Respiratory Medical Surgical Nursing Ch 27

____ 21. The nurse working with a student nurse is providing care for a patient requiring mechanical ventilation. The student nurse asks the meaning of assist control. Which response by the nurse is the most appropriate? 1)"Assist control is a means of delivering ventilation that delivers a preset volume and/or pressure each time the patient begins an inspiration." 2)"Assist control allows the patient to breathe independently but supplies a breath if the patient does not begin an inhalation in a specified period of time." 3)"Assist control is used when weaning a patient from the ventilator because the patient must exercise the muscles of respiration in order to get a full breath." 4)"Assist control is often used when a patient is receiving a paralytic agent."

)"Assist control is a means of delivering ventilation that delivers a preset volume and/or pressure each time the patient begins an inspiration." Assist control allows the patient to begin inspiration, but the ventilator provides a preset pressure or volume to boost the patient's tidal volume.

____ 22. The nurse is providing care for the patient requiring mechanical ventilation. Which action by the nurse would be inappropriate when providing care to this patient? 1)Confirming airway placement by auscultating the lungs and checking the length marking of the tube at the lip 2)Assuring that tube cuff inflation is no greater than 15 cm H2O, and that there is no audible air leak 3)Assuring ventilator tubing is secured and does not pull on the patient's airway 4)Verifying correct ventilator settings

2) Assuring that tube cuff inflation is no greater than 15 cm H2O, and that there is no audible air leak Tube cuff inflation is normally set at 20-30 cm H2O.

42. The nurse is caring for a patient with this device placed. What would be the purpose of it? 1) Increases coagulation of the blood 2) Filters clots from the lower extremities 3) Provides anticoagulation without medications 4) Expands the vessels to prevent clot formation

2) Filters clots from the lower extremities Rationale: Inferior vena cava (IVC) filters are placed to prevent clots from the lower extremities from migrating to the pulmonary vascular system.

37. The patient with a severe pneumonia is showing confusion, lethargy, and a pink complexion. What stage of respiratory failure are they exhibiting? 1)Early 2)Intermediate 3)Advanced 4)Late

2) INTERMEDIATE Rationale: Early signs of failure include dyspnea, restlessness, anxiety, fatigue, increased blood pressure (from baseline), and tachycardia.The patient with intermediate respiratory failure presents with confusion, lethargy (due to increased CO2), and pink skin coloration (due to increased CO2). Late signs of failure include cyanosis and coma. Test-Taking Tip Consider the symptoms of each.

30. The nurse is caring for a patient with acute respiratory distress syndrome with a severity ratio of 101 on positive end-expiratory pressure (PEEP). What category of severity is this patient? 1) Mild 2) Moderate 3) Progressive 4) Severe

2) Moderate This is a severity ratio of 100-200 on ventilator settings that include PEEP

39. A patient experiencing an acute pulmonary embolism (PE) is experiencing right heart failure without a significant change in the vital signs. Which classification of pulmonary embolism is this? 1) Massive 2) Sub-massive 3) Intermediate 4) Low risk

2) Sub-massive Rationale: A sub-massive PE is present when there is right heart dysfunction but no hemodynamic instability. Test-Taking Tip Understand the categories and their presenting symptoms.

32. The nurse is reviewing the chest x-ray report of a ventilated patient requiring an FiO2 of 70%. Which finding is most concerning? 1) Atelactasis 2) Bilateral Infiltrates 3) 5% pneumothorax 4) Endotracheal tube 4 cm above the carina

2)Bilateral infiltrates During the early phases of acute respiratory distress syndrome (ARDS), serial chest x-rays can be used to identify the bilateral infiltrates that are the hallmark sign of this disease process. Atelectasis can be corrected by increasing the tidal volume or positive end-expiratory pressure (PEEP). 5% pneumothorax is very small and does not typically cause compromise. Endotracheal tube 4 cm above the carina is the correct location of the tube. Test-Taking Tip Understand early findings.

48. The nurse is caring for a patient on a ventilator when the low-pressure alarm sounds. What action should the nurse take first? 1)Silence the alarm. 2)Check that connections are tight. 3)Suction the patient. 4)Increase the positive end-expiratory pressure (PEEP). 5)Avoid rectal temperature.

2)Check that connections are tight. Rationale: Decreases in airway pressure may indicate a leak in the system. 5)Avoid rectal temperature. Rationale: Avoid rectal temperature Test-Taking Tip Patient safety first.

____ 3. A patient with a respiratory rate of eight breaths per minute has an oxygen saturation of 82%. Which nursing diagnosis is a priority for this patient? 1)Risk for Infection 2)Impaired Spontaneous Ventilation 3)Risk for Acute Confusion 4)Decreased Cardiac Output

2)Impaired Spontaneous Ventilation A priority nursing diagnosis for a patient with a respiratory rate of eight breaths per minutes and an oxygen saturation of 82% is Impaired Spontaneous Ventilation. If the current pattern continues without intervention, the patient could experience respiratory arrest.

____ 6. The nurse caring for a newborn on a ventilator for acute respiratory distress syndrome (ARDS) informs the parents that the newborn is improving. Which data supports the nurse's assessment of the newborn's condition? 1)Increased PCO2 2)Oxygen saturation of 92% 3)Pulmonary vascular resistance increases 4)Less than 1 mL/kg/hour urine output

2)Oxygen saturation of 92% An expected outcome for a patient being treated for ARDS is maintaining an oxygen saturation of greater than 90%. The newborn diagnosed with ARDS with an oxygen saturation of 92% is improving.

____ 4. A patient with acute respiratory distress syndrome (ARDS) is being weaned from mechanical ventilation. Which nursing action is appropriate for this patient? 1)Increase percentage of oxygen being provided through the ventilator 2)Place in the Fowler position 3)Provide morning care during the weaning procedures 4)Medicate with morphine for pain as needed

2)Place in the Fowler position Weaning a patient from mechanical ventilation should begin in the morning when the patient is well-rested. The patient should be in the Fowler or high-Fowler position, as this facilitates lung expansion and reduces the work of breathing.

47. What should the nurse monitor for as a hallmark sign of a ventilator-associated pneumonia (VAP)? 1)Tachypnea 2)Purulent secretions 3)Hypoxemia 4)Hypothermia

2)Purulent secretions Rationale: Development of a fever, leukocytosis, increased respiratory effort, and purulent secretions are hallmark signs of VAP. Test-Taking Tip Hallmark signs is the key.

____ 18. The nurse is providing care to several patients on a medical-surgical unit. Which patient is at highest risk for a nonthrombotic pulmonary embolism? 1)The patient who is receiving intravenous pain medication 2)The patient who is postoperative from a femur fracture repair 3)The patient with a primary lung tumor 4)The patient who uses intravenous illicit drugs

2)The patient who is postoperative from a femur fracture repair The other patients may be at risk for pulmonary embolism; however, they are incorrect choices for the most common cause of nonthrombotic pulmonary emboli.

____ 9. The nurse in the intensive care unit (ICU) is caring for a patient diagnosed with acute respiratory distress syndrome (ARDS). Vital signs prior to endotracheal intubation: HR 108 bpm, RR 32 bpm, BP 88/58 mm Hg, and oxygen saturation 82%. The patient is intubated and placed on mechanical ventilation with positive pressure ventilation. Which assessment finding indicates a further decrease of cardiac output secondary to positive pressure ventilation? 1)Blood pressure 90/60 mm Hg 2)Urine output 25mL/hr 3)Heart rate 110 bpm 4)Oxygen saturation 90%

2)Urine output 25mL/hr Decreased cardiac output is supported by a decrease of urine output. Expected urine output is at least 30 mL/hr. This patient's urine output is decreased; therefore, this finding supports the diagnosis of decreased cardiac output.

____ 12. The nurse is providing discharge instructions to an older adult patient who is going home after having a total knee replacement. Which will the nurse include in the discharge teaching to decrease the patient's risk for developing a thrombosis or pulmonary embolism? 1)Place pillows under the knees when in bed 2)Use compression stockings 3)Limit ambulation 4)Limit fluids

2)Use compression stockings A patient being discharged after having orthopedic surgery is at increased risk for pulmonary embolism. The nurse should instruct the patient to continue with leg exercises and use compression stockings to reduce the risk of deep vein thrombosis formation.

____ 8. A patient admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS). Which health-care provider prescription does the nurse anticipate for this patient? 1)Mechanical ventilation 2)Oxygen via a nasal cannula 3)Face mask oxygen administration 4)Continuous positive airway pressure

1)Mechanical ventilation With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen therapy alone. With mechanical ventilation, the FiO2 (fraction of inspired oxygen-the percentage of oxygen administered) is set at the lowest possible level to maintain a PaO2 higher than 60 mm Hg and oxygen saturation of approximately 90%. It is important to remember that mechanical ventilation does not cure ARDS; it simply supports respiratory function while the underlying problem is identified and treated.

____ 26. The nurse educator prepares to speak to a group of nursing students about direct and indirect insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS). Which conditions will the nurse include in the teaching session? Select all that apply. 1)Septic shock 2)Viral pneumonia 3)Aspirin overdose 4)Head injury 5)Angioplasty

1)Septic shock 2)Viral pneumonia 3)Aspirin overdose 4)Head injury ARDS is a severe form of acute respiratory failure that occurs in response to pulmonary or systemic insults. Such insults include, but are not limited to, hemorrhagic or septic shock, smoke inhalation, aspiration, viral pneumonias, propoxyphene or aspirin overdose, burns, head injuries, pancreatitis, and multiple transfusions.

____ 20. The nurse is planning care for a newly admitted patient diagnosed with pulmonary embolism. The nurse anticipates the patient will need anticoagulant therapy. What is true regarding this therapy for the treatment of this condition? 1)It is considered second-line treatment. 2)Major hemorrhage is common. 3)Heparin and warfarin (Coumadin) are usually initiated at the same time. 4)Heparin alters the synthesis of vitamin K-dependent clotting factors, preventing further clots.

3)Heparin and warfarin (Coumadin) are usually initiated at the same time. Heparin and warfarin are usually initiated at the same time for the treatment of pulmonary embolus.

____ 27. A patient receiving treatment for acute respiratory distress syndrome (ARDS) is demonstrating anxiety and fear of having to stay on the ventilator indefinitely. Which interventions by the nurse are appropriate? Select all that apply. 1)Explain about care areas specifically designed for long-term ventilatory support. 2)Dim the lights and reduce distracting noise, such as the television. 3)Instruct that intubation and ventilation are temporary measures. 4)Encourage family visits and participation in care. 5)Remain with the patient as much as possible.

3)Instruct that intubation and ventilation are temporary measures. 4)Encourage family visits and participation in care. 5)Remain with the patient as much as possible. The nurse should also remain with the patient as much as possible and instruct that intubation and ventilation are temporary measures to allow the lungs to rest and heal. To reduce this patient's anxiety, the nurse should encourage the family to visit and participate in care. The nurse should also remain with the patient as much as possible and instruct that intubation and ventilation are temporary measures to allow the lungs to rest and heal.

35. The nurse is caring for a patient in acute respiratory failure whose oxygenation continues to decrease. The patient is currently on a nonrebreather mask with 100% FIO2. The nurse requests an order for the device in this image. How will this benefit the patient? 1)It provides a higher level of oxygen. 2)It breathes for the patient so they don't have to. 3)It provides pressure with each of the patient's own breaths. 4)It pushes air into the lungs.

3)It provides pressure with each of the patient's own breaths. Rationale: Noninvasive positive-pressure ventilation maintains one continuous pressure throughout the respiratory cycle to help keep the alveoli open while breathing. Test-Taking Tip Look closely at the image.

49. A patient with acute respiratory distress syndrome has this laboratory report. What is the nurse's primary concern? 1)Ventilator-associated infection 2)Hemorrhage 3)Multi-organ dysfunction syndrome 4)Disseminated intravascular coagulation (DIC)

3)Multi-organ dysfunction syndrome Rationale: The elevated ALT, BUN, and creatinine indicate liver and kidney failure. Test-Taking Tip Know normal laboratory reports.

____ 7. The nurse caring for a patient admitted with septic shock is aware of the need to assess for the development of acute respiratory distress syndrome (ARDS). Which early clinical manifestation would indicate the development of ARDS? 1)Intercostal retractions 2)Cyanosis 3)Tachypnea 4)Tachycardia

3)Tachypnea Dyspnea and tachypnea are early clinical manifestations of ARDS.

50. A nurse is at a high school baseball game when a teenager gets hit in the chest with a baseball. Which finding is most concerning? 1)The teen is screaming and crying. 2)The teen's respiratory rate is 28 breaths per minute. 3)The teen has paradoxical chest wall movement. 4)The teen refuses to follow directions to lay down.

3)The teen has paradoxical chest wall movement. Rationale: Paradoxical chest wall movement is the hallmark sign associated with a flail chest. Test-Taking Tip Understand normal for the situation.

____ 16. A patient scheduled for surgery is being instructed in leg exercises and the pneumatic compression device. The nurse includes these instructions to decrease which postoperative complication? 1)Infection 2)Delayed wound healing 3)Contractures 4)Deep vein thrombosis

4)Deep vein thrombosis The best care for a pulmonary embolism is prevention. Since surgical patients have an increased risk of developing a pulmonary embolism postoperatively, instructions should include ways to encourage movement, such as leg exercises, and the need for pneumatic compression devices to maintain lower extremity circulation and prevent the development of a deep vein thrombosis.

____ 19. A nurse caring for a patient with a pulmonary embolism expects to find which diagnostic result? 1)Patchy infiltrates on chest x-ray 2)Metabolic alkalosis on arterial blood gas 3)Elevated CO2 level found on end-tidal carbon dioxide monitor 4)Tachycardia and nonspecific T-wave changes on EKG

4)Tachycardia and nonspecific T-wave changes on EKG With pulmonary embolism, tachycardia and nonspecific T-wave changes occur on EKG.

36. The nurse is caring for a ventilated patient with respiratory failure who is restless and anxious. The nurse notes that the pulse oximetry saturation is decreasing as the patient becomes more agitated. What action should the nurse take? 1) Increase the FiO2 on the ventilator. 2) Suction the lungs. 3)Provide sedation. 4)Reposition the patient onto the side.

Provide sedation. Rationale: Sedation is used to control agitation and anxiety, which increase the work of breathing and oxygen consumption. It is especially needed if the patient requires mechanical ventilation. Test-Taking Tip Providing sedation will improve oxygenation.

44. The nurse is caring for a patient in respiratory distress whose pulse oximetry reading is 95%. What should the nurse anticipate the PaO2 level is on the arterial blood gases? 1) 60 mm Hg 2) 80 mm Hg 3) 95 mm Hg 4) 100 mm Hg

2) 80 mm Hg Rationale: The goal is to have an SpO2 greater than 94% (which correlates to a PaO2 of approximately 80 mm Hg)

43. The nurse is caring for a patient with lung disease. Which assessment changes indicate the patient may be experiencing hypercapnia? Select all that apply. 1) Headache 2) Confusion 3) Cyanosis 4) Somnolence 5) Dysrhythmias

1) Headache 2) Confusion 3) Cyanosis 4) Somnolence 5) Dysrhythmias Test-Taking Tip Differentiate between hypercapnia and hypoxemia.

45. The nurse is administering medications to a patient with respiratory distress. Which medication should be delivered first? 1) Inhaled bronchodilator 2)Intravenous steroid 3)Inhaled steroid 4) Intravenous antibiotic

1) Inhaled bronchodilator Rationale: The inhaled bronchodilator medications should be delivered first, to open the airways. Test-Taking Tip Understand route of administration and peak effect.

25. The nurse is providing care to a patient admitted to the emergency department with the diagnosis of acute respiratory distress syndrome (ARDS). When educating the patient's family on the disease progress, in which order will the nurse present the material? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Initiation of ARDS 2) Onset of pulmonary edema 3) End-stage ARDS 4) Alveolar collapse

1) Initiation of ARDS 2) Onset of pulmonary edema 4) Alveolar collapse 3) End-stage ARDS

41. The nurse is caring for a patient with dyspnea. Which diagnostic test findings demonstrate that the patient has a pulmonary embolism (PE)? Select all that apply. 1) Normal electrocardiogram (ECG) 2) Positive spiral computed tomography (CT) scan 3) High probability V/Q mismatch 4) Negative angiography test 5) Positive D-dimer

1) Normal electrocardiogram (ECG) 2) Positive spiral computed tomography (CT) scan 3) High probability V/Q mismatch 4) Negative angiography test 5) Positive D-dimer Test-Taking Tip Determine positive and negative findings.

33. The nurse is caring for a patient with acute respiratory distress syndrome (ARDS) whose condition is deteriorating. What ventilatory options may be considered to improve the refractory hypoxemia? Select all that apply. 1) Reduce the tidal volume. 2) Increase the PEEP. 3)Decrease the FiO2 4)High-frequency oscillating ventilation 5)Partial liquid ventilation

1) Reduce the tidal volume. 3)Decrease the FiO2 5)Partial liquid ventilation Increase the PEEPwill worsen the hypoxemia. High frequency oscillating ventilation delivers very small tidal volumes at high frequencies Test-Taking Tip Consider ventilatory options.

46. The patient with acute respiratory distress syndrome has been ventilated for 48 hours. What priority concern should the nurse address with the provider? 1) The need for enteral nutritional therapy Rationale: Enteral (nasogastric tube feedings through the gastrointestinal tract [GI]) should be initiated within 48 to 72 hours of the initiation of mechanical ventilation. Enteral nutrition is the preferred method unless contraindicated because of GI issues. 2)The need for parenteral nutritional therapy 3) The need for oral feedings 4) The need for increased IV fluids

1) The need for enteral nutritional therapy Rationale: Enteral (nasogastric tube feedings through the gastrointestinal tract [GI]) should be initiated within 48 to 72 hours of the initiation of mechanical ventilation. Enteral nutrition is the preferred method unless contraindicated because of GI issues. Test-Taking Tip Enteral therapy is always preferred over parenteral therapy.

____ 11. The nurse is concerned that a patient admitted for a total hip replacement is at risk for thrombus formation and pulmonary embolism. Which assessment finding supports the nurse's concern? 1)Body mass index (BMI) 35.8 2)Former cigarette smoker 3)Blood pressure 132/88 mm Hg 4)Age 45 years

1)Body mass index (BMI) 35.8 Risk factors for the development of thrombus formation that could lead to a pulmonary embolism include obesity, orthopedic surgery, myocardial infarction, heart failure, and advancing age. The BMI of 35.8 falls into the category of obese, which would increase the patient's risk of developing a thrombus and possible pulmonary embolism.

40. The nurse is caring for a patient with a deep vein thrombosis. As the nurse assists the patient to the restroom, she says, "I'm feeling very winded." What additional symptoms should the nurse assess for? Select all that apply. 1)Crackles in the lungs 2)Pleuritic chest pain 3)Orientation 4)Tachypnea 5)Capillary refill

1)Crackles in the lungs 2)Pleuritic chest pain 3)Orientation 4)Tachypnea 5)Capillary refill Test-Taking Tip Consider the early symptoms.

38. A nurse is reviewing the major predisposing factor for the development of a deep vein thrombosis (DVT). What should be included in this list? Select all that apply. 1)Dehydration 2)Venous stasis 3)Vessel wall damage 4)Irregular heart rhythm 5)Hypercoagulability

1)Dehydration 2)Venous stasis 3)Vessel wall damage 4)Irregular heart rhythm 5)Hypercoagulability Test-Taking Tip Consider the top three of Virchow's triad.

____ 28. Which assessment data would cause the nurse to document the patient is experiencing early respiratory distress? Select all that apply. 1)Dyspnea 2)Restlessness 3)Tachycardia 4)Confusion 5)Cyanosis

1)Dyspnea 2)Restlessness 3)Tachycardia Confusion is an intermediate sign of respiratory distress. .Cyanosis is a late sign of respiratory distress.

29. The charge nurse is revising the ventilated patients in the intensive care unit for their risk of developing acute respiratory distress syndrome (ARDS). Which patients should be most closely monitored for symptoms? Select all that apply. 1) 88 year old with aspiration pneumonia after a stroke 2) 19 year old in a multi car accident 3) 45 year old who had a five vessel coronary bypass graft surgery 4) 54 year old with a colostomy from a diverticulitis 5) 62 year old with a left lower lob removal from lung cancer

1, 2, 3, 5 1) 88 year old with aspiration pneumonia after a stroke Aspiration is a high risk for ARDS development. 2) 19 year old involved in a multi-car accident Severe trauma such as a car accident is a risk factor for ARDS. 3) 45 year old who had a five-vessel coronary bypass graft surgery Those who have been on cardiopulmonary bypass are at risk. 5) 62 year old with a left lower lobe removal from lung cancer A pneumonectomy is a risk factor. 4 Is not correct: Abdominal surgeries are not higher risk, unless in the presence of sepsis. Test-Taking Tip Understand risk factors and monitor closely.

____ 15. The nurse has instructed a patient recovering from a pulmonary embolism on long-term anticoagulant therapy. Which patient statement indicates that instruction has been effective? 1)"I will expect bloody sputum when I brush my teeth." 2)"I need to use a soft toothbrush and an electric razor and avoid injuries." 3)"I need to eat a well-balanced diet with green salads." 4)"I can expect to be bruised, since this is normal."

2) "I need to use a soft toothbrush and an electric razor and avoid injuries." Instruction on anticoagulant therapy should include the need to avoid injury, use a soft toothbrush, and use an electric razor.

31. During the early stages of acute respiratory distress syndrome (ARDS), the nurse should monitor for which arterial blood gas change? 1) Respiratory Acidosis 2) Respiratory alkalosis 3) Metabolis acidosis 4) Metabolic alkalosis

2 Respiratory acidosis Rationale: This occurs later is the process as hypercarbia and worsening hypoxemia develop. Respiratory alkalosis Rationale: Arterial blood gases (ABGs) initially reveal a respiratory alkalosis due to the tachypnea. Metabolic acidosis Rationale: Metabolic acidosis is not a concern for ARDS. Metabolic alkalosis Rationale: Metabolic alkalosis is not a concern for ARDS. Test-Taking Tip Understand acid-base imbalances of acute respiratory distress syndrome (ARDS).

____ 2. The nurse is providing care to a patient with an infected leg wound. The patient is exhibiting symptoms of a systemic infection and is receiving intravenous antibiotics. The patient states to the nurse, "I am having trouble breathing." Based on this data, which does the nurse suspect the patient is experiencing? 1)Allergic response from antibiotic therapy 2)Deep vein thrombosis 3)Acute respiratory distress syndrome 4)Anemia

3 Sepsis is the most common cause of acute respiratory distress syndrome (ARDS). The patient has a systemic infection, which is sepsis, and is complaining that it is getting hard to breathe. The nurse should suspect the patient is developing acute respiratory distress.

____ 24. The nurse is providing care for a patient requiring mechanical ventilation. When the nurse enters the room at the beginning of the shift, the patient's monitor displays a heart rate of 64 and oxygen saturation of 88%. Which nursing action is the priority? 1)Increasing the oxygen concentration and quickly assessing the patient 2)Removing the patient from the ventilator and hyperoxygenating and hyperventilating the patient 3)Assessing the patient for airway obstruction 4)Checking ventilator settings

3)Assessing the patient for airway obstruction Remembering the nursing process, the nurse would not intervene until assessing for the cause of the patient's distress.

____ 17. The nurse is preparing to discharge a patient recovering from a pulmonary embolism. Which topics are appropriate for the nurse to include in the teaching session? 1)Resume the use of any over-the-counter medications 2)Diet to include green leafy vegetables 3)Anticoagulant administration schedule 4)Resume normal activity level

3) Anticoagulant administration schedule The nurse should instruct the patient in symptoms of bleeding or recurrence of a pulmonary embolism and the schedule for anticoagulation administration.

34. The nurse is caring for a ventilated patient with acute respiratory distress syndrome whose temperature is 37.8ᵒ C. What action should the nurse take? 1) Deliver the scheduled intravenous antibiotic. 2) Administer the ordered antipyretic. 3) Assess for purulent secretions. 4) Send a sputum for culture.

3) Assess for purulent secretions. Rationale: This patient is at risk for developing a ventilator associated pneumonia (VAP). Development of a fever, leukocytosis, increased respiratory effort, and purulent secretions are hallmark signs of VAP. Sputum cultures will indicate infection. The earlier VAP is diagnosed, the earlier it can be treated. Test-Taking Tip Recognize early signs of ventilator associated pneumonia (VAP).

____ 13. A patient diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. Which is the priority nursing diagnosis for this patient? 1)Ineffective Tissue Perfusion 2)Anxiety 3)Impaired Gas Exchange 4)Impaired Physical Mobility

3) Impaired Gas Exchange A reduction in arterial oxygen saturation level and dyspnea indicates the patient is experiencing impaired gas exchange. This would be the priority for the patient at this time.

____ 14. The nurse is planning care for a patient with a pulmonary embolism. Which intervention would assist with the patient's decrease in cardiac output? 1)Provide oxygen 2)Keep protamine sulfate at the bedside 3)Monitor pulmonary arterial pressures 4)Assess for bleeding

3) Monitor pulmonary arterial pressures The patient with a pulmonary embolism and decreased cardiac output is at risk for developing right heart failure. The nurse should monitor pulmonary arterial pressures.

51. The nurse is caring for a patient with a chest tube placed for a spontaneous pneumothorax. Which assessment finding is anticipated? 1) Bloody return in the collection chamber 2) Continuous bubbling in the water seal chamber 3) Water level fluctuation in the water seal chamber with respiratory effort 4) Subcutaneous emphysema

3) Water level fluctuation in the water seal chamber with respiratory effort Rationale: This is called "tidaling" and is expected. Test-Taking Tip Understand normal and abnormal.

____ 5. A patient is brought into the emergency department (ED) after being in a motor vehicle accident. The patient has suffered traumatic injury that may involve multiple body systems. Which is the priority nursing assessment for this patient? 1)Breathing and ventilation 2)Circulation with hemorrhage control 3)Airway maintenance with cervical spine protection 4)Disability and neurological assessment

3)Airway maintenance with cervical spine protection When caring for the trauma victim the nurse must always prioritize assessments, with the ABCDEs as the highest-priority concerns. It is imperative that the nurse's first concern is airway maintenance with cervical spine protection.

____ 10. The nurse caring for a patient recovering from an abdominal hysterectomy suspects the patient is experiencing a pulmonary embolism. Which clinical manifestation supports the nurse's suspicion? 1)Nausea 2)Decreased urine output 3)Dyspnea and shortness of breath 4)Activity intolerance

3)Dyspnea and shortness of breath Manifestations of a pulmonary embolism include dyspnea, shortness of breath, pleuritic chest pain, anxiety, apprehension, cough, tachycardia, tachypnea, crackles, and a low-grade fever.

____ 23. The nurse working in the intensive care unit is assigned a patient requiring mechanical ventilation. When responding to the ventilator alarm, the nurse sees a high-pressure alarm. Which nursing action is the priority? 1)Silencing the alarm 2)Removing the patient from the ventilator and using a bag-valve device to oxygenate the patient until the respiratory therapist can be summoned 3)Emptying the collected water from the ventilator tubing 4)Assessing the patient

4) Assessing the patient In most instances, depending on facility policy, if a patient requires mechanical ventilation, he is placed on cardiorespiratory monitors with continuous oxygen saturation monitoring. The nurse would assess heart rate and oxygen saturation and examine the patient for any signs of distress.

____ 1. The nurse is providing care to a patient who is diagnosed with acute respiratory distress syndrome (ARDS). Which clinical manifestation does the nurse anticipate for this patient who is experiencing hypoxia as a result of the ARDS diagnosis? 1)Fluid imbalance 2)Hypertension 3)Bradycardia 4)Dyspnea

4 Dyspnea is a clinical manifestation that patients experiencing hypoxia secondary to ARDS.