Multisystem Care Exam #1

How do you calculate the mean arterial pressure (MAP)?

((Diastolic x 2) + Systolic) / 3

A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? A. "I should wash my hands after blowing my nose to prevent spreading the virus." B. "I need to avoid drinking fluids if I develop symptoms." C. "I need a flu shot every 2 years because of the different flu strains." D. "I should cover my mouth with my hand when I sneeze."

A. "I should wash my hands after blowing my nose to prevent spreading the virus." Hand hygiene decreases the risk of the client spreading influenza viruses. The client should increase fluid intake to loosen mucous, promote expectoration, and maintain hydration. The client should receive an influenza vaccination yearly to reduce the risk for acquiring influenza. The client should sneeze into the shoulder or elbow, rather than the hands, to reduce the risk of spreading the influenza virus..

The nurse is teaching a class regarding reduction of risk factors for cardiovascular disease. Which teaching statement is appropriate? Select all that apply. A. "If you tend to get angry easily, then your risk for heart disease is higher." B. "To reduce your overall risk, it is important to keep your BMI greater than 30." C. "Do not eat more calories on a daily basis that you are able to burn." D. "Decreasing the amount that you smoke will decrease your overall cardiovascular risk." E. "Secondhand smoke creates a significant risk to others for cardiovascular disease." F. "Exercise moderately at least 2 days per week for a total of 150 minutes."

A. "If you tend to get angry easily, then your risk for heart disease is higher." C. "Do not eat more calories on a daily basis that you are able to burn." E. "Secondhand smoke creates a significant risk to others for cardiovascular disease." F. "Exercise moderately at least 2 days per week for a total of 150 minutes." When teaching a class regarding risk reduction for cardiovascular disease the nurse will include that certain personality types have higher risks, such as those that tend to anger easily or stay frustrated. The nurse will also teach the importance of maintaining a BMI under 30 (ideally under 25) while not consuming more calories than an individual can burn on a daily basis. Secondhand smoke also creates a risk for CVD. Exercise is important and current guidelines include moderate exercise at least twice a week totaling 150 minutes. Smoking cessation is a critical teaching component. However, the key is cessation. Just a reduction in smoking does not decrease the risk, however, cessation does.

The nurse is teaching a client about the risk for bradydysrhythmias. What teaching will the nurse include? A. "Use a stool softener." B. "Stop smoking and avoid caffeine." C. "Avoid potassium-containing foods." D. "Take nitroglycerin for a slow heartbeat."

A. "Use a stool softener." The nurse will advise the client to use a stool softener. Patients at risk for bradydysrhythmias would avoid bearing down or straining during a bowel movement. The Valsalva maneuver associated with bearing down can cause bradycardia. Patients with renal failure and hyperkalemia are instructed to avoid potassium-containing foods; if risk for hypokalemia exists, such as with diuretic therapy, the patient is instructed to eat foods high in potassium. Smoking and caffeine increase heart rate; although all people would stop smoking, patients at risk for tachycardia, premature beats, and ectopic rhythms are instructed to stop smoking and avoid caffeine. Nitroglycerin is used to reduce oxygen demand in cardiac ischemia, not for bradycardia.

Which clients will the nurse monitor most closely for respiratory failure? (Select all that apply.) A. A 30 year old with a C-5 spinal cord injury B. A 55 year old with a brainstem tumor C. A 50 year old experiencing cocaine intoxication D. A 65 year old with COVID-19 pneumonia E. A 35 year old using client-controlled analgesia F. A 40 year old with acute pancreatitis

A. A 30 year old with a C-5 spinal cord injury B. A 55 year old with a brainstem tumor D. A 65 year old with COVID-19 pneumonia E. A 35 year old using client-controlled analgesia F. A 40 year old with acute pancreatitis Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome; abdominal distention also ensues, which can limit respiratory excursion. Clients with cervical and high thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect the diaphragm and inter-costal muscles are affected. Opioids used in client-controlled analgesia are respiratory depressants and can depress the breathing center in the brainstem causing respiratory failure. Pneumonia, whether bacterial or viral, can result in oxygenation respiratory failure, especially in an older client who often has respiratory muscle weakness. Cocaine is a stimulant, which would not cause respiratory failure unless a stroke ensued.

Which client will the nurse identify as having the greatest risk for development of acute leukemia? A. A 50 year old being treated with cyclophosphamide for a chronic autoimmune disease. B. A 20 year old with cystic fibrosis who has been on continuous enzyme replacement therapy since infancy. C. A 55 year old with diabetes mellitus type 1 who has received insulin injections for 43 years. D. A 38 year old who has used combination oral contraceptives without a break for 15 years.

A. A 50 year old being treated with cyclophosphamide for a chronic autoimmune disease. Cyclophosphamide is a cytotoxic agent that damages bone marrow and has been known to induce leukemia. Diabetes, long-term use of oral contraceptives, and enzyme replacement therapy for cystic fibrosis do not increase the risk for development of any type of leukemia.

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.) A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery C. A client who has a hemoglobin of 15.1 mg/dL D. A client who has dysphagia E. A client who experienced acute drug toxicity

A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery D. A client who has dysphagia E. A client who experienced acute drug toxicity A client who experienced a near-drowning incident is at risk for developing ARDS due to trauma to the lungs and cerebral edema. A client following coronary artery bypass graft surgery is at risk for developing ARDS due to trauma to the chest. Hemoglobin of 15.1 mg/dL is within the expected reference range. A client who has a low hemoglobin is at risk for developing ARDS. A client who has dysphagia is at risk for developing ARDS due to difficulty swallowing and risk for aspiration. A client who experienced acute drug toxicity is at risk for developing ARDS due to damage to the central nervous system.

A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonary embolism? (Select all that apply.) A. A client who has a BMI of 30 B. A female client who is postmenopausal C. A client who has a fractured femur D. A client who is a marathon runner E. A client who has chronic atrial fibrillation

A. A client who has a BMI of 30 C. A client who has a fractured femur E. A client who has chronic atrial fibrillation The client who has a BMI of 30 is considered obese and is at increased risk for a blood clot. A female who is postmenopausal has decreased estrogen levels. Increased estrogen levels are a risk factor for developing a pulmonary embolism. The client who has a fractured bone, particularly in a long bone such as the femur, increases the risk of fat emboli. The client who is a marathon runner has increased blood flow and circulation of his body, which decreases the risk for developing a pulmonary embolism. The client who has turbulent blood flow in the heart, such as with atrial defibrillation, is also at increased risk of a blood clot.

Drugs from which class will the nurse prepare to administer as first-line therapy for a client just diagnosed with pulmonary embolism (PE)? A. Anticoagulants B. Antihypertensives C. Antidysrhythmics D. Antibiotics

A. Anticoagulants A PE is collection of particulate matter (solids, liquids, or air) that enters venous circulation and lodges in the pulmonary vessels. Anticoagulants are the first-line therapy drugs for this problem, even if the actual particulate matter is not a clot. Anything lodged in the blood vessels will cause clot formation around it. Anticoagulants help prevent new clots from forming in the area and extension of existing clots. Depending on other problems cause by a PE, antibiotics, or antidysrhythmics may also be used but not always. Clients with PE are hypotensive, not hypertensive.

What is the primary emphasis for the nurse who is providing care to a client with acute respiratory distress syndrome (ARDS) currently in the exudative management stage of the disorder? A. Assessing the client at least hourly for tachypnea and dyspnea B. Performing meticulous mouth during mechanical ventilation C. Assessing for abnormal lung sounds D. Monitoring urine output to identify multiple organ dysfunction syndrome early

A. Assessing the client at least hourly for tachypnea and dyspnea The exudative phase includes early changes of dyspnea and tachypnea resulting from the alveoli becoming fluid filled and from pulmonary shunting and atelectasis. Early interventions focus on frequent assessment of respiratory status, supporting the client, and providing oxygen. Abnormal lung sounds are not present at this stage because the edema is present in the interstitial tissues and not in the airways. At this stage, clients are neither intubated nor being mechanically ventilated. Multiple organ dysfunction syndrome is not a feature of this stage.

The nurse is conducting an admission assessment on a male client. Which assessment data is a risk factor for cardiovascular disease? Select all that apply. A. BMI of 26 B. BP of 120/66 C. Triglycerides 140 mg/dL D. Moderate exercise for 20-30 minutes weekly E. Exposure to secondhand cigarette smoke F. History of repeated streptococcal tonsillitis G. Family history of cardiovascular disease

A. BMI of 26 D. Moderate exercise for 20-30 minutes weekly E. Exposure to secondhand cigarette smoke G. Family history of cardiovascular disease A BMI of 26 is considered overweight which is a risk for CVD. Exercise for 20-30 minutes does not adhere to the recommended guidelines to combat the known risk of a sedentary lifestyle. Exposure to second hand smoke is a risk factor, as well as a family history of cardiovascular disease. Recurrent streptococcal infections are associated with valvular disease and place the client at risk for CVD. A blood pressure of 120/66 is within normal limits. Triglycerides of 140 mg/dL for a male client is also considered within normal limits.

The nurse is assessing a client with septic shock. What assessment data indicates a progression of shock? Select all that apply. A. BP change from 86/50 to 100/64 B. HR change from 98 to 76 C. Cool and clammy skin D. Petechiae along the gum line E. Urine output 45 ml/hr

A. BP change from 86/50 to 100/64 C. Cool and clammy skin D. Petechiae along the gum line As sepsis progresses, cardiac output is higher as are heart rate and blood pressure. The nurse would interpret the increasing blood pressure as an indication of worsening condition versus improvement. As sepsis progresses, circulation is compromised and presents as cool, clammy skin, with pallor and cyanosis. DIC can occur with sepsis progression causing petechiae and ecchymoses, occurring anywhere on the body. The decrease in heart rate is not associated with progression of shock (the heart rate, like the BP would increase). The urine output is within normal limits and would not indicate progression of shock.

For a client with an 8-cm abdominal aortic aneurysm, which assessment data must be addressed immediately? A. Blood pressure (BP) 192/102 mm Hg B. Report of constipation C. Anxiety D. Heart rate 52 beats/min

A. Blood pressure (BP) 192/102 mm Hg The problem that must be addressed immediately in a client with an 8-cm abdominal aneurysm is a BP of 192/102 mm Hg. Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture. The nurse must consider the client's usual pulse. However, bradycardia does not pose a risk for aneurysm rupture. Straining at stool can elevate blood pressure and pose a risk for dissection. However, a potential problem would not be addressed before an actual problem. Anxiety may be benign or may be a symptom of something serious. However, the elevated blood pressure is an immediate risk.

A client who has been taking the four first-line drugs for tuberculosis treatment for a month reports all of the following changes. Which changes would cause the nurse to collaborate quickly with the health care provider? Select all that apply. A. Blurry vision B. Constipation C. Difficulty sleeping D. Nausea when drinking beer E. Red-tinged urine F. Sunburn with minimal sun exposure G. Yellowing of the sclera

A. Blurry vision G. Yellowing of the sclera The drug ethambutol can cause optic neuritis that can lead to blindness. The drug should be stopped and the patient's vision evaluated immediately. Yellowing of the sclera is associated with jaundice from liver problems, which can be serious and life-threatening. The client's liver status must be evaluated immediately. Although nausea when drinking alcohol is an expected side effect of ethambutol, it is a priority to report this change to the health care provider at this time. The nurse needs to explain the side effect to the client and remind him or her that alcohol must be avoided during TB therapy to prevent liver problems. This change only needs to be reported to the health care provider if the client continues to consume alcohol. Difficulty sleeping may or may not be associated with the TB drug therapy. It does not require immediate attention. Red-tinged urine is an expected side effect of rifampin. The nurse reinforces this information to the client to relieve his or her anxiety. The drug pyrazinamide increases photosensitivity. Sunburn is a common side effect that the nurse needs to instruct the client to prevent but does not require immediate attention from the healthcare provider.

A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (Select all that apply.) A. Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 6 months ago D. Client who is postoperative and has received local anesthesia E. Client who has a closed head injury and is receiving mechanical ventilation F. Client who has myasthenia gravis

A. Client who has dysphagia B. Client who has AIDS E. Client who has a closed head injury and is receiving mechanical ventilation F. Client who has myasthenia gravis The client who has difficulty swallowing is at increased risk for pneumonia due to aspiration. The client who has AIDS is immunocompromised, which increases the risk of opportunistic infections, such as pneumonia. The client who has recently been vaccinated in the past few months has a decreased risk to acquire pneumonia. A client who is postoperative and has received local anesthesia has a decreased risk to acquire pneumonia. Mechanical ventilation is invasive and places the client at risk for ventilator-associated pneumonia. A client who has myasthenia gravis has generalized weakness and can have difficulty clearing airway secretions, which increases the risk of pneumonia.

Which action has the highest priority for the nurse to take to prevent harm for a client being mechanically ventilated with 100% oxygen for the past 24 hours who now has new-onset crackles, decreased breath sounds, and a PaO2 level of 95 mm Hg? A. Collaborating with the pulmonary health care provider to lower the FiO2 level B. Assessing cognition C. Placing the client in the prone position D. Preparing to suction the client

A. Collaborating with the pulmonary health care provider to lower the FiO2 level Prompt identification and correction of the underlying disease process and potential oxygen toxicity may require delivery of a lower FiO2. The pulmonary health care provider needs to be notified when PaO2 levels are greater than 90 mm Hg. Preventing harm from oxygen toxicity and absorptive atelectasis (new onset of crackles and decreased breath sounds) are essential. Oxygen toxicity is related to the concentration of oxygen delivered, duration of oxygen therapy, and degree of lung tissue present. The need for 100% oxygen delivery indicates that the client continues to require intubation and mechanical ventilation. Suction is performed when rhonchi or noisy breath sounds on the anterior chest below the sternal notch (upper airway) are present. Crackles and diminished breath sounds reflect fluid or poor exchange in the lower airway, not the need for suctioning. Although prone-positioning has been used for clients with acute respiratory distress syndrome (ARDS), is not the priority action and this client has not been diagnosed with ARDS.

A client being mechanically ventilated has all of the following changes. Which changes are most relevant in helping the nurse determine whether suctioning is needed at this time? Select all that apply. A. Decreased SpO2 B. Elevated temperature C. Crackles auscultated over the trachea D. Crackles auscultated in the lung periphery E. High pressure ventilator alarm sounds F. Presence of fluid within the endotracheal tube G. Presence of fluid within the ventilator tubing

A. Decreased SpO2 C. Crackles auscultated over the trachea E. High pressure ventilator alarm sounds F. Presence of fluid within the endotracheal tube Decreased SpO2 is often caused by excessive airway secretions and is a major indicator of the nees for suctioning. Crackles over the trachea are caused by fluid in the trachea and suctioning is needed to remove this fluid. Pressure is increased when resistance is present in the airway such as that caused by secretions. Fluid in the endotracheal tube indicates a need for immediate suctioning regardless of how recently it was last performed. Elevated temperature is not related to the need for suction. Crackles in the lung periphery would not be reduced by endotracheal suctioning. Fluid in the ventilator tubing is caused by condensation, not increased secretions in the airway.

Which symptom or change in assessment of a client with 4 broken ribs on the right side indicates to the nurse the possibility of a tension pneumothorax? A. Distended neck veins B. Mediastinal shift toward the left side C. Right-sided pain on deep inhalation D. Right side of the chest more prominent than the left

A. Distended neck veins Any type of pneumothorax can shift the mediastinum to the unaffected side and cause the affected side to be more prominent. Pain on deep inhalation is related to the broken ribs and not a pneumothorax. The distended neck veins are a strong indicator of the life-threatening tension pneumothorax and immediate action is needed.

What type of percussion note or sound will the nurse expect on the affected chest side of a client who has a hemothorax? A. Dull B. Hyperresonant C. Crackling D. Hypertympanic

A. Dull With a hemothorax, percussion on the involved side produces a dull sound because the blood in the lung area prevents air from filling the area. Lung crackling sounds cannot be percussed, although skin crackling with subcutaneous emphysema can. Tympanic sounds on percussion are associated with abdominal assessment, not pulmonary. Any degree of resonance is associated with air-filled lung areas, not blood-filled areas.

Which condition, sign, or symptom does the nurse consider most relevant in assessing a client suspected to have ARDS? Select all that apply. A. Dyspnea B. Electrocardiograph shows ST elevation C. Intercostal retractions D. PaO2 84% on oxygen at 6 L/minute E. Substernal pain or rubbing F. Wheezing on exhalation

A. Dyspnea C. Intercostal retractions D. PaO2 84% on oxygen at 6 L/minute The defining feature of ARDS is continued hypoxemia despite vigorous oxygen therapy. The hypoxia and hypoxemia triggers dyspnea and an increased breathing effort seen as intercostal retractions. Substernal pain or rubbing are not associated with ARDS. The pathophysiological problems of ARDS are in the lung tissue and not in the airways. Thus, wheezing is not a manifestation of the disorder. Although the hypoxia stimulates a variety of dysrhythmias, there are no specific ECG changes. ST elevation is associated with an evolving myocardial infarction.

A nurse is caring for a client who is receiving vecuronium during mechanical ventilation. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.) A. Fentanyl B. Furosemide C. Midazolam D. Famotidine E. Dexamethasone

A. Fentanyl C. Midazolam Fentanyl is a pain medication administered to clients when a neuromuscular blocking agent, such as vecuronium, is administered. Furosemide is a diuretic used to release fluid from the body. Midazolam is a sedative medication administered to clients when a neuromuscular blocking agent, such as vecuronium, is administered. Famotidine is an H₂ receptor antagonist given to treat upset stomach and heartburn. Dexamethasone is a corticosteroid used to treat inflammation, such as arthritis or an immune disorder.

The nurse is caring for a patient in the initial stage of hypovolemic shock. What assessment data will the nurse anticipate? A. Heart rate 118 B. 2+ pedal pulses C. Bilateral fine crackles in lung bases D. BP change from 100/60 to 100/40

A. Heart rate 118 With the initial stage of shock, an increase is heart rate is often the first indicator. Because stroke volume is decreased the pedal pulses are often difficult to palpate and easily blocked. A normal pedal pulse (2+) would not be anticipate. The nurse would not anticipate bilateral fine crackles in the lungs with hypovolemic shock. The nurse would anticipate a narrow pulse pressure change (versus a widened pulse pressure). With vasoconstriction, diastolic pressure increases, but systolic pressure remains the same. This creates a narrow pulse pressure.

The nurse is assessing a client who had a coronary artery bypass graft yesterday. Which assessment data indicates the client is at risk for decreased perfusion? A. Heart rate of 50 beats/min B. Potassium level of 4.2 mEq/L C. Systolic blood pressure of 120 mm/Hg D. 50 ml of bloody drainage in chest tube over 4 hours

A. Heart rate of 50 beats/min A heart rate of 50 beats per minute is a risk for decreased perfusion. All other choices are not risks for decreased perfusion or normal parameters.

Which assessment findings in a postoperative client suggest to the nurse the possibility of a pulmonary embolism (PE) and pulmonary infarction? A. Hemoptysis and shortness of breath B. Fever and tracheal deviation C. Audible wheezing on inhalation and exhalation D. Paradoxical chest movements

A. Hemoptysis and shortness of breath Symptoms of a PE with infarction include profound shortness of breath and bloody sputum (hemoptysis) from poor gas exchange and hypoxic damage to lung tissues. Paradoxical chest movements are associated with a flail chest, not PE. Tracheal deviation is associated with a pneumothorax. Audible wheezing on inhalation and exhalation is a partial obstruction of the tracheobronchial tree.

A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? A. Hip arthroplasty 2 weeks ago B. Elevated sedimentation rate C. Incident of exercise-induced asthma 1 week ago D. Elevated platelet count

A. Hip arthroplasty 2 weeks ago The client who has undergone a major surgical procedure within the last 3 weeks should not receive thrombolytic therapy because of the risk of hemorrhage from the surgical site. An elevated sedimentation rate is not a contraindication to receiving heparin. An incident of exercise-induced asthma is not a contraindication to receiving heparin. An elevated platelet count is not a contraindication to receiving heparin.

For which side effect will the nurse monitor a client with pulmonary arterial hypertension (PAH) who is receiving endothelin receptor antagonist therapy? A. Hypotension B. Increased clot formation C. Sepsis D. Decreased urine output

A. Hypotension Endothelin receptor antagonists cause vasodilation of systemic as well as pulmonary blood vessels, which can lead to severe hypotension. These oral drugs do not increase clot formation or lead to sepsis. Urine output is only affected when hypotension becomes profound.

A client in the progressive stage of hypovolemic shock has all of the following signs, symptoms, or changes. Which signs will the nurse attribute to ongoing compensatory mechanisms? Select all that apply. A. Increasing pallor B. Increasing thirst C. Increasing confusion D. Increasing heart rate E. Increasing respiratory rate F. Decreasing systolic blood pressure G. Decreasing blood pH H. Decreasing urine output

A. Increasing pallor B. Increasing thirst D. Increasing heart rate E. Increasing respiratory rate H. Decreasing urine output Compensatory mechanisms attempt to maintain perfusion and gas exchange to vital organs. Thus these mechanisms shunt blood away from less vital organs and try to prevent further volume losses. The increasing pallor occurs because blood is shunted away from skin and mucous membranes to the heart, brain, liver, and lungs. Increasing thirst and decreasing urine output help to increase blood volume by stimulating the patient to drink and by preventing fluid loss through the urine. Increasing heart rate and respiratory rate work to maintain gas exchange to those selected organs that continue to be perfused. Increasing confusion indicates the compensatory mechanisms are failing and that the brain is not being adequately perfused. Decreasing systolic blood pressure also is an indication of worsening shock. Decreasing blood pH is not a compensatory action; it is an indication of inadequate gas exchange.

Which assessment findings in a client at high risk for pulmonary embolism (PE) indicates to the nurse the probably presence of a PE? (Select all that apply.) A. Inspiratory chest pain B. Dizziness and syncope C. Pink, frothy sputum D. Worsening dyspnea for 3 days E. Tachycardia F. Productive cough

A. Inspiratory chest pain B. Dizziness and syncope E. Tachycardia Symptoms consistent with PE include: dizziness, syncope, hypotension, and fainting. Sharp, pleuritic, inspiratory chest pain, hemoptysis, and tachycardia are also characteristic of PE. Typically SOB and dyspnea associated with PE develops abruptly rather than gradually over 2 weeks. Productive cough is associated with infection. PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema.

A nurse is caring for a client who, upon awakening, was disoriented to person, place, and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority? A. Obtain baseline vital signs and oxygen saturation. B. Obtain a sputum culture. C. Obtain a complete history from the client. D. Provide a pneumococcal vaccine.

A. Obtain baseline vital signs and oxygen saturation. The first action the nurse should take using the nursing process is to assess the client in order to determine the next nursing intervention and provide safe and effective client care. The nurse should obtain a sputum culture to determine sensitivity for antibiotic therapy. However, there is another action the nurse should take first. The nurse should obtain a complete history from the client to determine the plan of care. However, there is another action the nurse should take first. The nurse should provide for a pneumococcal vaccination to decrease the risk of pneumonia in the future. However, there is another action the nurse should take first.

Which statement about the genetics of cystic fibrosis is true? A. Recessive disorder affecting chloride transport B. Recessive disorder affecting alpha1-antitrypsin levels C. Dominant disorder inhibiting alveoli formation D. Dominant disorder increasing production of interleukin-5

A. Recessive disorder affecting chloride transport Cystic fibrosis is caused by a mutation in both alleles of the CFTR gene, which results in the inhibition of chloride transport in epithelial cells, especially of the lungs, allowing thick, stick mucus to plug the airways. Although alpha1-antitrypsin deficiency is inherited in an autosomal pattern, this problem is associated with emphysema, not CF. Alveolar formation are not affected by CF, nor is interleukin-5 production increased.

What type of acid-base problem will the nurse expect in a client who is being insufficiently mechanically ventilated for the past 4 hours and whose most recent arterial blood gas results include a pH of 7.29? A. Respiratory acidosis with an acid excess B. Metabolic acidosis with an acid excess C. Respiratory acidosis with a base deficit D. Metabolic acidosis with a base deficit

A. Respiratory acidosis with an acid excess When a person being mechanically ventilated is insufficiently ventilated respiratory acidosis occurs with retention of carbon dioxide. The retained carbon dioxide is converted to hydrogen ions resulting in an acid excess. Bases have neither been lost nor retained in an acute respiratory acidosis. Insufficient ventilation does not cause any form of metabolic acidosis.

Which complication will the nurse assess for first in any client with cystic fibrosis (CF)? A. Respiratory infection B. Pneumothorax C. Weight loss D. Osteoporosis

A. Respiratory infection In addition to respiratory failure, the most common cause of death for any client with CF is respiratory infection. Recognizing infections early and initiating appropriate therapy are essential life-saving strategies. Although weight loss and osteoporosis are complications of CF, they are not immediately life threatening. Pneumothorax is not a common complication of CF.

The nurse is caring for a client with chest pain. What assessment data would cause the nurse to suspect unstable angina? Select all that apply. A. ST changes B. Troponin T 0.6 ng/mL C. Pain lasts 15-25 minutes D. Increased number of angina attacks E. The intensity of the chest pain has increased.

A. ST changes C. Pain lasts 15-25 minutes D. Increased number of angina attacks E. The intensity of the chest pain has increased. A normal troponin value is anticipated with unstable angina. A troponin value of 0.6ng/mL is elevated and would be indicative of a myocardial infarction. All other assessment data can accompany unstable angina.

A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply.) A. Tachypnea B. Deviation of the trachea C. Bradycardia D. Decreased use of accessory muscles E. Pleuritic pain

A. Tachypnea B. Deviation of the trachea E. Pleuritic pain The client who has a pneumothorax can experience tachypnea related to respiratory distress caused by the injury. The client who has a pneumothorax can experience deviation of the trachea as tension increases within the chest. The client who has a pneumothorax can experience tachycardia related to respiratory distress and pain. The client who has a pneumothorax can experience an increase in the use of accessory muscles as respiratory distress occurs. The client who has a pneumothorax can experience pleuritic pain related to the inflammation of the pleura of the lung caused by the injury.

Which action is most important for the nurse to take when preparing a client with cystic fibrosis (CF) for a lung transplantation procedure? A. Teaching the client how to perform pulmonary muscle strengthening exercises B. Collaborating with the registered dietitian nutritionist to provide high-calorie, high-protein meals C. Reminding the client to continue taking prescribed vitamin supplementation D. Using aseptic technique when assisting the client to perform pulmonary hygiene

A. Teaching the client how to perform pulmonary muscle strengthening exercises Surgery for lung transplantation involves large "clam-shell" incisions that cut through ribs and muscle. This procedure is very painful and clients have a difficult time breathing deeply enough to wean from the ventilator. A critical factor in the outcome of the surgery and prevention of atelectasis and pneumonia in the new lungs is the strength of the muscles used for ventilation. These muscles must be strengthened before the transplantation.

The nurse is caring for a client who had abdominal aortic aneurysm (AAA) repair. Which assessment data is most concerning to the nurse? A. Urine output of 20 mL over 2 hours B. Blood pressure of 106/58 mm Hg C. +3 pedal pulses D. Absent bowel sounds

A. Urine output of 20 mL over 2 hours The nurse caring for a client who had an AAA repair would be most alarmed with the client's urine output of 20 mL over 2 hours. Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria. Reduction of systolic blood pressure to 100 to 120 mm Hg is appropriate. Paralytic ileus may be a complication of AAA repair, but is not a priority over decreased urine output. +3 pedal pulses is a normal physical assessment finding.

A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A. "I am allergic to morphine." B. "I take antacids several times a day for my ulcer." C. "I had a blood clot in my leg several years ago." D. "It hurts to take a deep breath."

B. "I take antacids several times a day for my ulcer." Document the client's allergy to morphine to manage the client's discomfort due to a blood clot. However, another action is the priority. The greatest risk to the client is the possibility of bleeding from a peptic ulcer. The priority intervention is to notify the provider of the finding. Document the client's history of a blood clot to provide preventative measures. However, another action is the priority. Expect the client to report pain with breathing. However, another action is the priority.

Which statement made by the client on the way to the catheterization laboratory requires an immediate action by the nurse? A. "My allergies are bothering me, so I took some Benadryl last night before bed." B. "I was nervous last night, but I still remembered to take my warfarin." C. "I sure am hungry. I haven't had anything to eat since I went to bed last night." D. "I don't know what I will do if they find a blockage in my heart."

B. "I was nervous last night, but I still remembered to take my warfarin." Warfarin should be held prior to the procedure to reduce the risk of excessive bleeding. The nurse will need to call the provider immediately to determine if the cardiac catheterization will need to be rescheduled. Benadryl prior to the procedure is not contraindicated. This statement requires no action by the nurse. The statement in option C informs the nurse that the client has been NPO which is required prior to the heart catheterization. This statement in option D indicates mild anxiety associated with the medical procedure. Emotional support from the nurse is an appropriate response.

A nurse interviewing an 82-year-old somewhat confused client who is becoming a nursing home resident today asks the client's daughter if she would consent for the client to receive an influenza vaccination today. The daughter replies "she had one 2 years ago and doesn't need another." What is the nurse's best response? A. "Your mother is older now and is more fragile, so she should have one this year too as a booster." B. "The virus causing influenza often changes each year and a new influenza vaccination is needed every flu season." C. "The "flu shot" she had 2 years ago will still protect her this year but if she has not had a previous pneumonia vaccination, she should have one now." D. "If you are worried that she is afraid to have an injection, we could use the nasal mist vaccination this year."

B. "The virus causing influenza often changes each year and a new influenza vaccination is needed every flu season." A is incorrect because each year's influenza vaccine is composed of some different strains of antigen and is not really a booster. C is incorrect because the older vaccination may not contain the viral antigens most likely to cause influenza this season. The nasal mist vaccination is not recommended for anyone over age 49 years.

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

B. "This medication is given to facilitate ventilation." Antibiotics are given to treat infection. Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption. Corticosteroids are given to treat inflammation. Benzodiazepines are given to treat anxiety.

Which adults are at higher risk for development of active tuberculosis? Select all that apply. A. A, 21-year-old college student living in a dorm at a Canadian university B. 38-year-old with AIDS who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years F. 70-year-old with moderate to severe chronic obstructive pulmonary disease (COPD)

B. 38-year-old with AIDS who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years Active tuberculosis is most likely to develop in adults who are heavily exposed to the organism, such as those living in crowded conditions (prison), from less affluent foreign countries, and anyone who is immunosuppressed (has AIDS and is not taking antiretroviral therapy). Adults who use/abuse injection drugs are also at increased risk because of life style and reduced cognition while under the influence of the drugs. This can result in choices that increase his or her exposure to the organism and may reduce immunity. A healthy 21-year-old living in a dorm in an affluent country is not at increased risk for TB. Having moderate to severe COPD alone does not increase risk for TB unless immunity is greatly reduced.

With which client will the nurse take immediate actions to reduce the risk for developing a pulmonary embolism (PE)? A. A 50 year old with type 2 diabetes mellitus and cellulitis of the leg B. A 36 year old who had open reduction and internal fixation of the tibia C. A 25 year old receiving IV antibiotics through a peripheral line D. A 72 year old with dehydration and hypokalemia taking oral potassium supplements

B. A 36 year old who had open reduction and internal fixation of the tibia To reduce the risk for developing PE, the nurse provides immediate interventions for the client who had an open reduction and internal fixation of the tibia. Lower limb surgery and perioperative immobility are high risks for deep vein thrombosis (DVT) formation and PE. Peripheral infusion of antibiotics in a younger client is not a significant risk for PE. Although dehydration is a mild risk for thrombosis, this is not as common as thromboembolic complications after orthopedic surgery.

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A. A 60 year old who was recently extubated and reports a sore throat. B. A 50 year old being mechanically ventilated who has tracheal deviation. C. A 30 year old receiving continuous positive airway pressure (CPAP) and has intermittent wheezing. D. A 40 year old receiving oxygen facemask and whose respiratory rate is 24 breaths/min.

B. A 50 year old being mechanically ventilated who has tracheal deviation. The nurse needs to immediately attend to the mechanically ventilated client with a tracheal deviation. This client is showing signs of a tension pneumothorax that could lead to hypoxemia, decreased cardiac output, and shock. The client receiving CPAP has intermittent wheezing, but is not in immediate danger or distress. The client recently extubated has sore throat which is anticipated after intubation. There is no indication this client is in need of immediate intervention. The client wearing oxygen has mild tachypnea, but is not in immediate distress or danger.

A client who is 3 days postoperative from extensive abdominal surgery for cancer reports having a difficult time "catching her breath" and having a reddish-purple, nonitchy rash on her chest. After assessing the client, what is the nurse's best action or response to prevent harm? A. Ask the client about possible drug allergies B. Apply oxygen and call the rapid response team C. Determine when she last received an opioid dose D. Check the oxygen saturation and encourage her to cough

B. Apply oxygen and call the rapid response team This client is at high risk for developing a pulmonary embolism from a venous thromboembolism (has cancer and recently underwent extensive abdominal surgery). She has two major symptoms of PE, sudden onset shortness of breath and petechiae on her chest. These are significant enough to call the rapid response team because and without assessing oxygen saturation or most recent opioid dose (she has no symptoms of respiratory depression) because time is of the essence in starting appropriate therapy to prevent permanent lung damage or death. Applying oxygen can help improve her gas exchange and should be done immediately. Rash caused by a drug allergy are usually red, raised, itchy, and do not look like petechiae.

A nurse in the emergency department is assessing a client who has sustained multiple rib fractures and has a flail chest. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Cyanosis C. Hypotension D. Dyspnea E. Paradoxical chest movement

B. Cyanosis C. Hypotension D. Dyspnea E. Paradoxical chest movement The client can have tachycardia as a manifestation when experiencing a flail chest due to inadequate oxygenation. The client can have cyanosis as a manifestation when experiencing a flail chest due to inadequate oxygenation. The client can have hypotension as a manifestation when experiencing a flail chest. The client can have dyspnea as a manifestation when experiencing a flail chest due to injury and the client's inability to effectively inhale and exhale. The client can have paradoxical chest movement as a manifestation when experiencing a flail chest due to injury to the chest and the inability to inhale and exhale.

The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol. Which data is essential for the nurse to assess prior to administration? A. Troponin B. Heart rate C. ST segment D. Myoglobin

B. Heart rate The monitoring of the patient's heart rate is essential. The effects of metoprolol are to decrease heart rate, blood pressure, and myocardial oxygen demand.ST segment elevation is consistent with MI; it does not address monitoring of metoprolol. Elevation in troponin is consistent with a diagnosis of MI, but does not address needed monitoring for metoprolol. Elevation in myoglobin is consistent with myocardial injury in ACS, but does not address needed monitoring related to metoprolol.

The nurse is caring for a client immediately following a cardiac catheterization. Which nursing assessment data requires immediate nursing intervention? A. Blood pressure 146/70 B. Hematoma developing at insertion site C. Client reports of headache pain D. Client reports of extreme thirst

B. Hematoma developing at insertion site Following cardiac catheterization the client is at risk for bleeding at the insertion site. Hematoma formation is an indication that the artery is bleeding internally, and the priority nursing action is to apply manual pressure to the insertion site immediately. While the client's blood pressure is slightly elevated the priority of care remains responding to the development of the hematoma at the insertion site. After the client is stable, the nurse can then address the client's headache and thirst.

A nurse assessing an older adult client with pneumonia notes the client is now confused and the oxygen saturation has dropped since the last assessment 1 hour ago from 90% to 84%. The nurse also notes the respiratory rate has increased from 26 to 32. What is the nurse's best first action? A. Encourage the client to use the incentive spirometer hourly. B. Increase her O2 flow rate by 2 L and re-assess in 5 minutes. C. Increase the flow rate of the IV antibiotic. D. Document the changes as the only action.

B. Increase her O2 flow rate by 2 L and re-assess in 5 minutes. The low oxygen saturation and the client's confusion suggests hypoxia and a possible worsening of the client's condition. The increased respiratory rate supports this possibility. Increasing the oxygen flow rate and re-assessing in 5 minutes helps the nurse to determine whether the hypoxia responds to increased oxygen. If more oxygen is going to help, it will do so quickly. Even if the oxygen saturation increases with more oxygen, the health care provider needs to be informed of these events urgently. The incentive spirometer is not likely to be performed correctly with a confused client and would not immediately improve the client's hypoxia. Increasing the flow rate of the antibiotic also is not going to help the hypoxia immediately.

For which problems will the nurse specifically assess when the low-pressure alarm of a client's mechanical ventilator sounds? (Select all that apply.) A. Mucous plugs are in the endotracheal tube. B. Leak in the ventilator tubing circuit. C. Client is not breathing. D. Cuff leak in the endotracheal or tracheostomy tube. E. Ventilator tubing is under the client. F. Client is attempting to breathe against the ventilator.

B. Leak in the ventilator tubing circuit. C. Client is not breathing. D. Cuff leak in the endotracheal or tracheostomy tube. Common causes of alarms indicating low-pressure include: cuff leaks in the endotracheal or tracheostomy tube, client stops breathing when a ventilator is in the "support" mode, and when a leak is present in the ventilator tubing circuit. Presence of increased airway secretions or mucous plugs, client coughing or gaging, client fighting or "bucking" the ventilators, anything that decreases airway size (i.e., bronchospasms), presence of a pneumothorax, displacement of the endotracheal tube further into the tracheal bronchial tree, and external obstruction of the tubing result in high-pressure, not low-pressure.

Which action is a priority for the nurse to prevent harm for a client with a pulmonary embolism who is receiving a continuous heparin infusion? A. Assessing gums daily for indications of bleeding B. Monitoring the platelet count daily C. Assessing breath sounds D. Comparing pedal pulses bilaterally

B. Monitoring the platelet count daily Daily platelet counts are a safety priority in assessing for heparin-induced thrombocytopenia (HIT), a potential side effect of heparin. Assessing breath sounds each shift is an important action, as is examining for indications of bleeding. However, identifying HIT early is a greater priority so that appropriate interventions can be initiated. Assessing bilateral pedal pulses is important if the source of the embolism is a venous thromboembolism (VTE) in the legs; however, this is not an important general action for a client with PE.

A nurse is assisting the provider to care for a client who has developed a spontaneous pneumothorax. Which of the following actions should the nurse perform first? A. Assess the client's pain. B. Obtain a large-bore IV needle for decompression. C. Administer lorazepam. D. Prepare for chest tube insertion.

B. Obtain a large-bore IV needle for decompression. Assessing the client's pain and administer pain medication. The priority action when using the airway. is important. However, another action is the priority. breathing, circulation (ABC) approach to client care is to establish and maintain the client's respiratory function. Obtaining a large-bore IV needle for decompression is the priority action by the nurse. Administering a benzodiazepine will treat the client's anxiety. However, another action is the priority. Gathering supplies to prepare for chest tube insertion is important. However, another action is the priority.

A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Bradypnea B. Pleural friction rub C. Hypertension D. Petechiae E. Tachycardia

B. Pleural friction rub D. Petechiae E. Tachycardia Expect the client to have tachypnea. Expect the client to have a pleural friction rub. Expect the client to have hypotension. Expect the client to have petechiae. Expect the client to have tachycardia.

A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following actions should the nurse include? (Select all that apply.) A. Administer antibiotics. B. Provide supplemental oxygen. C. Administer antiviral medications. D. Administer of bronchodilators. E. Maintain ventilatory support.

B. Provide supplemental oxygen. D. Administer of bronchodilators. E. Maintain ventilatory support. Antibiotics are given to treat bacterial infections. This would not be indicated for SARS. Providing supplemental oxygen should be included in the plan of care for SARS. Oxygen is administered to treat severe hypoxemia. SARS is caused by the coronavirus. There are no effective antiviral medications to treat this virus. Administration of bronchodilators should be included in the plan of care for SARS. Bronchodilators are used to vasodilate the client's airway. Maintaining ventilatory support should be included in the plan of care for SARS. Intubation can be required to maintain a patent airway.

In addition to the pulmonary health care provider, which other member of the interprofessional team will the nurse expect to collaborate with most frequently when providing care to a client with a pulmonary embolism (PE)? A. Registered dietitian nutritionist B. Respiratory therapist C. Occupational therapist (OT) D. Pharmacist

B. Respiratory therapist The client with a PE has ongoing respiratory problems that change gas exchange almost hourly and require adjustments in respiratory support. The respiratory therapist will be collaborating with the nurse and client at least daily. Other team members listed have roles than change with the client's condition and collaboration is more intermittent.

Which intervention provides safety during cardioversion? A. Setting the defibrillator at 220 joules B. Setting the defibrillator to the synchronized mode C. Applying oxygen D. Obtaining informed consent

B. Setting the defibrillator to the synchronized mode Safety during cardioversion depends upon setting the defibrillator to the synchronized mode to avoid discharging the shock during the vulnerable period on the T wave. Unsynchronized cardioversion may cause ventricular fibrillation. Cardioversion is usually performed starting at a lower rate of 120 to 200 joules for biphasic machines. Although it is imperative to obtain informed consent, this does not improve the safety of the procedure. Oxygen would be turned off because it presents a safety issue; fire could result.

Which action with the nurse take to prevent harm when prescribed to administer an IV antibiotic to a client with pulmonary artery hypertension (PAH) who is being managed with a continuous prostacyclin agonist infusion? A. Requesting a prescription for an oral antibiotic B. Starting a peripheral IV access to use for administering the antibiotic C. Stopping the prostacyclin agonist infusion for 15 minutes to administer the IV antibiotic D. Administering the IV antibiotic through the continuous infusion's side port

B. Starting a peripheral IV access to use for administering the antibiotic The prostacyclin agonist infusion cannot be stopped for even 15 minutes without endangering the client's life. The drug also cannot be mixed with any other drug. Clients with PAH are at high risk for sepsis. Thus, the antibiotic must be administered intravenously and the safest action is to insert a separate peripheral IV access for this purpose.

Why will the nurse administer vitamin supplements to a client who has cystic fibrosis (CF)? A. Clients are too fatigued to ingest sufficient vitamins and nutrients. B. Steatorrhea causes a deficiency of fat-soluble vitamins. C. Increased blood levels of vitamins enhance chloride transport activity. D. High doses of vitamins can slow the progression of the disease.

B. Steatorrhea causes a deficiency of fat-soluble vitamins. The stool of clients with CF contains large amounts of fat (steatorrhea), which promotes loss of fat-soluble vitamins, leaving the client deficient of such vitamins and malnourished. Vitamins are important for general health and nutrition and play no role in the disease or its progression.

What is the primary indication for the nurse to apply supplemental oxygen to the client with pulmonary artery hypertension (PAH)? A. Oxygen therapy is part of the client's ongoing clinical management and is applied continuously. B. The client determines when oxygen supplementation is needed. C. The nurse applies oxygen when the client's respiratory rate is decreased. D. The nurse applies oxygen when the client's respiratory rate is increased.

B. The client determines when oxygen supplementation is needed. The nurse applies supplemental oxygen when the client finds the dyspnea to be uncomfortable. This action is not dependent on a particular respiratory rate. It is also not a continuous therapy.

A 45 year old male client having an annual physical asks the nurse about his risk for developing a myocardial infarction (MI). Which modifiable risk factors will the nurse assess to guide the client's teaching plan? (Select all that apply.) A. Age B. Tobacco use C. Gender D. Diet E. Family history F. Weight

B. Tobacco use D. Diet F. Weight Tobacco use, diet, and weight are all considered modifiable risk factors and should be included in the plan of care.

The primary health care provider prescribes warfarin for a client with atrial fibrillation. Which client statement indicates that additional education is needed? A. "I need to go to the clinic once a week to have my blood level checked." B. "If my stools turn black, I will be sure to call my primary health care provider" C. "I'm glad I don't need to change my diet. Salads are my favorite food." D. "I need to stop taking my herbal supplement."

C. "I'm glad I don't need to change my diet. Salads are my favorite food." Clients taking warfarin need to avoid foods high in Vitamin K including green leafy vegetables; INR needs to be measured frequently; black stools are a sign of bleeding and should be reported; herbal medications interfere with functioning of coumadin.

The nurse is teaching a client with atrial fibrillation about a new prescription for warfarin. What teaching will the nurse include? A. "Avoid caffeinated beverages." B. "You would take aspirin or ibuprofen for headache." C. "Report bruising to your health care provider." D. "It is important to consume a diet high in green leafy vegetables."

C. "Report bruising to your health care provider." Bruising could be indicative of excessive dosing of warfarin. Warfarin is an anticoagulant and causes decreased ability for blood to clot. Green leafy vegetables are high in vitamin K, which may antagonize the effects of warfarin; these vegetables would be eaten in moderate amounts. Aspirin and nonsteroidal anti-inflammatory agents may prolong the prothrombin time and the international normalized ratio, causing predisposition to bleeding. These agents would be avoided. It is not necessary to avoid caffeine because this does not affect clotting; however, green tea may interfere with the effects of warfarin.

A nursing home client who has completed a 2 week course of antibiotics for bacterial pneumonia asks whether he can go out to a restaurant to celebrate his grandson's high school graduation if he uses a wheel chair. What is the nurse's best response? A. "No, going out now before you have recovered your strength can cause a relapse of the pneumonia." B. "No, the risk that you could spread this disease to other people is much too high." C. "Yes, if you want to and feel that you could tolerate a couple of hours of sitting." D. "Yes, if you agree to wear a face mask to prevent spreading droplets."

C. "Yes, if you want to and feel that you could tolerate a couple of hours of sitting." The client is no longer contagious after completing the course of antibiotics and is just in the recovery phase of the illness. If he feels rested enough to be up in a wheel chair, there is no reason he must be isolated physically or socially. A face mask is not needed to protect others.

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states, "I am anxious and unable to get enough air." Vital signs are heart rate 117/min, respirations 38/min, temperature 38.4° C (101.2° F), and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority? A. Notify the provider. B. Administer heparin via IV infusion. C. Administer oxygen therapy. D. Obtain a CT scan.

C. Administer oxygen therapy. Notify the provider about the condition to obtain guidance on treatment. However, another action is the priority. Administer IV heparin as a treatment to prevent growth of the existing clot and to prevent additional clots from forming. However, another action is the priority. When using the airway, breathing, circulation (ABC) priority approach to care, determine that the priority finding is related to the respiratory status. Meeting oxygenation needs by administering oxygen therapy is the priority action. Obtain a CT scan to detect the presence and location of the blood clot. However, another action is the priority.

A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6° C (101.4° F), and SaO₂ 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest x-ray. B. Prepare for chest tube insertion. C. Administer oxygen via a high-flow mask. D. Initiate IV access.

C. Administer oxygen via a high-flow mask. Obtaining a chest x-ray to determine the level of injury to the lungs is important, but is not the priority action at this time. Preparing the client for chest tube insertion is important to facilitate lung expansion and restore normal intrapleural pressure, but is not the priority action at this time. According to the airway, breathing, and circulation to client care, the nurse should place the priority on administering oxygen via high-flow mask to restore optimal breathing because the client is experiencing dyspnea and has decreased lung sounds. Initiating IV access to administer medications is important, but is not the priority action at this time.

The nurse administers amiodarone to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? (Select all that apply.) A. Urine output B. Respiratory rate C. Heart rate D. Heart rhythm E. QT interval

C. Heart rate D. Heart rhythm E. QT interval Amiodarone causes prolongation of the QT interval, which can precipitate dysrhythmia. Antidysrhythmic medications cause changes in cardiac rhythm and rate; therefore, monitoring of heart rate and rhythm is needed. Although it is always important to monitor respiratory rate and urine output, these assessments are not specific to amiodarone.

Which precaution is most important for the nurse to teach a patient with leukemia to prevent an infection by cross-contamination? A. Reporting any burning on urination immediately B. Taking antibiotics exactly as prescribed C. Avoiding crowds and people who are ill D. Performing mouth care three times daily

C. Avoiding crowds and people who are ill Infection by cross-contamination occurs when organisms from another person are transmitted to the client. This risk can be reduced for the neutropenic client by avoiding crowds and people who are ill (social distancing). Auto-contamination is the overgrowth of the client's own normal flora or the translocation of his or her normal flora from its normal location to a different one. Taking antibiotics does not prevent cross-contamination and neither does reporting symptoms of an infection. Performing mouth care frequently can reduce the number of normal flora organisms in the mouth and decrease the risk for developing an infection from auto-contamination but not cross-contamination.

The SpO2 of a client receiving oxygen therapy by nasal cannula at 6L/minute has dropped from 94% an hour ago to 90%. Which action does the nurse perform first to promote gas exchange before reporting the change to the primary health care provider? A. Tighten the straps on the nasal cannula B. Increase the oxygen flow rate to 8L/minute C. Check the tubing for kinks, leaks, or obstructions D. Check to determine whether the oxygen deliver system is adequately humidified

C. Check the tubing for kinks, leaks, or obstructions Oxygen tubing is flexible and has a narrow lumen. Tubing that is kinked or obstructed or has a leak can interfere with oxygen delivery to the client and result in desaturation. The maximum flow rate is 6 L/minute for a nasal cannula and increasing the rate above this value does not result in an increase in oxygen delivery to the client. Tightening the straps on the nasal cannula can make the client uncomfortable and does not increase oxygenation. Humidifying the oxygen prevents drying of mucous membranes but does not increase the actual amount of oxygen delivered.

When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse calls the Rapid Response Team (RRT) for intervention for which client? A. Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry reading of 94%. B. Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs. C. Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachy-cardia. D. Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain.

C. Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachy-cardia. The RRT needs to quickly assess the client with a diagnosed pulmonary embolism who is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin. Tachycardia, along with bloody sputum (hemoptysis), may be a symptom of hypoxemia or hemorrhagic shock, which requires immediate intervention. The client with deep vein thrombosis requires ongoing monitoring and is receiving appropriate treatment. Calf pain is expected in this situation. The client with a right pneumothorax requires ongoing monitoring but demonstrates adequate pulse oximetry of 94%. The client who was extubated 3 days ago requires ongoing nursing assessment, but does not have evidence of acute deterioration or severe complications.

Which body area on a client with darker skin is most appropriate for the nurse to examine for indications of pallor and cyanosis? A. Earlobes and bridge of the nose B. Palms and soles C. Conjunctiva of the eyes D. Tongue

C. Conjunctiva of the eyes Pallor and cyanosis are more easily detected in adults with darker skin by examining the oral mucous membranes and the conjunctiva of the eye, not the palms of the hands or soles of the feet (although petechiae may be more apparent there). The tongue is a poor indicator of pallor or cyanosis although changes in texture and color may indicate other hematology problems.

Which statements about oxygen and oxygen therapy are true? Select all that apply. A. An oxygen concentrator reduces the amount of carbon dioxide in atmospheric air. B. Clients must provide informed consent to receive oxygen therapy. C. Excessive oxygen use is a contributing cause of chronic obstructive pulmonary disease. D. In non-emergency situations, a health care provider's prescription is needed for oxygen therapy. E. Oxygen can explode when handled improperly. F. Oxygen is a beneficial element but can harm lung tissue. G. The liquid form of oxygen is a drug to manage hypoxia, whereas the gaseous form is only an atmospheric element. H. Unless humidity is added, therapy with oxygen dries the upper and lower mucous membranes.

C. Excessive oxygen use is a contributing cause of chronic obstructive pulmonary disease. D. In non-emergency situations, a health care provider's prescription is needed for oxygen therapy. F. Oxygen is a beneficial element but can harm lung tissue. H. Unless humidity is added, therapy with oxygen dries the upper and lower mucous membranes. An oxygen concentrator reduces the amount of nitrogen in atmospheric air, which has the highest concentration of all gases in the atmosphere. Oxygen is a drug that requires a prescription but not informed consent. Excessive oxygen can form reactive oxygen species that injures lung tissue but does not cause COPD. Oxygen is a gas that promotes combustion but does not explode. Only oxygen gas is directly inhaled to improve gas exchange. Liquid oxygen must first be converted to a gas before it can be used. When oxygen is delivered without humidification, especially at higher flow rates, respiratory mucous membranes can become dry and irritated.

Which actions does the nurse ensure are performed for a client being mechanically ventilated to prevent ventilator-associated pneumonia (VAP)? Select all that apply. A. Assessing temperature every 4 hours B. Checking ventilator settings every 4 hours C. Getting the patient out of bed as soon as prescribed D. Keeping the head of the bed elevated to 30 degrees or above E. Maintaining the client in the prone position F. Providing adequate humidification G. Providing meticulous mouth care every 12 hours H. Suggesting that the pneumonia vaccine be prescribed

C. Getting the patient out of bed as soon as prescribed D. Keeping the head of the bed elevated to 30 degrees or above G. Providing meticulous mouth care every 12 hours Getting the client out of bed as quickly as possible helps prevent VAP by reducing the risk for fluid stasis in the lungs and for aspiration, a common cause of VAP. Keeping the head of the bed elevated when the client is in bed also reduces the risk for aspiration. Meticulous oral care prevents colonization of bacteria that can move into the respiratory tract. Assessing temperature can help identify VAP early but does not prevent its occurrence. Checking the ventilator settings is crucial to ensure adequate gas exchange and prevent injury but does not prevent pneumonia. The prone position during mechanical ventilation is recommended only for clients with ARDS and does not prevent VAP. Humidifying the oxygen and air received by the client helps prevent drying of the respiratory tract but not VAP. VAP is not caused by the same organisms that cause infectious pneumonia and vaccination against these organisms does not prevent VAP.

The nurse is assessing the client's cardiac rhythm and notes the following: HR 64, regular rhythm, PR interval 0.20; QRS 0.10. How will the nurse document this rhythm interpretation in the electronic health record? A. Sinus Tachycardia B. Sinus Bradycardia C. Normal Sinus Rhythm D. Sinus arrhythmia

C. Normal Sinus Rhythm The nurse will document this rhythm interpretation as normal sinus rhythm. The heart rate does not reflect tachycardia or bradycardia and the rhythm is not irregular. All other assessment parameters are within normal sinus rhythm interpretation.

The nurse is reviewing the laboratory profile of a client with hypovolemic shock. What lab values will the nurse anticipate? A. pH 7.51 B. PaO2 106 mmHg C. PaCO2 49 mmHg D. Lactate 0.4 mmol/L

C. PaCO2 49 mmHg The client with hypovolemic shock is most likely experiencing anerobic cellular metabolism. As such, the nurse will anticipate decreased pH, decreased PaO2, increased PaCO2, and increased lactate levels.

The spouse of a 78-year-old client who was discharged to home 1 day ago after hospitalization for seasonal influenza calls to report the fever has returned and is now 103.4 degrees F (39.7 degrees C). What is the nurse's primary concern for this client? A. The client may not be taking the prescribed antiviral drug correctly B. A second strain of influenza is likely C. Pneumonia may be present D. The client may be dehydrated

C. Pneumonia may be present A major and relatively common complication of severe seasonal influenza is development of pneumonia. It is likely this client's influenza was severe because hospitalization was required. The client would no longer be receiving the antiviral drug after discharge. A second strain of influenza is not likely in this context. Temperature elevation from dehydration is usually less dramatic.

What is the nurse's best first action when assessing a client who was intubated a few minutes ago and finds the end-tidal carbon dioxide level is 0 and the SpO2 is 38%? A. Documenting the finding in the electronic health record as the only action B. Initiating the Rapid Response Team C. Removing the endotracheal tube and ventilating the client with a bag-valve-mask D. Obtaining a different monitor and rechecking the end-tidal carbon dioxide level

C. Removing the endotracheal tube and ventilating the client with a bag-valve-mask A reading of 0 for the end-tidal carbon dioxide and the very low SpO2 level indicate that the endotracheal tube is not in the airway. Immediate action is needed. While it is present in the client's throat, its presence is preventing air from reaching the airways. Removing the tube and ventilating the client with a bag-valve-mask device is critical to saving the client's life. The nurse will perform these actions while having another health care worker call the Rapid Response Team. If the client's SpO2 was in the normal range, obtaining a different monitor and rechecking end-tidal carbon dioxide level would be a good action. However, the low oxygen saturation level indicates there is no time for rechecking the carbon dioxide level.

Which ventilator mode does the nurse expect will be set for a client with a tracheostomy who is beginning to take spontaneous breaths at his own rate and tidal volume between set ventilator breaths? A. Assist-control (AC) ventilation B. Continuous positive airway pressure (CPAP) C. Synchronized intermittent ventilation (SIMV) D. Bi-level positive airway pressure (BiPAP)

C. Synchronized intermittent ventilation (SIMV) Synchronized intermittent mandatory ventilation (SIMV) is a ventilation mode in which volume and ventilatory rate are preset. It allows spontaneous breathing at the patient's own rate and tidal volume between the ventilator breaths to coordinate breathing between the ventilator and the client. BiPAP and CPAP are not used for clients who have an endotracheal tube. With assist-control ventilation, the preset tidal volume continues even when the client's own respiratory rate increases, which could lead to over-ventilation.

The client is a 5 foot 11 inch tall, 176 lb (80 kg) woman who has been mechanically ventilated at a tidal volume of 400 mL and a respiratory rate of 12 breaths per minute for the past 24 hours. The most recent arterial blood gas (ABG) results for this client are: pH= 7.32; PaO2 = 84 mm Hg; PaCO2 = 56 mm Hg. What is the nurse's interpretation of these results? A. Ventilation adequate to maintain oxygenation. B. Ventilation excessive; respiratory alkalosis present. C. Ventilation inadequate; respiratory acidosis present. D. Ventilation status cannot be determined from information presented.

C. Ventilation inadequate; respiratory acidosis present. The average-size adult female has a normal tidal volume of 400-500 mL. However this client is larger than average and would have a greater tidal volume. Usually the tidal volume is set at 6 to 8 mL/kg of body weight, which would range between 480mL to 640 mL. At the current tidal volume setting this woman is being underventilated with inadequate gas exchange. Not enough oxygen is available and not enough carbon dioxide is being lost leading to respiratory acidosis.

The nurse is assessing a client with heart failure. Which assessment data is the best indicator of fluid balance? A. Blood pressure 144/79 B. Urine output 200 mL in the last 4 hours C. Weight increase of 9 pounds in the past week D. Generalized edema in the lower extremities

C. Weight increase of 9 pounds in the past week A sudden weight increase of 2.2 lb (1 kg) can result from excess fluid (1 L) in the interstitial spaces. The best indicator of fluid balance is weight. A weight increase of 9 pounds in the past week is a significant indicator of fluid balance as weight often increases first, allowing for intervention before other symptoms such as edema develop.

A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates understanding? A. "Air should be instilled into the monitoring system prior to the procedure." B. "The client should be positioned on the left side during the procedure." C. "The transducer should be level with the second intercostal space after the line is placed." D. "A chest x-ray is needed to verify placement after the procedure."

D. "A chest x-ray is needed to verify placement after the procedure." Purge air from, rather than instill air into, the monitoring system. Place the client in the supine or Trendelenburg position. For hemodynamic monitoring, place the transducer level with the 4 intercostal space, which is at the base of the right atrium. Ensure that a chest x-ray is obtained to confirm proper placement of the lines following placement.

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? A. "I have a headache. May I have some acetaminophen?" B. "I have had hoarseness for a few weeks." C. "I feel my heart beating in my abdominal area." D. "I just started to feel a pain in my belly and low back."

D. "I just started to feel a pain in my belly and low back." The nurse suspects dissection of an AAA when the client says that "I just started to feel a tearing pain in my belly." Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA. The sensation of feeling the heartbeat in the abdomen is a symptom of AAA but not of dissection or rupture. Headache may be benign or indicative of cerebral aneurysm or increased intracranial pressure. Hoarseness, shortness of breath, and difficulty swallowing may be symptoms of thoracic aortic aneurysm.

A nurse is reviewing discharge instructions for a client who has COPD and experienced a pneumothorax. Which of the following statements should the nurse include? A. "Notify your provider if you experience weakness." B. "You should be able to return to work in 1 week." C. "You need to wear a mask when in crowded areas." D. "Notify your provider if you experience a productive cough."

D. "Notify your provider if you experience a productive cough." Weakness is an expected finding following recovery from a pneumothorax. The client should expect a lengthy recovery following a pneumothorax. It is not necessary to wear a mask following a pneumothorax, unless the client has another condition, such as immunosuppression. The client should notify the provider of a productive or persistent cough. This can indicate that the client might need treatment of a respiratory infection.

Which client will the nurse consider to be at the greatest risk for developing acute respiratory distress syndrome (ARDS)? A. A 22 year old with a fractured clavicle B. A 39 year old with uncontrolled diabetes C. A 56 year old with chronic kidney disease D. A 74 year old who aspirates a tube feeding

D. A 74 year old who aspirates a tube feeding ARDS is a type of acute respiratory failure with hypoxemia that persists even when 100% oxygen is given, decreased pulmonary compliance, dyspnea, bilateral pulmonary edema, and dense pulmonary infiltrates on x-ray (ground-glass appearance). It often occurs after an acute lung injury such as could result from aspiration of acidic gastric contents. Clients who are receiving tube feedings are at particular risk for lung damage by aspiration. Fractured clavicle, diabetes, and chronic kidney disease is associated with an increased risk for lung injury or ARDS.

The nurse is caring for a client with hypovolemic shock that is bleeding from a traumatic injury to the upper chest wall. What is the priority nursing action? A. Insert a large bore IV catheter. B. Administer supplemental oxygen. C. Elevate the client's feet, keeping the head flat. D. Apply direct pressure to the area of overt bleeding.

D. Apply direct pressure to the area of overt bleeding. The priority nursing action is to apply direct pressure to the area of overt bleeding. The nurse will first apply pressure then elevate the client's feet, administer supplemental oxygen if oxygen saturations are below 92% and insert a large bore IV catheter.

An attempt by a primary health care provider to intubate a client for mechanical ventilation is unsuccessful after 45 seconds. What is the nurse's priority action? A. Placing a naso-tracheal tube B. Assessing for bilateral breath sounds C. Assessing oxygen saturation by pulse oxymetry D. Applying oxygen with a bag-valve-mask device

D. Applying oxygen with a bag-valve-mask device During the intubation procedure the client is not breathing. The intubation attempt should last not longer than 15 to 30 seconds. After 45 seconds the client is very hypoxic and assessing oxygen saturation is not necessary. The client needs oxygen as quickly as possible. Assessment for bilateral breath sounds is performed after intubation to determine ensure that the tube is not in one bronchus. Placing a naso-tracheal tube is not a bedside nursing function.

A client in the telemetry unit is on a cardiac monitor. The monitor technician alerts the nurse that there are no ECG complexes, and the alarm is sounding. What is the first action by the nurse? A. Suspend the alarm. B. Call the emergency response team. C. Press the record button to get an ECG strip. D. Assess the client and check lead placement.

D. Assess the client and check lead placement. ALWAYS check the client first. Cardiac monitors are a tool for assessment, but they do not replace hands on nursing assessment.

Which action will the nurse take first for a client being mechanically ventilated who begins to pick at the bedcovers? A. Administering the prescribed sedating drug B. Explaining to the client that the tube helps with breathing C. Requesting that the family leave to decrease the client's agitation D. Assessing for adequate oxygenation

D. Assessing for adequate oxygenation The best first action by the nurse would be to assess for adequate oxygenation. Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia. Increasing sedation is not indicated for this client and may mask symptoms such as hypoxemia or worsening respiratory failure. Although the nurse may explain to the client that he or she is intubated, it does not take priority over assessing for hypoxemia. The presence of family members may decrease, not increase, the client's anxiety.

Which action will the nurse take first while caring for a client being mechanically ventilation when the high-pressure alarm sounds? A. Comparing the ventilator settings with the prescribed settings B. Turning off the alarm then assess the need for suctioning C. Notifying the respiratory therapist D. Auscultating the client's breath sounds

D. Auscultating the client's breath sounds The nurse will first listen to the client's breath sounds. Assessment always begins with the client. A typical reason for the high-pressure alarm to sound is obstruction of airflow through the ventilator circuit, usually indicating the need for suctioning. Other reasons for the high-pressure alarm to be triggered included biting the endotracheal tube or tension pneumothorax. The nurse is concerned with the assessment of the client first, not with the ventilator or ventilator settings and does not turn off the alarms before assessing the client. Although an excessively high tidal volume could contribute to the high-pressure alarm sounding, this is not the nurse's first concern. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention.

Which assessment finding on a client who is being mechanically ventilated with positive end-expiratory pressure indicates to the nurse a possible left-sided tension pneumothorax? A. Left chest caves in on inspiration and "puffs out" on expiration. B. The left lung field is dull to percussion and crackles are present on auscultation. C. The client has bloody sputum and wheezes. D. Chest is asymmetrical and trachea deviates toward the right side.

D. Chest is asymmetrical and trachea deviates toward the right side. Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention, cyanosis, and hyperresonance to percussion over the affected area. If not promptly detected and treated, tension pneumothorax is quickly fatal. Flail chest has paradoxical chest movement with a "sucking inward" of the loose chest area during inspiration and "puffing out" of the same area during expiration. Open pneumothorax presents with decreased breath sounds, hyperresonance, and poor respiratory excursion on the affected side. Pulmonary contusion presents with hemoptysis, dullness to percussion, and crackles or wheezes.

The nurse is caring for a patient on a telemetry unit who has a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 second. Additional vital signs are: blood pressure 118/68 mm Hg, respiratory rate 16 breaths/min, and temperature 98.8° F (37° C). All of these medications are available on the medication record. What action will the nurse take? A. Administer clonidine. B. Administer atropine. C. Administer digoxin. D. Continue to monitor.

D. Continue to monitor. The nurse needs to take no action other than to continue monitoring because the patient is displaying a normal sinus rhythm and normal vital signs. Atropine is used in emergency treatment of symptomatic bradycardia. This patient has a normal sinus rhythm. Digoxin is used in the treatment of atrial fibrillation, which is, by definition, an irregular rhythm. Clonidine is used in the treatment of hypertension; a side effect is bradycardia.

A client with primary pulmonary arterial hypertension (PAH) receiving treprosinil by continuous IV infusion now has a fever of 101.6 degrees F (38.7 degrees C). Which actions will the nurse perform to prevent harm? Select all that apply. A. Administer the prescribed antipyretic B. Ask the client whether a productive cough is present C. Apply oxygen by nasal cannula D. Culture the IV site E. Determine whether a durable power of attorney has been signed F. Increase the treprostinil flow rate G. Initiate a second IV access and administer prescribed antibiotic H. Place the client in protective isolation

D. Culture the IV site F. Increase the treprostinil flow rate G. Initiate a second IV access and administer prescribed antibiotic Clients with PAH receiving continuous IV drug therapy are at high risk for developing sepsis because of the long-term direct access line. Any client with a fever is considered to have sepsis until proven otherwise, not pneumonia or any other respiratory infection. Also, clients with PAH who develop sepsis are less likely to survive it. The critical actions to prevent harm are to give oxygen to promote better gas exchange, initiate a second IV (only the prostacyclin agonist is administered through the long-term continuous line) and give the prescribed antibiotic immediately, increase the treprostinil flow rate (as prescribed) to prevent the pulmonary pressure from becoming higher. Culturing the IV site instead of the blood is unlikely to provide useable information in a timely manner. Placing the client in protective isolation will not help fight the sepsis. A durable power of attorney is not going to prevent harm. Administering the antipyretic will not prevent harm and is not the priority.

Which new assessment finding in a client being managed for a pulmonary embolism (PE) indicates to the nurse that the client's condition is worsening? A. Increasing temperature B. Abdominal cramping C. Hand tremors D. Distended neck veins in the high-Fowler position

D. Distended neck veins in the high-Fowler position Distension of neck veins in the upright (high-Fowler) position occurs with right-sided heart failure, which is a complication of PE. None of the other changes in assessment findings are directly associated with worsening PE.

The nurse is caring for a patient with atrial fibrillation (AF). In addition to an antidysrhythmic, what medication does the nurse anticipate administering? A. Magnesium sulfate B. Atropine C. Dobutamine D. Heparin

D. Heparin The nurse plans to administer heparin in addition to the antidysrhythmic. AF is the loss of coordinated atrial contractions that can lead to pooling of blood, resulting in thrombus formation. The patient is at high risk for pulmonary and systemic embolism. Heparin and other anticoagulants (e.g., enoxaparin, warfarin, and novel oral anticoagulants, when nonvalvular, such as dabigatran, rivaroxaban, apixaban, or edoxaban) are used to prevent thrombus development in the atrium, leading to the risk of embolization (i.e., stroke).Atropine is used to treat bradycardia and not rapid heart rate associated with AF. Dobutamine is an inotropic agent used to improve cardiac output; it may cause tachycardia, thereby worsening atrial fibrillation. Although electrolyte levels are monitored in clients with dysrhythmia, magnesium sulfate is not used unless depletion is noted.

The nurse is caring for client who is experiencing occasional premature ventricular contractions. What assessment data is most concerning to the nurse? A. Potassium 4.8 mEq/L B. Magnesium 2 mEq/L C. Heart rate 90 D. History of smoking

D. History of smoking The client's potassium, magnesium, and heart rate are within normal limits. Nicotine can be a cause of premature ventricular contractions (PVSs) and should be discussed with this provider and the client.

In addition to notifying the pulmonary health care provider, what is the most important action for the nurse to take first for a client with a pulmonary embolism (PE) whose arterial blood gas (ABG) values are pH 7.28, PaCO2 50 mm Hg, PaO2 62 mm Hg, and HCO3− 24 mEq/L (24 mmol/L)? A. Administering sodium bicarbonate B. Having the client breathe rapidly and deeply into a paper bag C. Assessing for the presence of adventitious lung sounds D. Increasing the oxygen flow rate

D. Increasing the oxygen flow rate This client needs more oxygen now. Breathing more rapidly and deeply into a paper bag would decrease oxygen levels and increase CO2 further, making hypoxemia and acidosis worse. The bicarbonate level is normal and requires no intervention. Adventitious sounds are expected and identifying them is not the first priority.

A client admitted after using cocaine develops ventricular fibrillation. After determining unresponsiveness, which action will the nurse take next? A. Place an oral airway and ventilate. B. Start cardiopulmonary resuscitation (CPR). C. Establish IV access. D. Prepare for defibrillation.

D. Prepare for defibrillation. Defibrillating is the priority next action before any other resuscitative measures, according to advanced cardiac life support protocols. After immediate defibrillation, establish IV access, place an oral airway, and ventilate. CPR will be started after unsuccessful defibrillation.

The nurse is caring for a client with peripheral arterial disease (PAD). Which symptom will the nurse anticipate? A. Decreased pain when legs are elevated B. Unilateral swelling of affected leg C. Pulse oximetry reading of 90% D. Reproducible leg pain with exercise

D. Reproducible leg pain with exercise The symptom the nurse assesses the client with PAD is reproducible leg pain with exercise. Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances. Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin. PAD results from atherosclerotic occlusion of peripheral arteries.

Which new assessment finding in a client being treated for hypovolemic shock indicates to the nurse that interventions are currently effective? A. Oxygen saturation remains unchanged. B. Core body temperature has increased to 99° F (37.2° C). C. The client correctly states the month and year. D. Serum lactate and serum potassium levels are declining.

D. Serum lactate and serum potassium levels are declining. Serum lactate levels and serum potassium levels both rise when shock progresses and more tissues are metabolizing under anaerobic conditions. A decline in both values indicates that the client is responding to the current interventions for hypovolemic shock. Oxygen saturation staying the same suggests that the shock is not progressing at this time but does not indicate the interventions are correcting shock. The increase in body temperature is not great enough to indicate improvement or worsening of shock. The fact that the client can correctly state the month and the year by itself does not indicate improvement because information is not provided about his or her earlier cognition or level of consciousness.

What is the basis for the decreased oxygen saturation the nurse assesses in a client with a pulmonary embolism (PE)? A. Partial bronchial airway obstruction B. Thickened alveolar membranes and poor gas exchange C. Increased oxygen need resulting from a septic clot PE D. Shunting of deoxygenated blood to the left side of the heart

D. Shunting of deoxygenated blood to the left side of the heart A PE lodges in the blood vessels decreasing perfusion to a lung area, which wastes ventilation. When this blood that has not been oxygenated is returned to the left side of the heart, it dilutes the oxygen concentration of the arterial blood entering systemic circulation.PE does not block bronchial airways or thicken alveolar membranes. A septic clot is not the same as general sepsis, which when widespread, does increase tissue metabolism and the need for more oxygen.

A client's rhythm strip shows a heart rate of 116 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.16 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip? A. Sinus rhythm with premature ventricular contractions B. Normal sinus rhythm C. Sinus bradycardia D. Sinus tachycardia

D. Sinus tachycardia These are the characteristics of sinus tachycardia. A normal sinus rhythm would have a heart rate of 60 to 100 beats/min. A heart rate of less than 60 beats/min would indicate sinus bradycardia. Early QRS intervals would indicate sinus rhythm with premature ventricular contractions.

Which assessment finding for a client receiving oxygen therapy with a nonrebreather mask requires the nurse to intervene immediately? A. The oxygen flow rate is set at 12 L/minute. B. The exhalation ports are open during exhalation. C. The exhalation ports are closed during inhalation. D. The reservoir bag is not inflated during inhalation.

D. The reservoir bag is not inflated during inhalation. The nonrebreather mask has a one-way valve between the mask and the reservoir and has two flaps over the exhalation ports. The flaps should be closed during inhalation to prevent room air from entering and diluting the oxygen concentration. During exhalation, air leaves through these exhalation ports. The client can only draw needed air with oxygen from the reservoir bag, which must be inflated during inhalation. The flow rate of 12 L/min is sufficient to keep the bag inflated during inhalation.