Exam 1

peripherally inserted central catheter (PICC)

45-75cm with single or multiple lumens up to 12mo use insertion location: basilic or cephalic vein at least one fingerbreadth below or above the antecubital fossa. the catheter should be advanced until the tip is positioned in the lower one-third of the SVC. indications: administration of blood, long-term administration of chemotherapeutic agents, antibiotics, and total parenteral nutrition when possible, insert a PICC early in the course of therapy before veins are exposed to repeated venipunctures preprocedure: ensure informed consent has been signed cleanse the site with chlorhexidine ensure sterility of equipment place a STOP sign on the door to the room to restrict entry during the procedure postprocedure: confirm placement of the PICC with an x-ray assess site for redness, swelling, drainage, tenderness, and condition of dressing clean insertion port with alcohol for 15sec and allow to completely dry prior to accessing it. valve disinfection caps which contain alcohol are available for single use use transparent dressing to allow for visualization, follow facility protocol for dressing changes advise pt not to immerse arm in water. to shower, cover the dressing site to avoid water exposure educate pt not to have venipuncture or bp take in arm with a PICC line flushing: use a 10mL syringe to flush, do not apply force is resistance is met flush with 10mL 0.9%SC before, between, and after meds flush with 20mL 0.9%SC after drawing blood flush with 5mL heparin (10u/mL) when the PICC is not actively in use. the frequency of the flush depends on the type of PICC complications phlebitis common complication of PICCs and can be chemical (osmolarity or pH is different, veins too small for substance), bacterial, or mechanical irritation (excess IV manipulation) nursing actions monitor for findings: erythema at the site, pain or burning at the site and length of the vein discomfort when skin over the tip is palpated warmth over site edema at the site vein indurated (hard), red streak, and/or cordlike slowing infusion rate temp elevation of 1°F or more infection appearing 7-10 days after insertion

a nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on 4 clients. for which of the following clients should the nurse clarify the provider's prescription? A.) pt w/ epistaxis B.) pt w/ amyotrophic lateral sclerosis C.) pt w/ pneumonia D.) pt w/ emphysema

A client who has epistaxis rationale: The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding.

respiratory failure labs

ABGS to confirm and monitor ventilatory and oxygenation failure hypoxemic/oxygenation failure: PaO2 <60mmHg, SaO2 <90% or hypercapnic/ventilatory failure PaCO2 >45mmHg with pH <7.35

a nurse is planning care for a client who has asthma. which of the following meds should the nurse plan to administer during an acute asthma attack? A.) cromolyn sodium B.) prednisone C.) fluticasone/salmeterol D.) albuterol

Albuterol rationale: The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack.

A nurse is reviewing the common emergency management protocol for pt with asystole. Which of the following actions should the nurse plan to take during this cardiac emergency? Perform defibrillation Prepare for transcutaneous pacing Administer IV epinephrine Elevate the pt extremities

Administer IV epinephrine: epi increases HR, improves cardiac output, and promotes bronchodilation

a nurse in an ED is caring for a client who's experiencing a pulmonary embolism. which of the following actions should the nurse take first? A.) Apply supplemental oxygen. B.) Increase the rate of IV fluids. C.) Administer pain medication. D.) Initiate cardiac monitoring.

Apply supplemental oxygen. rationale: When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen.

a nurse is caring for a client who's in acute respiratory failure and is receiving mechanical ventilation. which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen? A.) BP B.) Cap refill C.) ABGs D.) HR

Arterial blood gases rationale: When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance.

a nurse is assessing a client who has emphysema. which of the following findings should the nurse report to the provider? A.) Rhonchi on inspiration B.) Elevated temperature C.) Barrel-shaped chest D.) Diminished breath sounds

Elevated temperature rationale: The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections.

A nurse is caring for a pt who has ingested a toxic agent. Which of the following actions should the nurse plant to take? SATA Induce vomiting Instill activated charcoal Perform a gastric lavage with aspiration Administer syrup of ipecac Infuse IV fluids

Instill activate charcoal : activated charcoal absorbs toxic substances, and does not pass into the bloodstream Perform gastric lavage with aspiration: gastric lavage with aspiration removes the toxic substance when the instilled fluid is suctioned from the GI tract Infuse IV fluids: IV fluids dilute the toxic substances in the bloodstream and promote elimination from the body through the kidneys

the nurse has obtained CVP measurement of 10 mmHg. the nurse anticipated that the physician will prescribe: Lasix 20mg IV BID no medication orders, continue to monitor 1L of NS bolus, following by NS @ 125mL/hr reposition the pt

Lasix 20mg IV BID

a nurse in an ED is caring for a client who's experiencing acute respiratory failure. which of the following lab findings should the nurse expect? A.) Arterial pH 7.50 B.) PaCO2 25 mm Hg C.) SaO2 92% D.) PaO2 58 mm Hg

PaO2 58 mm Hg rationale: The nurse should expect the client to have lower partial pressures of oxygen.

a nurse is caring for a client who's 1 hr postoperative following a thoracentesis. which of the following is the priority assessment finding? A.) Pallor B.) Insertion site pain C.) Persistent cough D.) Temperature 37.3° C (99.1° F)

Persistent cough rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is a persistent cough because this can indicate a tension pneumothorax, which is a medical emergency.

oxygenation failure

Pneumonia ARDS Heart failure COPD Pulmonary embolism Pulmonary edema Restrictive lung diseases (decrease lung volumes) Hypoventilation Hypovolemic shock Low hemoglobin

weaning modality

Pressure Support Ventilation (PSV) works to keep alveoli from collapsing during expiration allows for greater oxygenation an eases work of breathing allows for use of FiO2 can be used with IMV or AC modes to treat or prevent atelectasis settings 5-20cm H2O (>20 can cause lung damage) Continuous Positive Airway Pressure (CPAP) positive pressure supplied during spontaneous breathing, no ventilator delivered breaths unless in conjunction with SIMV risks include volutrauma, decreased cardiac output and ICP

a nurse in a provider's office is assessing a client who has COPD. which of the following findings is the priority for the nurse to report to the provider? A.) Increased anterior-posterior chest diameter B.) Productive cough with green sputum C.) Clubbing of the fingers D.) Pursed-lip breathing with exertion

Productive cough with green sputum rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection.

a nurse is creating a plan of care for a client who has COPD. which of the following interventions should the nurse include? A.) Schedule respiratory treatments following meals. B.) Have the client sit up in a chair for 2-hr periods three times per day. C.) Provide a diet that is high in calories and protein. D.) Combine activities to allow for longer rest periods between activities.

Provide a diet that is high in calories and protein. rationale: The nurse should provide a client who has COPD with a diet that is high in calories and protein and low in carbohydrates.

A nurse on a med-surg unit is caring for a group of patients. The nurse should notify the rapid response team for which of the following patients? Pt with a pressure injury of the R heel whose blood glucose is 300mg/dL Pt who reports R calf pain and shortness of breath Pt who had blood on a pressure dressing in the femoral area following a cardiac catheterization Pt who has dark red coloration of L toes and absent pedal pulse

Pt who reports R calf pain and shortness of breath The nurse should identify the pt is at risk for respiratory arrest due to possible embolism. Manifestations can indicate the beginning of a rapid decline in pt condition.

mass casualty triage

RED emergent, immediate threat to life YELLOW major injuries requiring immediate treatment GREEN minor injuries that do not require immediate treatment BLACK expected and allowed to die

a nurse is caring for a client who has asthma and is receiving albuterol. for which of the following adverse effects should the nurse monitor the client? A.) Hyperkalemia B.) Dyspnea C.) Tachycardia D.) Candidiasis

Tachycardia rationale: The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis.

chest tube systems

a disposable three-chamber drainage system is most often used First chamber: drainage collection second chamber: water seal third chamber: suction control (can be wet or dry)

a nurse is caring for a group of pt's. which of the following pt's are at risk for a pulmonary embolism? SATA a pt who has a BMI of 30 a female pt who is postmenopausal a pt who has a fractured femur a pt who is a marathon runner a pt who has chronic atrial fibrillation

a pt who has a BMI of 30 a pt who has a fractured femur a pt who has chronic atrial fibrillation

a nurse is caring for a pt who develops a pulmonary embolism. which intervention should the nurse implement first? give morphine IV administer oxygen therapy start an IV infusion of lactated ringer's initiate cardiac monitoring

administer oxygen therapy

a nurse is caring for a pt who has an endotracheal tube and is receiving mechanical ventilation. the pt pulls out his endotracheal tube. which of the following actions should the nurse take first? prepare for pt reintubation assess the pt airway suction the pt mouth elevate the pt head of the bed

assess the pt airway

the pt diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. which intervention should the nurse implement first? confirm that the ventilator settings are correct verify that the ventilator alarms are functioning properly assess the respiratory status and pulse oximeter reading monitor the pt's arterial blood gas results

assess the respiratory status and pulse oximeter reading

a nurse is providing discharge teaching to a client who has pulmonary TB and a new prescription for rifampin. which of the following instructions should the nurse include?

"Expect your urine and other secretions to be orange while taking this medication." rationale: The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur, including jaundice, fatigue, or malaise.

a nurse is providing discharge teaching to a client who has a temporary tracheostomy. which of the following statements by the client indicates an understanding of the teaching? A.) "Ringing in the ears is an adverse effect of this medication." B.) "Have your skin test repeated in 4 months to show a positive result." C.) "Expect your urine and other secretions to be orange while taking this medication." D.) "Remember to take this medication with a sip of water just before your first bite of each meal."

"I should remove the old twill ties after the new ties are in place." rationale: As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation.

a charge nurse is reviewing the care of a client who has a chest tube connected to a water seal drainage system in a place following thoracic surgery w/ newly licensed nurse. which of the following statements by the newly licensed nurse indicates an understanding of when to notify the provider? A.) "I will notify the provider if there is a fluctuation of drainage in the tubing with inspiration." B.) "I will notify the provider if there is continuous bubbling in the water seal chamber." C.) "I will notify the provider if there is drainage of 60 milliliters in the first hour after surgery." D.) "I will notify the provider if there are several small, dark-red blood clots in the tubing."

"I will notify the provider if there is continuous bubbling in the water seal chamber." rationale: Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while waiting for instructions from the provider.

a nurse is providing teaching to a client who has chronic asthma and a new prescription for montelukast. which of the following client statements indicates an understanding of the teaching? A.) "I will monitor my heart rate every day while taking this medication." B.) "I will make sure I have this medication with me at all times." C.) "I will need to carefully rinse my mouth after I take this medication." D.) "I will take this medication every night even if I don't have symptoms."

"I will take this medication every night even if I don't have symptoms." rationale: Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening.

a charge nurse is providing an in-service to a group of staff nurses about endotracheal suctioning. which of the following statements by a staff nurse indicates an understanding of the teaching? A.) "I will use clean technique when suctioning a client's endotracheal tube." B.) "I will use a rotating motion when removing the suction catheter." C.) "I will suction the oropharyngeal cavity prior to suctioning the endotracheal tube." D.) "I will suction a client's endotracheal tube every 2 hours."

"I will use a rotating motion when removing the suction catheter." rationale: The nurse should rotate the suction catheter during withdrawal to remove secretions from the sides of the airway.

nontunneled percutaneous central venous catheter (CVC)

18-25cm in length with 1-5 lumens short-term use only insertion location: subclavian vein, jugular vein; tip in the distal third of the superior vena cava indications: administration of blood, long-term administration of chemotherapeutic agents, antibiotics, and total parenteral nutrition

HCO3

21 - 28 mmHg

PaCO2

35 - 45 mmHg

common causes of pulseless activity

5 H's: Hypovolemia Hypoxia Hydrogen ion accumulation, resulting in acidosis Hyper/hypokalemia Hypothermia 5 T's Toxins, accidental or deliberate drug OD Tamponade, cardiac Tension pneumothorax Thrombosis, coronary Thrombosis, pulmonary

pH

7.35 - 7.45

PaO2

80 - 100 mmHg

SAO2

95% - 100%

a nurse is caring for 4 clients. which of the following clients is at greatest risk for a pulmonary embolism? A.) A client who is 48 hr postoperative following a total hip arthroplasty B.) A client who is 8 hr postoperative following an open surgical appendectomy C.) A client who is 2 hr postoperative following an open reduction external fixation of the right radius D.) A client who is 4 hr postoperative following a laparoscopic cholecystectomy

A client who is 48 hr postoperative following a total hip arthroplasty rationale: The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72 hr following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devices or antiembolic stockings and by administering anticoagulant medications.

a nurse is caring for a client who has pulmonary embolism. which of the following interventions is the nurse's priority? A.) Provide a quiet environment B.) Encourage use of incentive spirometer every 1-2 hrs C.) Obtain blood sample for electrolyte study D.) Administer heparin via continuous IV infusion

Administer heparin via continuous IV infusion. rationale: When using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.

a nurse developing a plan of care for a client who has active TB. which of the following isolation precautions should the nurse include in the plan? A.) Airborne B.) Neutropenic C.) Contact D.) Droplet

Airborne rationale: The nurse should initiate airborne precautions for a client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure that is filtered through a high-efficiency particulate air (HEPA) filter. Members of the health care team should not enter the client's room without wearing an N95 respirator mask.

ABCDE

Airway / Cervical Spine establish patent airway, brain injury or death within 3-5min if airway is not patent Breathing assess for effectiveness, if breathing is inadequate manual ventilation is indicated Circulation assess HR, BP, peripheral pulses, cap refill for adequate perfusion Disability assess LOC AVPU, Glasgow Coma Scale

modes of ventilation

Assist-Control (AC) preset rate and tidal volume, pt initiates breath and ventilator takes over for intubated pt hyperventilation can result in respiratory alkalosis client can require sedation to decrease respiratory rate Synchronized Intermittent Mandatory Ventilation (SIMV) preset rate and tidal volume for machine breaths pt initiates breath and tidal volume will depend on upon pt effort ventilator initiated breaths are synchronized to reduce competition between ventilator and pt used as regular mode of ventilation or a weaning mode for intubated pt can increase work of breathing, causing respiratory muscle fatigue Inverse Ratio Ventilation (IRV) lengthens inspiratory phase to maximize oxygenation in the intubated pt used for hypoxemia refractory to PEEP uncomfortable for pt and requires sedation and or neuromuscular blocking agents high risk of volutrauma and decreased cardiac output due to air trapping Airway Pressure Release Ventilation (APRV) allows alveolar gas to be expelled by the lungs own natural recoil time-triggered and pressure-limited breaths can be initiated spontaneously or by the vent causes less adverse effects on the cardiovascular system Independent Lung Ventilation (ILV) double0lumen ET tube allows ventilation of each lung separately used for pt who have unilateral lung disease requires two ventilators, sedation, and /or use of neuromuscular blocking agents High-Frequency Ventilation delivers small amount of gas at rates of 60-3000cycles/min often used in children pt must be sedated and/or receiving neuromuscular blocking agents breath sounds difficult to assess

ventilatory failure

COPD pulmonary embolism pneumothorax flail chest ARDS asthma pulmonary edema fibrosis of lung tissue multiple sclerosis guillain-barre syndrome spinal cord injuries cerebrovascular accidents that impair rate and depth of respiration post-op: anesthetic effects analgesic effects sedative agents pain, impaired cough and deep breathing

a nurse is caring for a client who has a chest tube following a lobectomy. which of the following items should the nurse keep easily accessible for the client? A.) Extra drainage system B.) Suture removal kit C.) Container of sterile water D.) Non adherent pads

Container of sterile water rationale: The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected to prevent a pneumothorax.

a nurse is assessing a client who's 4 hr postoperative following a total laryngectomy. which of the following findings is the priority for the nurse to report to the provider? A.) Bleeding at the surgical site B.) Decreased oxygen saturation C.) Urinary retention D.) Increased pain level

Decreased oxygen saturation rationale: When using the airway, breathing, circulation approach to client care, the nurse should identify decreased oxygen saturation as the priority finding to address and report to the provider. A client who is postoperative following a total laryngectomy is at higher risk for hypoxia because of airway obstruction.

A nurse in the ED is assessing a pt who is unresponsive. The pt partner states, "He was pulling weeds in the yard and slumped to the ground." Which of the following techniques should the nurse use to open the pt airway? Head-tilt, chin-lift Modified jaw thrust Hyperextension of head Flexion of the head

Head-tilt, chin-lift: pt is unresponsive without suspected trauma

a nurse is caring for a newly admitted client who has emphysema. the nurse should place the client in which of the following positions to promote effective breathing? A.) Lateral position with a pillow at the back and over the chest to support the arm B.) High-Fowler's position with the arms supported on the overbed table C.) Semi-Fowler's position with pillows supporting both arms D.) Supine position with the head of the bed elevated to 15°

High-Fowler's position with the arms supported on the overbed table rationale: The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the overbed table.

a nurse is assessing a client who has acute respiratory distress syndrome (ARDS). which of the following findings should the nurse report to the provider? A.) Decreased bowel sounds B.) Oxygen saturation 92% C.) CO2 24 mEq/L D.) Intercostal retractions

Intercostal retractions rationale: The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS.

a nurse is caring for a client who's in respiratory distress. which of the following low-flow delivery devices should the nurse use to provide the client w/ highest level of oxygen? A.) Nasal cannula B.) Nonrebreather mask C.) Simple face mask D.) Partial rebreather mask

Nonrebreather mask rationale: The nurse should use a nonrebreather mask for a client who is in respiratory distress to provide the highest oxygen level. A nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2.

A nurse in the ED is caring for a patient who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following actions should the nurse take? SATA Remove wet clothing Maintain normal room temp Apply warm blankets Use a rapid rewarming water of 40°-42°C (104°-108°F) Infuse warmed IV fluids

Remove wet clothing: body temp will rise more quickly when heat is applied to dry skin Apply warm blankets: body temp with rise more quickly with warm blankets Use a rapid rewarming water of 40°-42°C (104°-108°F): body temp will rise more quickly with rapid rewarming bath water Infuse warmed IV fluids: body temp will rise more quickly

acid base imbalance dx

STEP 1: pH if <7.35 = acidosis if >7.45 = alkalosis STEP2: PaCO2 and HCO3 which is wnl? the other is the indicator if imbalance PaCO2 <35 OR >45mmHG = respiratory HCO3 <22 OR >26mEq/L = metabolic STEP 3: combine step 1 and 2 to name the imbalance STEP 4: PaO2 and SaO2 if < expected reference range = hypoxic STEP 5: compensation uncompensated: pH is out of range, AND either HCO3 OR PaCO2 is out of range partially compensated: pH, HCO3, and PaCO2 are out of range fully compensated: pH is wnl, PaCO2 AND HCO3 are out of range ranges: pH: 7.35 - 7.45 PaCO2: 35-45 HCO3: 22-26

a nurse is assessing a client who has bacterial pneumonia. which of the following manifestations should the nurse expect? A.) decreased fremitus B.) SaO2 95% on room air C.) temperature 38.8° C (101.8° F) D.) bradypnea

Temperature 38.8° C (101.8° F) rationale: An elevated temperature is an expected finding for a client who has bacterial pneumonia.

thoracentesis

The surgical perforation of the chest wall and pleural space with a large-bore needle to obtain specimens for diagnostics, instill medication into the pleural space, and remove fluid or air for therapeutic relief of pressure potential diagnoses: transudates (heart failure, cirrhosis, nephritic syndrome, hypoproteinemia exudates (inflammatory, infectious, neoplastic conditions) empyema pneumonia blunt, crushing, or penetrating chest injuries/trauma, or invasive thoracic procedures such as long or cardiac surgery preprocedure: percussion, auscultation, radiography, or sonography is used to locate the effusion and needle insertion site assist older pt with positioning ensure pt has signed. informed consent gather supplies obtain procedure x-ray to locate pleural effusion position the pt sitting upright with arms and shoulders raised and supported on pillows and/or on overbed table with feet and legs well-supported educate pt to remain absolutely still during procedure and do not cough or talk unless instructed to intraprocedure: assisted provider with procedure, strict surgical aseptic technique prepare pt for feeling pressure with needle insertion and fluid removal monitor vitals, skin color, and O2 sat throughout measure and record the amount of fluid removed label specimens at bedside and promptly send to lab * the amount of fluid removes is limited to 1L at a times to prevent re-expansion pulmonary edema postprocedure: apply a dressing over puncture site, assess for bleeding or drainage monitor vitals and respiratory status, rate/rhythm, breath sounds, oxygenation status hourly for the first several hours after procedure auscultate lungs for reduced breath sounds on side of procedure encourage deep breathing to assist with lung expansion obtain x-ray, check resolution of effusions, rule out pneumothorax complications: mediastinal shift: shift of thoracic structures to one side of the body monitor vitals, auscultate for decrease in lung sounds pneumothorax: collapsed lung, can develop during the first 24hr post procedure. indications: diminished breath sounds, distended neck veins, asymmetry of chest wall, respiratory distress, tracheal deviation, pain on affected side that worsens at end of inhalation and exhalations, increased HR, rapid shallow respirations, nagging cough, air hunger bleeding: can occur if pt is moved during procedure or is at an increased risk monitor for coughing and hemoptysis monitor vitals and labs, hypotension, reduced Hgb asses site for bleeding infection: can occur due to introduction of bacteria with needle puncture ensure sterile technique is maintained monitor temp following procedure

a nurse working in an ED is caring for a client following an acute chest trauma. which of the following findings should indicate to the nurse that the client is possibly experiencing a tension pneumothorax? A.) Collapsed neck veins on the affected side B.) Collapsed neck veins on the unaffected side C.) Tracheal deviation to the affected side D.) Tracheal deviation to the unaffected side

Tracheal deviation to the unaffected side rationale: The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator that the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

a nurse is orienting a newly licensed nurse on the care of a pt who is to have a line places for hemodynamic monitoring. which of the following statements by the newly licensed nurse indicates understanding? air should be instilled into the monitoring system prior to the procedure the pt should be positioned on the left side during the procedure the transducer should be level with the second intercostal space after the line is placed a chest x-ray is needed to verify placement after the procedure

a chest x-ray is needed to verify placement after the procedure

a nurse is assisting a provider who's performing a thoracentesis at the beside of a client. which of the following actions should the nurse take? a.) Wear goggles and a mask during the procedure. b.) Cleanse the procedure area with an antiseptic solution. c.) Instruct the client to take deep breaths during the procedure. d.) Position the client laterally on the affected side before the procedure. e.) Apply pressure to the site after the procedure.

a.) Wear goggles and a mask during the procedure. b.) Cleanse the procedure area with an antiseptic solution. e.) Apply pressure to the site after the procedure. rationale: a.) Wear goggles and a mask during the procedure is correct. The nurse and provider should both wear goggles and a mask to reduce the risk for exposure to pleural fluid. b.) Cleanse the procedure area with an antiseptic solution is correct. The use of an antiseptic solution decreases the risk for infection, which is increased due to the invasive nature of the procedure. c.) Instruct the client to take deep breaths during the procedure is incorrect. The nurse should instruct the client to remain as still as possible during the procedure to reduce the risk for puncturing the pleura or lung. d.) Position the client laterally on the affected side before the procedure is incorrect. The nurse should position the client in a sitting position leaning over the bedside table or laterally on the unaffected side to promote access to the site and encourage drainage of pleural fluid. e.) Apply pressure to the site after the procedure is correct. The application of pressure decreases the risk for bleeding at the procedure site.

maintenance of acid-base balance

acid-base balance is maintained by chemical, respiratory, and kidney function. chemical (bicarbonate and intracellular fluid) and protein buffers (albumin and globulins) first line of defense either bind or release hydrogen ions as needed respond quickly to changes in pH respiratory buffers second line of defense control the level of hydrogen ions in the blood though the control of CO2 levels hyperventilation: decrease in hydrogen ions hypoventilation: increase in hydrogen ions kidney buffers kidneys are the third line of defense this buffering system is much slower to respond, but is the most effective buffering system with the longest duration kidneys control the movement of bicarbonate in the urine, bicarbonate can be reabsorbed into the bloodstream or excreted in the urine in response to blood levels of hydrogen. kidneys can also produce more bicarbonate when needed high hydrogen ions: bicarbonate reabsorption and production low hydrogen ions: bicarbonate excretion

Positive and expiratory pressure (PEEP)

adjunctive therapy preset pressure delivered during expiration added to prescribed ventilator settings to treat persistent hypoxemia improves oxygenation by enhancing gas exchange and preventing atelectasis amount of. PEEP added is 5-15cm H2O complications: decreased cardiac output/venous return hypotension alteration in renal function barotrauma/volutrauma

flail chest nursing care

administer humidified oxygen monitor vitals and SaO2 review findings of pulmonary function tests, periodic chest x-rays, and ABGs assess lung sounds, color, and cap refill promote lung expansion by encouraging deep breathing and proper positioning maintain mechanical ventilation in the event of severe injury to establish adequate gas exchange and stabilize the injury, flail chest is usually stabilized by positive-pressure ventilation suction trachea and ET tube as needed administer pain meds. Patient-controlled analgesia or an epidural block commonly is used administer IV fluids as prescribed monitor intake and output offer support and reassurance by explaining all procedures

a nurse in an emergency department is caring for a pt who has a sucking chest wound resulting from a gunshot. the pt has a bp of 100/60, a weak pulse rate of 118/min, and respiratory rate of 40/min. which action should the nurse take? raise the foot of the bed to a 90° angle remove the dressing to inspect the wound prepare to insert a central line administer oxygen

administer oxygen

a nurse is reviewing prescriptions for a pt who has acute dyspnea and diaphoresis. the pt states, 'i am anxious and unable to get enough air.' vital signs are HR 117/min, RR 38/min, temp 38.4°C (101.2°F), and BP 100/54 mmHg. which of the following nursing actions is the priority? notify the provider administer heparin via IV infusion administer oxygen therapy obtain a CT scan

administer oxygen therapy ABC's

pneumothorax / hemothorax nursing care

administer oxygen therapy auscultate heart and lung sounds and monitor vital signs every 4hr document ventilator settings hourly if the pt is receiving mechanical ventilation Check ABGs, SaO2, CBC, and chest x-ray results position the pt to maximize ventilation (high Fowler's 90°) provide emotional support to the pt and family monitor chest tube drainage administer medications as prescribed encourage prompt medical attention when evidence of infection occurs set up referral services (home health, respiratory services) to provide portable oxygen if needed

PE nursing care

administer oxygen therapy to relieve hypoxemia and dyspnea. high Fowler's position (90°) initiate and maintain IV administer meds assess respiratory status at least every 30min -auscultate lung sounds -measure rate, rhythm, and ease of respirations -inspect skin color and capillary refill -examine for position of trachea assess cardiac status -compare BP in both arms -palpate pulse quality -check for dysrhythmias on cardiac monitor -examine the neck for distended neck veins -inspect the thorax for petechiae provide emotional support and comfort to control pt anxiety monitor changes in LOC and mental status

A nurse in the ED is assessing a pt who was in a MVA. Findings include absent breath sound in the L lower lobe with dyspnea, blood pressure 118/68 mmHg, heart rate 124bpm, respirations 38/min, temp 38.6°C (101.4°F) and SaO2 92% on room air. Which of the following actions should the nurse take first? obtain chest x-ray prepare for chest tube insertion administer oxygen via high flow mask initiate IV access

administer oxygen via high flow mask follow ABC protocol due to dyspnea and decreased lung sounds

chest tube complcations

air leaks can result if a connection is not taped securely nursing actions: monitor water seal chamber for continuous bubbling (air leak finding). if observed, locate the source of the air leak, and intervene accordingly (tighten connection, replace drainage system) check all connections notify the provider if an air leak is noted. if prescribed, gently apply a padded clamp to determine location of the air leak. remove clamp immediately following assessment accidental disconnection, system breakage, or removal can occur at any time and requires immediate notification of provider on rapid response team nursing actions: if tubing separates, instruct the pt to exhale as much as possible and to cough to remove as much air as possible from the pleural space if chest tube drainage system is compromised, immerse the end of the chest tube in sterile water to provide a temporary water seal if chest tube is accidentally removed, dress the area with dry, sterile gauze tension pneumothorax sucking chest wounds, prolonged clamping of the tubing, kinks or obstruction in the tubing, or mechanical ventilation with high levels of positive and expiratory pressure (PEEP) can cause a tension pneumothorax assessment findings include tracheal deviation, absent breath sounds on one side, distended neck veins, respiratory distress, asymmetry of the chest, and cyanosis notify the provider or rapid response team immediately

PE meds

anticoagulants unfractionated and low molecular weight heparin, enoxaparin, and warfarin are used to prevent clots from getting larger or additional clots forming nursing actions: assess for contraindications: active bleeding, peptic ulcer disease, hx of stroke, recent trauma monitor bleeding times: prothrombin time (PT) and international normalized ratio (INR) for warfarin monitor partial thromboplastin time (aPTT) for heparin and CBC monitor for adverse effects: thrombocytopenia, anemia, hemorrhage direct factor Xa inhibitor Rivaroxaban, apixaban, fondaparinux bind directly with the active center of Xa, which inhibits the production of thrombin nursing actions: assess for bleeding from any site, pt have experienced epidural hematomas, intracranial, retinal, adrenal, and GI bleeds) hold med for 18hr prior to and 6hr after removal of epidural catheter direct thrombin inhibitor: dabigatran acts as a direct inhibitor of thrombin nursing actions: assess for bleeding and manifestations of blood loss thrombolytic therapy alteplase, reteplase, tenecteplase are used dissolve clots and restore pulmonary blood flow similar adverse effects and contraindications as anticoagulants nursing actions: assess for contraindications (known bleeding disorders, uncontrolled hypertension, active bleeding, peptic ulcer disease, hx of stroke, recent trauma or surgery, surgery) monitor for evidence of bleeding, thrombocytopenia, and anemia monitor BP, HR, respirations, and O2 sat before, during, and after administration of med

pneumothorax/hemothorax expected findings

anxiety pleuritic pain physical assessment manifestation of respiratory distress: tachypnea, tachycardia, hypoxia, cyanosis, dyspnea, and use of accessory muscles tracheal deviation to the unaffected side (tension pneumothorax) reduced or absent breath sounds on the affected side asymmetrical chest wall movement hyperresonance on percussion due to trapped air (pneumothorax) dull percussion (hemothorax) subcutaneous emphysema (air accumulating in subcutaneous tissue) labs ABGs: hypoxemia- PaO2 <80mmHg dx chest x-ray used to confirm pneumothorax or hemothorax thoracentesis can be used to confirm hemothorax, surgical perforation of the chest wall and pleural space with large-bore needle nursing actions: ensure informed consent has been obtained assist with pt positioning and specimen transport monitor status: vitals, SaO2, injection site assist pt to the edge of the bed and to lean over a bedside table pt education remain still during the procedure (no moving, coughing, or deep breathing) discomfort will be felt when the local anesthetic solution is injected. when the needle is inserted into the plural space, some pressure can be felt but no pain

PE expected findings

anxiety feelings of impending doom sudden onset of chest pressure pain upon inspiration and chest wall tenderness dyspnea and air hunger cough hemoptysis physical assessment pleurisy pleural friction rub tachycardia hypotension tachypnea adventitious breath sounds (crackles) and cough heart murmur in S3 and S4 diaphoresis low-grade fever decreased oxygen saturation levels, low SaO2, cyanosis petechiae over chest and axillae distended neck veins syncope cyanosis

a nurse is caring for a pt 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 the nurse take first? obtain a chest x-ray apply sterile gauze to the insertion site place tape around the insertion site assess respiratory status

apply sterile gauze to the insertion site ABC's

which actions by the nurse in the process of suctioning an endotracheal tube focus on reducing trauma to the airway mucosa? applying suction pressure only on the introduction of the suctioning tube administering less than 1 mL of normal saline to thin secretions applying suction pressure only on the withdrawal of the suctioning tube administering 5mL of normal saline during the suctioning process

applying suction pressure only on the withdrawal of the suctioning tube

a nurse is caring for a client who's receiving mechanical ventilation when the low-pressure alarm sounds. which of the following situations should the nurse recognize as a possible cause of the alarm? A.) Excess secretions B.) Kinks in the tubing C.) Artificial airway cuff leak D.) Biting on the endotracheal tube

artificial airway cuff leak rationale: An artificial airway cuff leak interferes with oxygenation and causes the low-pressure alarm to sound.

a nurse is caring for a pt who is receiving mechanical ventilation via an endotracheal tube. which of the following actions should the nurse take? apply a vest restraint of self-extubation is attempted monitor ventilator settings every 8hr document tube placement in centimeters at the angle of jaw assess breath sounds every 4hr

assess breath sounds every 4hr

a nurse is planning care for a pt who has quadriplegia. which of the following actions should the nurse take to prevent a pulmonary embolism (PE)? SATA assess legs for redness apply elastic compression stockings perform passive range of motion exercises place pillows under the pt knees when in pain massage the calves every shift

assess legs for redness apply elastic compression stockings perform passive range of motion exercises

a pt has acute respiratory distress syndrome (ARDS). the pt has been intubated and is mechanically ventilated. the pt is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. the nurse's first intervention for this pt would be to administer midazolam 5mg by intravenous push immediately assess the pt to see if a physiologic reason exists for his agitation obtain an order for a psych consult from the physician apply soft wrist restraints to keep him from pulling out the endotracheal tube

assess the pt to see if a physiologic reason exists for his agitation

Breathing

assessment: auscultate lung sounds observe expansion and effort note rate and depth of respirations identification of chest trauma assessment of tracheal position assess for jvd pt breathing inadequately: bag valve mask w/ 100% supplemental oxygen pt spontaneously breathing: nonrebreather mask 100% O2

Triage

being the worst makes you first! Level One: Resuscitation -airway, imminent intubation, cardiac arrest Level Two Emergent -life or limb-threatening situation -high risk, new onset neuro complaints, SOB, chest pain, blood loss, eye injury Level Three Urgent -treat soon, non-life-threatening risk Level Four Non-urgent -wait for extended length of time w/o serious deterioration Level Five Minor -non-life-threatening condition, simple evaluation and management of care

respiratory failure meds

benzodiazepines lorazepam, midazolam reduce anxiety and resistance to ventilation and decreases oxygen consumption nursing actions monitor respirations in pt who are not receiving mechanical ventilation monitor bp and SaO2 use cautiously with opioids general anesthesia propofol actions: contraindicated in pt with hyperlipidemia and egg allergies administer only to pt who are intubated and ventilated monitor ECG, bp, and sedation levels IV rate must be slowed to assess neuro status monitor for hypotension titrate to desired sedation no analgesic actions. monitor pain, and administer analgesics as prescribed corticosteroids cortisone acetate methylprednisolone sodium succinate dexamethasone sodium phosphate reduces WBC migration and decreases inflammation nursing actions discontinue medication gradually administer with an antiulcer medication to prevent peptic ulcer formation monitor weight and bp monitor glucose and electrolytes pt education take oral doses with food and avoid stopping the med suddenly opioid analgesics morphine sulfate fentanyl provide pain management nursing actions monitor respirations for pt who are not receiving mechanical ventilation monitor bp, hr, and SaO2 monitor ABGs (hypercapnia can result from depressed respirations) use cautiously in conjunction with hypnotic sedatives assess pain level and response to medication have naloxone and resuscitation in pt who are not receiving mechanical ventilation neuromuscular blocking agents vecuronium, atracurium, rocuronium facilitates ventilation and decreases O2 consumption often used with painful ventilatory modes (inverse ratio ventilation and PEEP) nursing actions administer only to pt who are intubated and ventilated monitor ECG, bp, and muscle strength give pain meds and sedatives with neuromuscular blocking agents neuromuscular blocking agents do not sedate or relieve pain (pt can be awake and frightened) have neostigmine and atropine available to reverse the effects of the neuromuscular blocking agent have resuscitation equipment available explain all procedures pt education paralysis is medication-induced antibiotics sensitive to cultured organism(s) vancomycin treats identified organisms nursing actions culture sputum prior to administration of first dose monitor for a hypersensitivity reaction give IV doses slowly (over at least 60min) to avoid red man syndrome monitor the IV site for infiltration do not give with other meds monitor coagulopathy and renal function pt education take oral doses with food and finish the prescribed dose

a nurse is assessing a pt who is undergoing hemodynamic monitoring. the pt has a CVP of 7mmHG and a PAWP of 17mmHg. which of the following findings should the nurse expect? SATA poor skin turgor bilateral crackles in the lungs jugular vein distention dry mucous membranes hepatomegaly

bilateral crackles in the lungs jugular vein distention hepatomegaly

a nurse is assessing a client who has lung cancer. which of the following manifestations should the nurse expect? A.) Blood-tinged sputum B.) Decreased tactile fremitus C.) Resonance with percussion D.) Peripheral edema

blood-tinged sputum rationale: The nurse should expect blood-tinged sputum secondary to bleeding from the tumor.

a nurse is assisting a pt following a bronchoscopy. which of the following findings should the nurse report the provider? blood-tinged sputum dry, nonproductive cough sore throat bronchospasms

bronchospasms can indicate the pt is having difficulty maintaining a patent airway

cardiac emergencies

cardiac arrest: sudden cessation of cardiac function, most commonly caused by v-fib or v-asystole ventricular fibrillation: fluttering of ventricles causing loss of consciousness, pulselessness, no breathing V-FIB=DEFIB pulseless ventricular tachycardia: irritable firing of ectopic ventricular beats at a rate of 140-180bpm, causing unconsciousness and deterioration into v-fib DEFIB ventricular asystole: complete absence of ventricular activity and ventricular movement of the heart, complete cardiac arrest requiring BLS/ ACLS protocols

central intravenous therapy

central IV catheters are appropriate for any fluids due to rapid hemodilution in the superior vena cava. x-ray verification of tip placement prior to use tunneled and implanted catheters require surgical removal types: nontunneled percutaneous central venous catheters, peripherally inserted central catheters, tunneled central venous catheters (Hickman, Groshong) and implanted ports complications occlusions, thromosis/emboli can coagulate and cause an occlusion nursing actions flush the line according to INS recommendations or facility policy do not force fluid if resistance is encountered (can dislodge thrombosis) use a 10mL to avoid excess pressure per square inch that could cause catheter fracture/rupture

a nurse checks on a pt following a lower lobectomy for lung cancer. the nurse finds that the pt is dyspneic with respirations in the 40s, is hypotensive, has a SaO2 of 86% on 10L close fitting oxygen mask, the trachea has deviated slightly to the left and the right side of the chest is not expanding. which actions should the nurse take first? strip the drainage tubing give the pt a sedative a ordered to decrease anxiety check the chest tube to make sure it is not obstructed increase the oxygen flow

check the chest tube to make sure it is not obstructed

pneumo / hemothorax therapeutic procedures

chest tube insertion inserted to drain fluid, blood, or air; re-establish a negative pressure, facilitate lung expansion, and restores normal intrapleural pressure nursing actions: obtain informed consent, gather supplies, monitor the client's status, vitals, SaO2, chest tube drainage report abnormalities to provider and administer pain meds continually monitor vitals and the pt response to procedure monitor chest tube placement, function of chest drainage system, and dressing pt education deep breath to promote lung expansion take rest periods as needed use proper hand hygiene to prevent infection participate in coughing, deep breathing, and use of incentive spirometry obtain immunizations for influenza and pneumonia recovery can be lengthy support family members to express feelings about condition and recovery if applicable, consider smoking cessation follow up with provider as instructed, and report the following: upper respiratory infection fever cough difficulty breathing sharp chest pain

chest tube

chest tubes are inserted into the pleural space to drain fluid, blood, or air, reestablish a negative pressure, facilitate lung expansion and restore normal intrapleural pressure chest tubes are removed when the lungs have re-expanded or there is no more fluid drainage into the pleural space

a nurse is observing the closed chest drainage system of a pt who is 24hr post thoracotomy. the nurse notes slow, steady bubbling in the suction control chamber. which actions should the nurse take? check the tubing connections for leaks check the suction control outlet on the wall clamp the chest tube continue to monitor the pt respiratory status

continue to monitor the pt respiratory status

noninvasive positive pressure ventilation

continuous positive airway pressure (CPAP): provides pressure using a leak-proof mask via respiratory cycle to open and improve gas exchange in the alveoli most effective tx for sleep apnea, positive pressure acts as a splint to keep the upper airway and trachea open during sleep. eliminates need for intubation, decreased risk of HAI, comfortable, eases work of breathing, enhances gas exchange bi-level positive airway pressure (BiPAP): machine cycles to provide a set positive inspiratory pressure when inspiration takes place and then during expiration to deliver a lower set and expiratory pressure requires wearing a leak-proof mask most often used for COPD and ventilatory assistance nursing actions: assess skin around masks for breakdown check oxygen percentage on machine for both inspiratory and expiratory pressure when pt is receiving BiPAP transtracheal oxygen therapy: delivers oxygen directly to lungs per small, flexible catheter passed through the trachea via small incision oxygen delivery is reduced by 55% for pt at rest and 30% for active pt catheter is less visible and avoids irritation from nasal prongs indications: acute or chronic respiratory failure acute pulmonary edema COPD chronic heart failure sleep-related breathing disorder end-of-life contraindications: respiratory arrest serious dysrhythmias cognitive impairment head or facial trauma

a nurse in the emergency department is assessing a pt who has sustained multiple rib fractures and has flail chest. which of the following findings should the nurse expect? SATA bradycardia cyanosis hypotension dyspnea paradoxical chest movement

cyanosis hypotension dyspnea paradoxical chest movement

pneumo / hemothorax complications

decreased cardiac output the amount of blood pumped by the heart decreases as intrathoracic pressure rises hypotension develops nursing actions administer IV fluids and blood products as prescribed monitor heart rate and rhythm monitor intake and output (chest tube drainage) respiratory failure inadequate gas exchange due to lung collapse nursing actions prepare for mechanical ventilation continue respiratory assessment

PE complications

decreased cardiac output blood volume is decreased nursing actions: monitor for hypotension, tachycardia, cyanosis, jugular venous distention and syncope assess for the presence of S3 or S4 heart sounds initiate and maintain IV access monitor urinary output (should be 30mL/hr or more) administer IV fluids (crystalloids) to replace vascular volume continuously monitor ECG monitor pulmonary pressures. IV fluids can contribute to pulmonary hypertension for pt who have right-sided heart failure (cor pulmonale) administer inotropic agents (milrinone, dobutamine) to increase myocardial contractility vasodilators can be need if pulmonary artery pressure is high enough to interfere with cardiac contractility hemorrhage risk for bleeding increases due to anticoagulant therapy nursing actions: assess for bleeding from or bruising around injection and surgical sites at least every 2hr monitor cardiovascular status (BP, HR and rhythm) monitor CBC (hemoglobulin, hematocrit, platelets) and bleeding times (PT, aPTT, INR) administer IV fluids and blood products as required test stool, urine, and emesis for occult blood monitor for internal bleeding (measure abdominal girth and check for abdominal or flank pain) at least every 8hr have antidote available for use if necessary

combined ventilatory and oxygenation failure

decreased gas exchange resulting in poor diffusion of oxygen into arterial blood w carbon dioxide retention hypoventilation, poor respiratory movement chronic bronchitis asthma attack emphysema cardiac failure

Disability

determine LOC AVPU: A Alert V Responsive to Voice P Responsive to Pain U Unresponsive Glasgow Coma Scale: 3: totally unresponsive, 15 wnl neurologically Eyes 4 Spontaneous 3 To voice 2 To pain 1 None Verbal 5 Oriented 4 Confused 3 Inappropriate words 2 Incomprehensible sounds 1 None Motor 5 Localizes pain 4 Withdraws 3 Flexion 2 Extension 1 None

pulmonary function tests

determine lung function and breathing difficulties by measuring lung volumes and capacity, gas exchange, flow rate, and airway resistance, along with distribution of ventilation helpful in identifying pt with lung disease, commonly performed for pt with dyspnea, and can be performed before surgical procedures to identify clients with respiratory risks smokers! no smoking 6-8hr before testing withhold inhaler 4-6hrs before testing

a nurse at a provider's office is reviewing information with a pt scheduled for pulmonary function tests (PFT's). Which of the following information should the nurse include? do not use inhaler medications for 6hr following the test do not smoke tobacco for 6-8hr prior to the test you will be asked to hold your breath during the test the arterial blood flow to your hand will be evaluated as part of the test

do not smoke tobacco for 6-8hr prior to the test to ensure accurate results, pt should not smoke for 6-8hr before the test

flail chest

due to free-floating rib segments, the lung below the flail segment caves in on inhalation and balloons out on exhalation. the portion of the lung below the flail segment cannot participate in gas exchange, so oxygenation is compromised risk factors multiple fractures from blunt chest trauma, often caused by MVA or as a result of CPR in older adults expected findings unequal chest expansion (the unaffected side will expand, and affected side can appear to diminish or remain stationary) paradoxical chest wall movement (inward movement of segment during inspiration, outward movement of segment during expansion) tachycardia hypotension dyspnea cyanosis anxiety chest pain

a nurse is caring for a pt following a thoracentesis. which of the following manifestations should the nurse recognize as risks for complications? SATA dyspnea localized bloody drainage on the dressing fever hypotension report of pain at puncture site

dyspnea fever hypotension

a nurse is assessing a pt who has pancreatitis. the pt's arterial blood gases reveal metabolic acidosis. which of the following are expected findings? SATA tachycardia hypertension bounding pulses hyperreflexia dysrhythmia tachypnea

dysrhythmia tachypnea

PE therapeutic procedures

embolectomy surgical removal embolus nursing actions: prepare the pt for the procedure (NPO status, informed consent) monitor postoperatively vital signs, SaO2, incision drainage, pain management) vena cava filter insertion of a filter in the vena cava to prevent further emboli from reaching the pulmonary vasculature nursing actions: prepare the pt for procedure (NPO status, informed consent) monitor postoperatively, vitals, SaO2, incision drainage, pain management) pt education: if homebound, set up home care services to perform weekly blood draws for severe dyspnea, set up referral services to supply portable oxygen follow recommendations for prevention of a PE -if smoking consider smoking cessation -avoid long periods of immobility -perform physical activity, such as walking -wear compression stocking to promote circulation avoid crossing legs if taking warfarin, do not increase or decrease the amount of vitamin K foods consumed (green, leafy vegetables). vitamin K can reduce the anticoagulant effects of warfarin adhere to schedule for monitoring PT and INR, and follow instruction regarding medication dosage adjustments (if on warfarin) and regular blood draws there is an increased risk for bruising and bleeding -avoid taking aspirin products, unless specified by provider check mouth and skin daily for bleeding and bruising use electric shavers and soft-bristled toothbrushes avoid blowing the nose hard, and gently apply pressure if nosebleeds occur if traveling, take measures to prevent PE arise from a sitting position 5min of every hour wear support stockings remain hydrated by drinking plenty of water perform active ROM exercises when sitting (ankle pump exercises)

a nurse is caring for a pt who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. which action should the nurse take? clamp the chest tube prior to transferring the pt to a wheelchair disconnect the chest tube from the drainage system during transport keep the drainage system below the level of the pt chest at all times empty the collection chamber prior to transport

empty the collection chamber prior to transport

a nurse is planning care for a pt following the insertion of a chest tube and drainage system. which of the following should be included in the plan of care?SATA encourage the pt to cough and deep breathe check for continuous bubbling in the suction chamber strip the drainage tubing every 4hr clamp the tube once a day obtain a chest x-ray

encourage the pt to cough and deep breathe check for continuous bubbling in the suction chamber obtain a chest x-ray

a nurse is caring or a pt who has pneumonia. which action should the nurse take promote thinning of secretions? encourage the pt to ambulate frequently encourage coughing and deep breathing encourage the pt to increase fluid intake encourage regular use of the incentive spirometer

encourage the pt to increase fluid intake

a pt is admitted to an emergency department with multiple injuries from a MVA. the nurse sees that the pt's head had been immobilized at the scene. prioritize the nurse's management of the pt during admission to the emergency department (place in order) control hemorrhage evaluate for head and neck injuries and other injuries splint fractures prevent and treat hypovolemic shock carry out a more thorough examination establish airway patency and ventilation

establish airway patency and ventilation control hemorrhage prevent and treat hypovolemic shock evaluate for head and neck injuries and other injuries splint fractures carry out a more thorough examination

the nurse in trauma unit has received report on a pt who has multiple injuries following a mva. which action should the nurse plan to take first? evaluate chest expansion check pupillary response to light assess the capillary refill check pt's response to questions about the events

evaluate chest expansion

poisoning

exposure to a toxic agent: meds, illicit drugs, ingestion of toxic agent, environmental, pollutants, snake/spider bites medical emergency requiring rapid management interventions: airway/breathing monitor for compromised circulation IV fluid therapy monitor BP, cardiac monitoring, ECG Assess for tissue edema every 15-30min for snake/spider bite No tourniquets, ice, steroids, sucking out wound Antivenom Administer opioid pain meds for snake/spider bite monitor ABG's, glucose, coagulation profile Administer diazepam for seizures Administer naloxone for heroin and opiate toxicity ingested poison: activated charcoal, gastric lavage if done within 1hr of ingestion, aspiration nonpharmacologic technique: dialysis and an exchange blood transfusion to remove toxic agents

a pt is clinical deteriorating and showing signs of poor cardiac output. the nurse receives a dopamine drip prescription. what are the priority assessments and interventions? frequent re-assessment of vital and drug titration focused cardiac assessment monitoring of urine output and review lab findings place peripheral IV and assess cardiac rhythm on monitor

frequent re-assessment of vital and drug titration

a nurse is assessing a pt who has a chest tube and drainage system in place. which of the following are expected findings? SATA continuous bubbling in the water seal gentle constant bubbling in the suction control chamber rise and fall in the level of water in the water seal chamber with inspiration and expiration exposed sutures without dressing drainage system upright at chest level

gentle constant bubbling in the suction control chamber rise and fall in the level of water in the water seal chamber with inspiration and expiration

Environmental emergencies

heat exhaustion: prolonged exposure to elevated temps excessive diaphoresis and tachycardia, leading to dehydration rapid tx for dehydration and low sodium to prevent developing heat stroke heat stroke: medical emergency requiring immediate tx manifestations: temp > 40°C (104°F) no perspiration low BP high HR low urinary output alterations in mental status abnormal blood potassium or sodium levels nursing actions: ABCDE administer O2 as needed large bore IV for rapid 0.9% SC infusion ice packs and cooling blankets frostbite: prolonged exposure to freezing temps may not be evident for at least 24hr after injury 1st degree (superficial): least severe, only superficial layers of exposed skin affected, hyperemia and edema 2nd degree (partial thickness): blisters over exposed skin areas causing necrotic tissue death and swelling 3rd degree (full thickness): non-blanchable extensive edema and blisters to exposed skin areas, debridement of damaged tissue indicated 4th degree (full thickness): complete lack of blood supply to area, full thickness necrosis of skin with potential progression to gangrene, may require amputation

a nurse is caring for a pt who is to receive thrombolytic therapy. which of the following factors should the nurse recognize as a contraindication to therapy? hip arthroplasty 2 weeks ago elevated sedimentation rate incident of exercise-induces asthma 1 week ago elevated platelet count

hip arthroplasty 2 weeks ago major surgical procedure within 3 weeks should not receive thrombolytic therapy bc of risk of hemorrhage from the surgical site

respiratory alkalosis

hyperventilation results from hyperventilation due to fear, anxiety, intracerebral trauma, salicylate toxicity, or excessive mechanical ventilation hypoxemia from asphyxiation, high altitudes, shoch, or early-stage asthma or pneumonia results in decreased CO2 decreased or normal H+ concentration manifestations tachypnea inability to concentrate, numbness, tingling, tinnitus, and possible LOC tachycardia, ventricular, and atrial dysrhythmias rapid, deep respirations nursing care: oxygen therapy anxiety reduction interventions and rebreathing techniques pH: >7.45, PaCO: <35, HCO3: wnl

respiratory acidosis

hypoventilation results from respiratory depression from opioids, poisons, anesthetics, pt with brain tumors, cerebral aneurysm, stroke or overhydration, trauma, or neurologic diseases (myasthenia gravis, guillain-barre when respiratory effort is affected) inadequate chest expansion due to muscle weakness, pneumothorax/hemothorax, flail chest, obesity, sleep apnea, tumors, or deformities airway obstruction that occurs from neck edema, or localized lymph node enlargement, foreign bodies or mucus alveolar-capillary blockage secondary to a pulmonary embolus, thrombus, ARDS, chest trauma, drowning, or pulmonary edema inadequate mechanical ventilation results in increased CO2 increased or normal H+ concentration manifestations initial tachycardia and hypertension, bradycardia and hypotension develop as acidosis worsens v-fib can be the first indication in a pt receiving anesthesia initial anxiety, irritability, and confusion; lethargy and possibly coma develop as acidosis worsens ineffective, shallow, rapid breathing pale or cyanotic skin chronic respiratory acidosis seen in pt who have pulmonary disease, sleep apnea, and obesity nursing care oxygen therapy, maintain patent airway, and enhance gas exchange (positioning and breathing techniques, ventilatory support, bronchodilators, mucolytics) pH: <7.35, PaCO2: >45, HCO3: wnl

a nurse is caring for a pt who has a new prescription for heparin therapy. which of the following statements by the pt should indicate an immediate concern for the nurse? i'm allergic to morphine i take antacids several times a day for my ulcer a had a blood clot in my leg several years ago it hurts to take a deep breath

i take antacids several times a day for my ulcer risk for bleeding form a peptic ulcer

Airway

if airway is lost: inspect for blood, broken teeth, vomitus or foreign materials to rule out obstruction Unresponsive w/o trauma: head tilt/chin lift Unresponsive with trauma: jaw thrust airway can be maintained with adjuncts: oropharyngeal / nasopharyngeal

mechanical ventilation complications

increased intrathoracic pressure PEEP increases intrathoracic pressure, which can cause a decreased blood return to the heart, decreased cardiac output, and/or hypotension decreased cardiac output can activate the renin-angiotensin-aldosterone system, leading to fluid retention and/ decreased urine output nursing actions monitor input and output, weight and hydration status pt education avoid using the Valvalva maneuver (straining with bowel movement) because it can further increase intrathoracic pressure barotrauma ventilation with positive pressure causes damage to the lungs (pneumothorax, subcutaneous emphysema) nursing actions monitor oxygenation status and chest x-ray assess for subcutaneous emphysema (crackles and/or air movement felt under skin) monitor for a high-pressure ventilator alarm which can indicate pneumothorax immobilization can result in muscle atrophy, pneumonia, and pressure injury nursing action reposition and suction every 2hr and as needed provide routine skin care implement range-of-motion exercises to prevent muscle atrophy

endotracheal intubation

indications: emergency airway management, tube is inserted through pt nose or mouth into trachea oral is easiest and quickest form of intubation, most common in ED nasal is used when pt has facial or oral trauma, contraindicated for pt with clotting problem placement: typically performed by nurse anesthetist, anesthesiologist, critical care or emergency physician, pulmonologist chest x-ray verifies placement cuff is inflated to ensure placement and formation of a seal between cuff and tracheal wall, preventing air from leaking around ET tube can be uncuffed pt is unable to speak when cuff is inflated equipment: ET tube of proper size stylet laryngoscope and blade suction syringe to inflate balloon topical anesthetic water soluble lubricant tape or tube securement device stethoscope bag-valve device with reservoir connected to O2 meds: Neuromuscular blocking agents, short and long acting Succinlycholine (Quelicin, Pro) Mivacron (mivacurium) Rocuronium (Zemuron, Pro) (Nimbex) Sedatives, short and long acting Propofol (Diprivan) Etomidate Fentanyl nursing actions: have resuscitation equipment available including manual bag with face mask at bedside at all times hyperoxygenate with bag valve mask 100% O2 ensure intubation attempt lasts no longer than 30sec, then reoxygenate before another attempt monitor vitals and verify ET tube placement by checking end-tidal carbon dioxide levels and chest xray auscultate for breath sounds bilaterally after intubation observe for symmetric chest movement stabilize ET tube with tube-holding device or tape monitor for hypoxemia, dysrhythmias, and aspiration document: ET tube size, depth, confirmation of placement, vent settings ex: Pt intubated with ET tube 7.5 secured at 21cm. Confirmed placement with..... vent settings: A/C 16 Vt 500 PEEP +5 FiO2 100%

Circulation

interventions: CPR assess for external bleeding, apply direct pressure if indicated IV, large bore to both AC's infuse isotonic fluids: LR, 0.9% SC, and/or blood products shock can develop if circulation is compromised: increased HR, decreased BP tissue ischemia, necrosis interventions same as above

respiratory failure therapeutic procedures

intubation and mechanical ventilation artificial airway insertion with mechanical ventilation nursing actions monitor ECG, SaO2, lung sounds, and color sedate as needed provide reassurance to calm the pt have suction equipment, manual resuscitation bag, and face mask available at all times suction secretions as needed preintubation oxygenate with 100% oxygen assist ventilation with manual resuscitation bag and face mask have emergency resuscitation equipment readily available postintubation assess end-tidal carbon dioxide levels, bialteral lung sounds, symmetrical chest movement, and chest x-ray findings to confirm placement of the ET tube secure the ET tube per facility policy assess balloon cuff for air leaks periodically PEEP positive pressure is applied at the end of expiration to keep the alveoli expanded PEEP is added to the ventilator setting to increase oxygenation and improve lung expansion pt education alternate methods of communication will be provided because speaking is not possible while the ET tube is in place kinetic therapy a kinetic bed that rotated laterally alter pt positioning to reduce atelectasis and improve ventilation nursing actions begin slowly and gradually to increase the degree of rotation as tolerated monitor ECGs, SaO2, breath sounds, and bp stop rotation if pt becomes distressed provide routine skin care to prevent breakdown sedate as needed

hemodynamic monitoring

involves special indwelling catheters which provide information about blood volume and perfusion, and how well the heart is pumping. hemodynamic status is assessed with several parameters central venous pressure (CVP) pulmonary artery pressure (PAP) pulmonary artery wedge pressure (PAWP) cardiac output (CO) intra-arterial blood pressure a hemodynamic monitoring system is used to display a pt's hemodynamic data pressure transducer pressure tubing monitor pressure bag and flush device

a nurse is caring for a pt 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? it keeps the alveoli open and prevent atelectasis it allows preset pressure delivered during spontaneous ventilation it guarantees minimal minute ventilator it delivers a preset ventilatory rate and tidal volume to the pt

it allows preset pressure delivered during spontaneous ventilation PSV allows preset pressure delivered during spontaneous ventilation to decrease the work of breathing

PE labs & diagnositics

labs ABG analysis PaCO2 low (<35 mmHg) due to hyperventilation (respiratory alkalosis) as hypoxemia progresses, respiratory acidosis occurs further progression leads to metabolic acidosis due to buildup of lactic acid from tissue hypoxia D-dimer elevated in response to clot formation and release of fibrin degradation products (>0.4 mcg/mL) dx computed topography scan multidetector-row computed tomography angiography (MDCTA) is criterion standard for detecting PE when available, as it provides high-quality visualization of the lung parenchyma ventilated-perfusion scan (V/Q) scan images show circulation of air and blood in the lungs and can detect a PE, useful when pt is allergic to contrast media is a contraindication to other types of imaging pulmonary angiography gold standard test when MDCTA is unavailable to detect a PE, but is invasive and costly. A catheter is inserted into the vena cava to visualize the embolus pulmonary angiography is a higher risk procedure than a (V/Q) scan nursing actions: verify informed consent monitor status (vitals, SaO2, anxiety, bleeding with angiography) during and postprocedure chest x-ray can provide data to support the occurrence of PE, such as elevation of the diaphragm on the affected side or pleural effusion

tunneled percutaneous central venous catheter

long-term use insertion location: a portion of the catheter lies in a subcutaneous tunnel separating the point where the catheter enters the vein from where it enters the skin with a cuff. tissue granulates in the cuff to provide a mechanical barrier to organisms and anchoring for the catheter indications: frequent and long-term need for vascular access no dressing is needed because entrance into skin and vein are separate and tissue granulates into catheter cuff, providing barrier. Groshong catheters have pressure-sensitive valves to prevent blood reflux and do not require a clamp

tracheostomy

may be needed for long term ventilation long term airway management similar to ET tube to ensure adequate ventilation fenestrated tracheostomy tube: has hold in the outer cannula that allows air to flow above the larynx nursing actions: suction only as indicate by assessment assemble equipment: suction kit with gloves, sterile water or saline for rinsing catheter use sterile technique set suction vacuum 80-150mmHg hyperoxygenate pt via vent circuit before, between, and after suctioning gently insert suction catheter until resistance is met, then pull back 1cm suction the pt no longer apply intermittent or constant suction after endotracheal suction is performed, rinse the catheter suction mouth and oropharynx auscultate the lungs to assess effectiveness of suctioning document the amount, color, and consistency of secretion

a charge nurse is teaching a group of nurses about condition related to metabolic acidosis. which of the following statements by a unit nurse indicates the teaching has been effective? metabolic acidosis can occur due to diabetic ketoacidosis metabolic acidosis can occur in a pt who has myasthenia gravis metabolic acidosis can occur in a pt who has asthma metabolic acidosis can occur due to cancer

metabolic acidosis can occur due to diabetic ketoacidosis metabolic acidosis results from an excess production of hydrogen ions, which occurs in dka

a nurse is obtaining arterial blood gases for a pt who has vomited for 24hr. the nurse should expect which of the following acid-base imbalances to result from vomiting for 24hr? respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis

metabolic alkalosis a loss of gastric acids and accumulation of bicarbonate in the blood results in metabolic alkalosis

tidaling

movement of the fluid level with respiration, this is expected in the water seal chamber. with normal respirations, the water will rise with inspiration (increase in negative pressure in the lung) and will fall with expiration. With positive-pressure mechanical ventilation, the fluid level will rise with expiration and fall with inspiration. cessation of tidaling in the water seal chamber signals lung re-expansion or an obstruction within the system. continuous bubbling in the water seal chamber indicates an air leak in the system. when the tubes are inserted to remove air from the pleural space, intermittent bubbling is expected; it is common to see bubbling during exhalation, sneezing, or coughing, in this case when bubbling is no longer seen, it indicates all the air has been removed. when tubes are in the mediastinal space (such as following open heart surgery,) bubbling and tidaling are not expected; pulsations in the fluid level might be seen

a nurse is reviewing discharge instruction for a pt who has COPD and experienced a pneumothorax. which of the following statements should the nurse include? notify your provider if you experience weakness you should be able to return to work in 1 week you need to wear a mask when in crowded areas notify your provider if you experience a productive cough

notify your provider if you experience a productive cough this can indicate the pt has a respiratory infection

a nurse is assisting the provider to care for a pt who has developed spontaneous pneumothorax. which of the following actions should the nurse perform first? assess the pt pain obtain a large-bore IV needle for decompression administer lorazepam prepare for chest tube insertion

obtain a large-bore IV needle for decompression ABC's

pulmonary embolism

occurs when a substance (solid, gaseous, or liquid) enters venous circulation and forms a blockage in the pulmonary vasculature emboli originating from venous thromboembolism are the most common cause, other types include fat, air, septic (due to bacterial invasion of a thrombus,) and amniotic fluid. increased hypoxia to pulmonary tissue and impaired blood flow can result from a large embolus. a PE is a medical emergency prevention promote smoking cessation encourage maintenance of appropriate weight for height and body frame encourage a health diet and physical activity prevent DVT by encouraging pt to do leg exercises, wear compression stockings, and avoid sitting for long periods of time risk factors long-term immobility oral contraceptive use and estrogen therapy pregnancy tobacco use hypercoagulability (elevated platelet count) obesity surgery (especially ortho of lower extremities or pelvis) central venous catheters heart failure or chronic atrial fibrillation autoimmune hemolytic anemia (sickle cell) long bone fractures cancer trauma septicemia advanced age

a nurse is preparing to care for a pt following chest tube placement. which of the following items should be available in the pt room? SATA oxygen sterile water enclosed hemostat clamps indwelling urinary catheter occlusive dressing

oxygen sterile water enclosed hemostat clamps occlusive dressing

a nurse is caring for a pt who is scheduled for a thoracentesis. which of the following supplies should the nurse ensure are in the pt's room? SATA oxygen equipment incentive spirometer pulse oximeter sterile dressing suture removal kit

oxygen equipment pulse oximeter sterile dressing

a nurse is caring for a pt admitted with confusion and lethargy. the pt was found at home unresponsive with and empty bottle of aspirin lying next to the bed. vitals reveal bp 104/72 mmHg, hr 116/min with regular rhythm, and rr 42/min and deep which of the following arterial blood gas findings should the nurse expect? pH 7.68 PaO2 96mm Hg PaCO2 38mm Hg HCO3 28mEq/L pH 7.48 PaO2 100mmHg PaCO2 28mmHg HCO3 23mEq/L pH 6.98 PaO2 100mmHg PaCO2 30mmHg HCO3 18mEq/L pH 7.58 PaO2 96mmHg PaCO2 38mmHg HCO3 29mEq/L

pH 6.98 PaO2 100mmHg PaCO2 30mmHg HCO3 18mEq/L aspirin toxicity would result in arterial blood gas findings of metabolic acidosis

A nurse is caring for a pt who was in a mva. the pt reports chest pain and difficulty breathing. a chest x-ray reveals the pt has a pneumothorax. which of the following arterial blood gas findings should the nurse expect? pH 7.06 PaO2 86 PaCO2 52 HCO3 24 pH 7.42 PaO2 100 PaCO2 38 HCO3 23 pH 6.98 PaO2 100 PaCO2 30 HCO3 18 pH 7.58 PaO2 96 PaCO2 38 HCO3 29

pH 7.06 PaO2 86 PaCO2 52 HCO3 24 a pneumothorax can cause alveolar hypoventilation and increased carbon dioxide levels, resulting in a state of respiratory acidosis.

a nurse is caring for a client who's postoperative and has an RR of 9/min secondary to general anesthesia effects na incisional pain. which of the following ABG values indicates the client is experiencing respiratory acidosis? A.) pH 7.50, PO2 95 mm Hg, PaCO2 25 mm Hg, HCO3- 22 mEq/L B.) pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3- 30 mEq/L C.) pH 7.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3- 20 mEq/L D.) pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L

pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L rationale: These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis.

a nurse is caring for a pt who is experiencing respiratory distress. which of the following early manifestations of hypoxemia should the nurse recognize? SATA confusion pale skin bradycardia hypotension elevated blood pressure

pale skin elevated blood pressure

Acute respiratory distress syndrome

persistent hypoxemia despite oxygen therapy lung volume capacity and elasticity is reduced dyspnea worsens as bilateral pulmonary edema develops that is non cardiac related chest x-ray reveals area of density with a ground-glass appearance blood gas findings include high arterial blood levels of carbon dioxide (hypercarbia) despite pulse ox showing decreased saturation lung injury as a result of: localized lung damage, other systemic problems shock disseminated intravascular coagulopathy (DIC) aspiration pulmonary emboli pneumonia lung infections sepsis near drowning trauma multiple blood transfusion CNS damage smoke/toxic gas inhalation drug ingestion/overdose Severe acute respiratory syndrome (SARS): exposure to infected individual immunocompromised (chemo, AIDS) expected findings: SOB dyspnea with or w/o exertion orthopnea rapid, shallow breathing cyanotic, mottled, dusky skin or mucous membranes tachycardia hypotension retractions wheezing, rales cardiac arrhythmias confusion lethargy bilateral noncardiogenic pulmonary edema (crackles) reduced lung capacity dense patchy bilateral pulmonary infiltrates severe hypoxemia despite administration of 100% oxygen diagnostics: chest x-ray: pulmonary edema, diffuse infiltrates and white-out or ground-glass appearance

a nurse is assisting a provider with the removal of a chest tube. which of the following actions should the nurse take? instruct the pt to lie prone with arms by the sides complete a surgical checklist on the pt remind the pt that there is minimal discomfort during the removal process place an occlusive dressing over the site once the tube is removed

place an occlusive dressing over the site once the tube is removed the nurse should place an occlusive dressing over the site once the tube is removed and observe the site for drainage.

a nurse is planning care for a pt who has ARDS. which of the following interventions should the nurse include in the plan? administer low-flow oxygen continuously via nasal cannula encourage oral intake of at least 3000mL of fluids per day offer high-protein and high-carbohydrate foods frequently place in prone position

place in prone position

a nurse is reviewing the lab results data on a pt who has a new prescription for heparin for the treatment of a pulmonary embolism. which of the following data should the nurse report to the provider? hematocrit 45% partial thromboplastin time (PTT) 65sec white blood cell count 8,000/mm3 platelets 74,000/mm3

platelets 74,000/mm3

a nurse is assessing a pt who has pulmonary embolism. which of the following manifestations should the nurse expect? SATA bradypnea pleural friction rub hypertension petechiae tachycardia

pleural friction rub petechiae tachycardia

chest tube indications

pneumothorax: partial to complete collapse of the lung due to accumulation of air in the pleural space hemothorax: partial to complete collapse of the lung due to accumulation of blood in the pleural space postoperative chest drainage: thoracotomy or open-heart surgery pleural effusion: abnormal accumulation of fluid in the pleural space pulmonary empyema: accumulation of pus in the pleural space due to pulmonary infection, lung abscess, or infected pleural effusion s/s: dyspnea distended neck veins hemodynamic instability pleuritic chest pain cough absent or reduced breath sounds of the affected side hyperresonance on percussion of affected side (pneumothorax) dullness or flatness on percussion of the affected side (hemothorax, pleural effusion) asymmetrical chest wall motion

implanted port

port is comprised of a small reservoir covered by a thick septum insertion location: surgically implanted into chest wall pocket. catheter is inserted into the subclavian vein with the tip in the SVC indications: long-term (1yr or more) need for vascular access, commonly used for chemotherapy complications mechanical complications, catheter tip and port become dislodged. nursing actions use only a noncoring (Huber) needle to avoid damaging the mesh on implanted ports pt education manifestations of a dislodged port include swelling at the port site, unrestricted movement of the port, and inability to access the port. report findings to the provider immediately manifestations of a dislodged catheter tip include gurgling or swishing sounds, and pain on the affected side in the neck or ear. report findings to the provider immediately

a nurse is caring for a pt who is scheduled for a thoracentesis. prior to the procedure, which of the following actions should the nurse take? position pt in an upright position, leaning over bedside table explain the procedure obtain ABGs administer benzocaine spray

position pt in an upright position, leaning over bedside table this widens the intercostal space for the provider to access the pleural fluid.

chest tube insertion

preprocedure: verify that the consent form is signed inform the pt that breathing will improve when the chest tube is in place assess for allergies to local anesthetics assist the pt into the desired position (supine or semi-Fowler's) prepare the chest drainage system per facility protocol (fill water seal chamber) administer pain and sedation medications as prescribed prep the insertion site with povidone-iodine or other facility-approved agent intraprocedure: when the tube is inserted to drain fluid from the lung, the tip of the tube in inserted near the base of the lung on the side. when the tube is inserted to remove air from the pleural space, the tip of the tube will be near the apex of the lung assist the provider with insertion of the chest tube, application of dressing to the insertion site, and set-up of drainage system place drainage system below the pt's chest level with tubing coiled on the bed, ensure that tubing from the bed to the drainage system is straight to promote drainage via gravity monitor vitals and response to procedure postprocedure: assess vitals, breath sounds, SaO2, color, and respiratory efforts as indicated by the status of the pt and at least every 4hr encourage coughing and deep breathing every 2hr keep the drainage system below the pt chest level, including during ambulation monitor chest tube placement and function check water seal level evert 2hr, and add fluid as needed. the fluid level should fluctuate with respiratory effort document amount and color of drainage hourly for the first 24hr and then at least every 8hr. mark the date, hour, and drainage level on the container at the end of each shift. report excessive drainage that is cloudy or red to the provider. drainage often increases with position changes or coughing. monitor the fluid in the suction control chamber, and maintain prescribed fluid level. check for expected findings of tidaling in the water seal chamber and continuous bubbling only in the suction chamber. routinely monitor tubing for kinks, occlusions, or loose connections. monitor the chest tube insertion site for redness, pain, infection, and crepitus (air leakage in subcutaneous tissue) tape all connections between chest tube and chest tube drainage system position the pt semi-to-high-fowler's position to promote optimal lung expansion and drainage of fluid from the lungs administer pain meds as prescribed obtain a chest x-ray to verify the chest tube's placement keep two enclosed hemostats, sterile water, and an occlusive dressing located at bedside at all times due to the risk of causing a tension pneumothorax, chest tubes are clamped only when prescribed in specific circumstances do not clamp, strip, or milk tubing, only perform this action when prescribed notify the provider immediately if the pt's SaO2 is less than 90%, if the eyelets of the chest tube become visible, if drainage is above the prescribed amount, or stops in the first 24hrs, or complications occur

a nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. the nurse should identify that which of the following assessments if the priority? A.) presence of gag reflex B.) pain level rating using 0 to 10 scale C.) hydration status D.) appearance of the IV insertion site

presence of gag reflex rationale: The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex.

which actions should the nurse initiate to reduce the risk fir ventilator-assisted pneumonia (VAP)? SATA alternate vent settings provide a 'sedation holiday' daily elevate the head of the bed at least 30° give prescribed pantoprazole 40mg IV BID provide oral care with chlorhexidine (0.12%) solution daily

provide a 'sedation holiday' daily elevate the head of the bed at least 30° give prescribed pantoprazole 40mg IV BID

chest tube removal

provide pain meds 30min prior to removal assist the provider with sutures and chest tube removal instruct pt to take a deep breath, exhale, and bear down (Valsalva maneuver) or to take a deep breath and hold it (increases intrathoracic pressure and reduces risk of air emboli) during chest tube removal apply airtight sterile petroleum jelly gauze dressing secure in place with a heavyweight stretch tape obtain chest x-rays as prescribed. this is performed to verify continued resolution of the pneumothorax, hemothorax, or pleural effusion monitor for excessive wound drainage, findings of infection, or recurrent pneumothorax

mechanical ventilation

provides breathing support until lung function is restored, delivering 100% oxygen that is warmed (37°C, 98.6°F) and humidified at FiO2 levels between 21%-100% positive pressure ventilators deliver air to the lungs under pressure throughout inspiration to keep the alveoli open and prevent alveolar collapse during expiration benefits include: forced/enhanced lung expansion improved gas exchange (oxygenation) decreased work of breathing mechanical ventilation can be delivered via: ET tube tracheostomy tube can be cycled based on pressure, volume, time, and/or flow complications: problems with ventilator circuit alterations in cardiac function barotrauma pneumothorax sepsis alarms: volume (low pressure) alarm indicates low exhaled volume due to a disconnection, cuff leak, and/or tube displacement pressure (high pressure) alarm indicate excess secretions, pt biting the tubing, kinks in tubing, pt coughing, pulmonary edema, bronchospasm, or pneumothorax apnea alarms indicate that ventilator does not detect spontaneous respiration in a preset time period

primary survey

rapid assessment of life-threatening conditions standard precautions: gloves, gown, eye protection, face masks, and shoe covers must be worn to prevent contamination with bodily fluids ABCDE principle

exposure

remove pt clothing for complete physical assessment preserve items of evidence, clothing, drugs, weapons hypothermia: pt core temp 35°C (95°F) or less trauma victims at risk due to exposure, unwarmed oxygen, and cold IV fluids can lead to coma, hypoxemia and acidosis prevention: remove wet clothing warm blankets increase room temp heat lamp warm IV fluids

a nurse is working on an ICU unit and caring for a one-to-one pt on mechanical ventilation. there is a power outage and the generators fail to restore power. which action should the nurse perform immediately? call the manager and maintenance contact the physician for further orders remove the ventilator and administer breaths via a bag valve mask extubate the pt to allow for spontaneous respirations

remove the ventilator and administer breaths via a bag valve mask

arterial blood gases

reports the status of oxygenation and acid-based balance of the blood, can be obtained by an arterial puncture or through an arterial line pH: amount of free hydrogen ions in the arterial blood (H+) PaO2: partial pressure of oxygen PaCO2: partial pressure of carbon dioxide HCO3: concentration of bicarbonate in arterial blood SaO2: percentage of O2 bound to Hgb as compare with total amount that can be possibly carried

a pt is admitted to the emergency room with a respiratory rate of 37/min. arterial blood gases (ABGs) reveal the following values. which is an appropriate analysis of the ABGs? pH 7.58 PaCO2 22 PaO2 88 saturation 91% bicarbonate 22 respiratory acidosis metabolic acidosis metabolic alkalosis respiratory alkalosis

respiratory alkalosis

metabolic alkalosis

results from base excess oral ingestion of excess amount of bases (antacids) venous administration of bases (blood transfusions, total parenteral nutrition, or sodium bicarbonate) acid deficit -loss of gastric secretions through prolonged vomiting, NG suction -potassium depletion (due to thiazide diuretics, laxative overuse, Cushing's syndrome, hyperaldosteronism) increased digitalis toxicity results in increased HCO3 decreased H+ concentration manifestations tachycardia, normotensive or hypotensive atrial tachycardia, ventricular issue when pH increases numbness, tingling, tetany, muscle weakness, hyperreflexia, confusion, convulsion depressed skeletal muscles resulting in ineffective breathing nursing care: varies with causes GI losses: administer antiemetics, fluid, and electrolyte replacements potassium depletion: discontinue causative agent pH >7.45, PaCO2 wnl, HCO3 >26

metabolic acidosis

results from excess production of hydrogen ions diabetic ketoacidosis (DKA) starvation lactic acidosis can result from: heavy exercise, seizure activity, hypoxia excessive intake of acids: ethyl alcohol, methyl alcohol, aspirin inadequate elimination of hydrogen ions: kidney failure, severe lung problems inadequate production of bicarbonate: kidney failure, pancreatitis impaired liver or pancreatic function: liver failure excess elimination of bicarbonate: diarrhea results in decreased HCO3 increased H+ concentration manifestations dysrhythmias bradycardia, weak peripheral pulses, hypotension, tachypnea headache, drowsiness, confusion rapid, deep respirations (Kussmaul respirations) warm, dry pink skin nursing care: varies with causes if DKA, administer insulin if GI losses, administer antidiarrheals and provide rehydration if blood bicarbonate is low, administer sodium bicarbonate 1mEq/kg pH: <7.35, PaCO2 wnl, HCO3: <22

a nurse is caring for a pt who has an endotracheal tube and is receiving mechanical ventilation. which of the following interventions should the nurse take to reduce the risk for ventilator-associated pneumonia? position the head of the bed in the flat position turn the pt every 4hr rinse the pt mouth with an antimicrobial solution every 4hr suctioning the pt endotracheal tube every hour

rinse the pt mouth with an antimicrobial solution every 4hr

acute respiratory failure

sudden, life-threatening deterioration of the gas exchange function of the lung insufficient oxygen transfer / exchange (oxygenation) insufficient carbon dioxide removal (ventilation) decrease in arterial oxygen to <50mmHg increase in arterial carbon dioxide tension >50mmHg with arterial pH <7.35 chronic causes: COPD, neuromuscular disease expected findings: dyspnea orthopnea cyanosis pallor hypoxemia tachycardia confusion irritability or agitation restlessness hypercarbia (high carbon dioxide levels in the blood) medical management: correct underlying cause meds ET tube positive pressure ventilation, invasive/noninvasive pharmacologic therapy: bronchodilators Albuterol, Atrovent corticosteroids Solumedrol diuretics Lasix antibiotics Vancomycin, Rocephin anti-anxiety medications Ativan, Versed enteral or parenteral nutrition nursing interventions: monitor LOC, pulse ox, vitals ABG's Med management turning schedule mouth care skin care ROM coughing and deep breathing adequate hydration and humidification chest physical therapy tracheal suctioning correct hypoxemia: -O2 >93% -PaO2 75-100 mmHg O2 via NC/nonrebreather diagostics: Chest x-ray: pulmonary edema, cardiomegaly SARS: infiltrates ECG hemodynamic monitoring: pulmonary capillary wedge pressure is low in ARDS or within range (4-12mmHg). continuous hemodynamic monitoring is important for fluid management labs ABGs to confirm and monitor ARF, ARDS, and SARS PaO2 <60mmHg and O2 less than 90% on room air (hypoxemia) PaCO2 > 45mmHg and pH <7.35 (hypoxemia, hypercarbia)

a nurse is caring for a pt who has acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. the pt receives a prescription for pancuronium. the nurse recognizes that this medication is for which purpose? decrease chest wall compliance suppress respiratory effort induce sedation decrease respiratory secretions

suppress respiratory effort

a nurse is reviewing the plan of care for a pt who is receiving mechanical ventilation. which of the following ventilator modes will increase the pt's work of breathing? SATA assist-control synchronized intermittent mandatory ventilation continuous positive airway pressure pressure support ventilation independent lung ventilation

synchronized intermittent mandatory ventilation continuous positive airway pressure pressure support ventilation

a nurse is assessing a pt following a gunshot wound to the chest. for which of the following findings should the nurse monitor to detect a pneumothorax? SATA tachypnea deviation of the trachea bradycardia decreased use of accessory muscles pleuritic pain

tachypnea deviation of the trachea pleuritic pain

rapid response team

team of critical care experts: ICU nurse, respiratory therapist, critical care provider, hospitalist who respond to codes in hospital

wet suction

the height of the sterile fluid in the control chamber determines the amount of suction transmitted to the pleural space. a suction pressure of -20cm H2O is commonly prescribed, the level of water in the suction control chamber determines the suction pressure. the system is attached to a suction source, and suction initiated until gentle bubbling begins in the suction chamber

pneumothorax

the presence of air or gas in the pleural space that causes lung collapse tension pneumothorax occurs when air enters the pleural space during inspiration through a one-way valve and is not able to exit upon expiration. the trapped air causes pressure on the heart and the lung. as a result, the increase in pressure compresses blood vessels and limits venous return. leading to a decrease in cardiac output. death can result if not treated immediately. as a result of a tension pneumothorax, air and pressure continue to rise in the pleural cavity, which causes and mediastinal shift hemothorax an accumulation of blood in the pleural space spontaneous pneumothorax can occur when there has been no trauma. a small bleb on the lung ruptures and air enters the pleural space a flail chest occurs when at least two neighboring ribs, usually on one side of the chest, sustain multiple fractures, causing instability of the chest sustain multiple fractures, causing instability of the chest wall and paradoxical chest wall movement. this results in significant limitation in chest wall expansion. risk factors blunt chest trauma penetrating chest wounds closed/occluded chest tube older adult pt have decreased pulmonary reserves due to normal lung changes, including decreased lung elasticity and thickening alveoli COPD meds benzodiazepines (sedative) nursing actions monitor vitals, lookout for hypotension and respiratory distress remember that meds have amnesiac effects monitor for paradoxical effects (euphoria, rage) pt education amnesiac effects and drowsiness opioid agonists (pain) morphine sulfate and fentanyl are opioid agents used to treat moderate to severe pain. analgesia (pain relief) respiratory depression, euphoria, sedation, and decrease in GI motility if pt is on mechanical ventilation, nursing actions and pt education can vary nursing actions use cautiously for pt with asthma or emphysema, due to risk of respiratory depression assess pain every 4hr monitor pt, especially older adults, for respiratory depression. if RR <12/min, stop med and call provider monitor vitals for hypotension and bradypnea assess for nausea and vomiting assess level of sedation (drowsiness, LOC) monitor for constipation encourage fluid intake and activity related to decrease in gastric motility monitor intake and output. report fluid retention as an adverse effect of opioid medications pt education if receiving a fentanyl patch, the initial patch take several hours to take effect. a short-acting pain med is administered for breakthrough pain if there are no fluid restrictions due to other conditions, drink plenty of fluids to prevent constipation follow instruction on how to use PCA pump if applicable pt is the only person to push button, safety lockout mechanism prevent pt from using too much

compensation

the process by which the body attempts to correct changes and imbalances in pH levels full compensation occurs when the pH level of the blood returns to normal (7.35-7.45) if the pH level is not able to normalize, it is referred to as partial compensation acid-base imbalances are a result of insufficient compensation. respiratory and kidney function play a large role in the body's ability to effectively compensate for acid-base alterations. organ dysfunction negatively effects acid-base compensation

severe acute respiratory syndrome (SARS)

the result of a viral infection from a mutates strain of the coronaviruses, a group of viruses that also cause the common cold. the virus invades the pulmonary tissue, which leads to an inflammatory response the virus is spread through airborne droplets from sneezing, coughing, or talking the virus does not spread to the bloodstream because it flourishes at temps slightly below normal core body temp

a nurse is providing preoperative teaching for a pt who will undergo surgery. the nurse explains that the pt will wear antiembolism stockings during and after the procedure. when the pt asks what the stockings do, which response should the nurse make? the protect your legs and heels from skin breakdown they help keep you warm after your surgery they improve your circulation to keep blood from pooling in your legs they make it easier for you to do leg exercises after your surgery

they improve your circulation to keep blood from pooling in your legs

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? this medication is given to treat infection this medication is given to facilitate ventilation this medication is given to decrease inflammation this medication is given to reduce anxiety

this medication is given to facilitate ventilation vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption.

ET tube complications

trauma during intubation or long-term intubation cause damage to trachea and vocal cords a tracheostomy might be required for long-term ventilation altered position of ET tube nursing actions check tube positioning every 1-2hr as needed assess lung sounds, SaO2, and chest movement each time the pt is moves, transferred or turned secure ET tube per facility guideline to maintain tube placement aspiration pneumonia nursing actions check the cuff on the ET tube for leaks assess suction contents for gastric secretions verify NG tube placement infection nursing actions prevent infection by using proper hand hygiene and suctioning technique assess color, amount, and consistency of secretions blocked ET tube indicated by high-pressure alarm on ventilator nursing actions suction secretions to relieve mucous plug or insert an oral airway to prevent biting on the tube

a nurse is planning care for a pt who has a PICC line in the right arm. which of the following interventions should the nurse include? SATA use a 10mL syringe to flush the PICC line apply gentle force if resistance is met during injection cleanse ports with alcohol for 15sec prior to use maintain a transparent dressing over the insertion site flush with 10mL heparin before and after medication administration

use a 10mL syringe to flush the PICC line cleanse ports with alcohol for 15sec prior to use maintain a transparent dressing over the insertion site

a nurse is caring for a pt who has dyspnea and will receive oxygen continuously. which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the pt? nonrebreather mask venturi mask nasal cannula simple face mask

venturi mask incorporates an adapter that allows a precise amount of oxygen to be delivered

which observation would the nurse be concerned with when caring for a pt on a three chambered closed chest tube system? tidaling in the water seal chamber occasional buildup in the water seal chamber when the pt coughs visualization of the eyelets of the chest tube bloody drainage in the collection chamber

visualization of the eyelets of the chest tube

water seal

water seals are created by adding sterile fluid to a chamber up to the 2cm line, allowing air to exit from the pleural space on exhalation and stops air from entering the lungs with inhalation. keep the chamber upright and below the chest tube insertion site at all times, routinely monitor the water level due to the possibility of evaporation

dry suction

when a dry suction control device is used, the provider prescribes a level of suction for the device, typically -20cm H2O. When connected to wall suction, the regulator on the chest tube drainage system is set to manufacturer's recommendation