Quiz

in addition to treatment of the underlining cost, which medical intervention should the nurse anticipate will be introduced in the management of a client with acute respiratory distress syndrome?

A. PEEP

A client has an endotracheal tube and is receiving mechanical ventilation. The nurse identifies that periodic suctioning may be necessary. The nurse follows a specific protocol when performing this procedure. in what order should they be performed?

B. 2-1-5-3-4

A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct?

A. Keep the drainage system lower than the level of the client's chest

A patient was complaining of a racing heart and feeling anxious comes to the ED. The nurse places the client on a heart monitor and obtains the 1st readings. What should the nurse do next?

A. Obtain the patients vital signs including oxygen saturation

To prevent septic shock in hospitalized client, which should the nurse do?

A. Use aseptic technique during all invasive procedures.

A client is admitted to the intensive care unit with acute pulmonary edema. Which diuretic does the nurse anticipate will be prescribed?

A. furosemide

The nurse is caring for a client with a new more thorax and chest too period to evaluate the effectiveness of the chest soup, the nurse's sizes for which finding?

A. return of breath sounds

A nurse is caring for a client after cardiac surgery. Which signs will cause the nurse to suspect cardiac tamponade? Select all that apply

ABC muffled heart sounds, pulses paradoxes, jugular vein distention.

A client is admitted with full blown anaphylactic shock that developed due to a type one latex allergy reaction. Which findings will the nurse observe upon assessment? Select all that apply.

ABC stridor dyspnea, hypotension

the client is admitted with sinus tachycardia period to treat the dysrhythmias, the nurse will look for potential causes. Which causes will the nurse look for in this client? Select all that apply

ABCE anemia anxiety exercise caffeine.

What clinical indicators should the nurse expect to identify in a client with acute respiratory distress syndrome? Select all that apply

ACDE hypoxemia, crackles, atelectasis, severe dyspnea.

A nurse is caring for several clients in the intensive care unit. Which is the greatest risk factor for client to develop acute respiratory distress syndrome?

B. Aspirating gastric contents

A client with acute respiratory distress syndrome is intubated and placed on a ventilator what should the nurse do when caring for the client and the mechanical ventilator?

B. Assess the need for suctioning when the high pressure alarm of the ventilator is activated.

A nurse performs an admission assessment of a 75 year old client with multiple chronic diseases the client's blood pressure is 135/75 and oxygen saturation.. rhythm on the cardiac monitor and observes the reading shown below. which action should the nurse take first?

B. BEGIN external temporary pacing

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take?

C. Check the tube to ensure that it is not kinked

A client with pulmonary embolism is integrated and placed on mechanical ventilation. When suctioning the endotracheal tube, what should the nurse do?

C. Hyper oxygenate with 100% oxygen before and after suctioning

After calling for assistance and a defibrillator, which action should the nurse take next?

C. Initiate cardiopulmonary resuscitation

While helping a patient with a chest tube reposition in bed, the chest who becomes this launched. What is your immediate nursing interaction?

C. Place a sterile dressing over the site and tape it on three sides and notified the physician

A client has a chest tube for pneumothorax. The nurse finds the client in respiratory difficulty, with the chest tube separated from the drainage system. What is the immediate nursing action?

C. Reconnect the clients tube to the drainage system

A client has a pneumothorax, and a closed-chest drainage system is inserted to allow the lung to reinflate. Identify the chamber in the figure below that provides the water seal.

C. the chamber that goes to suction

A client is experiencing hypovolemic shock with decreased tissue perfusion. Which information should the nurse consider when planning care?

D. The body initially attempts to compensate by maintaining peripheral vasoconstriction.

After spontaneous pneumothorax, the client becomes extremely drowsy, and the pulse and respirations increased. What do these client responses indicates the nurse?

D. hypercapnia

A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and closed chest drainage system are effective, what type of pressure will be reestablished?

D. negative pressure in the pleural space

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply.

DE. the RR intervals are relatively consistent. E. One P wave precedes each QRS complex.