lecture 3 ati Q's

a nurse in the ED is caring for a client with myasthenia gravis and is in crisis. which of the following factors should the nurse identify as the cause of crisis?

developing a respiratory infection. other causes: inadequate or over amount of med surgery, and high temp.

at risk for AD?

distended bladder

a client who has myasthenia gravis has a new prescription of baclofen. which of the following should be included in the teaching?

do not take with antihistamines. Antihistamines will intensify the depressant effects of baclofen.

a nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. which of the following indicates a need for catheterization

dribbling of urine.

A nurse is assessing a client with Guillian barre syndrome. Which of the following questions should the nurse ask?

have you had a recent influenza infection. the nurse should ask the client about a recent haemophilus infection. the cause is unknown but usually follows a viral infection.

conversion

1g=1ml 30ml=1 oz

A home health nurse is teaching a child's parents about the endotracheal suctioning. Which of the following information should the nurse include in the teaching?

Apply suction for less than 10 sec Prolonged suctioning can cause damage to tissues and induce hypoxia.

A client has a right subclavian central venous catheter. When reconnecting a new administration set, which of the following instructions should the nurse give?

Bear down while holding breath. The client should perform a valsalva maneuver by holding a breath and bearing down while the nurse disconnects the old set and reconnects the new one. This prevents air form entering the lumen, heart, pulmonary circulation.

A nurse is assessing a client 1 day postop following a lobectomy and has a chest tube drainage system in place. which of the following findings indicate intervention.

Development of subq emphysema. this indicates that air is trapped in and under the skin, which be the result of pneumothorax and should be reported to the HCP.

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases 86/min to 110/min and irregular. which of the following actions should the nurse take?

Perform pre-oxygenation prior to suctioning. Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury. The client should be pre-oxygenated using a manual resuscitation bag set at 100% oxygen.

A nurse is caring for a pt postop and whose respirations are shallow and 9/min. which of the following acid-base imbalances is the client at risk of developing?

Resp acidosis

A nurse is reviewing ABG's PH- 7.32 PaCo2- 48 HCO3-23 What acid balance is this?

Respiratory acidosis conditions like COPD and pneumonia can lead to RA. In RA PH is low PACO2 is greater HCO is normal or slightly elevated

A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed?

Semi-fowlers Pneumonectomy is the surgical removal of the lung, which is the most commonly performed to remove a tumor in a client who has lung cancer. Following exubation from the ventilator, the client should be placed in semi-fowlers to help ensure adequate ventilation & decrease the risk of complications.

A nurse is assessing a client immediately after the provider removed the clients endotracheal tube. Which of the following findings should the nurse report to the provider?

Stridor a high pitched crowing sound heard during inspiration, is a result of laryngeal edema; obstruction of airway. Report to HCP!

a nurse is caring for a client who has acute respiratory distress syndrome and needs mechanical ventilation. the client receives a prescription of pancuronium. purpose of med?

supress resp effort. its a neuromuscular blocking agents, that induce paralysis and suppress the clients respiratory efforts to the point of the apnea, allowing the mechanical ventilator to take over the work of breathing for the client. this therapy is useful in ARDS and poor lung compliance.

a nurse is applying wrist restrains to a client who is confused and attempting to pull out a chest tube. which of the following actions should the nurse take when using restraints?

tie the restraint using a quick release knot. The nurse should use a half bow (clove hitch, quick release) knot that does not tighten and can be removed quickly.

nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. which of the following nursing actions are appropriate?

use pillows to keep heels off the bed surface minimize skin exposure to moisture/

A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. when assessing the 3-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. action by nurse?

verify that the suction regulator is on and check the tubing for leaks. A lack of bubbling may indicate that either the suction regulator is turned off or that there is a leak in the tubing.

patient has new diagnosis of Myasthenia gravis. What to monitor for?

weakness generalized weakness of the diaphragmatic and intercostal muscle may produce respiratory distress or predispose the client to respiratory infections.

a nurse in the intensive care unit is providing teaching for a client prior to removal of the endotracheal tube. which of the following instructions should the nurse include in teaching?

Avoid speaking for long periods of time. helps promote gas exchange.

A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the clients lung has reexpanded?

No fluctuations in the water seal chamber. Fluctuations stops when the lung has reexpanded. but the nurse should check for other indications of re-expansion: -equal breath sounds bilaterally; fluctuation can also stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or suction source is not functioning.

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first?

Assess the airway The first action is assess airway for obstructions. -listen to the clients lung for air movement. -provide mechanical ventilation with a bag valve mask device to reduce the risk of hypoxia.

A nurse is caring for a client who has disposable 3-chamber chest tube in place. which of the following findings should the nurse indicate to the nurse that the client is experiencing a complication?

Continuous bubbling in the water-seal chamber Excessive and continuous bubbling in the water seal chamber indicates an air leak in the drainage system.

a nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. the nurse should intervene for which of the following observation?

Continuous bubbling in water-seal chamber. this indicated an air leak between the water seal and the client's chest. however, gentle bubbling on the forceful exhalation or coughing is normal.

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for getting UTI infections. Which of the following actions should the nurse include in the client's plan of care?

Encourage fluid intake at and between meals. increased fluid intake dilutes the urine, reduced stasis, and greatly reduced the urinary bacterial count.

The nurse is caring postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicated to the nurse that the chest tube is functioning properly?

Fluctuation of the fluid level within the water seal chamber

A nurse is assessing a client who has pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Movement of the trachea toward the unaffected side A CT inserted for a PT may result in the developments of tension PT (med emer) - air in the pleural space compressing the blood vessels of the thorax and limiting blood return to the heart. An assessment of tracheal deviation, or movement of the trachea toward the unaffected side is indicative of Tension PT and needs o be reported!

A nurse is reviewing the ABG. HCP suspects metabolic acidosis. What should the nurse expect?

PH below 7.35 With acidosis, the ph is below 7.35

A nurse is caring for a client who has a single lumen central venous catheter. Which of the following actions should the nurse take when accessing the catheter?

Use a 10 ml syringe to flush the catheter -during the flushing procedure, the nurse should use a 10 ml barrel syringe, because the pressure that is exerted by smaller barrel syringes increases the risk of rupturing the catheter.

A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has resp acidosis. which of the following findings should the nurse expect?

Widened QRS complex A client who has RA is likely to cardiac changes from the delayed electrical conduction thru the heart such as: -widened QRS -Tall T waves -Prolonged PR intervals -heart rate changes (bradycardia-heartblock)

a nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of the C5. which of the following rehabilitation goals should the nurse add in the plan of care>

ability to self-feed with the use of adaptive equipment fifth cervical vertebrae; should have full neck, partial shoulder, back, biceps, and gross elbow movements.

a nurse assessing a client with a SCI/ Which of the following actions should the nurse take to monitor C4 fuction.

apply downward pressure while the client shrugs his shoulders. this assessment monitors the function of C4 and C5.

a nurse is caring for an unconscious client who has a loss of the corneal reflex. which of the following actions should the nurse take?

apply lubricating eye drops.

a nurse is preparing to administer PO meds to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client med?

ask client to take a few sips of water

ask the client to grasp an object and form a fist.

assessment of motor function C8.

a nurse is caring for a client who has a central venous catheter and reports hearing a gurgling sound on the side of the catheter insertion. which of the folowing complication should the nurse suspect?

catheter migration

a client comes to the ED in severe resp distress following left-sided blunt chest trauma. the norse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client?

chest tube insertion and then connect it to a water-seal drainage system. CM indicate pneumothorax due to blunt chest trauma.

A nurse is caring for a client who has central venous catheter and develops acute shortness of breath. which of the following actions should the nurse take first.

clamp the catheter The greatest risk to the client is injury from further air entering the central venous catheter; therefore need to clamp catheter first!

A nurse is caring for a client who has a 3-chamber closed chest tube. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?

continue to monitor the client -the fluid in the water seal chamber rises 2-4 inches during inhalation and falls during exhalation; process called tidaling. an absence of tidaling may indicate a fully expanded lung or an obstruction in the chest tube.

myasthenia gravis caused by what hypersensitivities?

cytotoxic

the nurse in the emergency department is monitoring a client who has cervical spinal cord injury from a fall. the nurse should monitor the client for which of the following complication?

hypotension absence of bowel sounds weakened gag reflex hypotension; lack of sympathetic input can cause a decrease in BP. The nurse should maintain the client's SBP at 90 mmhg or above to adequately perfuse spinal cord. Absence of bowel; spinal shock lead to decreased peristalsis, which could cause the client to develop a patalytic ileus. weakened gag reflex; the nurse should monitor the client for difficulty swallowing or coughing and drooling noted with oral intak.e

a nurse is teaching a client who has multiple sclerosis and a new prescription for dantrolene. which of the following statements by the client indicates an understanding of the teaching?

i need to apply sunscreen when i go outside. this med can cause photosensitivity.

A nurse is teaching a client who is about to undergo the insertion of a non-tunneled central venous access device. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

i will turn my head in the opposite direction during insertion. The client should turn his head from insertion site to allow optimal accuracy in placing the catheter.

a nurse is presenting discharge teaching yo a client with MS. the client reports symptoms of diplopia, dysmetria, and sensory change. which of the following statements are appropriate?

implement a schedule to include periods of rest.

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the xray department. which of the following actions should the nurse take?

keep the drainage system below the level of the clients chest at all times. During transport, the drainage system should be kept below the level of the client's chest to prevent air and drainage fluid from re-entering the thoracic cavity.

ABG HCO3 18 PaCO2 28 Ph 7.30 what acid base imbalance?

metabolic acidosis

a nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?

monitor the client for an elevated temperature. a halo fixation device is used to stabilize a cervical fracture on a client. The device is secured with four screws inserted directly into the client's skull to promote cervical alignment. complications: loose pins, local infection, and scarring. more serious complications; osteomyelitis, subdural abscess, and instability. the nurse should monitor for infection, such as fever and purulent drainage form pin sites.

apply resistance while client lifts his legs from the bed.

monitors function of L2-L4

apply resistance while the client flexes his arms.

monitors the motor fuction of C7.

a nurse in the pacu is assessing a client who has a endotracheal tube in place and observed the absence of the left-side chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

movement of the ET tube into the right main bronchus. During intubation, the staff can misplace the ET tube in the right mainstream bronchus. the nurse should identify absence of chest wall movement or breath sounds on a single side as indicating ET tube displacement, and should notify appropriate personnel to reposition the tube.

suspected myasthenia gravis. the HCP prescribes a tensilon test. what indicates a positive test ?

muscle contractions become progressively stronger. a positive tensilon test is indicated by a 4-5 min period of improved muscle tone and strength.

a nurse is assessing a client who has a urine output of 250 ml in 24 hr period. Which of the following descriptive terms should the nurse place in the client's electronic record?

oliguria the nurse should document the client has oliguria, which is urine output between 100 ml and 400 ml of urine in 24 hr.

a nurse is caring for a client who has had a spinal cord injury at level of T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of instability?

paraplegia paralysis of both legs, is seen after a spinal cord injury below T1

experiencing AD

place in high fowlers position

A nurse is planning care for a client who has ARDS. which of the following interventions should the nurse plan?

place in prone position oxygenation is improved in prone position.

a nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, tachycardia. the nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time?

place the client on his left side in trendelenburg position. This position helps trap the air i the apex of the right atrium rather than allowing it to enter the right ventricle and move to the pulmonary arterial system.

patient has increased ICP and is showing decorticate posturing. which are the following findings?

plantar flexion of the legs

a nurse suspects a client who has myasthenia gravis is experiencing myasthenia crisis. which of the following interventions should the nurse take?

prepare the client for mechanical venilation the client who is experiencing a myasthenic crisis is at risk for loss of adequate respiratory function. the nurse should closely monitor the clients resp status and prepare for possible mechanical ventilation.

halo traction device

purpose: to immobilize the cervial spine for the period of 8-12 weeks.

a nurse is caring for a client who is postop following a wedge resection of a lung and has a chest tube with a water seal chest tube drainage system. the client reports a burning sensation in chest. what action?

put in side lying positon

A nurse is monitoring a client who has a chest tube in place connected to wall due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?

reposition the patient. need to relieve chest burning.

ABG's ph 7.30 Paco2 50 which acid-base imbalance is this?

resp acidosis

patients RR 7/min ABG Ph 7.22 PaCO2 68 base excess -2 PaO2 78 Saturation 80 % bicarbonate 26 what acid-base imbalance ?

resp acidosis

A nurse is caring for a client who has an endotracheal tube is receiving mechanical ventilation. Which of the following interventions should the nurse take to reduce the risk of ventilator associated pneumonia?

rinse the client's mouth with an antimicrobial solution every 4 hr. The nurse should brush the teeth q 8 hr and rinse mouth q 2hr to reduce growth of bacteria.