NURS 482 - Exam 1 Practice Questions (Module 1-2)

The nurse instructs a patient on calcium supplement therapy. Which statement indicates that the patient understands how to take calcium supplementation? "I will take the calcium with meals." "I will take the calcium with a full glass of water." "I will take these supplements as needed for tremulousness." "I will take these supplements all at one time in the morning."

"I will take the calcium with a full glass of water." Rationale: Calcium should be taken with a full glass of water to allow maximum absorption. Calcium does not need to be taken with meals. These supplements are not used as needed to treat tremulousness. Calcium supplements should be taken 1 to 1.5 hours after meals and at bedtime.

The patient admitted to the ICU is diagnosed with Acute Respiratory Distress Syndrome (ARDS). His son asks why he needs to be in intensive care for pneumonia. The MOST accurate response by the nurse is which of the following: "The pneumonia is unrelated to the diagnosis of ARDS, it just happens to have occurred at the same time." "Pneumonia can sometimes cause an indirect injury to the lungs resulting in pulmonary edema." "The pneumonia has triggered a complex response which could cause multiple organs to fail." "We are admitting your father as a precaution, there is nothing to worry about."

"The pneumonia has triggered a complex response which could cause multiple organs to fail."

The patient admitted to the ICU is diagnosed with Acute Respiratory Distress Syndrome (ARDS). His son asks why he needs to be in intensive care for pneumonia. The MOST accurate response by the nurse is which of the following: "The pneumonia is unrelated to the diagnosis of ARDS, it just happens to have occurred at the same time." "The pneumonia has triggered a complex response which could cause multiple organs to fail." "We are admitting your father as a precaution, there is nothing to worry about." "Pneumonia can sometimes cause an indirect injury to the lungs resulting in pulmonary edema."

"The pneumonia has triggered a complex response which could cause multiple organs to fail." Rationale: ARDS represents a complex clinical syndrome rather than a single disease process, and carries a high risk of mortality (p. 519). Pneumonia is a direct injury to the lung and is a precipitating factor in the development of ARDS.

The graduate nurse asks why the patient with ARDS is being managed from a standard treatment bundle. The BEST explanation by the nurse is as follows: "Treatment bundles have been created as a best practice to manage complex conditions." "It's just how this physician chooses to manage this patient." "Treatment bundles are replacing protocols to manage common conditions." "If we do not use a standardized approach to treat ARDS, we will not be reimbursed for care."

"Treatment bundles have been created as a best practice to manage complex conditions." Rationale: ...extensive work has gone into creating "bundles," which are elements of care considered core to the management and treatment of specific critical illnesses in intensive care units (ICUs). Box 27-2 lists essential critical care bundles that apply to managing ARDS. These treatments span prevention at early stages of disease onset, such as early goal-directed fluid resuscitation and longer-term prevention of complications, such as sedation protocols. Regardless, one of the most important roles for critical care nurses is ensuring attention to all these elements to prevent mortality, complications, and to promote recovery. See page 525.

The nurse is completing a respiratory assessment with a patient. Which question should be included to identify health problems? "Tell me how much you exercise each day." "Do your children have trouble breathing at night?" "What did the doctor recommend for your emphysema?" "Has anyone in your family had a stroke or heart attack?"

"What did the doctor recommend for your emphysema?" Rationale: A health assessment interview to determine problems with respiratory structure and function may be conducted during a health screening, may focus on a chief complaint, or may be part of a total health assessment. If the patient has a problem with respiratory function, analyze its onset, characteristics, course, severity, precipitating and relieving factors, and any associated symptoms, noting the timing and circumstances. Amount of exercise each day does not focus on respiratory problems. Children's breathing or family member's health history does not provide information about the patient's health status or potential problems.

Which client is most at-risk for a primary spontaneous pneumothorax? An 80 year-old client with pneumonia. A 40 year-old client whose airbag deployed during a motor vehicle accident. A 25 year-old client with a penetrating chest wound. A 17 year-old tall male client with a BMI of 15.

A 17 year-old tall male client with a BMI of 15. Rationale: Primary spontaneous pneumothorax is most often seen in tall skinny, young males.

The patient is experiencing respiratory acidosis. What nursing action is most likely to alleviate this condition? A) Suction the endotracheal tube. B) Reduce the respiratory rate on the ventilator. C) Administer intravenous bicarbonate. D) Increase the rate of crystalloid intravenous fluids.

A) Suction the endotracheal tube.

The nurse is assessing a patient with chronic obstructive airway disease. Which finding would be expected when conducting the physical examination of this patient? Mental confusion and lethargy Oxygen saturation readings of 85% or less Three+ pitting edema of ankles and lower legs AP chest diameter equal to or greater than lateral chest diameter

AP chest diameter equal to or greater than lateral chest diameter Rationale: In the patient with chronic obstructive airway disease, air trapping and hyperinflation increase the anterior-posterior chest diameter, causing barrel chest. Mental confusion, oxygen saturation levels below 85%, and 3+ pitting edema of the ankles and lower legs are not expected assessment findings and should be reported to the healthcare provider

Ms. S. is admitted to the ICU with a diagnosis of Acute Respiratory Distress Syndrome (ARDS). As the nurse plans the patient's care, she inquires as to whether the precipitating injury was a direct or indirect injury. How is the management of ARDS caused by direct injury differentiated from the management caused by indirect injury? ARDS caused by direct injury (e.g. toxic inhalation) or indirect injury (e.g. drug reaction) is essentially managed with the same principles of treatment. ARDS caused by direct injury (e.g. toxic inhalation) is managed by mechanical ventilation, whereas ARDS caused by indirect injury (e.g. drug reaction) is managed by treatment of the underlying condition.

ARDS caused by direct injury (e.g. toxic inhalation) or indirect injury (e.g. drug reaction) is essentially managed with the same principles of treatment. Rationale: Although there are multiple potential causes of ARDS, management principles are similar. Treatment is supportive, that is, contributing factors are minimized, corrected, or reversed, and while the lungs heal, care is taken so that treatment does no further damage (p. 525).

Which of the following statements best describes acute respiratory distress syndrome (ARDS)? ARDS is a severe respiratory infection that is managed by prolonged antibiotic treatments. ARDS is caused by indirect injury to the lungs and damage develops slowly over time causing decreased oxygenation. ARDS is an acute lung injury caused by an uncontrolled systemic inflammatory response. ARDS is caused by chronic hypoxia to the lung parenchyma which causes decreased lung compliance.

ARDS is an acute lung injury caused by an uncontrolled systemic inflammatory response. Rationale: ARDS is an acute lung injury, either direct or indirect, which is caused by an uncontrolled systemic inflammatory response that damages the alveoli and causes significantly decreased gas exchange.

The nurse is evaluating the chest radiograph of a critically ill patient and notices that the patients trachea has shifted to the left of midline. What additional finding would confirm the presence of a pneumothorax? A) Absent or diminished breath sounds on the right B) Lung fields generally white on chest radiograph C) Lung fields dull to percussion on the right D) Blunting of costophrenic angles on chest radiograph

Absent or diminished breath sounds on the right

Amy Campbell, a 30-year-old female, is being treated after having a severe asthma attack. Her current vital signs are temperature 37.2°C (99°F), pulse 64 bpm, respirations 26/min, and blood pressure 124/84 mmHg. She has inspiratory and expiratory wheezing. Her O2 Sat reading is 94% on 4L/min O2 via nasal cannula. In planning care for Ms. Campbell, what will you teach her to help decrease anxiety during an asthma attack?

Allow family members or significant others to remain with the patient while maintaining a quiet environment. Assist with guided imagery, relaxation techniques, and gentle massage, and administer medication as needed.

The nurse is caring for a client who just had a chest tube removed by the provider. What should the nurse do after the removal of the chest tube? Position the client prone to reduce fluid accumulation. Remove dressing and assess the insertion site. Auscultate lung sounds. Administer oxygen via nonrebreather face mask.

Auscultate lung sounds. Rationale: After removing a chest tube the site is covered with an occlusion dressing to prevent air leaks. Lung sounds should be auscultated to ensure breath sounds bilaterally. Client should be in semi-fowlers to fowlers. There is no need to administer oxygen.

Which of the following ABG results should be promptly conveyed to the healthcare provider? A. Mr. Holt: pH: 7.36; pO2: 92 mmHg; pCO2: 40 mmHg; HCO3: 25 mEq/L B. Ms. Sawyer: pH: 7.22; pO2: 50 mmHg; pCO2: 58 mmHg; HCO3: 29 mEq/L C. Mr. Mohr: pH: 7.35; pO2: 80 mmHg; pCO2: 44 mmHg; HCO3: 26 mEq/L D. Ms. Campbell: pH: 7.46; pO2: 90 mmHg; pCO2: 33 mmHg; HCO3: 26 mEq/L

B. Ms. Sawyer: pH: 7.22; pO2: 50 mmHg; pCO2: 58 mmHg; HCO3: 29 mEq/L Rationale: The ABG results are reflective of partially compensated respiratory acidosis. Although respiratory acidosis is expected in COPD patients, the greatest concern is due to Ms. Sawyer's pCO2 of 58 mmHg. Therefore, the healthcare provider should be promptly notified. The remaining patients have no acid-base or slight acid-base disturbance and no oxygenation issues.

The nurse is caring for a client on positive pressure mechanical ventilation via an endotracheal (ET) tube when the volume (low pressure) alarm goes off on the ventilator. What should the nurse do first? Suction the client Request a chest x-ray to assess placement Check all tubing and connections Increase the FiO2 and flow rate

Check all tubing and connections Rationale: A low pressure volume alarm indicates either a connection is loose or leaking or the ET tube has been displaced. Check the connections first and then the placement of the ET tube. Increased flow rate or FiO2 will not correct the problem and can harm the client. Suctioning would be used for a high pressure alarm not a low pressure alarm.

The nurse begins her shift in the critical care unit and is assessing the newly admitted patient with a chest tube and drainage of a pleural effusion caused by severe congestive heart failure. The nurse notes no accumulated drainage marked for the past 2 hours. What should the nurse do first? Request removal of chest tube. Continue monitoring drainage. Check the system for obstruction. Encourage fluid intake.

Check the system for obstruction.

The nurse begins her shift in the critical care unit and is assessing the newly admitted patient with chest tube drainage of a pleural effusion caused by severe congestive failure. The nurse notes no accumulated drainage marked for the past 2 hours. What is the MOST appropriate nursing consideration? Request removal of chest tube. Encourage fluid intake. Continue monitoring drainage. Check the system for obstruction.

Check the system for obstruction. Rationale: The nurse assesses and documents the color, consistency, and amount of drainage while remaining alert to significant changes. A sudden increase indicates hemorrhage or sudden patency of a previously obstructed tube. A sudden decrease indicates chest tube obstruction or failure of the chest tube or drainage system. See p. 462.

Which of the following conditions is NOT an indication for insertion of a chest tube? Pneumonia causing exudative effusions into the pleural cavity. Rupture of fluid filled blisters between the parietal and visceral layers of the lung. Chronic obstructive lung disease resulting in collapsed alveoli. Chest wall trauma resulting in bleeding into the pleural space.

Chronic obstructive lung disease resulting in collapsed alveoli.

Which of the following conditions is NOT an indication for insertion of a chest tube? Rupture of fluid filled blisters between the parietal and visceral layers of the lung Pneumonia causing exudative effusions into the pleural cavity Chest wall trauma resulting in bleeding into the pleural space Chronic obstructive lung disease resulting in collapsed alveoli.

Chronic obstructive lung disease resulting in collapsed alveoli. Rationale: The chest tube is a drain. Its purposes are to remove air, fluid, or blood from the pleural space; restore negative pressure to the pleural space; re-expand a collapsed or partially collapsed lung (pneumothorax); and prevent reflux of drainage back into the chest. COPD may affect the bronchial tree or the alveoli but does not typically effect the pleural cavity. See p. 468.

Which client is most at risk for the following acid-base imbalance: Arterial Blood Gas (ABG) results are pH 7.25, PaCO2 55, HCO3 22? Client with pulmonary edema Client with diabetic ketoacidosis Client with severe diarrhea Client living at high altitudes

Client with pulmonary edema Rationale: These numbers represent respiratory acidosis. This is most often caused by respiratory depression or distress such as in pulmonary edema.

There are several modes of delivering positive pressure ventilation. Which mode should be used to provide positive pressure to the airways of a spontaneously breathing client? Synchronized intermittent mandatory ventilation (SIMV) Continuous positive pressure ventilation (CPAP) Pressure support ventilation (PSV) Assist-control mode ventilation (ACMV)

Continuous positive pressure ventilation (CPAP) Continuous positive airway pressure (CPAP) applies positive pressure to the airways of a spontaneously breathing patient. CPAP may be used with either endotracheal intubation or a tight-fitting face mask. All breathing is spontaneous (patient triggered) and pressure controlled. CPAP is used to help maintain open airways and alveoli, decreasing the work of breathing.

The patient has experienced a significant drop in hemoglobin levels and is slightly tachycardic. The pulse oximetry value is 100% and arterial blood gas values are normal. What is the most important adverse physiologic effect that the nurse would expect? A) Polycythemia B) Diminished blood pressure C) Hyperalertness and hyperreflexia D) Diminished tissue oxygenation

Diminished tissue oxygenation

While assessing a patient with a left pneumothorax, the nurse notes decreased diaphragmatic excursion on the left. What should the nurse do next? Document the assessment. Notify the physician immediately. Repeat the assessment several times. Tell the patient to hold his or her breath.

Document the assessment. Rationale: Decreased diaphragmatic movement on the left side should be documented. This is an expected outcome with pneumothorax on the left since air movement and diaphragm movement would be decreased. The physician does not need to be notified with this finding. The assessment does not need to be repeated. Having the patient hold his or her breath is not going to change the finding

The nurse is caring for a patient who has undergone thoracic surgery. What assessment information would best support the nurses suspicion of pulmonary consolidation? A) Vesicular lung sounds at bases B) Bronchial breath sounds over upper airway C) Egophony at left posterior base of lung D) Basal crackles that clear with cough

Egophony at left posterior base of lung

A patient has experienced a cardiopulmonary arrest and is receiving cardiopulmonary resuscitation. As the nurse evaluates the effectiveness of this therapy, what value on arterial blood gases is most indicative of hypoventilation? A) Diminished PaO2 B) Diminished SaO2 C) Elevated HCO3 D) Elevated PaCO2

Elevated PaCO2

A critically ill patient has arterial blood gas results of pH 7.6, PaCO2 40 mm Hg, and HCO3 30 mEq/L. With what medical situation do these results most clearly correlate? A) Excess nasogastric drainage B) Severe diarrhea C) Diabetic ketoacidosis D) Lobular pneumonia

Excess nasogastric drainage

Match the following mechanical ventilation terms to their definitions: FIO2 Tidal Volume PEEP PIP SP The percentage or concentration of oxygen that a person inhales Highest level of air applied to the lungs during inspiration Amount of pressure needed to inflate the alveoli with each breath Positive pressure that will remain in the airways at the end of the respiratory cycle (end of exhalation) Amount of air that moves in or out of the lungs with each respiratory cycle

FIO2 - The percentage or concentration of oxygen that a person inhales Tidal Volume - Amount of air that moves in or out of the lungs with each respiratory cycle Positive end-expiratory pressure (PEEP) - Positive pressure that will remain in the airways at the end of the respiratory cycle (end of exhalation) Peak Inspiratory Pressures (PIP) - Highest level of air applied to the lungs during inspiration Static Pressure (SP) - Amount of pressure needed to inflate the alveoli with each breath Rationale: Peak inspiratory pressures are the highest level of air applied to the lungs during inspiration. High pressures can be caused by any type of obstruction such as accumulation of secretions, kinked tubing, etc. The Inspiratory Pressure Limit (IPL) is a setting which controls the maximum PIP. If the maximum is reached the IPL forces a cessation to inspiration to reduce the PIP. The SP (static pressure) is the amount of pressure needed to inflate the alveoli with each breath which represents compliance of the physical structures of the lungs, chest wall, and abdomen. Conditions which decrease compliance (ARDS, pneumothorax, etc.) will cause the SP to rise.

The nurse is concerned that a patient is at risk for developing lung cancer. What risk factor did the nurse most likely assess in this patient? Childhood obesity Family history of asthma Family history of lung cancer Frequent upper respiratory infections

Family history of lung cancer Rationale: A familial history of lung cancer increases the risk of developing lung cancer, and small-cell lung cancer has a definite genetic component. Childhood obesity, family history of asthma, and frequent upper respiratory infections do not increase the risk of developing lung cancer.

The home care nurse is providing direction to a home care aide who is scheduled to care for a patient with cystic fibrosis. Which information should the nurse instruct the aide to report immediately? (Select all that apply.) Fever Bulky, fatty stools Difficulty clearing mucous secretions Increasing shortness of breath and fatigue Thick, tenacious, milky, and white sputum

Fever Difficulty clearing mucous secretions Increasing shortness of breath and fatigue Thick, tenacious, milky, and white sputum Rationale: Thick, tenacious, milky white sputum and fever indicate possible infection. Difficulty coughing up mucus and increased shortness of breath and fatigue indicate potential early manifestations of respiratory failure. Steatorrhea causing frequent, bulky, foul-smelling stools is a common manifestation as a result of associated pancreatic insufficiency.

A patient who is critically ill is attached to a saturation of mixed venous oxygen monitor (SvO2) and has an SvO2 value that is trending downward and is currently below normal at 55%. What clinical abnormality should the nurse suspect? A) Increased cardiac output B) Fever and shivering C) Fluid volume overload D) Oversedation

Fever and shivering

What age-related change of the respiratory system makes the older adult more susceptible to respiratory complications? Increased elastic recoil of the lungs. Decreased compensation time for acid-base imbalance More effective coughing and deep breathing Flattening of the diaphragm

Flattening of the diaphragm Rationale: The older adult is more susceptible to respiratory complications due to decreased recoil and elasticity, Increased compensation time, less effective cough and flattening of the diaphragm.

The nurse is teaching a patient about a thoracentesis. What should the nurse include in this teaching? (Select all that apply.) Fluid is removed from around the lung. A chest x-ray is done after the procedure. A needle is inserted through the chest wall. General anesthesia is used for the procedure. Strict bed rest is required for 2 hours afterwards.

Fluid is removed from around the lung. A chest x-ray is done after the procedure. A needle is inserted through the chest wall. Rationale: A thoracentesis is done to obtain a specimen of pleural fluid for diagnosis, to remove excess pleural fluid, or instill medication. A large-bore needle is inserted through the chest wall and into the pleural space. Following the procedure, a chest x-ray is taken to check for a pneumothorax. General anesthesia is not required for the procedure. Strict bed rest is not required for 2 hours after the procedure.

A critically ill patient has arterial blood gas results of pH 7.35, PaCO2 55 mm Hg, and HCO3 28 mEq/L. How does the nurse interpret these results? A) Respiratory acidosis B) Metabolic alkalosis C) Partially compensated metabolic alkalosis D) Fully compensated respiratory acidosis

Fully compensated respiratory acidosis

The nurse is completing a history of a newly admitted patient with a pulmonary embolism. The patient asks what caused the condition. What information is MOST relevant to gather to answer the patient's question? Health conditions, recent activities, habits Race, socioeconomic status, and age Geographic region of birth, gender, and recent surgery Family history, number of healthy births, and age

Health conditions, recent activities, habits Rationale: There are number of environmental and genetic factors that contribute to the risk of developing venous thromboembolism (VTE). Acquired risk factors include age, recent surgery, cancer, and thrombophilia. Risk factors that increase the incidence of VTE are listed in Box 26-5. Most incidents of PE occur when a thrombus (clot) breaks loose and migrates to the pulmonary arteries, obstructing part of the pulmonary vascular tree (Fig. 26-2). Nonthrombotic causes of PE include fat (from long bone fracture), air (during neurosurgery, or from central venous catheters), and amniotic fluid (occurs during active labor), but these are much less common than thromboembolism. See p. 496, box 26-5 (risk factors).

Tamra Sanders is a 22-year-old patient with Down syndrome. She is admitted in sickle cell crisis with a temperature of 38.9°C (102°F), pulse 90 bpm, respirations 30/min and shallow, and blood pressure of 110/84 mmHg. She is complaining of severe chest pain with shortness of breath. She states her pain scale level is 10 of 10. She has an order to begin morphine PCA. In what position should the nurse place Ms. Sanders to ease her breathing? A. Sims' position B. High Fowler's C. Trendelenburg D. Dorsal recumbent

High Fowler's Rationale: High-Fowler's position places the body angle at 90 degrees and helps to promote lung expansion. Sims' and Trendelenburg positions can impair lung expansion; dorsal recumbent does not promote lung expansion and ease of breathing.

A critically ill patient has arterial blood gas results of PaO2 60 mm Hg, SaO2 80%, pH 7.35, PaCO2 35 mm Hg, and HCO3 24 mEq/L. How does the nurse interpret these results? A) Hypoxemia and respiratory acidosis B) Hypoxemia and normal acidbase balance C) Normal oxygenation and metabolic acidosis D) Normal oxygenation and acidbase balance

Hypoxemia and normal acidbase balance

The patient with an acute asthmatic attack is admitted for acute respiratory failure (ARF). ABGs depict respiratory acidosis secondary to retention of CO2. The desired outcome is to correct the acid/base balance. Considering the pathophysiology of an acute asthmatic attack, what is the appropriate focus to correct the acid/base balance? Administer neuro-muscular blocking agents Increase ventilation Increase percentage of oxygen delivered Administer bicarbonate

Increase ventilation Rationale: Acute asthmatic attack causes an impairment in ventilation secondary to bronchial spasm and airway obstruction resulting in hypercapnia. Correcting acid-base balance is achieved by improving ventilation. Without proper ventilation, an increase in oxygen will not have the desired effect, neither will administering bicarbonate. See p. 517, Table 26-11.

The nurse identifies nursing diagnoses that are appropriate for a patient with an acute asthma attack. Which diagnosis is of the highest priority? Anxiety related to difficulty breathing Ineffective Breathing Pattern related to anxiety Ineffective Airway Clearance related to bronchoconstriction and increased mucous production Ineffective Health Maintenance related of lack of knowledge about attack triggers and appropriate use of medications

Ineffective Airway Clearance related to bronchoconstriction and increased mucous production Rationale: Ineffective Airway Clearance is the highest priority. Bronchospasm and bronchoconstriction, increased mucous secretion, and airway edema narrow the airways and impair airflow during an acute attack of asthma. Both inspiratory and expiratory volumes are affected, decreasing the oxygen available at the alveolus for the process of respiration. Narrowed air passages increase the work of breathing, increasing the metabolic rate and tissue demand for oxygen. The diagnoses that address anxiety, ineffective breathing pattern, and ineffective health maintenance are important and can be focused on after the patient's ineffective airway clearance is addressed.

A patient's serum potassium level is 2.2 mEq/L. Which nursing action is the highest priority for this patient? Start oxygen at 2 L/min. Initiate cardiac monitoring. Initiate seizure precautions. Keep the patient on bed rest.

Initiate cardiac monitoring. Rationale: Hypokalemia affects nerve impulse transmission, including the transmission of cardiac impulses. The patient may develop ECG changes and atrial or ventricular dysrhythmias. Oxygen therapy is not indicated for hypokalemia. There is no risk of seizures in the patient with hypokalemia. The patient with hypokalemia should be kept on bed rest; however, this is not the priority action for this patient.

The nurse is assessing breath sounds. Where should the nurse place the diaphragm of the stethoscope to listen to the apex of the left lungs? In the mediastinum Just below the clavicle Within the parietal pleura Resting on the diaphragm

Just below the clavicle Rationale: The apex of each lung lies just below the clavicle. The base of each lung rests on the diaphragm. The hilus, on the mediastinal surface of each lung, is where blood vessels of the pulmonary and circulatory systems and the primary bronchus enter and exit the lungs. The parietal pleura line the thoracic wall and mediastinum.

A patient is demonstrating confusion, hallucinations, and a positive Chvostek's sign. Which medication(s) should the nurse prepare to provide to this patient? Calcium chloride Magnesium sulfate Insulin and glucose Sodium bicarbonate

Magnesium sulfate Rationale: A positive Chvostek's sign indicates increased neuromuscular excitability, commonly associated with both hypomagnesemia and hypocalcemia. Additional manifestations of hypomagnesemia include confusion, hallucinations, and possible psychoses. Administration of magnesium sulfate helps restore magnesium balance and neuromuscular function. Calcium chloride would be administered for manifestations of hypocalcemia. Insulin and glucose are used to treat hyperkalemia. Sodium bicarbonate is used in the treatment of hyperkalemia and metabolic acidosis.

The nurse is planning care for a patient with acute hypernatremia. What should the nurse include in this patient's plan of care? (Select all that apply.) Maintain IV access. Limit length of visits. Restrict fluids to 1500 mL per day. Conduct frequent neurologic checks. Orient to time, place, and person every 2 hours

Maintain IV access. Conduct frequent neurologic checks. Orient to time, place, and person every 2 hours Rationale: Frequent neurologic checks are necessary as hypernatremia draws water out of brain cells, causing them to shrink. As the brain shrinks, tension is placed on cerebral vessels, which may cause them to tear and bleed. Hypernatremia affects mental status and brain function including orientation to time, place, and person. Fluid replacement is the primary treatment for hypernatremia. Maintaining intravenous access is necessary for administration of fluids and possible emergency medications. There is no reason to limit the length of visits for the patient with hypernatremia.

Prior to providing care to a patient, the nurse reviews the previous day's vital sign assessments and notes that broncho-vesicular breath sounds were documented. What should the nurse do next? Notify the physician Measure and record vital signs as usual. Request a respiratory therapy treatment. Document the inability to hear breath sounds.

Measure and record vital signs as usual. Rationale: Bronchovesicular breath sounds are normal. The nurse should measure and record the vital signs as usual. The physician does not need to be notified of normal breath sounds. A respiratory treatment is not required. The nurse has not assessed breath sounds yet, so documenting the inability to hear the sounds would be incorrect data

A patient's arterial blood gas results are pH 7.21, PaO2 98 mmHg, PaCO2 32 mmHg, and HCO3 17 mEq/L. Which acid-base imbalance do these results indicate to the nurse? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic acidosis

Due to diarrhea, Ms. Windham's arterial blood gas results are pH, 7.30; pCO2, 35 mmHg; pO2, 90 mmHg; HCO3, 19 mEq/L. How does the nurse correctly interpret these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

Metabolic acidosis

Interpret the following ABGs of pH 7.55, pCO2 35 mm Hg, HCO3 30: Metabolic alkalosis Metabolic acidosis Respiratory alkalosis Respiratory acidosis

Metabolic alkalosis

The nurse is caring for a patient undergoing gastric decompression. For which potential acid-base balance should the nurse plan interventions? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Metabolic alkalosis Rationale: Gastric suctioning removes highly acidic gastric secretions, increasing the risk of metabolic alkalosis. Gastric suctioning will not cause metabolic or respiratory acidosis. Respiratory alkalosis is caused by hyperventilation

The nurse is completing a history on a patient with dyspnea. What characteristic of dyspnea is most indicative of pulmonary disease? A) Most severe when patient is supine B) Awakens patient from sleep at night C) Accompanied by anginal chest pain D) Most severe with exertion

Most severe with exertion

Which of the following artificial airways is MOST appropriate for the patient who is alert, can sit upright, and has excessive secretions? Nasopharyngeal airway Oropharyngeal airway Endotracheal airway Tracheal airway

Nasopharyngeal airway Rationale: A nasopharyngeal airway provides access to suction excretions while protecting the mucosa. The oropharyngeal airway should not be placed in a patient who is alert with a gag reflex. The endotracheal is appropriate for patient's needing ventilation, and who needs protection from aspiration, perhaps secondary to being sedated, and/or bed bound.

A patient with Duchennes muscular dystrophy requires an intermittent short-term therapy to maintain alveolar ventilation. The patient is not a candidate for aggressive mechanical ventilation as provided through an artificial airway. Which of the following would be the most appropriate treatment for this patient? A) Manual resuscitator B) Negative-pressure ventilator C) Volume ventilator D) Pressure ventilator

Negative-pressure ventilator

The post-CBG patient develops atelectasis as a complication of anesthesia. The attending physician determines the needs for extended high-pressured mechanical ventilation. In addition to sedatives, the nurse anticipates an order for which of the following to facilitate effective ventilation? Neuromuscular blocking agent to support synchronous breathing. Multiple intravenous antibiotics to prevent sepsis. High-dose corticosteroids to reduce inflammation. Narcotic analgesics to diminish pain and anxiety secondary to intubation.

Neuromuscular blocking agent to support synchronous breathing. Rationale: Neuromuscular blocking agents (NMBAs) and general anesthetics, such as propofol, although not sedatives, are frequently used in these patients to facilitate patient-ventilator synchrony, decreasing the work of breathing and facilitating ventilation, especially when high airway pressures or prone position is applied. NMBAs require concurrent use of sedation to prevent patients who are chemically paralyzed from being alert but unable to move. Frequent assessment of adequacy of both neuromuscular blockade and sedation is an important nursing intervention. See p. 528.

The nurse is evaluating the following arterial blood gas values: pH 7.35, PaO2 95 mm Hg, SaO295%, PaCO2 40 mm Hg, and HCO3 24 mEq/L. How does the nurse interpret these results? A) Normal B) Respiratory acidosis C) Metabolic acidosis D) Technical error

Normal

The nurse caring for a patient with asthma notices that the patient's respirations have slowed and coughing has stopped. Breath sounds are diminished throughout his lung fields and absent in the bases. Which action should the nurse take? Obtain a chest x-ray. Ask family members to leave. Notify the healthcare provider. Allow the patient to rest undisturbed.

Notify the healthcare provider. Rationale: Respiratory status can change rapidly during an acute asthma attack and its treatment. Slowed, shallow respirations with significantly diminished breath sounds and decreased wheezing may indicate exhaustion and impending respiratory failure. Immediate intervention is necessary so the healthcare provider needs to be notified. The healthcare provider might prescribe a chest x-ray. Asking the family members to leave is not a priority. Allowing the patient to rest undisturbed could eventually lead to respiratory arrest.

A patient being mechanically ventilated after a severe chest wall injury and flail chest complains of chest tightness, anxiety, and air hunger. The patient fears that a heart attack is pending. What should the nurse do first? Notify the physician. Obtain arterial blood gases. Administer prescribed analgesic. Contact respiratory therapy to evaluate ventilator settings.

Obtain arterial blood gases. Rationale: The patient is demonstrating classic manifestations of respiratory alkalosis, a potential complication of mechanical ventilation when the rate or volume of ventilations is too high. Arterial blood gases (ABGs) provide the data necessary to confirm and treat this problem. The nurse should obtain recent ABG values before contacting the physician. An analgesic is not going to reduce the patient's symptoms because the respiratory rate on the ventilator is set too high. The nurse should obtain an ABG to validate the patient's manifestations before contacting the respiratory therapist to change or evaluate the ventilator settings.

Which manifestations should the nurse expect to assess in a patient with fluid volume deficit? Headache and muscle cramps Dyspnea and respiratory crackles Increased pulse rate and blood pressure Orthostatic hypotension and flat neck veins

Orthostatic hypotension and flat neck veins Rationale: In fluid volume deficit, there is less volume in the vascular system, which decreases venous return and cardiac output, leading to manifestations of dizziness, orthostatic hypotension, and flat neck veins. The heart rate increases and the blood pressure falls. Headache and muscle cramps are associated with hyponatremia. Dyspnea, respiratory crackles, and increased pulse rate and blood pressure are associated with fluid volume excess

The nurse notes that a patient has an elevated body temperature. What process is initiated between oxygen and hemoglobin as the temperature of body tissues increases? Respiratory rate decreases. Lung compliance increases. Oxygen unloading is inhibited. Oxygen unloading is enhanced.

Oxygen unloading is enhanced. Rationale: The organic chemical 2,3-DPG is formed in red blood cells and increases the release of oxygen from hemoglobin by binding to it during times of increased metabolism such as when body temperature increases. This binding alters the structure of hemoglobin to facilitate oxygen unloading. The increase in body temperature does not decrease respiratory rate or increase lung compliance. Oxygen unloading is enhanced and not inhibited.

What finding would be consistent with a diagnosis of acute hypercapnic respiratory failure? PaO2 60 mmHg PaCO2 40 mmHg PaCO2 60 mmHg PaO2 40 mmHg

PaCO2 60 mmHg

Which of the following BEST describes the meaning of PaO2? PaO2 is the percentage of oxygen carried by the venous system. PaO2 reflects the pressure necessary for gas exchange within the alveoli. The PaO2 represents the amount of oxygen necessary for organ function. The partial pressure of oxygen delivered via mechanical ventilation.

PaO2 reflects the pressure necessary for gas exchange within the alveoli. Rationale: PaO2 is the partial pressure created when oxygen is dissolved in the bloodstream (and reflects SaO2) which is necessary for gas exchange in the alveoli.

A patient in the ICU is on a volume ventilator. The nurse recognizes that which of the following are true for this type of ventilator? Select all that apply. A) Peak inspiratory pressure varies from breath to breath and must be monitored closely. B) Amount of pressure depends on patients lung compliance and patient-ventilator resistance factors. C) The device fits like a tortoise shell, forming a seal over the chest. D) Exhaled tidal volume must be monitored closely. E) Volume varies based on changes in resistance or compliance. F) Small tidal volumes are used at frequencies greater than 100 breaths/minute.

Peak inspiratory pressure varies from breath to breath and must be monitored closely. Amount of pressure depends on patients lung compliance and patient-ventilator resistance factors.

The nurse is caring for a patient undergoing mechanical ventilation for acute respiratory failure. Which measure should the nurse use to help maintain effective alveolar ventilation? Keep the patient in the supine position. Maintain ordered oxygen concentration. Increase the tidal volume on the ventilator. Perform endotracheal suctioning as indicated.

Perform endotracheal suctioning as indicated. Rationale: A patent airway is necessary to maintain effective alveolar ventilation and gas exchange. Endotracheal suctioning as needed will ensure a patent airway for the patient. The supine position will not ensure effective alveolar ventilation. Providing oxygen as prescribed will not ensure effective alveolar ventilation. Increasing the tidal volume on the ventilator could cause lung tissue trauma.

The nurse is completing an assessment on a client with a deep vein thrombosis who suddenly develops dyspnea and chest pain. What should the nurse do first? Administer oxygen via nasal cannula Place the client in high fowler's position Administer oral dose of warfarin Place pulse oximeter on the client

Place the client in high fowler's position Rationale: The client is showing signs of PE and should be placed in High Fowlers to assist with breathing. Oxygen and pulse ox may be used but not the priority. For PE parenteral anticoagulants will be used.

Mr. J is placed on mechanical ventilation. His physician tells the nurse to increase PEEP. The nurse knows a complication of PEEP (positive end expiratory pressure) is potential damage to the baroreceptors resulting in: Pneumothorax Paralytic ileus Aspiration Gastric ulcers

Pneumothorax Rationale: Increased peep can cause barotrauma and lead to pneumothorax.

Mr. J is placed on mechanical ventilation. His physician tells the nurse to increase PEEP. The nurse knows a complication of PEEP (positive end expiratory pressure) is potential damage to the baroreceptors resulting in: Pneumothorax Volutrauma Subcutaneous emphysema Pneumoconiosis

Pneumothorax Rationale: The persistent pressure from PEEP may result in air leaking from the alveoli into the pleural space (pneumothorax). Excessive volume (large tidal volumes) may result in leakage of fluid and protein into the lung, a form of pulmonary edema (noncardiogenic in etiology). Subcutaneous emphysema is air trapped under the skin. Pneumoconiosis is a disease caused by inhalation of particles, e.g. dust.

The client on mechanical ventilation is at risk for ventilator-associated pneumonia (VAP). All of the following methods should be use to reduce the risk of VAP EXCEPT: Hand washing Positioning client supine Brushing the client's teeth every 8 hours Thorough suctioning of secretions

Positioning client supine Rationale: Clients should be positioned with HOB elevated at least 30 degrees to avoid aspiration and risk of pneumonia.

A patient in the ICU with pneumonia and on mechanical ventilation is suspected to have pulmonary embolus. Which diagnostic study would be best for assessing for this condition? A) Chest radiography B) Ventilation-perfusion scanning C) Pulmonary angiography D) Bronchoscopy

Pulmonary angiography

What assessment finding would be expected for a client compensating for the following ABG results pH 7.23, PaCO2 40, HCO3 19 ? Increased urine output Rapid respirations Increased blood pressure Decreased heart rate

Rapid respirations Rationale: This client is showing metabolic acidosis. The compensatory mechanism is to increase the reate and depth of respirations to blow off CO2 and increase pH.

The alarm on the patient's continuous pulse oximeter is not functional. Which of the following nursing actions is most directed toward patient safety? A. Go into the patient's room every 30 minutes to 1 hour to check the pulse oximetry results. B. Contact the healthcare provider to determine if continuous pulse oximetry is necessary. C. Replace the defective device immediately. D. Notify the biomedical department that the device alarm is not functioning

Replace the defective device immediately. Rationale: Because the alarm is not functioning, it will not alert the nurse if the patient has deterioration in oxygenation status. As a result, the device requires immediate replacement. Although the biomedical department may need to be notified, the patient's safety is the priority.

A patient has arterial blood gas results of pH 7.2, PaCO2 55 mm Hg, and HCO3 24 mEq/L. How does the nurse interpret these results? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis

Respiratory acidosis

The patient is being monitored with an end-tidal CO2 monitor and has values trending upward. What acidbase abnormality should the nurse assess for? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis

Respiratory acidosis

The critical care patient with acute respiratory failure, Arterial Blood Gas (ABG) results are pH 7.25, pCO2 55, HCO3 22. What is the interpretation of the ABG results? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic alkalosis

Respiratory acidosis Rationale: The pH is acidotic (<7.35); the carbon dioxide is high (>45 mmHg), meaning it is also acidotic; however, the bicarbonate (base) is normal (22 to 26 mEq/L). This means it is the respiratory system (which manages carbon dioxide) is causing the pH to be acidotic.

Interpret the following ABGs of pH 7.55, pCO2 30 mm Hg, HCO3 24: Metabolic alkalosis Metabolic acidosis Respiratory alkalosis Respiratory acidosis

Respiratory alkalosis

A patient has arterial blood gas testing performed. His PaO2 is 83 mm Hg, SaO2 is 91%, pH is 7.5, PaCO2 is 24 mm Hg, and HCO3 is 22 mEq/L. Which of the following indicates this patients condition? A) Respiratory acidosis with normal saturation (uncompensated) B) Metabolic alkalosis with low saturation (uncompensated) C) Respiratory alkalosis with low saturation (uncompensated) D) Metabolic alkalosis with low saturation (fully compensated)

Respiratory alkalosis with low saturation (uncompensated)

A patient in the ICU has just undergone arterial blood gas testing. Her results are as follows: PaO2 is 90 mm Hg, pH is 7.43, PaCO2 is 24, and HCO3 is 19 mEq/L. Which of the following indicates this patients condition? A) Respiratory alkalosis, fully compensated B) Respiratory acidosis, partially compensated C) Metabolic alkalosis, fully compensated D) Metabolic acidosis, partially compensated

Respiratory alkalosis, fully compensated

A patient with an indirect pulmonary injury from a transfusion-related acute lung injury (TRALI) is admitted to the ICU. The nurse knows the patient is at risk for Systemic Inflammatory Response Syndrome (SIRS), and subsequent organ failure. What is the best explanation for the relationship of TRALI, SIRS and MODS? There is no relationship; these are distinct and unrelated syndromes. The patient with ARDS secondary to an indirect lung injury may develop SIRS, but is not at risk for organ dysfunction (MODS). TRALI related Acute Respiratory Distress Syndrome (ARDS) always results in organ failure. Respiratory distress may precipitate or result from a systemic inflammatory response complicated by multisystem organ dysfunction.

Respiratory distress may precipitate or result from a systemic inflammatory response complicated by multisystem organ dysfunction. Rationale: The respiratory system may be the earliest and most common organ system to be involved in the systemic response of SIRS. Often, patients with SIRS develop multisystem organ dysfunction (MODS). As endothelial damage progresses and tissue hypoxia ensues, the inflammatory response is perpetuated, and the cascade intensifies (upregulates) with the release of more mediators. ARDS and MODS are therefore part of a vicious cycle in the continuum of SIRS. See page 522-523.

The nurse caring for a patient with COPD is concerned that the patient is developing respiratory failure. What did the nurse assess as an early sign of possible respiratory failure? Deep coma Decreased urine output Restlessness and tachypnea Hypotension and tachycardia

Restlessness and tachypnea Rationale: The manifestations of respiratory failure are caused by hypoxemia and hypercapnia, as well as the underlying disease process. Dyspnea and headache are early signs. Hypoxemia causes dyspnea and neurologic symptoms such as restlessness, apprehension, impaired judgment, and motor impairment. Tachycardia and hypertension develop as the cardiac output increases in an effort to bring more oxygen to the tissues. As hypoxemia progresses, dysrhythmias, hypotension, and decreased cardiac output may develop. Increased carbon dioxide levels depress CNS function and cause vasodilation.

While reviewing a patient's assessments, the nurse notes an absence of right-sided breath sounds. Which information in the health history would explain this assessment finding? Right lung removed History of tuberculosis Pneumonia 10 years ago Diagnosed with childhood asthma

Right lung removed Rationale: Breath sounds are absent over collapsed lung, surgical removal of lung, pleural effusion, and primary bronchus obstruction. The patient had a lung removed, which means breath sounds are absent because without air movement no sound would be generated. There are no other reasons in the patient's health history that would cause absent breath sounds.

A patient has arterial blood gas testing performed. Her PaO2 is 95 mm Hg, SaO2 is 90%, pH is 7.4, and HCO3 is 23 mEq/L. Which of these values should the nurse be most concerned about? A) PaO2 B) HCO3 C) pH D) SaO2

SaO2

Mr. Mohr will be discharged with a tracheostomy. Which of the following points should the nurse teach the patient about the tracheostomy? A. The tracheostomy will not interfere with lifting when returning to work. B. Water skiing is allowed but swimming in a pool or lake is not allowed. C. Showering is allowed as long as the tracheostomy is covered with a washcloth. D. A small amount of alcohol is allowed but smoking is not allowed.

Showering is allowed as long as the tracheostomy is covered with a washcloth. Rationale: Showering and bathing are allowed as long as the tracheostomy is protected from the flow of water.

The UAP notifies the RN the new patient admitted with aspiration pneumonia looks worse, describing bluish lips, wet cough, and increased difficulty in breathing. If the patient is developing ARDS, what stage would this represent? Stage 1 Stage 2 Stage 3 Stage 4

Stage 2 Rationale: Initially, neutrophils accumulate, the patient experiences dyspnea, and the CXR is unremarkable (stage 1). As the neutrophils grow, they invade structures causing hypoxia (hence, the cyanosis), and increasing dyspnea (stage 2). In stage 3, the abnormal immune response intensifies causing a systemic response, including the beginning of structural changes as collagen becomes deposited. The final stage 4 results in systemic damage as multiple organs are damaged, fibrotic changes cause restructuring and the result can be intractable respiratory damage (p. 523, Table 27-2).

A client with ARDS is experiencing increased generalized edema. Chest X-ray shows decreased lung volumes. An arterial blood gas (ABG) is drawn and the results are PaO2 50 mmHg, PaCO2 42 mmHg. Which Stage of ARDS would this client be classified? Stage 4 Stage 1 Stage 3 Stage 2

Stage 3 Rationale: The client is showing decline with increased edema and decreased lung volumes. The client has hypoxemia but not hypercapnia indicating Stage 3 not yet Stage 4.

A patient in skeletal traction suddenly develops right-sided chest pain and shortness of breath. What should the nurse do? (Select all that apply.) Check for Homans' sign. Start oxygen per nasal cannula. Place in the high-Fowler's position. Administer the prescribed analgesic. Auscultate heart sounds every 2 to 4 hours.

Start oxygen per nasal cannula. Place in the high-Fowler's position. Auscultate heart sounds every 2 to 4 hours. Rationale: These manifestations may indicate pulmonary embolism. Oxygen should be administered to support gas exchange and tissue oxygenation. The high-Fowler's position facilitates oxygenation. Auscultating heart sounds can help detect cardiac compromise. Checking for Homans' sign would not be beneficial at this time. Pain medication should not be provided until a pain assessment is completed.

Upon discharge, the nurse teaches Mrs. Sawyer ways to prevent having another pulmonary embolism. Which intervention is appropriate for preventing pulmonary embolism? A. Use pillows under the knees when in bed. B. Apply knee-high elastic stockings when ambulating. C. Exercise the legs vigorously to encourage blood flow. D. Stop every 1 to 2 hours to stretch legs when traveling.

Stop every 1 to 2 hours to stretch legs when traveling. Rationale: Stretching the legs and walking every 1 to 2 hours when traveling will reduce the risk of pulmonary embolism. Hose that bind around the knee and use of pillows can contribute to deep venous thrombus formation and subsequently pulmonary embolism.

What assessment findings would indicate a client is suffering from an open traumatic pneumothorax? Tracheal deviation towards the affected side. Sucking sound with respirations. Distended neck veins. Decreased breath sounds on the affected side.

Sucking sound with respirations. Rationale: Open traumatic pneumothorax would cause a sucking sounds with breathing. Tracheal deviation and distended neck veins indicate tension pneumothorax. Breath sounds would be absent not diminished.

During a code, the patient's EtCO2 is 65 mm Hg (normal is 35-45 mm Hg). We know EtCO2 approximates the percentage of carbon dioxide in the alveoli. Which of the following is the MOST accurate analysis of this patient's EtCO2? The alveoli are unable to exchange gases adequately indicating a need for increased ventilation. The alveoli are retaining CO2 indicating a need for increased oxygenation.

The alveoli are unable to exchange gases adequately indicating a need for increased ventilation. Rationale: EtCO2 informs rescuers of the effectiveness of ventilation (air movement in and out of the lungs). Pulse oximetry indicates the amount of oxygenation within the blood stream.

The primary difference between volume modes and pressure modes of mechanical ventilation is: There is no primary difference between volume modes and pressure modes. The difference is the degree to which the mode effects ventilation. The difference in the ability of the alveoli to exchange gases. The difference is the primary mechanism to support breathing.

The difference is the primary mechanism to support breathing. Rationale: Volume controlled modes are set to deliver a specific volume of oxygenated air, the effect of which is pressure. Pressure controlled modes are set to deliver a specific amount of pressure of oxygenated air; the effect of which is volume.

The kidneys are part of the acid-base buffering system of the body to help maintain homeostasis. Which statement is correct about kidney buffering? The kidneys responds quickly to changes in pH and produce more bicarbonate when there is acidosis. The kidneys controls the level of carbon dioxide (CO2)in the body which helps maintain normal pH levels. The kidneys are the most effective buffering system with the longest duration of effect. The kidneys bind to or release hydrogen ions in the blood to adjust pH levels.

The kidneys are the most effective buffering system with the longest duration of effect. Rationale: The kidneys are the most effective buffering system with the longest duration of effect by controlling the movement of bicarbonate in or out of the blood as needed to maintain acid-base balance. It is the slowest buffering system, the respiratory system controls CO2 and the chemical system binds and release hydrogen.

A patient is being monitored with continuous pulse oximetry. Under what circumstance would the nurse question the accuracy of the pulse oximetry reading? A) The patient is a victim of a fire in an enclosed space. B) Cardiac monitor pattern shows normal sinus rhythm. C) Extremities are warm and dry with intact pulses. D) Respiratory rate and pulse rate are elevated.

The patient is a victim of a fire in an enclosed space.

The nurse is planning care for a patient with chronic obstructive pulmonary disease. Which information should the nurse con-sider when determining if the patient should have supplemental oxygen? Oxygen is used only at night for patients with COPD. Because oxygen is flammable, the patient should not smoke. The patient needs to be closely monitored for signs of respiratory depression. Oxygen is never used for patients with COPD because they may become dependent on it.

The patient needs to be closely monitored for signs of respiratory depression. Rationale: Administering oxygen to patients with chronic elevated carbon dioxide levels in the blood can actually increase the PaCO2, leading to increased somnolence and even respiratory failure. Close monitoring of level of consciousness and arterial blood gases during oxygen therapy is vital. Long-term oxygen therapy is used for severe and progressive hypoxemia. It also reduces the rate of hospitalization and increases length of survival. Oxygen may be used intermittently, at night, or continuously. For severely hypoxemic patients, the greatest benefit is seen with continuous oxygen. The patient with chronic obstructive pulmonary disease should be working on a smoking cessation plan.

Maggie Sawyer is an 82-year-old female who is ready to be discharged today back to the nursing home. She was hospitalized for treatment for a deep venous thrombosis and chronic obstructive pulmonary disease (COPD). Suddenly she complains of difficulty breathing, chest pain, coughing, restlessness, and a feeling that she is going to die. What data provided on Ms. Sawyer leads you to suspect pulmonary embolism?

Thromboemboli, or blood clots, that develop in the venous system (deep venous thrombosis or DVT), as in the case of Ms. Sawyer, are the most frequent cause of pulmonary embolism. Ms. Sawyer is exhibiting some of the following common clinical manifestations of pulmonary embolism: dyspnea and shortness of breath, chest pain, anxiety and apprehension, cough, tachycardia and tachypnea, crackles, and low-grade fever.

A patient in her first trimester is in the ICU and is displaying signs of metabolic alkalosis. On speaking with the patient, the nurse learns that she has been experiencing much vomiting, diarrhea, and anxiety in the past week. The nurse should recognize that which of the following is the most likely cause of this acid-base imbalance? A) Pregnancy B) Diarrhea C) Vomiting D) Anxiety

Vomiting

Mr. Holt's bacterial pneumonia is spread by droplet infection. When using standard precautions, which protective equipment is necessary to prevent spread of the infection? A. Wear a gown when bathing the patient. B. Wear gown and gloves when touching the patient. C. Wear a mask and gloves when suctioning the patient. D. Wear a cap to keep hair from touching the patient.

Wear a mask and gloves when suctioning the patient. Rationale: Wearing a mask is a standard precaution for a patient with a droplet infection.

While auscultating a patient's breath sounds, the nurse notes continuous musical sounds. How should the nurse document this finding? Crackles Wheezes Murmurs Friction rub

Wheezes Rationale: Wheezes are continuous musical sounds heard in the chest. Crackles are short, discrete, crackling or bubbling sounds. A friction rub is a loud, dry, creaking sound. Murmurs are not typically heard during the assessment of breath sounds

Allen Barber is a 55-year-old patient with diabetes mellitus who is 4 days postoperative abdominal surgery with an inflammation of the incision site. Temperature is 38.3°C (101°F), pulse 94 bpm, respirations 24/min, and blood pressure 138/82 mmHg. The abdominal incision appears red with warmth and edema around the incision. The patient states his pain level is 8 on a pain scale of 0 to 10. Labs and wound cultures have been ordered. The nurse collaborates with the healthcare provider regarding Mr. Barber's temperature and condition of his incision. Which laboratory studies does the nurse anticipate being ordered? A. White blood cell count/differential, erythrocyte sedimentation rate, C-reactive protein B. Troponins, metabolic panel for electrolytes, cultures of wound site C. Blood cultures, hematocrit and hemoglobin, blood glucose level D. Complete blood cell count, alkaline phosphatase, urine creatinine, and blood urea nitrogen

White blood cell count/differential, erythrocyte sedimentation rate, C-reactive protein Rationale: White blood cell count indicates extent of inflammatory process, erythrocyte sedimentation rate detects inflammation, and C-reactive protein indicates presence of inflammatory process.

The nurse is determining goals of care for a patient with chronic obstructive pulmonary disease. Which would be an appropriate goal for this patient? Will maintain SaO2 of 90% or higher. Will verbalize self-care measures to regain lost lung function. Arterial blood gases will be within normal limits by discharge. Will identify strategies to help reduce number of cigarettes smoked per day.

Will maintain SaO2 of 90% or higher.

The most accurate explanation of Arterial Blood Gases (ABG's) is that pH is determined by the proportion of acids (which produce hydrogen ions) and bases (which accept hydrogen ions); and, more specifically? carbon dioxide is determined by the exposure to toxic chemicals, and bi-carbonate by the ingestion of carbonated liquids. carbon monoxide is a gas emitted from combustible engines, and bi-carbonate determines the amount of H+ which can be removed from the blood. carbon dioxide gas is managed by respiration, and bi-carbonate is managed by metabolic processes of the kidney. carbon dioxide gas and bicarbonate are managed by the kidneys which respond to a feedback loop to maintain acid/base balance

carbon dioxide gas is managed by respiration, and bi-carbonate is managed by metabolic processes of the kidney. Rationale: The respiratory center in the brain along with other sensors direct the respiratory rate and depth in response to the amount of CO2 in the blood. The kidneys manage the amount of base primarily in the form of HCO3 to maintain the proper acid/base balance necessary for vital functions of the blood.

A patient is admitted to the emergency department with hypovolemia. Which IV solution should the nurse anticipate administering? 3% sodium chloride 10% dextrose in water 0.45% sodium chloride lactated Ringer's solution

lactated Ringer's solution Rationale: Ringer's solution is an isotonic, balanced electrolyte solution that can expand plasma volume and help restore electrolyte balance. Three percent saline solution is hypertonic and not used to expand body fluid volume. Solutions containing 0.45% sodium chloride are used as maintenance solutions. Solutions containing 10% dextrose are hypertonic and not used to expand body fluid volume.

A patient diagnosed with a suspected heroin overdose has a respiratory rate of 5 to 6 per minute. Which additional data should the nurse expect to collect on this patient? (Select all that apply.) pH 7.29 PaCO2 54 mmHg HCO3− 32 mEq/L Alert and oriented Skin warm and flushed

pH 7.29 PaCO2 54 mmHg Skin warm and flushed Rationale: The slow respiratory rate leads to inadequate alveolar ventilation. As a result, carbon dioxide is not effectively eliminated from the blood, causing it to accumulate. This increases carbonic acid levels, leading to respiratory acidosis, as indicated by the low pH and high PaCO2. The bicarbonate level is initially unchanged in acute respiratory acidosis because the compensatory response of the kidneys occurs over hours to days. Excess carbon dioxide causes vasodilation, leading to warm, flushed skin, particularly in acute respiratory acidosis. The increased carbon dioxide level will affect neurologic function and the patient will not be alert and oriented.

A patient is admitted with influenza with a history of 3 days of vomiting. Which of the following ABG's does the nurse expect for this patient: pH 7.50, pCO2 37, HCO3 30 mEq/L secondary to an excessive loss of acids pH 7.50, pCO2 37, HCO3 30 mEq/L secondary to an excessive ingestion of base pH 7.25, pCO2 37, HCO3 15 mEq/L secondary to excessive loss of acids pH 7.25, pCO2 37, HCO3 15 mEq/L secondary to excessive ingestion of base

pH 7.50, pCO2 37, HCO3 30 mEq/L secondary to an excessive loss of acids Rationale: Vomiting gastric acids increases the risk of acid/base balance resulting in an increased pH (less acidotic, more alkaline), and a higher proportion of bicarbonate/base to acids.

A client is admitted with influenza with a history of 3 days of vomiting. Which of the following ABG's does the nurse expect for this patient: pH 7.52, PaCO2 42, HCO3 28 mEq/L pH 7.50, PaCO2 37, HCO3 20 mEq/L pH 7.30, PaCO2 40, HCO3 15 mEq/L pH 7.28, PaCO2 50, HCO3 24 mEq/L

pH 7.52, PaCO2 42, HCO3 28 mEq/L Rationale: Excessive vomiting makes clients at risk for metabolic alkalosis.

If Mr. Holt is receiving percussion and vibration with postural drainage for left lower lobe pneumonia, which position most facilitates removal of secretions? A. semi-Fowler's position with arms elevated B. right Sims' position with head in Trendelenburg C. high-Fowler's position leaning on a bedside tray D. left Sims' position with head flat

right Sims' position with head in Trendelenburg Rationale: The patient is positioned with the area to be drained above the trachea or mainstem bronchus. Head down allows gravity to facilitate drainage of secretions