test 9 ch 27
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."
1) "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.
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.
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.
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) 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.
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 lea Tube cuff inflation is normally set at 20-30 cm H2O.
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
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% Increased PCO2 and pulmonary vascular resistance are indicative of continued distress.
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.
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.
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.
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.
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) Acute respiratory distress syndrome 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.
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.
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.
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.
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
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.
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 indicate the patient is experiencing impaired gas exchange. This would be the priority for the patient at this time.
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.
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.
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 cardio-respiratory monitors with continuous oxygen saturation monitoring. The nurse would assess heart rate and oxygen saturation, and examine the patient for any signs of distress.
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.
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 Dyspnea is a clinical manifestation that patients experiencing hypoxia secondary to ARDS.
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.
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
ANS: 1, 2, 3 1. This is correct. Dyspnea, or shortness of breath, is an early sign of respiratory distress. 2. This is correct. Restlessness is an early sign of respiratory distress. 3. This is correct. Tachycardia is an early sign of respiratory distress.
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
ANS: 1, 2, 3, 4 1. This is correct. 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. 2. This is correct. 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. 3. This is correct. 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. 4. This is correct. 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.
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.
ANS: 3, 4, 5 3. This is correct. 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. 4. This is correct. To reduce this patient's anxiety, the nurse should encourage the family to visit and participate in care. 5. This is correct. 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.