Ch 32- Book/Evolve/PPTs

intubation management

-always hyperoxygenate -intubation attemps should take less than 30 seconds, if not, supply O2 - drug/fluid therapy

A 242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole numbe.r ) ___ mL

660 mL A low tidal volume of 6 mL/kg is used to prevent lung injury. 242 pounds = 110 kg. 110 kg 6 mL/kg = 660 mL.

D-Dimer

A normal or low value can be used to rule out an PE. D-dimer measurement is an important diagnostic of pulmonary thromboembolism (PE) evaluation An elevated D-dimer level is not normal. It is usually found after a clot has formed and is in the process of breaking down.

The nurse is caring for a group of clients on a Telemetry unit. When providing client education, which client will the nurse determine most needs information regarding preventing pulmonary embolism (PE)? A. A woman who frequently flies to Europe B. A man who works on a farm C. A man admitted for a myocardial infarction D. A woman with a bleeding disorder

A. A woman who frequently flies to europe

When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse calls the Rapid Response Team (RRT) for intervention for which client? A. Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia B. Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain C. Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry reading of 94% D. Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs

A. Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia

The nurse is caring for a group of clients on a medical surgical unit. Which clients will the nurse monitor closely for respiratory failure? (Select all that apply.) A. Client with a brainstem tumor B. Client with acute pancreatitis C. Client with a C5 spinal cord injury D. Client using client-controlled analgesia E. Client experiencing cocaine intoxication

A. Client with a brainstem tumor B. Client with acute pancreatitis C. Client with a C5 spinal cord injury D. Client using client-controlled analgesia

The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms consistent with PE will the nurse assess? (Select all that apply.) A. Dizziness and syncope B. Shortness of breath (SOB) worsening over the last 2 weeks C. Inspiratory chest pain D. Productive cough E. Pink, frothy sputum F. Tachycardia

A. Dizziness and syncope C. Inspiratory chest pain F. Tachycardia

The nurse is caring for a client who has just been extubated after receiving mechanical ventilation. Which action will the nurse delegate to unlicensed assistive personnel (UAP)? A. Keep the head of the bed elevated. B. Teach about incentive spirometer use. C. Monitor vital signs every 5 minutes. D. Adjust the nasal oxygen flow rate.

A. Keep the head of the bed elevated.

The intensive care nurse is working on a unit-based project to prevent intensive care unit (ICU) psychosis. Which intervention does the nurse recommend to best decrease the incidence of ICU psychosis? A. Providing frequent explanations and reassurance B. Keeping the lights on to promote orientation C. Administering sedation D. Providing television or radio for stimulation

A. Providing frequent explanations and reassurance

When caring for a client with a pulmonary embolism, which priority intervention will the nurse use to reduce anxiety? A. Remain with the client and provide oxygen in a calm manner. B. Have the client breathe into a brown paper bag using pursed lips. C. Offer the client a mild sedative. D. Allow a family member to remain in the room.

A. Remain with the client and provide oxygen in a calm manner

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning

ANS: A, B, C, D The ventilator bundle is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

ANS: A, B, C, E Clients with PEs are often anxious. The nurse can acknowledge the clients fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the clients anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing

ANS: A, B, D Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity.

A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the clients bedside. b. Ensure the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.

ANS: A, B, D, E There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the clients skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.

A client in the emergency department has several broken ribs. What care measure will best promote comfort? a. Allowing the client to choose the position in bed b. Humidifying the supplemental oxygen c. Offering frequent, small drinks of water d. Providing warmed blankets

ANS: A. Allowing the client to choose the position in bed. Allow the client with respiratory problems to assume a position of comfort if it does not interfere with care. Often the client will choose a more upright position, which also improves oxygenation. The other options are less effective comfort measures.

20.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)

ANS: A. Alteplase 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.

7.A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other manifestations of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths.

ANS: A. Assess for other manifestations of hypoxia Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the clients hands. d. Sedate the client immediately.

ANS: A. Assess the cause of the agitation. The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain and confusion can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary, but not as a first step.

A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse? a. Assessing the clients platelet count b. Choosing an 18-gauge, 2-inch needle c. Not aspirating prior to injection d. Swabbing the injection site with alcohol

ANS: B. Choosing an 18-gauge, 2 inch needle Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions are appropriate.

A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority? a. Assessing that the ventilator settings are correct b. Ensuring there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room

ANS: B. Ensuring there is a bag valve mask in the room Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse should know and check the settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or may not need suctioning on arrival.

4.A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin (Coumadin).

ANS: B. Increase heparin rate For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working. A normal PTT is 25 to 35 seconds, so this clients PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication? a. Hamburger and French fries b. Large chefs salad and muffin c. No selection; spouse brings pizza d. Tuna salad sandwich and chips

ANS: B. Large chef salad and muffin Warfarin works by inhibiting the synthesis of vitamin K dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. The chefs salad most likely has too many leafy green vegetables, which contain high amounts of vitamin K. The other selections, while not particularly healthy, will not interfere with the medications mechanism of action.

1.A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? a. Assess the clients lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs.

ANS: B. Notify Rapid Response This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.

6.A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL b. Platelet count: 82,000/L c. Red blood cell count: 4.8/mm3 d. White blood cell count: 8.7/mm3

ANS: B. Platelet count: 82,000/L This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.

5.A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best? a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush.

ANS: B. Prepare preoperative teaching for an inferior vena cava filter Often clients are discharged from the hospital on warfarin (Coumadin) after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be implanted. The nurse should prepare to do preoperative teaching on this procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy.

A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management? a. Poor visual acuity b. Strict vegetarian c. Refusal to stop smoking d. Wants weight loss surgery

ANS: B. Strict Vegetarian Warfarin works by inhibiting the synthesis of vitamin K dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have trouble maintaining this diet. The nurse should explore this possibility with the client. The other options are not related.

3.A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients 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.

ANS: 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 client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Apply oxygen at 100%. b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines.

ANS: C. Ensure a patent airway The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs.

8.A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? a. Ensure the client has adequate sedation. b. Find another provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the clients oxygen saturation.

ANS: C. Interrupt the procedure to give oxygen Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation during the procedure and monitor the clients oxygen saturation, but these do not take priority. Finding another provider is not appropriate at this time.

9.An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b. Ensure all connections are patent. c. Listen to the clients lung sounds. d. Suction the endotracheal tube.

ANS: C. Listen to client's lung sounds When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.

10.A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools.

ANS: C. Provide frequent oral care per protocol The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse.

2.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.

ANS: 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 student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best? a. It is chronic hypoxemia that accompanies restrictive airway disease. b. It is hypoxemia from lung damage due to mechanical ventilation. c. It is hypoxemia that continues even after the client is weaned from oxygen. d. It is hypoxemia that persists even with 100% oxygen administration.

ANS: D. It is hypoxemia that persists even with 100% oxygen Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.

A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best? a. It will increase the motility of the gastrointestinal tract. b. It will keep the gastrointestinal tract functioning normally. c. It will prepare the gastrointestinal tract for enteral feedings. d. It will prevent ulcers from the stress of mechanical ventilation.

ANS: D. It will prevent ulcers from the stress of mechanical ventilation. Stress ulcers occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Zantac is a histamine blocking agent.

A client is brought to the emergency department after sustaining injuries in a severe car crash. The clients chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority? a. Administer oxygen and reassess. b. Auscultate the clients lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.

ANS: D. Prepare to assist with intubation. This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.

A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.

ANS: D. The upper peak airway pressure limit alarm is on The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury.

nursing management vent

Always assess patient first, ventilator second Monitor patient response Manage ventilator system Prevent complications!

et tubes nursing care

Assess tube placement ET Tip should be 2cm above carina p. 628 Minimal cuff leak Bilateral breath sounds & chest wall movement Prevent movement of tube by patient Check pilot balloon 20 to 30 cm H2O Soft wrist restraints Mechanical sedation Sometimes bite block used

When receiving report on a group of clients on the step down unit, which client needs immediate attention by the nurse? A. A client who is receiving continuous positive airway pressure (CPAP) and has intermittent wheezing B. A client receiving mechanical ventilation who has tracheal deviation C. A client who was recently extubated and is reporting a sore throat D. A client who is receiving O2 by facemask and whose respiratory rate is 24 breaths/min

B. A client receiving mechanical ventilation who has tracheal deviation

The nurse is reviewing the medical record of a client with pulmonary embolism (PE). What priority does the nurse set after reviewing the blood gas result below? pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L (26 mmol/L), PaO2 62 mm Hg A. Have the client breathe rapidly and deeply B. Apply oxygen C. Administer sodium bicarbonate D. Collaborate with the provider to increase the pH

B. Apply oxygen

A client in the intensive care unit (ICU) who is receiving mechanical ventilation begins to pick at the bedcovers. Which action will the nurse take next? A. Increase the sedation. B. Assess for adequate oxygenation. C. Explain that the tube in the client's throat helps with breathing. D. Request that the family leave to decrease the client's agitation

B. Assess for adequate oxygenation

The nurse coming on shift prepares to perform an initial assessment of a client receiving sedation and mechanical ventilation through a tracheostomy. Which are priorities for the nurse to carry out? (Select all that apply.) A. Ask visitors to leave the room. B. Assess the client's color and respirations. C. Confirm alarms and ventilator settings. D. Ensure that the tube is in proper position. E. Auscultate for bilateral breath sounds. F. Provide routine tracheostomy and mouth care

B. Assess the client's color and respirations C. Confirm alarms and vent settings D. Ensure that the tube is in proper position E. Auscultate for bilateral breath sounds

The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which respiratory modality does the nurse suggest to the interdisciplinary team as an alternative to mechanical ventilation? A. Oropharyngeal airway B. Bi-level positive airway pressure (BiPAP) C. Non-rebreather mask with 100% oxygen D. Positive end-expiratory pressure (PEEP)

B. Bi-level positive airway pressure (BiPAP)

The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure. Which findings would cause the nurse to suspect a left-sided tension pneumothorax? A. The left chest caves in on inspiration and "puffs out" on expiration. B. Chest asymmetry and jugular vein distention are present. C. The left lung field is dull to percussion with crackles present on auscultation. D. The client has bloody sputum and wheezes.

B. Chest asymmetry and jugular vein distention are present.

The nurse is caring for a group of clients with respiratory disorders. For which of these clients does the nurse plan for immediate intubation? A. Client who requires suctioning of oral secretions B. Client with hypoventilation and decreased breath sounds C. Client with O2 saturation of 90% D. Client with thick, purulent secretions and crackles

B. Client with hypoventilation and decreased breath sounds

When caring for the client receiving mechanical ventilation, the nurse includes which of these interventions to prevent ventilator-associated pneumonia (VAP)? (Select all that apply.) A. Administering antibiotic prophylaxis B. Continuous removal of subglottic secretions C. Elevating the head of the bed at least 30 degrees whenever possible D. Handwashing before and after contact with the client E. Placing a nasogastric tube F. Placing the client in a negative-airflow room

B. Continuous removal of subglottic secretions C. Elevating the head of the bed at least 30 degrees whenever possible D. Handwashing before and after contact with the client

23.A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Shortness of breath for 20 minutes Feels frightened Laboratory Analysis Physical Assessment Cant catch my breath pH: 7.12 PaCO2: 28 mm Hg PaO2: 58 mm Hg SaO2: 88% Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles What action by the nurse is most appropriate? a. Call respiratory therapy for a breathing treatment. b. Facilitate a STAT pulmonary angiography. c. Prepare for immediate endotracheal intubation. d. Prepare to administer intravenous anticoagulants.

B. Facilitate Stat pulmonary angiography This client has manifestations of pulmonary embolism (PE); however, many conditions can cause the clients presentation. The gold standard for diagnosing a PE is pulmonary angiography. The nurse should facilitate this test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of PE.

A client has been admitted with a diagnosis of pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? A. Teach the client to avoid using dental floss. B. Monitor the platelet count daily. C. Ensure adequate staffing for the unit. D. Notify radiology of an impending scan.

B. Monitor platelet count daily

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femur

B. Spinal cord injury on rotating bed D. 1 day post hip replacement E. Obese with fractured femur Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.

The nurse is overseeing a nursing student who is administering medications to a group of clients receiving treatment for pulmonary embolism. The nurse recognizes the student understands safety and administration of anticoagulant therapy when the student makes which of these statements? A. "The client will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days." B. "Therapy with warfarin (Coumadin) is effective when the INR is between 2 and 3." 3. "Once the health care provider orders warfarin (Coumadin), the intravenous heparin can be discontinued." 4. "If bleeding develops, we will give platelets to reverse the anticoagulant."

B. Therapy with warfarin (coumadin) is effective when the INR is between 2 and 3.

The nurse is caring for a group of clients on a medical surgical unit. For which of these individuals does the nurse provide immediate interventions to reduce the risk for pulmonary embolism (PE)? A. A client with diabetes and cellulitis of the leg B. A client receiving IV fluids through a peripheral line C. A client returning from an open reduction and internal fixation of the tibia D. A client with fluid volume deficit and hypokalemia receiving potassium supplements

C. A client returning from an open reduction and internal fixation of the tibia

The charge nurse in the intensive care unit is overseeing care for a group of clients. The nurse is especially vigilant in collaboration with the primary nurse and interprofessional team in assessing for acute respiratory distress syndrome (ARDS) in which of these clients? A. Client with diabetic ketoacidosis (DKA) B. Client with atrial fibrillation C. Client with aspiration pneumonia D. Client with acute kidney failure

C. Client with aspiration pneumonia

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 D. Healthy Weight E. Quit 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.

The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority? A. Inadequate nutrition related to food-drug interactions with anticoagulant therapy B. Risk for infection related to leukocytosis C. Hypoxemia related to ventilation-perfusion mismatch D. Insufficient knowledge related to the cause of PE

C. Hypoxemia related to ventilation-perfusion mismatch

The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action will the nurse take first? A. Check the ventilator alarm settings. B. Assess the set tidal volume. C. Listen to the client's breath sounds. D. Call the respiratory therapist

C. Listen to the client's breath sounds

The nurse is providing education about the management of respiratory failure to the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse will communicate? A. "Sedation is needed so your loved one does not rip the breathing tube out." B. "Suctioning is important to remove organisms from the lower airway." C. "Paralytics and sedatives help decrease the demand for oxygen." D. "We are encouraging oral and IV fluids to keep your loved one hydrated."

C. Paralytics are sedatives help decrease the demand for oxygen.

A client was intubated 30 minutes ago for acute respiratory distress syndrome (ARDS) and possible sepsis. The following prescriptions have been given for the client. In what sequence will the nurse perform these actions? 1. Infuse levofloxacin (Levaquin) 500 mg IV. 2. Obtain baseline aerobic and anaerobic sputum cultures. 3. Teach the client and family methods of communicating. 4. Analyze post-intubation arterial blood gases (ABGs). A. 2, 1, 3, 4 B. 4, 3, 1, 2 C. 3, 4, 2, 1 D. 4, 2, 1, 3

D. 4,2,1,3

The nurse is caring for a client who developed GI bleeding 3 weeks after a diagnosis of pulmonary embolism (PE). The international normalized ratio (INR) is 6.9. Which one of these questions is most appropriate for the nurse to ask at this time? A. "Have you eaten a lot of green leafy vegetables?" B. "Have you experienced swelling of your legs?" C. "Were you massaging your calves?" D. "Have you taken any aspirin or salicylates?"

D. Have you taken any aspirin or salicylates?

classic symptoms PE

Dyspnea, sudden onset Sharp, stabbing chest pain Anxiety & Restlessness Feeling of impending doom Cough Hemoptysis

Labs PE

Elevated D-Dimer: 208-318 Partial thromboplastin time (PTT): 20-30 seconds Prothrombin time (PT): 11-12.5 seconds International normalized ratio: 0.8-1.1

extubation interventions

Hyperoxygenate patient Thoroughly suction ET and oral cavity Rapidly deflate ET cuff Remove tube at peak inspiration Instruct patient to cough Monitor patient every 5 min Assess for respiratory distress

vent complications

Infections: Ventilator-associated pneumonia (VAP) Muscle deconditioning Ventilator dependence Barotrauma Volutrauma Atelectrauma Biotrauma Ventilator associated lung injury Acid- base imbalances Nutritional Problems

ARDS management

Intubation (Mechanical Ventilator) Positioning Antibiotics Enteral or Parenteral nutrition

ARDS diagnostic assessments

Lower Pao2 value on ABG Hypoxemia "Whited-out" (ground glass) appearance to chest x-ray No cardiac involvement on EKG Low-to-normal PCWP *PCWP- pulmonary capillary wedge pressure

high pressure alarm causes

Mucous Bronchospasms Tension Pneumothorax ET tube slips to right mainstem Decreased compliance

Acute Respiratory Distress Syndrome (ARDS)

Persisting hypoxia Decreased pulmonary compliance Dyspnea Noncardiac-associated bilateral pulmonary edema Dense pulmonary infiltrates seen on x-ray

positive pressure ventilator

Pressure-cycled- Preset pressure Time-cycled- Preset time Volume-cycled- Preset volume

Risk factors PE

Prolonged immobilization Central venous catheters Surgery Obesity Advancing age Conditions that increase blood clotting History of thromboembolism- higher risk- anticoagulation meds- make sure pt adheres to meds Heparin flush every 8 hours

Best practices PE

Provide Oxygen Reassure patient Reposition to High Fowlers Place on telemetry Ensure IV access Ensure chest imaging and labs done Administer meds per orders, like anticoagulants Fibrolytics may be used

assist control ventilation (AC)

Resting mode, Tidal Volume (TV) & rate preset If pt does not breathe, ventilator will provide breath. Responds to inspiratory effort Negative- Continues to provide preset in addition to pts own

ARDS distress

Sepsis Shock Aspiration Inhalation injury Pulmonary Embolism

synchronized intermittent mandatory ventilation (SIMV)

TV & Resp Rate preset Allows spontaneous breaths & TV of pt Weaning mode

fibrolytics

activase, TPA (tissie plasminogen activator) break up existing clots

rate

breaths/min

CPAP

continuous positive airway pressure

surgical management

embolectomy inferior vena cava filtration

How do you verify endotracheal tube placement?

end tidal co2 (35-45 mmHg) chest x ray

Bi-level positive airway pressure (BiPAP)

face mask most often used in sleep apnea

FiO2

fraction on inspired oxygen

anticoagulant meds

heparin lovenox arixtra coumadin xarelto

tidal volume (TV)

inhaled breath

Weaning of the ventilator

intubation -> AC -> SIMV -> PS -> Extubation

low pressure alarm cause

leak in tubing or cuff

PIP

peak airway pressure *pressure vent uses to deliver tidal volume

PEEP

positive end expiratory pressure *improves oxygenation and gas exchange *during expiration

PS

pressure support

Imaging techniques

pulmonary angiography- gold standard Cat scan