Med Surg Exam 3 practice Q's

- How many seconds per ET tube placement attempt - RN job during insertion

- 30 seconds - watch the clock for the 30 seconds and WATCH VITALS. Alert MD that it is time to stop and give some breaths before reattempt - after 2 attempts, call another MD

Tx of ARDS - what is the first thing you check - how frequently do you two what two assessments - how do you prevent infection - how often do you do oral cares - what position is most beneficial - nutrition, how does it work with ARDS

- AIRWAY IS FIRST - least to most invasive for oxygenation - assess resp and cardiac status every 2 hours - prevent infection -- suctioning PRN. ORAL CARE EVERY 2 HOURS - reposition pt every 2 hours - put in prone position - IF they have a good functioning gut, use it -- if they can feed orally, then do it first. limit carbohydrates - feeding tube - If gut does not work, TPN

How to do confirm ET tube placement

- CO2 capnigrophy device - listen to lung sounds **IF WE ONLY HEAR IT ON RIGHT SIDE, the ET tube went down the right bronchus. - chest x-ray to confirm placement ** do not use tape for securement - tube should should be measured by teeth or lips - assess placement each time you go into the room

Emergency equipment for ET tube placement

- ambu bag - suction - cardiac monitor - continuous pulse ox - intubation kit

Meds for ARDS

- benzos (ativan) to help with anxiety - propofol to sedate and comfort while on vent - steroids help with inflammation - watch glucose -watch WBC for infection while on steroids - opioids for decreasing air hunger (fentynl and morphine) - paralytic (vecronium) - inhalers and nebulizers - albuterol --TACHYCARDIA - antibiotics PRN

Barriers to care while on ET tube

- communication and mobility (try to get them to sit on the side of the bed) - being on the vent weakens the abd muscles - mobility gets them off the vent sooner

S/S of ARDS - what lung sounds can be heard - what will the chest x-ray show - what Ph imbalance - what would the PO2 be

- hypoxia - increased RR - lung sounds are noisy -- crackles, ronchi, wheezes - chest x-ray whited out - resp acidosis - PO2 will be low (70-100)

Drugs for intubation what order for sedative or paralytic? what station is the bed in

- paralytic and sedative - sedative like propofol or versed to make them sleepy - paralytic -- relax the gag reflex -- even paralyzes the diaphragm sedative first because we dont want our PT TO BE PARALYZED AND AWAKE HOB flat

why do you place a oral or nasal-gastric tube

- place oral or nasal-gastric tube - set to low-intermittent suction - can be used for med administration or tube feeding - place a foley for accurate I's and o's since they cannot let us know when they go - bilateral soft wrist restraints (pt safety) -- we only get an order once ever 24 hours, and we document on the restraints ever 2 hours - need an order for continuous sedation while on vent

What can lead to ARDS

- pulmonary contusion - trauma - TROLI transfusion - PNA - spesis - significant PE - burn pts

What is noninvasive positive pressure ventilation?

- uses positive pressure to keep alveoli open to improve gas exchange WITHOUT intubation (CPAP AND BIPAP) Bipap: has two pressures, one to open alveoli and another one that helps pt have a deeper breath watch for dry mouth, stuffy nose, skin break down, oral care every 2 hours - pt needs to be able to breathe on their own. Must be greater than 12 RR

A client is intubated on high levels of PEEP to treat ARDS. Because this client is at risk for a tension pneumothorax, what is the nurse's priority action? 1. assess lung sounds every 30-60 minutes 2. Obtain an order for an ABG 3. Have chest tube equipment at standby 4. Direct the UAP to turn the client every 2 hours

1

Which client has the greatest risk for developing ARDS? 1. 74 y/o who aspirates tube feeding 2. 34 y/o with chronic renal failure 3. 56 y/o with uncontrolled DM 4. 18 y/o with a fractured femur

1

What are the two types of respiratory failure

1) vent failure -- physical problem with the lungs or chest wall, can be poor function of diaphgram or brain control function, sedatives 2) Oxygen failure - perfusion problem (PE) - decreased hemoglobin - vent is normal, perfusion is decreased 3) mix of both -- these are the chronic lung disease pts -- lung tissue is stiff and a hard time oxygenation

The nurse is caring for a client on a ventilator. Which assessments does the nurse perform for this client (SATA)? 1. observe the mouth around the tube for ulcers 2. auscultate lung sounds every 4 hours 3. assess the placement of the ET tube 4. check at least every 24 hours the prescribed vent settings 5. check to be sure alarms are set 6. observe the need for tracheal, oral or nasal suctioning

1,2,3,5,6

Which conditions are related to ARDS? SATA 1. lung fluid increases 2. systemic inflammatory response 3. lungs dry out and become stiff 4. lung volume decreased 5. hypoxemia

1,2,4,5

The high-pressure alarm of a client's ventilator goes off. What are the potential cause for this (SATA)? 1. mucus plug 2. ET tube cuff leak 3. client fighting the vent 4. bronchospasm 5. coughing

1,3,4,5

The nurse is caring for several clients on the med-surg unit who are experiencing respiratory problems. Which conditions may eventually require a client to be intubated (SATA)? 1. trouble maintaining a patent airway because of mucosal swelling 2. history of CHF and demonstrating orthopnea 3. copious secretions and lacking muscular strength to cough 4. pulse ox 93% with high-flow oxygen mask 5. increasing fatigue because of work of breathing

1,3,5

Which are the risk factors for pulmonary embolism and deep vein thrombosis SATA Trauma Swimming activity Heart Failure COPD Cancer (lung or prostate)

1,3,5

The nurse is caring for a client with acute hypoxemia. Which nursing interventions are best (SATA)? 1. minimal self-care 2. sedatives prn 3. upright position 4. oxygen therapy 5. keep NPO while dyspneic 6. prescribed meter-dose inhaler

1. minimal self-care 3. upright position 4. oxygen therapy 6. prescribed meter-dose inhaler

The low-pressure alarm of a client's ventilator goes off. What are the potential cause for this (SATA)? 1. blockage of circuit 2. cuff leak 3. client stopped breathing 4. cuff is overinflated 5. leak in circuit

2,3,5

An older adult client arrives to the ED after falling off a roof. The nurse observes "sucking inward" of the loose chest area during inspiration and "puffing out" during expiration. ABG shows severe hypoxemia and hypercarbia. Which intervention should the nurse prepare for? 1. chest tube insertion 2. endotracheal intubation 3. needle thoracotomy 4. tracheostomy

2. endotracheal intubation

The nursing student is assisting in the care of a client on a vent. Which action by the student contributes to the prevention of ventilator associated pneumonia? 1. suction the client frequently 2. performs oral care every 2 hours 3. encourages visitors to wear masks 4. obtains sputum for culture

2. performs oral care every 2 hours

A client in the critical care unit requires an emergent ET intubation. The nurse immediately obtains and prepares which supplies to perform this procedure (SATA)? 1. tracheostomy tube or kit 2. resuscitation ambu bag 3. source for 100% oxygen 4. suction equipment 5. airway equipment box 6. oral airway 7. bronchodilator inhaler

2. resuscitation ambu bag 3. source for 100% oxygen 4. suction equipment 5. airway equipment box 6. oral airway

The nurse is assessing a client who was extubated several hours ago. Which client finding should the nurse report to the health care provider? 1. hoarseness 2. sore throat 3. inability to clear secretions 4. 90% pulse ox on room air

3

A client in the ED required emergency intubation for the status asthmaticus. Immediately after the insertion of the ET tube, what is the most accurate method for the nurse and/or provider to use to verify correct placement? 1. observe for chest excursion 2. listen for expired air from ET tube 3. check end-tidal CO2 level 4. Chest x-ray

3. check end-tidal CO2 level

A client in the hospital being treated for a PE is receiving a continuous infusion of heparin. When the nurse comes to take vitals, the client has blood on the front of his chest and nose, and is holidng a tissue saturated in blood to his nose. What is the first priority action the nurse must take? 1. have the client sit up and lean forward, pinching the nostrils 2. have the patient care tech set up oral suctioning to suction excess blood from the client's mouth 3. stop the heparin IV infusion 4. obtain lab results for PTT and CBC

3. stop the heparin IV infusion

The client is to be extubated. In what order should the nurse take? 1. hyperoxygenate 2. rapidly deflate the cuff 3. thoroughly suction the oral cavity 4. explain the procedure 5. remove ET tube

4,1,3,2,5

A client sustained a chest injury from a MVA. The client is asymptomatic at first, but slowly develops decreased breath sounds, crackles, wheezes and blood sputum. The mechanism of injury and findings are consistent with which condition? 1. flail chest 2. rib fracture 3. pneumothorax 4. pulmonary contusion

4. pulmonary contusion

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

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

A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action? a. Increased temperature b. Absent breath sounds c. Productive cough d. Incisional discomfort

B Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a needle biopsy or open lung biopsy. The other manifestations are not life threatening.

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin)

ANS: A Activase is a clot-busting agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.

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

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

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

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

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

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

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

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

A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first? a. Encourage the client to increase fluid intake. b. Assess the clients level of consciousness. c. Raise the head of the bed to at least 45 degrees. d. Provide the client with humidified oxygen.

ANS: B Assessing the clients level of consciousness will be most important because it will show how the client is responding to the presence of the infection. Although it will be important for the nurse to encourage the client to turn, cough, and frequently breathe deeply; raise the head of the bed; increase oral fluid intake; and humidify the oxygen administered, none of these actions will be as important as assessing the level of consciousness. Also, the client who has a pulmonary infection may not be able to cough effectively if an area of abscess is present.

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

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

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

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

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

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

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

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

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen saturation has not significantly improved. What response by the nurse is best? a. Breathing so rapidly interferes with oxygenation. b. Maybe the client has respiratory distress syndrome. c. The blood clot interferes with perfusion in the lungs. d. The client needs immediate intubation and mechanical ventilation.

ANS: C A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

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

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

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

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

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

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

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

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

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

Assess for other manifestations of hypoxia.

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

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

What's most important to assess following thoracentesis?

Lung sounds (decreased/absent) and vitals (pulse ox) any indication for respiratory distress

A client demonstrates chest pain, dyspnea, dry cough, and change in LOC. The nurse suspects PE and notifies the health care provider who orders an ABG. In the early stage of a PE, what would ABG results indicate? 1. Respiratory alkalosis 2. Respiratory acidosis 3. metabolic alkalosis 4. metabolic acidosis

Respiratory alkalosis

Do you need a order for an ET tube?

Yes, unless it is an emergency like cardiac arrest

A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this clients plan of care? a. Assistance with activities of daily living b. Physical therapy activities every day c. Oxygen therapy at 2 liters per nasal cannula d. Complete bedrest with frequent repositioning

a. Assistance with activities of daily living A client with dyspnea and difficulty completing activities such as climbing a flight of stairs has class III dyspnea. The nurse should provide assistance with activities of daily living. These clients should be encouraged to participate in activities as tolerated. They should not be on complete bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.

A nurse auscultates a harsh hollow sound over a clients trachea and larynx. Which action should the nurse take first? a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowlers position. d. Administer prescribed albuterol.

a. Document the findings. Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse should document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the clients position because the finding is normal.

A client report pain with inspiration after falling off a skateboard. The provider makes the diagnosis of rib fracture. The nurse prepares of do client teaching for which treatment? 1. Mechanical ventilation 2. tight bandage around the chest 3. coughing and deep breathing 4. home oxygen

coughing and deep breathing

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

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