Evolve Ch. 32
The nurse is teaching the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate?
"Paralysis and sedatives help decrease the demand for oxygen."
The nurse is overseeing a nursing student who is administering medications to a group of clients with pulmonary disorders. Which statement by the student nurse indicates a correct understanding about thrombolytic therapy?
"Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3."
A client was intubated 30 minutes ago for acute respiratory distress syndrome and possible sepsis. The following orders have been given for the client. In what sequence would the nurse perform these orders for this client? 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 postintubation arterial blood gases (ABGs).
4, 2, 1, 3
Which client has the highest risk for developing a pulmonary embolism (PE)?
A 25-year-old woman who frequently flies to different countries
Which client needs immediate attention by the nurse?
A 54-year-old who is mechanically ventilated and has tracheal deviation
The nurse is caring for a group of clients. Which person does the nurse identify as having the highest risk for pulmonary embolism (PE)?
A client returning from an open reduction and internal fixation of the tibia
All of these nursing actions are included in the plan of care for a client who has just been extubated. Which action should the nurse delegate to unlicensed assistive personnel (UAP)?
All of these nursing actions are included in the plan of care for a client who has just been extubated. Which action should the nurse delegate to unlicensed assistive personnel (UAP)?
A ventilated client in the intensive care unit (ICU) begins to pick at the bedcovers. Which action should the nurse take next?
Assess for adequate oxygenation.
The nurse coming on shift prepares to perform an initial assessment of a sedated, ventilated client. Which are priorities for the nurse to carry out?
Assess the client's color and respirations .Confirm alarms and ventilator settings. Ensure that the tube cuff is inflated and is in the proper position.Listen for bilateral breath sounds.
The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which method provides an alternative to mechanical ventilation?
Bi-level positive airway pressure (BiPAP)
The nurse is caring for a group of clients. Which clients should be monitored closely for respiratory failure?
Client with a brainstem tumor, Client with acute pancreatitis, Client with a T3 spinal cord injury, Client using patient-controlled analgesia
The medical-surgical unit nurse should call the Rapid Response Team to assess which client?
Client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis
Which critically ill client has the greatest risk for developing acute respiratory distress syndrome (ARDS)?
Client with aspiration pneumonia
Which components belong to the ventilator bundle approach to prevent ventilator-associated pneumonia (VAP)?
Continuous removal of subglottic secretions, Elevating the head of the bed at least 30 degrees whenever possible, Handwashing before and after contact with the client
Which intervention for a client in the intensive care unit (ICU) will decrease the incidence of "ICU psychosis?"
Decreasing nighttime disruptions
The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms should the nurse assess?
Dizziness and fainting, Inspiratory chest pain
The client with which condition is in greatest need of immediate intubation?
Hypoventilation and decreased breath sounds
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?
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 should the nurse take first?
Listen to the client's breath sounds.
A client has been admitted for a pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care?
Monitor the platelet count daily.
Which intervention will be most effective in reducing anxiety in a client with a pulmonary embolism (PE)?
Remain with the client and provide oxygen in a calm manner.
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?
The trachea is deviated to the right side and cyanosis is present.
The nurse is caring for a client who was discharged 3 weeks ago after a diagnosis of pulmonary embolism (PE). He is currently admitted with gastrointestinal (GI) bleeding and an international normalized ratio (INR) of 6.9. For which factors should the nurse assess this client?
Use of aspirin or salicylates
When caring for a client with pulmonary embolism (PE), which arterial blood gas results does the nurse anticipate early in the course of the disease?
pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L, PaO2 68 mm Hg
