Quiz #4
Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate?
"PEEP prevents the lung air sacs from collapsing during exhalation"
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, resp rate 24/min, BP 132/76 mmHg, and temperature 36.8 (98.2). Which of following actions should the nurse perform?
Complete a neuro check
A nurse is caring for a client who has an acute respiratory failure. The nurse should monitor the client for which of the following manifestations of this condition?
-Severe dyspnea -decreased level of consciousness -headache -hypotension
A nurse in a providers office is assessing am older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?
Confusion
A nurse in the emergency department is preparing to administer naloxone 0.4mg IV bolus to a client who has opiod-induced respiratory depression. Available is naloxone injection 0.2mg/mL. How many mL should the nurse administer per dose?
2mL
After recieving change-of-shift report on a medical unit, which oatient should the nurse assess first?
A patient with septicemia who has intercoastal and suprasternal retrctions
Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure?
ABG analysis
A nurse is caring for a female client in the emergency department who reports shortness of breath and pain the lung are. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, RR 40/min, BP 140/80. ABG are pH 7.50, PaCO2 29, PaO2 60, HCO3 20mEq,L, SaO2 86%. which of the following is the priority nursing intervention?
Admin O2 via face mask
When the nurse is assessing a patient with COPD, the nurse finds a new onset of agitation and confusion. Which action should the nurse take first?
Assess oxygenation using pulse oximetry
The O2 sat for a patient with lower lobe pneumonia is 90%. The patient has wheezes, a weak cough effort, and complains of fatigue. Which action should the nurse take next?
Assist the patient with staged coughing
A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyper ventilatioO and apnea. The nurse should document that the client has which of the following breathing patterns?
Cheyne-strokes respiration
A nurse is assessing a client who has chronic respiratory insufficiency. which of the following findings should the nurse expect as a result of the long-term inadequate oxygenation?
Clubbing of the finger
A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilation-associated pneumonia, which action will the nurse include in the plan of care?
Elevate the head of the bed to 30 to 45 degrees
A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote the thinning of respiratory secretions?
Encourage the client to increase fluid intake
a patient with respiratory failure has a respiratory rate of 6 breaths/min and in O2 sat of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?
Endotracheal intubation and positive pressure ventilation
A patient with acute respiratory distress syndrome and acute kidney injury has the following drugs ordered. Which drug should the nurse discuss with the healthcare provider before giving?
Gentamicin 60 mg IV
While caring for a patient who has been admitted with a PE, the nurse notes a change in the patient's oxygen sat form 94% to 88%. Which action should the nurse take.
Increased the prescribed O2 flow rate
Which nursing intervention included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse delegate to an experienced LPN/LVN working in the ICU?
Insert an indwelling urinary catheter
A patient developes increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome or pulmonary edema caused by heart failure, the nurse will plan to assist with?
Insertion of a pulmonary artery catheter
A patient with acute respiratory distress syndrome who is intubated and receiving mechanical ventilation develops a right pneumothroax. Which collaborative action will the nurse anticipate?`
Lower the positive end-expiratory pressure (PEEP)
A nurse is caring for a client who has opiod toxicity and has respiratory rate of 6/min. Which of the following medications should the nurse plan to administer?
Naloxone
Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?
No sedative ordered for the patient
A nurse is caring for a patient with acute respiratory distress syndrome who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation. The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/min, and positive end-expiratory pressure (PEEP) of 5cm. Which assessment findings is most important for the nurse to report to the healthcare provider?
O2 sat of 99%
The nurse assess vital signs for a patient admitted 2 days ago with gram negative sepsis: temp 101.2, BP 90/56mmHg, pulse 92, RR 34. What action should the nurse take next?
Obtain O2 sat using pulse oximetry
A patient admitted with acute respiratory failure has ineffective airway clearance related to thick secretions. Which nursing intervention would specifically address this problem?
Offer the patient fluids at frequent intervals
The nurse is caring for an older patient who was hospitalized 2 days earlier with community-aquired pneumonia. which assessment information is most important to communicate to the health care provider?
Oxygen saturation 90% on 100% O2 by nonrebreather mask
A nurse is reviewing the lab values of a client who has resp. acidosis. Which of the following findings should the nurse expect?
PaCO2 50mmHg
The nurse is caring for a patient who arrived in the ED with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action?
Patient's PaO2 is 45mmHg
A nurse is planning care for a client who has acute respiratory distress syndrome. Which of the following interventions should the nurse include in the plan?
Place in prone position
The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome. Which finding is most important to report to the health care provider?
Red-brown drainage from nasogastric tube
A client is admitted to the emergency room with a respiratory rate of 7/min. ABG reveal the follwing values. Which of the following is an appropirate analysis of the ABGS? pH: 7.22 PaCO2: 68mmHg Base excess: -2 PaO2 78 mmHg Saturation: 80% Bicarb: 26mEq/L
Respiratory acidosis
A nurse is developing a plan of care for a client who is 12hrs postoperative following a colon resection. which of the following interventions should the nurse include in the plan to reduce respiratory complications?
Splint the incision tp support coughing every 2hrs
A nurse is caring for a client who has acute respiratory distress syndrome and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?
Suppress respiratory effort
A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced?
The patient has subcutaneous emphysema on the upper thorax
When admitting a patient with possible respiratory failure and a high PaCO2. Which assessment information should be immediately reported to the heathcare provider?
The patient is very somnolent
A patient with COPD arrives in the ED complaining of SOB and dyspnea on minimal exertion. Which assessment finding by the nirse is most important to report to the healthcare provider?
The patient's RR has dropped to 10/min
When the prone position is used for a patient with acute respiratory distress syndrome, which information obtained by the nurse indicates that the positioning is effective?
The patients PaO2 is 89mmHg and the SaO2 is 91%
A nurse is performing chest physiotherapy on a client who has respiratory infection. To increase the velocity and turbulance of the air the client exhales, which of the following techniques should the nurse use?
Vibration
A nurse is reviewing the ABGs for a client in the ICU who as kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect?
Widened QRS complexes
During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first?
c. Use pulse oximetry to check the oxygen saturation.