Critical Care Exam 2

Brain stem

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates dysfunction in the _________________________.

1. Place the patient in High-Fowlers. 2. Initiate oxygen therapy.

A patient brought into the ER with a respiratory infection has a temp of 102, HR 110, RR 32, O2 86%, & cyanosis around the mouth. What immediate actions should the nurse take?

SIMV

A patient has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document this setting as ___________________.

Checking & taping all the connections.

A physician inserts a chest tube into a client to treat pneumothorax. The tube is connected to a water-seal drainage system. How can the nurse prevent chest tube air leaks?

1. Pneumothorax (from needle going in chest) 2. Tension Pneumothorax " " 3. Subcutaneous Emphysema " " 4. Pulmonary Edema (lots of fluid removed from chest causing a shift)

For a client is undergoing a thoracentesis, what complications should the nurse monitor for during & immediately after the procedure?

Auscultating the lungs for bilateral breath sounds to ensure tube placement & effective oxygen delivery.

For a client with an endotracheal (ET) tube, which nursing action is the most important?

1. Elevate HOB to 90 degrees. 2. Give ordered diuretics to decrease fluid build up.

For a patient with HF & pulmonary edema, what actions would the nurse take to help relieve respiratory distress?

1. Exhale fully 2. Inhale with mouthpiece & hold for 3 seconds 3. Passively exhale 4. Take a deep breath & cough

How should a patient be instructed to use an incentive spirometer?

1. The SpO2 & PO2 have decreased. 2. Tachycardia with a drop in BP. 3. Patient's face has skin breakdown & edema.

The nurse has placed the intubated client with ARDS in prone position for 30 minutes. What are some factors that would require the nurse to discontinue prone positioning & return to supine position?

Increased ICP

The nurse is assessing a client with a head injury. On admission, the pupils were equal; now the right pupil is fully dilated and nonreactive & the left pupil is 4 mm and reacts to light. What would this change suggest to the nurse?

Assess for Pneumothorax

The nurse is caring for a client with a left chest tube to drain a pleural effusion & notes the water is below the required level in the water seal chamber. What is the priority assessment that the nurse needs to make?

1. Rising BP 2. Bradycardia 3. Widening pulse pressure (weak & thready)

What are late signs of increased ICP?

1. GI hemorrhage 2. Decreased CO 3. Fluid imbalance 4. Infection 5. Pneumothorax/Atelectasis 6. Oxygen Toxicity 7. Incorrect ventilation

What are some examples of complications associated with mechanical ventilation?

-Pallor -Decreased BP -Bradycardia -N/V -Loss of consciousness -Weakness -Dizziness

What are some examples of parasympathetic responses to pain?

1. Crackles or Rhonchi 2. Fever/Malaise 3. Use of accessory muscles to breathe 4. Pleuritic pain/Pleural friction rub 5. Tachycardia/Tachypnea/Dyspnea 6. Coughs up green/yellow/bloody/rusty sputum

What are some signs & symptoms of Pneumonia?

1. Sudden sharp pain when breathing/coughing 2. Tachypnea 3. Dyspnea 4. Diminished or absent breath sounds 5. Tachycardia 6. Anxiety/Restlessness

What are some signs & symptoms of Pneumothorax?

1. Light-headedness 2. Parasthesia (numbness/tingling in arms & legs)

What are some symptoms usually seen in Respiratory Alkalosis?

1. Hypotension 2. Hypothermia 3. Vasoconstriction

What are some things that could potentially alter noninvasive pulse oximetry values?

-Wrist pronation -Stiff extension of the arms & legs -Plantar flexion of the feet -Opisthotonos

What are the characteristics of decerebrate posture?

1. Splint the incisional site 2. Inhale through the nose 3. Exhale through pursed lips 4. Cough deeply from the lungs

What are the steps a post-op abdominal surgery patient should do when performing diaphragmatic breathing & coughing exercises?

Diminished or absent breath sounds on the affected side.

What assessment finding supports the possibility of Pneumothroax?

Decreased CO

What effect does PEEP therapy have on the heart?

Cushing's Triad: bradycardia, hypertension, & bradypnea.

What findings confirm a diagnosis of brainstem herniation?

1. Elevate HOB 2. Start oxygen 2 L NC 3. Activate Rapid Response team 4. Insert IV

What interventions should the nurse take for a confused COPD patient whose O2 sat has dropped to 84% & RR is 32 with cyanosis around the lips?

Restlessness

What is an early indicator of hypoxia in an unconscious client?

Hypoxia not responsive to oxygen therapy. PaO2 will continue to fall despite higher O2 concentrations.

What is an early sign of ARDS?

Coiled flat on the bed & secured without putting tension on the tube.

What is the best way for the nurse to position a chest tube for a client to prevent dislocation?

Take a deep breath through the nose, hold it for 5 seconds, then blow it out through pursed lips.

What is the correct post-operative breathing technique to help avoid atelectasis & pneumonia?

22-26

What is the normal range for HCO3-?

Men: 45-52% Women: 37-48%

What is the normal range for Hematocrit?

Men: 13-17 Women: 12-15

What is the normal range for Hemoglobin?

1.1 or lower in healthy people

What is the normal range for INR?

45-35

What is the normal range for PaCO2?

80-100 mmHg

What is the normal range for PaO2?

150,000-450,000

What is the normal range for Platelets?

Men: 4.7-6.1 Women: 4.2-5.4

What is the normal range for RBCs?

4,000-11,000 per microliter

What is the normal range for WBCs?

25-35 seconds

What is the normal range for aPTT?

7.35-7.45

What is the normal range for pH?

Avoiding impeding venous outflow from the head, which could increase ICP.

What is the nurse's best rationale for positioning a client with decreased level of consciousness related to a head injury?

Diminished responsiveness

What is usually the first sign of increased ICP?

Those on steroid therapy or with a history of ulcers.

What mechanically ventilated patients are most at risk for GI hemorrhage?

Warm it in hot water to dissolve the crystals.

What should the nurse do if there are crystals in the Mannitol solution?

-BP -MAP -CPP -Urine output -Respirations -Pain

What things should the nurse closely monitor in a patient with increased ICP?

CO2

When a client's ventilation is impaired, the body retains which substance?

1. Fluid drainage into the 1st chamber of drain system. 2. Dry dressing at chest wall insertion site. 3. Tidaling in water seal chamber during respirations.

When assessing a client with a chest tube inserted for a hemothorax, what assessment findings would the nurse expect to see?

The tubing disconnecting from the suction source. (could let air in the pleural cavity & cause pneumothorax)

When assessing a client with a chest tube, what situation does the nurse recognize as an immediate emergency?

Medicate with prescribed Morphine to minimize incisional pain. It will make it easier to cough. (medicate before sitting up, coughing, or teaching)

When caring for a client following a thoracotomy, assessment reveals incisional pain, poor cough effort, & scattered rhonchi throughout all lung fields bilaterally. What action should the nurse take first?

1. Measure drainage at the end of each shift. 2. Check chest tube dressing for bleeding. 3. Ensure connections are securely taped. 4. Wall suction should be continuously bubbling. 5. Patient should be in Fowlers.

When caring for a client who has undergone a left lung lobectomy, what important postoperative measures related to care of chest tubes should be performed by the nurse?

1. Hypercapnia 2. Hyperventilation 3. Hypoxemia

When caring for a client with Acute Respiratory Failure, the nurse should expect to focus on resolving what 3 cardinal problems?

Chest x-ray

When caring for a patient that had chest tube insertion for pneumothorax, to assess for pneumothorax resolution, the nurse can anticipate that the client will require a ________________.

Prepare to administer Protamine Sulfate. (frank hematuria indicates Heparin overdose)

While receiving Heparin to treat a PE, the client passes bright red urine. What should the nurse do first?

A patient who receives massive fluid resuscitation or blood transfusions, or who aspirates stomach contents.

Who is at highest risk for ARDS?

Crackles

_______________ are an expected auscultated finding with pneumonia.

Malnourishment

_________________ is a risk factor for postoperative pulmonary complications.

GI hemorrhage

_________________ occurs in about 25% of clients receiving prolonged mechanical ventilation because of the development of stress ulcers.

Stridor

___________________ is an assessment finding indicating an extremely narrowed airway, & airway is always the top priority.

ET intubation & mechanical ventilation.

________________________ & _____________________ are required in ARDS to maintain adequate respiratory support.

Hypovolemia

A client with a crushing chest injury is in the ICU & the client's vital signs have not stabilized. What finding puts the client at risk for ARDS?

Cardiac Arrythmias

Hyperventilating & hyperoxygenating a client before & during (or after) suctioning helps prevent _________________________.

1. Extreme anxiety (hyperventilation) 2. HF 3. Fever 4. Injury to respiratory center in the brain. 5. Overventilation with a mechanical vent 6. PE 7. Early Aspirin poisoning

What are some examples of risk factors for Respiratory Alkalosis?

1. Gram-negative Septic Shock (bacteremia) 2. Gastric content aspiration 3. Fluid resuscitation/Blood transfusions (extreme) 4. Multiple traumas 5. Pneumonia 6. Smoke inhalation 7. Near drowning

What are some risk factors commonly associated with the development of ARDS?

Petroleum Gauze

The nurse is preparing to assist with the removal of a chest tube. What dressing is appropriate at the site from which the chest tube is removed?

Pulmonary Embolus (in Acute Respiratory Failure with hypoxia & hyperventilation)

A client has the following ABG values: pH 7.52, PaO2 50 mmHg, PaCO2 28 mmHg, HCO3- 24. What is a possible cause for these findings?

Place the patient in respiratory isolation. (symptoms suggest respiratory infection, possibly TB)

A client is admitted to the facility with a productive cough, night sweats, & a fever. What action is most important in the initial care plan?

Administer a stool softener to reduce straining.

A client is brought to the ICU after evacuation of a subdural hematoma. What is an example of a nursing intervention that reduces the client's risk of increased ICP?

A hematologic problem.

A client is chronically short of breath and yet has normal lung ventilation, clear lungs, & an arterial oxygen saturation (SaO2) of 96% or better. The client most likely has _________________________________.

Fighting the ventilator

A client on mechanical ventilation is receiving Pancuronium I.V. as needed. Which assessment finding indicates that the client needs another Pancuronium dose?

Atelectasis (collapsed lung)

A client who smokes is at increased risk for __________________ postoperatively.

Offer pain medication before having the client deep-breathe & use incentive spirometry. (more effective when pain is minimal)

To help a client prevent atelectasis & pneumonia after surgery, what should the nurse do?

Initiate oxygen therapy. (symptoms suggest PE, so maintaining respiratory function takes priority)

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest & complains of acute chest pain. What action should the nurse take first?

1. Monitor Creatinine & BUN 2. Give humidified oxygen 3. Auscultate lungs (risk for superinfection, renal failure, & inadequate perfusion)

A client with ARDS has fine crackles at lung bases, respirations are shallow with a rate of 28, they're restless &anxious. In addition to monitoring ABG results, what should the nurse do?

Initiating IV sedation (the patient may be fighting the ventilator breaths & need to be sedated to comply to lower peak inspiratory pressure)

A client with ARDS is on a ventilator. The peak inspiratory pressures & spontaneous respiratory rate are increasing, & the PO2 is not improving. Using the SBAR, what recommendation should the nurse give to the physician?

Elevate HOB 30-45 degrees to facilitate breathing & lung expansion.

A client with DVT suddenly develops dyspnea, tachypnea, & chest discomfort. What should the nurse do first?

The lung has fully expanded (could also indicate occlusion or tube in wrong place)

A chest tube is attached to a water seal drainage system, & the nurse notes that the fluid in the chest tube & in the water seal column has stopped fluctuating. How should the nurse interpret this finding?

Nonrebreather mask

A client admitted with DVT abruptly sits up in bed, reports having difficulty breathing, & has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to improve these manifestations?

1. Place patient in High Fowlers 2. Notify the physician 3. Auscultate bilateral lung sounds for crackles.

A client with HF develops pink, frothy sputum & restlessness. What are the priority actions by the nurse?

Blood pressure (because intracerebral hemorrhage is a major side effect of thrombolytic therapy)

A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital sign?

1. Provide sedation 2. Hyperoxygenate 3. Suction the airway 4. Suction the mouth

A client with a hemorrhagic stroke is slightly agitated, heart rate is 118 bpm, respirations are 22 breaths/min, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88 mm Hg, and oral secretions are noted. What order of interventions from first to last should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?

Reinsert the tube immediately to restore the airway.

A client with a tracheostomy tube coughs & dislodges the tracheostomy tube. What should the nurse's first action be?

Absence of reflexes along with flaccid extremities.

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Cerebral bleeding

A client with thrombocytopenia has a severe headache, what does the nurse interpret that this may indicate?

Respiratory Acidosis

A client's ABG's reveal an excess of CO2, which indicates ___________________.

Instruct the client to take a deep breath & hold it.

A nurse is assisting with the removal of a central venous access device (CVAD). What should the nurse do to prepare the client?

Runs of V-Tach

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?

The system has an air leak.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The alveoli expand & increase the lung surface available for ventilation.

After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises?

2,500 mL

After surgery, the client should drink a minimum of _________________ of fluid per day to keep secretions liquefied & easier to cough up & eliminate from the upper respiratory tract.

Tension Pneumothorax

Tracheal deviation away from the affected side of pneumothorax indicates ____________________________, which is a medical emergency.

Pneumonia

Deep breathing exercises after surgery can help prevent _________________.

Below the patient's chest level.

If a patient has a chest tube, how should the drainage apparatus be placed?

Assist the client to take several deep breaths & cough.

On the day of surgery, a client has been breathing room air. The vital signs are normal, and the O2 saturation is 89%. What should the nurse do first?

2-3 L

Patients need to keep their respiratory secretions thin by drinking ______________ of clear liquids per day.

Increased urinary output

The client with a head injury receives Mannitol during surgery to help decrease ICP. Which finding indicates that the drug is having the desired effect?

Monitor respirations frequently for 4-6 hours because the client may need repeated doses.

The health care provider prescribed IV Naloxone to reverse the respiratory depression from Morphine. After administering Naloxone, what should the nurse do?

Assess breath sounds. (Pneumothorax is a complication of central line insertion)

The nurse assisted the health care provider with insertion of a left subclavian, triple lumen catheter in a client with lung cancer. Suddenly, the client becomes restless & tachypneic. What should the nurse do next?

Increased ICP

The nurse detects bradycardia, bradypnea, & systolic HTN. The nurse must notify the physician immediately because these findings may reflect ____________________.

Immediately tell the client to cough or exhale forcibly while the wound is covered with an occlusive dressing. (prevent sucking chest wound & air leakage)

When repositioning a client with a chest tube in bed, the chest tube accidentally disconnects from the chest tube container. What is the nurse's priority action?

Irritability

Which mental status change may occur when a client with Pneumonia is first experiencing hypoxia?

Mark the area with a skin pencil at the outer periphery of the crackling. (Sign of Subcutaneous Emphysema, want a baseline to detect expansion)

While assessing a thoracotomy incisional area where a chest tube exits, the nurse feels a crackling sensation under the fingertips along the incision. What should the nurse do next?