, so hypoxemia is more likely during exercise than at rest *Intrapulmonary shunt occurs when alveoli fill with fluid (e.g., acute respiratory distress syndrome, pneumonia). Alveolar hypoventilation occurs when there is a generalized decrease in ventilation (e.g., restrictive lung disease, central nervous system diseases, neuromuscular diseases). Ventilation-perfusion mismatch occurs when the amount of air does not match the amount of blood that the lung receives (e.g., chronic obstructive pulmonary disease, pulmonary embolus).
The nurse is providing care for an older adult patient who has a low partial pressure of oxygen in arterial blood (PaO2) due to worsening left-sided pneumonia. Which intervention should the nurse use to help the patient mobilize his secretions? A. Augmented coughing or huff coughing B. Positioning the patient side-lying on his left side C. Frequent and aggressive nasopharyngeal suctioning D. Application of noninvasive positive pressure ventilation
A - aid in mobilization of secretions should be positioned with good lung down
A client has a chest tube attached to a water seal drainage system, and the nurse notes that the fluid in the chest tube and in the water seal column has stopped fluctuating. How should the nurse interpret this finding? A. The lung has tully expanded B. The lung has collapsed. C. The chest tube is in the pleural space. D. The mediastinal space has decreased
A - can indicate the lung has fully expanded & negative intrapleural pressure has been reestablished, chest tube is occluded, or chest tube is not in pleural space
A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following does the nurse recognize in a contraindication to therapy? A. hip arthroplasty 2 weeks ago B. elevated sedimentation rate C. incident of exercise induced asthma 1 week ago D. elevated PLT count
A - major surgery in past 3 weeks is contraindication to due risk of hemorrhage
A client has the following arterial blood gas values: pH 7.52; PaO2; 50 mm Hg; PaCO2, 28 mm Hg; HCO;- 24 mEq/L. Based upon the client's PaO2, which nursing clinical judgment should the nurse make? A. The client is severely hypoxic. B. The oxygen level is low but poses no risk for the client C. The client's PaO, level is within normal range. D. The client requires oxygen therapy with very low oxygen concentrations.
A - normal levels are 80-100; when levels fall below 50 there is impending respiratory failure
A client has been in an automobile accident, and the nurse is assessing the client for possible pneumothorax. What finding should the nurse immediately report to the health care provider? A. sudden, sharp chest pain B. wheezing breath sounds over affected side C. hemoptysis D. cyanosis
A - sudden, sharp chest pain, tachypnea, tachycardia, diminished or absent breath sounds, anxiety, restlessness are signs of pneumothorax
When should the nurse check for leaks in the chest tube and pleural drainage system? A. There is continuous bubbling in the water-seal chamber. B. There is constant bubbling of water in the suction control chamber. C. Fluid in the water-seal chamber fluctuates with the patient's breathing. D. The water levels in the water-seal and suction control chambers are decreased.
A - the water seal chamber should bubble intermittently as air leaves the lungs with exhalation in a spontaneously breathing pattern; continuous bubbling indicates a leak *the water in the suction control chamber will bubble continuously & the fluid in the water-seal chamber fluctuates with breathing (tidaling); water in the chambers evaporate & may have to be replaced periodically
A nurse is assisting the provider to care for a client who has developed a spontaneous pneumothorax. Which of the following should the nurse perform first? A. assess clients pain B. obtain large bore IV needle for decompression C. administer lorazepam D. prepare for chest tube insertion
B - ABCs, establish & maintain resp function *others are necessary but not priority
A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should be taken first? A. obtain CXR B. apply sterile gauze to insertion site C. place tape around insertion site D. assess respiratory status
B - allows air to escape & reduces risk for developing tension pneumo
The nurse observes a constant gentle bubbling in the water seal column of a water seal chest drainage system What should the nurse do? A. Continue monitoring as usual: this is expected. B. Check the connectors between the chest and drainage tubes and where the drainage tube enters chest drainage system C. Decrease the suction and continue observing the system for changes in bubbling during the next several hours D. Notify the health care provider (HCP)
B - bubbling should be intermittent; constant bubbling in the water seal chamber indicates an air leak which means that less negative pressure is being exerted on the pleural space *decreasing suction will not decrease the leak; do not notify HCP until system has been checked & problem is identified
A nurse is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the nurse indicates an understanding of PSV? A. it keeps the alveoli open & prevents AS B. it allows preset pressure delivered during spontaneous ventilation C. it guarantees minimal minute ventilator D. it delivers a preset ventilatory rate & tidal volume to the client
B - decreases WOB
The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? A. elevated carbon dioxide level B. hypoxia not responsive to oxygen therapy C. metabolic acidosis B. severe, unexplained electrolyte imbalance
B - hallmark sign of early ARDS is refractory hypoxemia - PaO2 will continue to fall despite higher oxygen concentrations *elevated CO2 & metabolic acidosis are late signs
While caring for a patient with idiopathic pulmonary arterial hypertension (IPAH), the nurse observes that the patient bds exertional dyspnea and chest pain in addition to fatigue. To what are these symptoms related? a. Decreased left ventricular output b. Right ventricular hypertrophy and failure c. Increased systemic arterial blood pressure d. Development of alveolar interstitial edema
B - high pressure in pulmonary arteries increases workload of the RV and eventually causes RV hypertrophy (cor pulmonale)
A nurse is caring for a client who has dyspnea and will receive continuous oxygen. WHich of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. nonrebreather mask B. venturi mask C. nasal cannula D. simple face mask
B - incorporates an adapter that allows precise amount of oxygen to be delivered *others deliver approximated amount of oxygen
What assessment finding would indicate the presence of a tension pneumothorax in a patient with chest trauma? A. Dull percussion sounds on the injured side B. Severe respiratory distress and tracheal deviation C. Muffled and distant heart sounds with decreasing BP D. Decreased movement and diminished breath sounds on the affected side
B - severe respiratory distress from collapse of the entire lung with movement of the mediastinal structures & tracheal deviation to unaffected sides is present with tension pneumo *Percussion dullness on injured site indicates presence of blood or fluid; decreased & diminished breath sounds are characteristic of a pneumothorax; muffled heart sounds & hypotension are signs of cardiac tamponade
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (SATA) A. continuous bubbling in water seal chamber B. gentle constant bubbling in suction control chamber C. rise & fall in level of water in water seal chamber with inspiration and expiration D. exposed sutures without a dressing E. drainage system upright at chest level
B, C *continuous bubbling indicates air leak D
A nurse is reviewing the plan of care for a client who is receiving mechanical ventilation. Which of the following ventilator modes will increased the clients WOB? (SATA) A. assist control B. synchronized intermittent mandatory ventilation C. continuous positive airway pressure D. pressure support ventilation E. independent lung ventilation
B, C, D *assist control takes over WOB; independent lung ventilation mode is used for unilateral lung disease to vent lungs individually
A nurse in the ED is assessing a client who has sustained multiple rib fractures and has a flail chest. Which of the following findings should the nurse expect? (SATA) A. bradycardia B. cyanosis C. hypotension D. dyspnea E. paradoxical chest movement
B, C, D, E *tachycardia due to inadequate oxygenation
A nurse is planning care for a client who has severe ARDS. which of the following actions should be included? (SATA) A. administer antibiotics B. provide supplemental oxygen C. administer antiviral meds D. administer bronchodilators E. maintain ventilatory support
B, D, E *only administer antibiotics if infection is present
A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6° C (101.4° F), and Sa0z 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest xray B. Prepare for chest tube insertion. C. Administer oxygen via a high flow mask. D. Initiate IV access.
C
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water seal chest tube drainage system. The nurse notes that the fluid in the water seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? A. An obstruction is present in the chest tube. B. The client is developing subcutaneous emphysema. C. The chest tube system is functioning properly. D. There is a leak in the chest tube system.
C *If obstruction was present fluid fluctuation would be absent; if there was a leak there would be continuous bubbling in the water seal column
A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states, "I am anxious and unable to get enough air." vital signs are heart rate 117, respirations 38, temperature 100.2F, blood pressure 100/54. Which of the following actions is the nurses priority? A. notify provider B. administer heparin via IV infusion B. administer oxygen therapy D. obtain CT scan
C - ABCs, need to meet oxygen needs *should do others but not priority action
With initial application of PEEP, which assessment will be of highest priority? A. Heart rate B. Urinary output C. Blood pressure D. peripheral pulses
C - PEEP increases intrathoracic pressure. This results in decreased venous return to the heart, decreased left ventricular end-diastolic volume (preload), decreased cardiac output (CO), and hypotension. Thus the monitoring of the patient's blood pressure would be of highest priority.
A pulmonary embolus is suspected in a patient with a deep vein thrombosis who develops dyspnea, tachycardia. chest pain. Diagnostic testing is scheduled. Which test should the nurse plan to teach the patient about? A. D-dimer B. Chest x-ray C. Spiral (helical) CT scan D. Ventilation-perfusion lung scan
C - allows illumination of all anatomic structures & produces 3D picture; if pt cannot have contrast dye a V/Q scan is done (pulmonary angiography is more sensitive but it is expensive, invasive, and has risk for complications) *D-dimer is not specific or sensitive for a small PE; CXR does not always detect PE unless necrosis or abscess occurs
The nurse is caring for a patient with multiple fractured ribs from a motor vehicle crash. Which assessment findings would be early indications that the patient is developing respiratory failure? A. Tachycardia and pursed lip breathing B. Kussmaul respirations and hypotension C. Frequent position changes and agitation D. Cyanosis and increased capillary refill time
C - change in mental status is early indication (restlessness, confusion, agitation, & combative behavior = inadequate oxygen delivery to the brain)
An unlicensed assistive personnel (UP) is taking care of a patient with a chest tube. The nurse should intervene when she observes the UAP: A. looping the drainage tubing on the bed. B. securing the drainage container in an upright position. C. stripping or milking the chest tube to promote drainage. D. reminding the patient to cough and deep breathe every 2 hours.
C - this procedure should only be done by the nurse (it is no longer recommended because it can increase the pleural pressure
A nurse should interpret which finding as an early sign of a tension pneumothorax in a client with chest trauma? A. diminished bilateral breath sounds B. muffled heart sounds C. respiratory distress D. tracheal deviation
C - universal finding of pneumothorax *unilateral absent or diminished breath sounds is a common fining; tracheal deviation is a late sign
To promote effective airway clearance in a client with acute respiratory distress, what should the nurse do? A. Administer oxygen every 2 hours. B. Turn the client every 4 hours. C. Administer sedatives to promote rest. D. Suction if cough is ineffective.
D *administering oxygen will not promote airway clearance; patient should be turned every 2 hrs to promote secretion movement; administering sedatives is contraindicated in ARD
A client has a chest tube and water seal drainage system. What should the nurse do to ensure safe & effect use of the drainage system? A. Verify that the air vent on the water seal drainage system is capped when the suction is off B. Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs C. Ensure that the chest tube is clamped when moving the client out of the bed D. Make sure that the drainage apparatus is alway below the client's chest level
D *air vent must always be open in the closed chest drainage system to allow air to escape; stripping can cause excessive negative intrapleural pressure; clamping a chest tube when moving a client is not recommended
Following of MVA, the nurse assesses the driver for which distinctive sign of flail chest? A. Severe hypotension B. Chest pain over ribs C. Absence of breath sounds D. Paradoxical chest movement
D - chest wall cannot provide support for ventilation, & the injured segment will move paradoxically on the stable portion on the chest (in on expiration & out on inspiration)
