MEDSURG II: Prioritization Ch 4 Respiratory Management

The nurse is caring for a client who has a chest tube. What should the nurse do? Prioritize the nurse's actions from first (1) to last (5). 1. Assess the client's lung sounds. 2. Note the amount of suction being used. 3. Check the chest tube dressing for drainage. 4. Make sure that the chest tube is securely taped. 5. Place a bottle of sterile saline at the bedside.

Correct Answer: 1, 4, 3, 2, 5 1. The nurse should begin the care by assessing the client. Remember the nursing process. 4. The nurse should have the client's chest and dressing exposed and should check to make sure the chest tube is securely taped at this time. 3. The nurse then follows the chest tube to the drainage system and assesses the system. 2. The last part of the chest tube drainage system to assess is the suction system. 5. The nurse should make sure that emergency supplies are at the bedside last.

The husband of a client diagnosed with a terminal lung cancer asks the nurse, "How am I going to take care of my wife when we go home?" Which action by the nurse is most appropriate? 1. Notify the social worker about the husband's concerns. 2. Contact the hospital chaplain to talk to the husband. 3. Leave a note on the chart for the HCP to talk to the husband. 4. Reassure the husband that everything will be all right.

Correct answer: 1 1. A social worker is qualified to assist the client with referrals to any agency or personnel that may be needed after the client is discharged home. 2. The chaplain should be contacted if spiritual guidance is required, but the stem did not specify this need. 3. The HCP can talk to the husband but will not be able to address his concerns of taking care of his wife when she is discharged home. 4. This is false reassurance and does not address the husband's concern after his wife is discharged home. The nurse does not know whether everything is going to be all right.

The client diagnosed with acute respiratory distress syndrome (ARDS) is having increased difficulty breathing. The arterial blood gas indicates an arterial oxygen level of 54% on O2 at 10 LPM. Which intervention should the intensive care unit nurse implement first? 1. Prepare the client for intubation. 2. Bag the client with a bag/mask device. 3. Call a Code Blue and initiate cardiopulmonary resuscitation (CPR). 4. Start an IV with an 18-gauge catheter.

Correct answer: 1 1. Acute respiratory distress syndrome is diagnosed when the client has an arterial blood gas of less than 50% while receiving oxygen at 10 LPM. The nurse should prepare for the client to be intubated. 2. The nurse should intervene while the client is breathing by calling the HCP and assisting in the intubation and setup of the mechanical ventilator. If the client has an arrest before this can be arranged, the client would be ventilated with a bag/mask device. 3. If the nurse does not intervene immediately, an arrest situation will occur, at which time a Code Blue would be called and CPR started. 4. If the client does not have a patent IV, the nurse should start one, but not before preparing for intubation.

The nurse has been made the chairperson of a quality improvement committee. Which statement is an example of effective group process? 1. The nurse involves all committee members in the discussion. 2. The nurse makes sure all members of the group agree with the decisions. 3. The nurse asks two of the committee members to do the work. 4. The nurse does not allow deviation from the agenda to occur.

Correct answer: 1 1. Effective group process involves all members of the group. 2. Unanimous decisions may indicate group- think, which can be a problem in a group process. 3. Effective group process involves all members of the group, not just two. 4. Not allowing deviation from the agenda is an autocratic style and limits the creativity and involvement of the group.

Which client should the medical unit nurse assess first after receiving the shift report? 1. The 84-year-old client diagnosed with pneumonia who is afebrile but getting restless. 2. The 25-year-old client diagnosed with influenza who is febrile and has a headache. 3. The 56-year-old client diagnosed with a left-sided hemothorax with tidaling in the water-seal compartment of the Pleurvac. 4. The 38-year-old client diagnosed with a sinus infection who has green drainage from the nose.

Correct answer: 1 1. Elderly clients diagnosed with pneumonia may not present with the "normal" symptoms, such as fever. The client's increased restlessness may indicate a decrease in oxygen to the brain. This client should be seen first. 2. The client with influenza would be expected to have an elevated temperature and a headache; therefore, this client would not need to be assessed first. 3. Tidaling in the water-seal compartment is expected; therefore, the nurse would not need to assess this client first. 4. Sinus drainage is to be expected in a client diagnosed with a sinus infection.

The client involved in a motor vehicle accident is being prepped for surgery when the client asks the emergency department nurse, "What happened to my child?" The nurse knows the child is dead. Which statement is an example of the ethical principle of non-malfeasance? 1. "I will find out for you and let you know after surgery." 2. "I am sorry but your child died at the scene of the accident." 3. "You should concentrate on your surgery right now." 4. "You are concerned about your child. Would you like to talk?"

Correct answer: 1 1. Nonmalfeasance means to do no harm. This statement is letting the client know that the concern has been heard but does not give the client bad news before surgery. The nurse is aware that someone having surgery should be of sound mind, and finding out your child is dead would be horrific. 2. This is an example of veracity. 3. This is an example of paternalism, telling the client what he or she should do. 4. This is a therapeutic response, not an example of nonmalfeasance.

The new graduate has accepted a position at a facility that is accredited by the Joint Commission. Which statement describes the purpose of this organization? 1. The Commission reviews facilities for compliance with standards of care. 2. Accreditation by the Commission guarantees the facility will be reimbursed for care provided. 3. Accreditation by the Commission reduces liability in a legal action against the facility. 4. The Commission eliminates the need for Medicare to survey a hospital.

Correct answer: 1 1. The Joint Commission is an organization that monitors healthcare facilities for compliance with standards of care. Accreditation is voluntary, but most third-party payers will not reimburse a facility that is not accredited by some outside organization. 2. Accreditation does not guarantee reimbursement, although most third-party payers require some accreditation by an outside organization. 3. Accreditation does not reduce the hospital's liability. 4. Medicare/Medicaid will not review a facility routinely if the Joint Commission has accredited the facility, but a representative will review the facility in cases of reported problems.

The home health nurse is visiting the client diagnosed with end-stage chronic obstructive pulmonary disease (COPD) while the unlicensed assistive personnel (UAP) is providing care. Which action by the UAP would warrant intervention by the nurse? 1. Keeping the bedroom at a warm temperature. 2. Maintaining the client's oxygen rate at 2 L/min. 3. Helping the client sit in the orthopneic position. 4. Allowing the client to sleep in the recliner.

Correct answer: 1 1. The client with end-stage COPD usually prefers a cool climate, with fans to help ease breathing. A warm area would increase the effort the client would require to breathe. This action would warrant intervention by the nurse. 2. The client with end-stage COPD should be maintained on a low oxygen rate, such as 2 L/min to prevent depression of the hypoxic drive. High levels of oxygen will depress the client's ability to breathe. This action would not warrant intervention by the nurse. 3. The client will usually sit in the orthopneic position, usually slumped over a bedside table, to help ease breathing. This is called the three-point stance. This action would not warrant intervention by the nurse. 4. The client in end-stage COPD has great difficulty breathing; therefore, sleeping in a recliner is sometimes the only way the client can sleep. This action would not warrant intervention by the nurse.

The client has arterial blood gas values of pH 7.38, PaO2 77, PaCO2 40, HCO3 24. Which intervention should the critical care nurse implement? 1. Administer oxygen 2 L/min via nasal cannula. 2. Encourage the client to take deep breaths. 3. Administer intravenous sodium bicarbonate. 4. Assess the client's respiratory status.

Correct answer: 1 1. The client's PaO2 is below the normal level of 80-100; therefore, the nurse should administer oxygen. {If all the ABGs values are within normal limits (WNL) except the PaO2 is low, then the pt will be given oxygen}. 2. The client should take deep breaths if the client's PaCO2 is greater than 45 {Respiratory Acidosis}. 3. The nurse should administer sodium bicarbonate if the client's HCO3 is less than 22 {Metabolic Alkalosis}. 4. The client needs oxygen due to the low arterial oxygen level; the client does not need a respiratory assessment.

The clinic nurse is returning phone messages from clients. Which phone message should the nurse return first? 1. The elderly client with pneumonia who reports being dizzy when getting up. 2. The client with cystic fibrosis who needs a prescription for pancreatic enzymes. 3. The client with lung cancer on chemotherapy who reports nausea. 4. The client with pertussis who reports coughing spells so severe that they cause vomiting.

Correct answer: 1 1. The elderly client should be called first so that the nurse can determine whether the dizziness when getting up is the result of medication or some other reason. Orthostatic hypotension can be life threatening; therefore, this client may need to be assessed immediately. 2. Ordering a prescription is not priority over a client with a physiological problem. 3. Nausea is often expected with chemotherapy; therefore, this client's phone call would not be returned prior to calling a client with a potentially life-threatening problem. 4. Pertussis—known as whooping cough—is a serious, very contagious disease that causes severe, uncontrollable coughing fits. The coughing makes it difficult to breathe and often ends with a "whoop" noise. Because coughing spells are expected, the nurse would not call this client first.

The clinic nurse is reviewing laboratory results for clients seen in the clinic. Which client requires additional assessment by the nurse? 1. The client who has a hemoglobin of 9 g/dL and a hematocrit of 29%. 2. The client who has a WBC count of 9.0 mm3. 3. The client who has a serum potassium level of 4.8 mEq/L. 4. The client who has a serum sodium level of 137 mEq/L.

Correct answer: 1 1. The normal hemoglobin level is 12 to 15 g/dL, and normal hematocrit is 39% to 45%. This client's H&H is low. The nurse should contact the client and make an immediate appointment. 2. The normal WBC count is 4.0 to 10.0 mm3. This client's WBC count is within normal range and does not warrant intervention from the clinic nurse. 3. The normal serum potassium level is 3.5 to 5.5 mEq/L. This client's level is within normal range and does not warrant intervention from the clinic nurse. 4. The normal serum sodium level is 135 to 145 mEq/L. This client's level is within the normal range, and the client does not warrant intervention from the clinic nurse.

The client in a critical care unit died. What action should the nurse implement first? 1. Stay with the significant other. 2. Gather the client's belongings. 3. Perform post-mortem care. 4. Ask about organ donation.

Correct answer: 1 1. The nurse should "offer self " to the significant other. Ignoring the needs of the significant other at this time makes the significant other feel that the nurse does not care, and if the nurse does not care for "me," then did the nurse provide adequate care to my loved one? This action is very important to assist in the grieving process. 2. The UAP can gather the deceased client's belongings. 3. The UAP can perform post-mortem care. 4. The representative of the organ donation team will make this request. Organ banks think it is best for specially trained individuals to discuss organ donation with the significant others.

At 1700, the HCP is yelling at the nursing staff because the early morning lab work is not available for a client's chart. Which is the most appropriate response by the charge nurse? 1. Call the lab and have the lab supervisor talk with the HCP. 2. Discuss the HCP's complaints with the nursing supervisor. 3. Form a committee of lab and nursing personnel to fix the problem. 4. Tell the HCP to stop yelling and calm down.

Correct answer: 1 1. The problem is not a nursing problem. The HCP should be discussing the problem with an individual from the department that "owns" the problem. 2. This is not a nursing problem. 3. This is not a nursing problem. 4. This will only make the HCP angrier. The HCP should be directed to discuss the problem with the department that can "fix" the problem.

The client's arterial blood gas (ABG) results are pH 7.34, PaCO2 50, HCO3 24, PaO2 87. Which intervention should the nurse implement first? 1. Have the client turn, cough, and deep breathe. 2. Place the client on oxygen via nasal cannula. 3. Check the client's pulse oximeter reading. 4. Notify the HCP of the ABG results.

Correct answer: 1 1. These blood gases indicate respiratory acidosis that could be caused by ineffective cough, with resulting air trapping. The nurse should encourage the client to turn, cough, and deep breathe. 2. The PaO2 level is within normal limits, 80 to 100. Administering oxygen is not the first intervention. 3. The nurse knows the arterial blood gas oxygen level, which is an accurate test. The pulse oximeter only provides an approximate level. 4. This is not the first intervention. The nurse can intervene to treat the client before notifying the HCP.

The emergency department nurse is preparing to assist the surgeon to insert chest tubes in a client with a right hemothorax. Which position is appropriate for the procedure? 1. Have the client sit upright and bend over the over bed table. 2. Place the client in the left lateral recumbent position. 3. Have the client sit on the side of the bed with the back arched like a Halloween cat. 4. Place the client lying on the back with the head of the bed up 45 degrees.

Correct answer: 1 1. This position allows for access to the client's back area. The chest tube for a hemothorax is positioned low and posterior to allow for gravity to assist in the removal of fluid from the thoracic area. 2. This is the position for giving an enema. 3. This is the position used to assist with a lumbar puncture. 4. This is a resting position; it is not preparing for a chest tube placement.

The 92-year-old client has a hospital bed in the home and is on strict bed rest. The unlicensed assistive personnel (UAP) cares for the client in the morning 5 days a week. Which statement indicates that the UAP needs additional education by the nurse? 1. "I do not give her a lot of fluids so she won't wet the bed." 2. "I perform passive range-of-motion exercises every morning." 3. "I put her on her side so that there will be no pressure on her butt." 4. "I do not pull her across the sheets when I am moving her in bed."

Correct answer: 1 1. This statement warrants intervention because fluids will help prevent dehydration and renal calculi. The nurse should explain the client needs to increase fluids. 2. ROM exercises help prevent deep vein thrombosis (DVT). This statement does not require intervention by the nurse. The UAP can perform skills if taught and performance is evaluated by the nurse. 3. Keeping the client off the buttocks is an appropriate intervention for a client on strict bed rest. This comment does not require intervention by the nurse. 4. Pulling the client across the sheets will cause skin breakdown. Because the UAP is not doing this, no intervention by the nurse is needed.

Which tasks are appropriate to assign to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Perform mouth care on the client with pneumonia. 2. Apply oxygen via nasal cannula to the client. 3. Empty the trashcans in the clients' rooms. 4. Take the empty blood bag back to the laboratory. 5. Show the client how to ambulate on the walker.

Correct answer: 1 and 4 1. The UAP can perform mouth care on a client who is stable.2. Oxygen is a medication and the nurse cannot delegate medication administration to the UAP.3. The housekeeping staff empty trashcans, not the UAP. Remember not to assign tasks that should be done by another hospital department.4. The UAP can take the empty blood bag to the laboratory.5. The nurse cannot delegate teaching to the UAP.

The client in the intensive care unit is on a ventilator. Which interventions should the nurse implement? Select all that apply. 1. Ensure there is a manual resuscitation bag at the bedside. 2. Monitor the client's pulse oximeter reading every shift. 3. Assess the client's respiratory status every 2 hours. 4. Check the ventilator settings every 4 hours. 5. Collaborate with the respiratory therapist.

Correct answer: 1, 3, 4, 5 1. There must be a manual resuscitation bag at the bedside in case the ventilator does not work appropriately. The nurse must use this to bag the client. 2. The pulse oximeter reading should be done more often than every shift. 3. The client's respiratory status should be assessed frequently—every 2 hours. 4. The ventilator's settings should be monitored throughout the shift. 5. The respiratory therapist is the member of the multidisciplinary team who is responsible for ventilators.

The nurse is caring for a client diagnosed with flail chest who has had a chest tube for 3 days. The nurse notes there is no tidaling in the water-seal compartment. Which initial action should be taken by the nurse? 1. Check the tubing for any dependent loops. 2. Auscultate the client's posterior breath sounds. 3. Prepare to remove the client's chest tubes. 4. Notify the HCP that the lungs have re-expanded.

Correct answer: 2 1. After 3 days, the nurse should suspect that the lung has re-expanded. The nurse should not expect dependent loops to have caused this situation. 2. After 3 days, the nurse should assess the lung sounds to determine whether the lungs have re-expanded. This would be the nurse's first intervention. 3. This will be done if it is determined the lungs have re-expanded, but it is not the first intervention. 4. The nurse should notify the HCP if it is determined the lungs have re-expanded; a chest x-ray can be taken prior to removing the chest tubes.

The day surgery admission nurse is obtaining operative permits for clients having surgery. Which client should the nurse question signing the consent form? 1. The 16-year-old married client who is diagnosed with an ectopic pregnancy. 2. The 39-year-old client diagnosed with paranoid schizophrenia. 3. The 50-year-old client who admits to being a recovering alcoholic. 4. The 84-year-old client diagnosed with chronic obstructive pulmonary disease (COPD).

Correct answer: 2 1. An emancipated minor under the age of 18 but married or independently earning his or her own living would not warrant the nurse's questioning whether she should sign the permit. "Married" indicates an independently functioning individual. 2. An incompetent client cannot sign the consent form. An incompetent client is an individual who is not autonomous and cannot give or withhold consent, for example, individuals who are cognitively impaired, mentally ill, neurologically incapacitated, or under the influence of mind-altering drugs. The client may be able to sign the permit, but the nurse should question the client's ability to sign the permit because paranoid schizophrenia is a mental illness. 3. A recovering alcoholic is not considered incapacitated. If the client is currently under the influence of alcohol, then the permit could not legally be signed by the client. 4. The elderly client is considered competent until deemed incompetent in a court of law or meets the criteria to be considered incompetent.

The primary nurse in the critical care respiratory unit is very busy. Which nursing task should be the nurse's priority? 1. Assist the HCP with a sterile dressing change for a client with a left pneumonectomy. 2. Obtain a tracheostomy tray for a client who is exhibiting air hunger. 3. Transcribe orders for a client with cystic fibrosis who was transferred from the ED. 4. Assess the client diagnosed with mesothelioma who is upset, angry, and crying.

Correct answer: 2 1. Changing the dressing is not priority over a client who is in respiratory distress. 2. The client who is exhibiting air hunger indicates respiratory distress; therefore, a tracheostomy tray should be obtained first. 3. The transcribing of orders is important, but not more important than a client in respiratory distress. 4. The client who is angry and upset needs to be assessed but not priority over the client who is in respiratory distress.

The nurse assists with the insertion of a chest tube in a client diagnosed with a spontaneous pneumothorax. Which data indicates that the treatment has been effective? 1. The chest x-ray indicates consolidation. 2. The client has bilateral breath sounds. 3. The suction chamber has vigorous bubbling. 4. The client has crepitus around the insertion site.

Correct answer: 2 1. Consolidation indicates fluid or exudates in the lung—pneumonia. This would not indicate the client is improving. 2. Bilateral breath sounds indicate the left lung has re-expanded and the treatment is effective. 3. Vigorous bubbling in the suction chamber indicates that there is a leak in the system, but this does not indicate the treatment is effective. 4. Crepitus (subcutaneous emphysema) indicates that oxygen is escaping into the subcutaneous layer of the skin, but this does not indicate the lung has re-expanded, which is the goal of the treatment.

The nurse caring for client BC is preparing to administer medications. Based on the laboratory data given in this table, which intervention should the nurse implement? 1. Administer warfarin (Coumadin) IVP. 2. Continue the heparin drip. 3. Hold the next dose of warfarin. 4. Administer the daily aspirin.

Correct answer: 2 1. Coumadin is an oral, not intravenous, medication. 2. The therapeutic PTT results should be 1.5 to 2 times the control, or 51 to 68 seconds. The client's value of 53 is within the therapeutic range. The nurse should continue the heparin drip as is. 3. The INR is 1.7, not up to therapeutic range yet, so warfarin (Coumadin) should be administered. 4. These lab values do not provide any information about aspirin administration, but the nurse should ask the HCP whether aspirin (an antiplatelet) should be discontinued because the client is receiving two anticoagulants—heparin and warfarin.

The nurse is preparing to make rounds after receiving shift report. Which client should the nurse assess first? 1. The patient diagnosed with end-stage COPD complaining of shortness of breath after ambulating to the bathroom. 2. The patient diagnosed with a deep vein thrombosis who is requesting an anti-anxiety medication. 3. The patient diagnosed with cystic fibrosis who has a sputum specimen to be taken to the laboratory. 4. The patient diagnosed with an empyema who has a temperature of 100.8°F, pulse of 118, respiration rate of 26, and BP of 148/64.

Correct answer: 2 1. Shortness of breath after ambulating is expected for a patient diagnosed with COPD. 2. Patients diagnosed with deep vein thrombosis are at risk for pulmonary embolism (PE). Anxiety is a symptom of PE. The nurse must determine if interventions are needed for PE, a life-threatening emergency. 3. Anyone can take a specimen to the laboratory. 4. An empyema is an abscess in the thoracic cavity. These vital signs would be expected for this patient.

The nurse is admitting a patient diagnosed with pneumonia. Which healthcare provider's order should be implemented first? 1. 1,000 mL normal saline at 125 mL/hour. 2. Obtain sputum for Gram stain and culture. 3. Ceftriaxone (Rocephin) 1,000 mg IVPB every 12 hours. 4. Ultrasonic nebulization treatment every 6 hours.

Correct answer: 2 1. Starting an intravenous line must be done prior to being able to initiate a piggyback medication. 2. In order to treat the client with the most effective medication and not skew the results of a sputum culture, the specimen must be obtained prior to initiating antibiotics. 3. New orders for intravenous antibiotics must be considered a priority to prevent the client from going into gram-negative sepsis, a potentially lethal situation. However, in order to initiate the antibiotic the nurse must make sure a correct diagnosis is able to be made. 4. Respiratory treatments are important, but not before starting the antibiotics.

The client who is 1 day postoperative following chest surgery is having difficulty breathing, has bilateral rales, and is confused and restless. Which intervention should the nurse implement first? 1. Assess the client's pulse oximeter reading. 2. Notify the Rapid Response Team. 3. Place the client in the Trendelenburg position. 4. Check the client's surgical dressing.

Correct answer: 2 1. The client is in distress; therefore, the nurse should do something to help the client. {In distress Do NOT Assess} 2. The Rapid Response Team was mandated by The Joint Commission. It is a team of healthcare professionals who respond to clients who are breathing but who the nurse thinks are in an emergency situation. A code is called if the client is not breathing. 3. The Trendelenburg position is used for a client who is in hypovolemic shock, so this would not be appropriate for a client in respiratory distress. 4. The stem of the question provides enough information to indicate the client is in distress, and assessing the surgical dressing will not help the client. {In distress Do NOT Assess}

The home health client is diagnosed with chronic obstructive disease. The unlicensed assistive personnel (UAP) tells the home health nurse that the client has trouble breathing when the client lies in a supine position. Which priority instruction should the nurse provide to the UAP? 1. To ensure the client's oxygen is in place correctly. 2. To allow the client to sleep in a recliner. 3. To allow a fan to blow on the client when lying in bed. 4. To have the client take slow, deep breaths.

Correct answer: 2 1. The client's oxygen should always be placed correctly but it is not the priority intervention for difficulty breathing. 2. Because the client has difficulty breathing while lying in bed, allowing the client to sit in a recliner will help the client; therefore, this is the priority intervention. 3. Often clients report a fan blowing on the face helps with difficulty breathing but this is not a priority intervention. 4. Slow, deep breaths will not help the client with difficulty breathing as much as will sitting in a recliner.

The nurse is accidentally stuck with a needle used to administer an intradermal injection for a PPD. Which intervention should the nurse implement first? 1. Complete the accident/occurrence report. 2. Immediately wash the area with soap and water. 3. Ask the client whether he or she has AIDS or hepatitis. 4. Place an antibiotic ointment and bandage on the site.

Correct answer: 2 1. The documentation of the accident must be completed but it is not priority over caring for the wound first. 2. The nurse should wash the area with soap and water and attempt to squeeze the area to make it bleed. 3. The nurse should not ask this question directly to the client. The nurse could ask whether the client would agree to have blood drawn for testing, but not directly ask whether the client has AIDS or hepatitis. 4. The puncture site would not require antibiotic ointment unless it is infected, which it wouldn't be immediately after the incident.

The female charge nurse on the respiratory unit tells the male nurse, "You are really cute and have a great body. Do you work out?" Which action should be taken by the male nurse if he thinks he is being sexually harassed? 1. Document the comment in writing and tell another staff nurse. 2. Ask the charge nurse to stop making comments like this. 3. Notify the clinical manager of the sexual harassment. 4. Report this to the corporate headquarters office.

Correct answer: 2 1. The male nurse should document the comment and tell other people, such as family, friends, and staff, but this is not the nurse's first intervention. 2. The first action is to ask the person directly to stop. The harasser needs to be told in clear terms that the behavior makes the nurse uncomfortable and that he wants it to stop immediately. 3. The male nurse could take this action, but it is not the first action. 4. This male nurse could take this action, but only if direct contact and the chain of command at the hospital do not stop the charge nurse's behavior.

The client with a right-sided pneumothorax had chest tubes inserted 2 hours ago. There is no fluctuation in the water-seal chamber of the Pleurovac. Which intervention should the nurse implement first? 1. Assess the client's lung sounds. 2. Check for any kinks in the tubing. 3. Ask the client to take deep breaths. 4. Turn the client from side to side.

Correct answer: 2 1. The nurse should assess the client's breath sounds but not prior to determining why there is no tidaling in the water-seal chamber. 2. The nurse should first determine why there is no tidaling in the water-seal chamber. Since the client just had the chest tubes inserted, it is probably a kink or a dependent loop, or the client is lying on the tubing. The nurse should first check for this prior to taking any other action. {However, if there's no fluctuation in the water-seal chamber of the Pleurovac a couple of days after the insertion of the chest tube, then most likely the lungs have expanded and the pt does not need the chest tube anymore; so first the nurse will auscultate the lung sounds and if clear, a CXR will be done to confirm no more hemo/pneumothorax after which the chest tube will be removed BY THE PROVIDER, NOT the nurse} 3. The nurse should encourage the client to take deep breaths and cough, which may push a clot through the tubing, but should not do so before checking for a kink. 4. Turning the client side to side will not help determine why there is no tidaling in the water-seal compartment of the Pleurovac.

The client is admitted to the emergency department with an apical pulse rate of 134, respiration rate of 28, and BP of 92/56, and the skin is pale and clammy. What action should the nurse perform first? 1. Type and crossmatch the client for PRBCs. 2. Start two IVs with large-bore catheters. 3. Obtain the client's history and physical. 4. Check the client's allergies to medications.

Correct answer: 2 1. The nurse should first prevent circulatory collapse by starting two IVs and initiating normal saline or Ringer's lactate. The cross- match may be needed if the shock condition is caused by hemorrhage. 2. The client is exhibiting symptoms of shock. The nurse should start IV lines to prevent the client from progressing to circulatory collapse. 3. All clients have a history taken and physical examination performed as part of the admission process to the emergency department, but this is not the first intervention. 4. Checking the client's allergies to medications is important, but it is not the first intervention in a client exhibiting signs of shock.

In the local restaurant, the nurse overhears another hospital staff member talking to a friend about a client. The staff member discloses that the client was just diagnosed with lung cancer. What is the most appropriate action by the nurse? 1. Do not approach the staff member in the restaurant. 2. Ask the staff member not to discuss anything about the client. 3. Contact the staff member's clinical manager and report the behavior. 4. Tell the client that the staff member was discussing confidential information.

Correct answer: 2 1. The staff member is violating HIPAA, and the nurse should take action immediately. 2. The nurse should first ask the staff member not to discuss the client with a friend. Discussing any information about a client is a violation of HIPAA. 3. The nurse should address the staff member in the restaurant. The nurse could tell the clinical manager, but the nurse must stop the conversation in the restaurant immediately. 4. The nurse should not tell the client about the breach of confidentiality.

The client diagnosed with active tuberculosis tells the public health nurse, "I am not going to take any more medications. I am tired of them." Which statement is the nurse's best response? 1. "You are tired of taking your tuberculosis medications." 2. "You must take your TB medications. It is not an option." 3. "You must discuss this with your healthcare provider." 4. "As long as you wear a mask, you do not have to take the meds."

Correct answer: 2 1. This is a therapeutic response with the goal of having the client ventilate feelings. This is not appropriate for the client's comment the nurse must give factual information. 2. The client with active TB must take the medication as prescribed for 9-12 months. If the client refuses to take the medication, a court order will be obtained to make the client take the medication because tuberculosis is a community threat. {This option would not be true for other meds, e.g. analgesics, etc.} 3. The nurse should provide factual information when possible and not "pass the buck" to the HCP. 4. This is not a true statement. The client must be on the prescribed medications.

The respiratory unit nurse is calculating the shift intake and output for a client diagnosed with right-sided chest tube. The client has received 1,500 mL of D5W, IVPB of 100 mL of 0.9% NS, 12 ounces of water, 6 ounces of milk, and 4 ounces of chicken broth. The client has had a urinary output of 800 mL and chest drainage of 125 mL. What is the total intake and output for this client? _______ mL intake; _______ mL output

Correct answer: 2160 mL intake and 925 mL output The urinary output is not used in this calculation. The nurse must add up both intravenous fluids and oral fluids to obtain the total intake for this client; 1500 + 100 = 1500 IV fluids; (1 ounce = 30 mL) 12 ounces ? 30 mL = 360 mL, 6 ounces ? 30 mL = 180 mL, 4 ounces ? 30 mL = 120 mL; 360 + 180 + 120 = 660 oral fluids. Total intake is 1,500 + 660 = 2,160. The urinary output 800 mL plus chest drainage 125 mL equals 925 mLs for shift output.

The nurse is developing a nursing care plan for a client diagnosed with chronic obstructive pulmonary disease (COPD). What should be the client's priority nursing diagnosis? 1. Activity intolerance. 2. Altered coping. 3. Impaired gas exchange. 4. Self-care deficit.

Correct answer: 3 1. Activity intolerance is not priority over gas exchange. If gas exchange does not occur, the client will die. 2. Coping is a psychosocial problem, and physiological problems are priority. 3. Impaired gas exchange is the priority problem for this client. If the client does not have adequate gas exchange, the client will die. Remember Maslow's Hierarchy of Needs. 4. Self-care deficit is not priority over gas exchange.

The charge nurse on the critical care respiratory unit is evaluating arterial blood gas (ABG) values of several clients. Which client would require an immediate intervention by the charge nurse? 1. The client with chronic obstructive pulmonary disease who has a pH 7.34, PaO2 70, PaCO2 55, HCO3 24. 2. The client with Adult Respiratory Distress Syndrome who has a pH 7.35, PaO2 75, PaCO2 50, HCO3 26. 3. The client with reactive airway disease with a pH 7.48, PaO2 80, PaCO2 30, HCO3 23. 4. The client with a pneumothorax with a pH 7.41, PaO2 98, PaCO2 43, HCO3 25.

Correct answer: 3 1. Although these are abnormal ABG values, respiratory acidosis, they are expected in a client with COPD; therefore, the nurse would not need to see this client first. 2. The client with ARDS would be expected to have a low arterial oxygen level; therefore, the nurse would not assess this client first. 3. The ABG shows respiratory alkalosis; therefore, the nurse should assess this client first to determine if the client is hyperventilating, in pain, or has an elevated temperature. 4. These are normal ABGs; therefore, the nurse would not need to assess this client first.

The nurse is working in an outpatient clinic along with a licensed practical nurse (LPN). Which client should the nurse assign to the LPN? 1. The client whose purified protein derivative (PPD) induration of the left arm is 14 mm. 2. The client diagnosed with pneumonia whose pulse oximeter reading is 90%. 3. The client with acute bronchitis who has a chronic clear mucous cough and low fever. 4. The client with reactive airway disease who has bilateral wheezing.

Correct answer: 3 1. An induration greater than 10 mm is positive for tuberculosis. This client needs to be assessed and followed up to rule out tuberculosis. This client should not be assigned to an LPN. 2. A pulse oximeter reading less than 93% is life threatening; therefore, this client should not be assigned to an LPN. 3. Acute bronchitis is an inflammation of the bronchial tubes, the major airways into the lungs. The client is exhibiting expected signs/symptoms; therefore, the LPN could care for this client. 4. The client is exhibiting wheezing, an acute exacerbation of reactive airway disease. This client should be assigned to a nurse.

The Hispanic female client diagnosed with bacterial pneumonia is being admitted to the medical unit. The Hispanic husband answers questions even though the nurse directly asks the client. Which action should the nurse take? 1. Ask the husband to allow his wife to answer the questions. 2. Request the husband to leave the examination room. 3. Continue to allow the husband to answer the wife's questions. 4. Do not ask any further questions until the client starts answering.

Correct answer: 3 1. In the Hispanic culture, the husband often speaks for the wife and family, and requesting the husband not to speak may be insulting. This action may cause the wife to leave as well. 2. In the Hispanic culture, the husband often is the spokesperson and makes decisions for the wife and family. Asking the husband to leave the room may cause the client to leave as well. 3. This behavior may be cultural, and the nurse should continue to allow the husband to answer the questions, while the nurse looks at the client. The nurse must be respectful of the client's culture. The nurse can, however, ask whether the client agrees with the husband's answers. 4. This is disrespectful to the client's culture. Many times the nurse must honor the client's culture while caring for the client.

The client in the post-anesthesia care unit (PACU) has noisy and irregular respirations (Rs) with a pulse oximeter reading of 89%. Which intervention should the PACU nurse implement first? 1. Increase the client's oxygen rate via nasal cannula. 2. Notify the respiratory therapist to draw arterial blood gases. 3. Tilt the head back and push forward on the angle of the lower jaw. 4. Obtain an intubation tray and prepare for emergency intubation.

Correct answer: 3 1. Increasing the oxygen rate will not help open the client's airway, which is the first intervention. Oxygen can be increased after the airway is patent. 2. The respiratory therapist could be notified and arterial blood gases (ABGs) drawn if positioning does not increase the pulse oximeter reading, but this is not the first intervention. 3. The client is exhibiting signs/symptoms of hypo-pharyngeal obstruction, and this maneuver pulls the tongue forward and opens the air passage. 4. The client may need to be intubated if positioning does not open the airway, but this is not the first intervention.

The client calls the clinic nurse and asks, "What is the best way to prevent getting influenza?" Which statement is the nurse's best response? 1. "Take prophylactic antibiotics for 10 days after being exposed to influenza." 2. "Stay away for large crowds and wear a scarf over your mouth during cold weather." 3. "The best way to prevent getting influenza is to get a yearly flu vaccine." 4. "You must eat three well-balanced meals a day and exercise daily to prevent influenza."

Correct answer: 3 1. Influenza, or the flu, is a serious respiratory illness caused by a virus. Antibiotics are not prescribed to treat influenza. 2. Staying away from large crowds and a scarf over the mouth is not the best way to prevent getting influenza. 3. Influenza, or flu, is a serious respiratory illness. It is easily spread from person to person and can lead to severe complications, even death. The best way to prevent the influenza is to get a flu vaccine every year. The influenza virus is constantly changing. Each year, scientists work together to identify the virus strains that they believe will cause the most illness, and a new vaccine is made based on their recommendations. 4. Three meals a day and daily exercise will help the client stay healthy in general but it is not the best way to prevent getting influenza.

The healthcare provider ordered the loop diuretic, bumetanide (Bumex), to be administered STAT to a client diagnosed with pulmonary edema. After 4 hours, which of the following assessment data indicates the client may be experiencing a complication of the medication? 1. The client develops jugular vein distention. 2. The client has bilateral rales and rhonchi. 3. The client complains of painful leg cramps. 4. The client's output is greater than the intake.

Correct answer: 3 1. Jugular vein distention would indicate the client has CHF. This is not a complication of a loop diuretic. 2. Rales and rhonchi are symptoms of pulmonary edema, not a complication of a loop diuretic. 3. Leg cramps may indicate a low serum potassium level, which can occur as a result of the administration of a diuretic. {You MUST know the meds, Bumetanide is a loop diuretic, similar to Furosemide, NEED TO KNOW hypokalemia is a serious side effect of both} 4. This would indicate the medication is effective and is not a complication of the medication.

The nurse is working with a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) to care for a group of clients. Which nursing task should not be delegated or assigned? 1. The routine oral medications for the clients. 2. The bed baths and oral care. 3. Evaluating the client's progress. 4. Transporting a client to dialysis.

Correct answer: 3 1. The LPN may be assigned to administer the routine oral medications to the clients. 2. Bed baths and oral care can be performed by the UAP. 3. The nurse cannot delegate or assign tasks that require nursing judgment, such as evaluating a client's progress. 4. The UAP can transport a client to dialysis.

The UAP enters the elderly female client's room to give the bath, but the client is watching her favorite soap opera. Which instructions should the nurse give to the UAP? 1. Tell the UAP to complete the bath at this time. 2. Have the UAP skip the client's bath for the day. 3. Instruct the UAP to give the bath after the program. 4. Document the attempt to give the bath as refused.

Correct answer: 3 1. The UAP should be sensitive to the client's preferences and not insist that the client miss the program. 2. The UAP should arrange an acceptable time for the client, and the UAP can return to complete the task at the agreed-on time. 3. This is the best instruction for the nurse to give to the UAP. 4. The bath has not been refused. The client does not want the program interrupted.

The nurse is teaching the parents of a child diagnosed with cystic fibrosis. Which information is priority to teach the parents? 1. Explain that the child's skin tastes salty. 2. Observe the consistency of the stools daily. 3. Give pancreatic enzymes with every meal. 4. Increase the intake of salt in the child's diet.

Correct answer: 3 1. The child's skin will normally taste salty, but this is not the priority intervention to teach. 2. The parents should be asked about the client's stools during an assessment because the effectiveness of the pancreatic enzymes is evaluated by the consistency of the stool. This is not the priority intervention because the child must take the enzymes before monitoring the consistency of the stool. 3. Cystic fibrosis is a genetic condition that results in blockage of the pancreatic ducts. The child needs pancreatic enzymes to be administered with every meal and snack so the enzymes will be available when the food gets to the small intestine. 4. Cystic fibrosis is one of the few diseases that requires salt replacement, but salt replacement is not more important than taking the pancreatic enzymes.

The client diagnosed with abdominal pain of unknown etiology has a nasogastric tube draining green bile and reports abdominal pain of 8 on a scale of 1 to 10. The client's arterial blood gas values are pH 7.48, PaO2 98, PaCO2 36, HCO3 28. Which intervention should the nurse implement based on the client's ABGs? 1. Assess the client to rule out any complications secondary to the client's pain. 2. Determine the last time the client was medicated for abdominal pain. 3. Check the amount of suction on the client's nasogastric tube. 4. Administer intravenous sodium bicarbonate to the client.

Correct answer: 3 1. The client is in metabolic alkalosis, so this intervention is not appropriate for the client's ABGs. 2. The client is in metabolic alkalosis, so this intervention is not appropriate for the client's ABGs. 3. The ABG indicates metabolic alkalosis, which could be caused by too much hydrochloric acid being removed via the N/G tube. Therefore, the nurse should check the N/G wall suction. 4. Sodium bicarbonate is administered for metabolic acidosis not metabolic alkalosis.

Which client should the charge nurse assign to the new graduate on the respiratory unit? 1. The client diagnosed with lung cancer who has rust-colored sputum and chest pain of 10 on a scale of 1 to 10. 2. The client diagnosed with atelectasis who is having shortness of breath and difficulty breathing. 3. The client diagnosed with tuberculosis who has a non-productive cough and orange colored urine. 4. The client diagnosed with pneumonia who has a pulse oximeter reading of 91% and has a CRT >3 seconds.

Correct answer: 3 1. The client with lung cancer is expected to have rust-colored sputum; however, complaining of pain rated as a 10 warrants a more experienced nurse to assess the cause of the pain and medicate as needed. 2. The client with atelectasis (collapsed lung) who is having difficulty breathing needs a more experienced nurse to assess the client. This client is not stable. 3. The orange-colored urine is secondary to rifampin, an anti-tubercular medication, and a non-productive cough is expected. Therefore, this client is stable and should be assigned to a new graduate nurse. 4. The client is exhibiting respiratory compromise and is not stable. The pulse oximeter reading should be greater than 93% and the CRT should be less than 3 seconds.

The nurse on a medical unit has a client with adventitious breath sounds, but the nurse is unable to determine the exact nature of the situation. Which multidisciplinary team member should the nurse consult first? 1. The healthcare provider. 2. The unit manager. 3. The respiratory therapist. 4. The case manager.

Correct answer: 3 1. The client's HCP should be consulted if the nurse determines a need, but at this time, the nurse should discuss the client with the respiratory therapist. 2. The unit manager may or may not be capable of helping the nurse assess a client with adventitious breath sounds; therefore, this is not the first person the nurse should consult. 3. Respiratory therapists assess and treat clients with lung problems multiple times every day. Therefore, this is the best person to consult when the nurse needs help identifying a respiratory problem. 4. The case manager is usually capable of maneuvering through the maze of healthcare referrals, but is not necessarily an expert in lung sounds.

The client has just been told a medical condition cannot be treated successfully and the client has a life expectancy of about 6 months. To whom should the nurse refer the client at this time? 1. A home health nurse. 2. The client's pastor. 3. A hospice agency. 4. The social worker.

Correct answer: 3 1. The home health nurse may be a possibility if a hospice organization is not available, but hospice is the best referral. 2. The nurse would not refer the client to his or her own pastor. The nurse could place a call to notify the pastor at the client's request, but this would not be considered a referral. 3. One of the guidelines for admission to a hospice agency is a terminal process with a life expectancy of 6 months or less. These organizations work to assist the client and family to live life to its fullest while providing for comfort measures and a peaceful, dignified death. 4. The hospital social worker is not an appropriate referral at this time.

The intensive care unit (ICU) nurse is caring for a client on a ventilator who is exhibiting respiratory distress. The ventilator alarms are going off. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Ventilate with a manual resuscitation bag. 3. Check the ventilator to resolve the problem. 4. Auscultate the client's lung sounds.

Correct answer: 3 1. The nurse must first address the client's acute respiratory distress and then notify other members of the multidisciplinary team. 2. If the ventilator system malfunctions, the nurse must ventilate the client with a manual resuscitation bag (Ambu) until the problem is resolved. The nurse should determine whether the nurse can remedy the situation by assessing the ventilator before beginning manual ventilations. 3. The client is having respiratory distress and the ventilator is sounding an alarm; therefore, the nurse should first assess the ventilator to determine the cause of the problem and correct it because the client is totally dependent on the ventilator for breathing. This is one of the few situations wherein the nurse would assess the equipment before assessing the client. 4. In most situations, assessing the client is the first intervention, but because the client is totally dependent on the ventilator for breathing, the nurse should first assess the ventilator to determine the cause of the alarms.

The charge nurse in the intensive care unit asks a nurse to float from the medical/ surgical unit to the ICU. Which client should the charge nurse assign to the float nurse? 1. The client who is 3 hours postoperative lung transplant. 2. The client who has a central venous pressure of 13 cm H2O. 3. The client who is diagnosed with bacterial pneumonia. 4. The client who is diagnosed with Hantavirus pulmonary syndrome.

Correct answer: 3 1. This client is critical and there is a possibility of organ rejection; therefore, this client should not be assigned to a float nurse. 2. The normal CVP is 4-10 cm H2O and an elevated CVP indicates right ventricular failure or volume overload; therefore, this client should not be assigned to a float nurse. 3. The float nurse from the medical unit is able to administer antibiotic therapy and complete respiratory assessments; therefore, this client would be the most appropriate client to assign to the float nurse. 4. Hantavirus pulmonary syndrome is a disease that results from contact with infected rodents or their urine, droppings, or saliva. HPS is potentially deadly. There is no specific treatment for HPS, and there is no cure. This client should be assigned to a more experienced nurse.

The hospice client asks the nurse, "What should I do about my house? My son and daughter are fighting over it." Which statement is the nurse's best response? 1. "I think you should tell your children that you will leave the house to a charity." 2. "I would sell the house and go on an extended vacation and spend the money." 3. "What do you want to happen to your house? It is your decision." 4. "Wait and let your children fight over the house after you are gone."

Correct answer: 3 1. This is advising and crossing professional boundaries. The nurse should not try to influence the client in these types of concerns. 2. This is advising and crossing professional boundaries. The nurse should not try to influence the client in these types of concerns. 3. This response allows the client to make his or her own decision. It validates that the nurse heard the concern but does not advise the client. 4. This is advising and crossing professional boundaries. The nurse should not try to influence the client in these types of concerns.

The charge nurse of the respiratory care unit is making assignments. Which clients should be assigned to the intensive care nurse who is working on the respiratory care unit for the day? Select the patient/patients that apply. 1. The client who had four coronary artery bypass grafts 3 days ago. 2. The client who has anterior and posterior chest tubes after a motor vehicle accident. 3. The client who will be moved to the intensive care unit when a bed is available. 4. The client who has a do not resuscitate order and is requesting to see a chaplain. 5. The client who is on multiple intravenous drip medications needed to be titrated.

Correct answer: 3 and 5 1. This client is nearing discharge status. Postoperative clients are progressed rapidly. A medical-surgical nurse could take care of this client. 2. Chest tubes are frequently cared for on a medical-surgical unit, the medical-surgical nurse can care for this client. 3. This client's status is uncertain. The ICU nurse would be an appropriate assignment for this client since the patient will be moved to ICU soon. 4. A medical-surgical nurse can care for this client. 5. The intensive care nurse should care for this client requiring titration of multiple medications simultaneously.

The clinic nurse encounters a client who does not respond to verbal stimuli and initiates cardiopulmonary resuscitation (CPR). What should the nurse do? Prioritize the nurse's actions from first (1) to last (5). 1. Open the client's airway. 2. Check the client's carotid pulse. 3. Assess the client for unresponsiveness. 4. Perform compressions at a 30:2 rate. 5. Pinch the nose and give two breaths

Correct answer: 3, 4, 1, 5, 2 3. The nurse needs to determine if the client is unresponsive prior to taking any action. If the client is unresponsive, then perform compressions. 4. The American Heart Association recommends 30 compressions followed by two breaths. 1. After completing compressions, open the client's airway to ensure a patent airway. 5. The nurse should then administer two breaths while the client's nose is pinched. 2. The nurse then must determine whether the client's heart is pumping by checking the carotid pulse.

The client who is 2 days postoperative following a left pneumonectomy has an apical pulse (AP) rate of 128 beats per minute and a blood pressure (BP) of 80/50 mm Hg. Which intervention should the nurse implement first? 1. Notify the healthcare provider (HCP) immediately. 2. Assess the client's incisional wound. 3. Prepare to administer dopamine, a vasopressor. 4. Increase the client's intravenous (IV) rate.

Correct answer: 4 1. The HCP should be notified, but this is not the first intervention. The HCP will require other information, such as what the incision looks like and whether there is any bleeding that can be seen, before making any decisions. The nurse, therefore, should first provide emergency care to the client—in this case, support the client's circulatory system by increasing the IV rate—and then assess the patient before reporting to the HCP. 2. The incisional wound should be assessed, but the priority is maintaining circulatory status because the client's vital signs indicate shock. 3. The client may require medication, such as dopamine, to increase the blood pressure, but the client's circulatory system needs immediate support, which increasing the IV rate will provide. That, then, is the priority. 4. Increasing the IV rate will provide the client with circulatory volume immediately. Therefore, this is the first intervention.

Which task is most appropriate for the home health nurse to delegate to unlicensed assistive personnel (UAP)? 1. Changing the client's subclavian dressing. 2. Reinserting the client's Foley catheter. 3. Demonstrating ambulation with a walker. 4. Getting the client up in a chair three times a day.

Correct answer: 4 1. The UAP cannot perform sterile dressing changes. 2. The UAP cannot perform sterile procedures. 3. The UAP cannot teach the client. 4. The UAP can transfer the client from the bed to the chair three times a day.

The client in the intensive care unit (ICU) has been on a ventilator for 2 weeks with an endotracheal tube in place. Which intervention should the nurse prepare the client for next? 1. Transfer to a long-term care facility. 2. Daily arterial blood gases. 3. Removal of life support. 4. Placement of a tracheostomy.

Correct answer: 4 1. The client may eventually need to be transferred to a facility that accepts long-term ventilator-dependent clients, but the nurse would not anticipate this at this time. 2. The client on a ventilator will have blood gases ordered more often than daily. 3. The stem does not indicate that the client is ready to be removed from the ventilator. 4. A client who has been intubated for 10 to 14 days and still requires mechanical ventilation should have a surgically placed tracheostomy to prevent permanent vocal cord damage.

The clinic nurse is scheduling a chest x-ray for a female client who may have pneumonia. Which question is most important for the nurse to ask the client? 1. "Have you ever had a chest x-ray before?" 2. "Can you hold your breath for a minute?" 3. "Do you smoke or have you ever smoked cigarettes?" 4. "Is there any chance you may be pregnant?"

Correct answer: 4 1. The nurse could ask this question because the radiologist may need to compare the previous chest x-ray with the current one, but this is not the most important question. 2. The client will have to hold her breath when the chest x-ray is taken, but this is not the most important question. 3. Smoking or a history of smoking is pertinent to the diagnosis of pneumonia, but it is not the most important question. 4. This is the most important question because if the client is pregnant, the x-rays can harm the fetus.

The clinic nurse is scheduling a 14-year-old client for a tonsillectomy. Which intervention should the clinic nurse implement? 1. Obtain informed consent from the client. 2. Send a throat culture to the laboratory. 3. Discuss the need to cough and deep breathe. 4. Request the laboratory to draw a PT and a PTT.

Correct answer: 4 1. The parent/guardian must sign the consent for surgery because the client is under the age of 18. 2. The client has already been diagnosed with tonsillitis; therefore, a throat culture is not needed prior to surgery. 3. The client should not cough after this surgery because it could cause bleeding from the incision site. 4. A PT/PTT will assess the client for any bleeding tendencies. This is priority before this surgery because bleeding is a life-threatening complication.

The unlicensed assistive personnel (UAP) is bathing the client diagnosed with adult acute respiratory distress syndrome (ARDS) who is on a ventilator. The bed is in the high position with the opposite side rail elevated. Which action should the ICU nurse take? 1. Demonstrate the correct technique when giving a bed bath. 2. Encourage the UAP to put the bed in the lowest position. 3. Explain that the client on a ventilator should not be bathed. 4. Give the UAP praise for performing the bath safely.

Correct answer: 4 1. This is the correct technique when bathing a client; therefore, the nurse does not need to demonstrate the correct technique to give a bath. 2. The bed should be at a comfortable height for the UAP to bathe the client, not in the lowest position. 3. All clients should receive a bath; therefore, this would not be an appropriate action for the nurse to take. 4. Part of the delegation process is to evaluate the UAP's performance and the nurse should praise any action on the part of the UAP that ensures the client's safety.