Acute Two Midterm

You are caring for a client who is 42-years-old and status post adenoidectomy. You find the client in respiratory distress when you enter their room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect?

Edema of the upper airway

Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy?

impaired verbal communication

Which of the following is a potential complication of a low pressure in the endotracheal cuff?

Aspiration pneumonia

The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Auscultate lung sounds

A client with pulmonary hypertension has a positive vasoreactivity test. What medication does the nurse anticipate administering to this client?

Calcium channel blockers

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

Develop an alternate method of communication.

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

Encouraging increased fluid intake

A client in acute renal failure has been prescribed 2 units of packed red blood cells (PRBCs). The nurse explains to the client that the blood transfusion is most likely needed for which reason?

Lack of erythropoietin

A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure?

Partial pressure of arterial oxygen (PaO2)

The health care provider believes that the client has a deficiency in the leukocyte responsible for cell-mediated immunity. What should the nurse check the WBC count for?

T lymphocytes

The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?

Total laryngectomy

One hour after the completion of a fresh frozen plasma transfusion, a client reports shortness of breath and is very anxious. The client's vital signs are BP 98/60, HR 110, temperature 99.4°F, and SaO2 88%. Auscultation of the lungs reveals posterior coarse crackles to the mid and lower lobes bilaterally. Based on the symptoms, the nurse suspects the client is experiencing which problem?

Transfusion-related acute lung injury

The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include?

You can use writing or a communication board to communicate."

A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer?

a feeling of swelling at the back of the throat

When a client has undergone a laryngectomy and there is evidence of wound breakdown, the nurse monitors the client very carefully because of the high risk for

carotid artery hemorrhage.

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder?

pH 7.28, PaO2 50 mm Hg

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:

sit upright, leaning slightly forward.

A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client?

"Gargle with a warm salt solution."

The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse?

"The tube will drain air from the space around the lung."

Which would be least likely to contribute to a case of hospital-acquired pneumonia?

A nurse washes her hands before beginning client care.

A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that:

A permanent tracheal stoma would be necessary.

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?

Acute respiratory distress syndrome

A nurse is assigned to care for a patient with ascites, secondary to cirrhosis. The nurse understands that the fluid accumulation in the peritoneal cavity results from a combination of factors including an alteration in oncotic pressure gradients and increased capillary permeability. Therefore, the nurse monitors the serum level of the plasma protein responsible for maintaining oncotic pressure, which is:

Albumin.

A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis?

Apply direct continuous pressure.

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?

Bleeding

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema?

Crackles in the lung bases

Wound drains, inserted during the laryngectomy, stay in place until what criteria are met?

Drainage is <30 mL/day for 2 consecutive days.

A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?

Dyspnea

The nurse is assessing a patient who has been admitted with possible ARDS. Which finding would be evidence for a diagnosis of cardiogenic pulmonary edema rather than ARDS?

Elevated B-type natriuretic peptide (BNP) levels

Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require?

Emotional support

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?

Encourage increased fluid intake.

A client receiving a blood transfusion reports shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the health care provider?

Ensure there is an oxygen delivery device at the bedside.

A client with severe anemia is admitted to the hospital. Because of religious beliefs, the client is refusing blood transfusions. The nurse anticipates pharmacologic therapy with which drug to stimulate the production of red blood cells?

Epoetin alfa

A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for:

Fever

The occupational nurse is completing routine assessments on the employees at a company. What might be revealed by a chest radiograph for a client with occupational lung diseases?

Fibrotic changes in lungs

A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected?

Flail chest

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis cariniipneumonia. Which nursing diagnosis has the highest priority?

Impaired gas exchange

The nurse makes the observations shown in the accompanying notes about a client who will be discharged following a laryngectomy. The nurse makes a referral to the home health nurse for client reteaching based on which observation?

Initial washing of hands after cleaning inner cannula.

The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs?

Initiate enteral feedings.

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?

Initiate oxygen therapy.

Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following?

Liver

Which term refers to a form of white blood cell involved in immune response?

Lymphocyte

Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets?

Myeloid stem cell

The body responds to infection by increasing the production of white blood cells (WBCs). The nurse should evaluate the differential count for what type of WBCs, which are the first WBCs to respond to an inflammatory event?

Neutrophils

A client involved in a motor vehicle accident arrives at the emergency department unconscious and severely hypotensive. The nurse suspects the client has several fractures in the pelvis and legs. Which parenteral fluid is the best choice for the client's current condition?

Packed red blood cells (RBCs)

A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?

Partial laryngectomy

A client is diagnosed with extreme thrombocytosis. The nurse knows this condition is a result of which elevated blood cell count?

Platelets

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?

Progressive loss of lung function associated with chronic disease

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS?

Rapid onset of severe dyspnea

A nurse cares for several mothers and babies in the postpartum unit. Which mother does the nurse recognize as being most at risk for a febrile nonhemolytic reaction?

Rh-negative mother; Rh-positive child

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?

Hypercapnia, hypoventilation, and hypoxemia

A nurse is transfusing whole blood to a client with impaired renal function. During the transfusion, the client tells the nurse, "I feel very short of breath all of a sudden." What is the nurse's primaryaction?

Stop infusion

A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia?

Streptococcus pneumoniae

The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells?

The kidneys sense low oxygen levels in the blood and produce erythropoietin, stimulating the bone marrow to produce more red blood cells.