Adult III Exam 2

A nurse is caring for a client with history of heart failure that presents to the ER with symptoms indicating a PE. The nurse documents admission findings of sudden shortness of breath, chest pain, and immobility. Which nursing diagnoses are admission priorities? (Select all that apply) a. Impaired nutrition: less than body requirement related to anorexia b. Disturbed sleep pattern related to restlessness in the night c. Anxiety related to breathlessness d. Activity intolerance related to inadequate oxygenation e. Ineffective breathing pattern related to hypoxia

Correct Answer(s): c. Anxiety related to breathlessness d. Activity intolerance related to inadequate oxygenation e. Ineffective breathing pattern related to hypoxia

A client just involved in a motor vehicle accident presents to the ER with sustained blunt chest trauma injuries. The nurse notes absent breath sounds on the left side. A left-sided pneumothorax is suspected and is further validated when assessment of the trachea reveals which finding? a. A shift to the right b. A shift to the left c. No deviation d. Subcutaneous emphysema

Correct Answer: a. A shift to the right

The client with pneumonia has developed dyspnea, has a respiratory rate of 32 breaths/min, and is having difficulty expelling secretions. The nurse auscultates the lung fields and hears bronchial sounds in the lower left lobe. Which action should the nurse take first? a. Apply oxygen b. Encourage bedrest c. Administer antibiotics d. Assess nutritional intake

Correct Answer: a. Apply oxygen

The nurse is taking care of a client whose ABG results show that the client is hypercapnia. The nurse knows that the oxygen therapy should be used in caution with this client due to the possibility of what situation? a. Carbon dioxide retention b. Pneumothorax c. Oxygen toxicity d. Absorption atelectasis

Correct Answer: a. Carbon dioxide retention

The nurse is suctioning a client's tracheostomy tube, and waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent: a. Depriving the client of sufficient oxygen supply b. Dislodging the tracheostomy tube c. Stimulating the client's cough reflex d. Obstructing the suctioning catheter with secretions

Correct Answer: a. Depriving the client of sufficient oxygen supply

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? a. Kinking of the ventilator tubing b. An ET cuff leak c. A disconnected ventilator tube d. A change in the oxygen concentration without resetting the oxygen level alarm

Correct Answer: a. Kinking of the ventilator tubing

What is the most important goal of nursing care for a client who is in shock? a. Manage adequate tissue perfusion b. Manage fluid overload c. Manage increased cardiac output d. Manage vasoconstriction of vascular beds

Correct Answer: a. Manage adequate tissue perfusion

The nurse is caring for a client in the ICU with signs of shock. Assessment findings include hypertension, warm skin, hypothermia, and bradycardia. The nurse knows which type of shock is indicated by this assessment data? a. Neurogenic shock b. Anaphylactic shock c. Septic shock d. Cardiogenic shock

Correct Answer: a. Neurogenic shock

The nurse is taking care of a client with acute respiratory distress syndrome (ARDS) that has become hypotensive and hypoxic. Which of the following interventions is MOST important? a. Placing client in Prone position b. Administering intravenous dexamethasone c. Administering intravenous furosemide d. Administering lorazepam

Correct Answer: a. Placing client in Prone position

A client has a ventilation-perfusion (V/Q) scans ordered. The nurse understands this is ordered to evaluate the possibility of which of the following? a. Pulmonary emboli b. Pneumonia c. Acute respiratory distress syndrome d. Acute lung failure

Correct Answer: a. Pulmonary emboli

The nurse is taking care of a client in the ICU. The nurse knows that the two scales that are recommended for assessment of agitation and sedation in adult critically ill patients are what? a. Riker Sedation-Agitation Scale (SAS) and the Richmond Agitation-Sedation Scale (RASS) b. Ramsay Scale and Motor Activity Assessment Scale (MASS) c. Ramsay Scale and Riker Sedation-Agitation Scale (SAS) d. Richmond Agitation-Sedation Scale (RASS) and Motor Activity Assessment Scale (MAAS)

Correct Answer: a. Riker Sedation-Agitation Scale (SAS) and the Richmond Agitation-Sedation Scale (RASS)

The nurse is caring for a client with a tracheostomy. When suctioning the client, which actions would be considered safe nursing practice? (Select all that apply) a. Suction when need to prevent secretions from accumulating b. Suction q4h when there are copious thick secretions c. Oxygenate the client, then suction for 10-15 seconds while withdrawing the catheter d. Insert the suction catheter as far as the client can tolerate and suction for 25 seconds

Correct Answer: a. Suction when need to prevent secretions from accumulating c. Oxygenate the client, then suction for 10-15 seconds while withdrawing the catheter

A client with a suspected pulmonary embolus is brought to the emergency department stating shortness of breath and chest pain. Which additional signs and symptoms are anticipated? Select all that apply. a. blood-tinged sputum b. bradycardia c. anxiety d. frothy sputum e. tachycardia

Correct Answer: a. blood-tinged sputum c. anxiety e. tachycardia

Arterial blood gas analysis would reveal which of the following related to acute respiratory failure? a. pH 7.24 b. PaCO2 32 mm Hg c. pH 7.35 d. PaO2 80 mm Hg

Correct Answer: a. pH 7.24

The nurse is analyzing the arterial blood gas results of a client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis? a. pH: 7.20, PaCO2: 65 mm Hg, HCO3: 26 mEq/L b.pH: 7.50, PaCO2: 30 mm Hg, HCO3: 24 mEq/L c.pH: 7.42, PaCO2: 45 mm Hg, HCO3: 22 mEq/L d.pH: 7.32, PaCO2: 40 mm Hg, HCO3: 18 mEq/L

Correct Answer: a. pH: 7.20, PaCO2: 65 mm Hg, HCO3: 26 mEq/L

Which statement by the nurse when explaining the purpose of positive-expiratory pressure (PEEP) to the family members of a client with acute respiratory distress syndrome (ARDS) is correct? a. "PEEP will push more are into the lungs during inhalation" b. "PEEP prevents the lung air sacs from collapse during exhalation" c. "PEEP will prevent fibrosis of the lung from occurring" d. "PEEP allows the ventilator to 100% oxygen into the lungs"

Correct Answer: b. "PEEP prevents the lung air sacs from collapse during exhalation"

The nurse is taking care of a client in the ICU on a ventilator. For a client with an endotracheal tube, which nursing action is the most important? a. Providing frequent oral hygiene b. Auscultating the lungs for bilateral breath sounds c. Turning the client from side to side q2h d. Monitoring serial blood gas values q4h

Correct Answer: b. Auscultating the lungs for bilateral breath sounds

The nurse is assessing a client with irreversible shock. The nurse should document which finding? a. Increased alertness b. Circulatory collapse c. Hypertension d. Diuresis

Correct Answer: b. Circulatory collapse

Before seeing a newly assigned client in the ER with respiratory alkalosis, a nurse quickley reviews the client's medical history in the chart. The nurse knows which condition is a predisposing factor for respiratory alkalosis. a. Type 1 DM b. Extreme anxiety c. Alcohol intoxication d. Oversedation

Correct Answer: b. Extreme anxiety

A client with a bleeding ulcer is vomiting bright red color. The nurse should assess the client for which indicator of early shock? a. Dry, flushed skin b. Heart rate above 100 beats/min c. Increased urine output d. Loss of consciousness

Correct Answer: b. Heart rate above 100 beats/min

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? a. Hyperventilation, hypertension, and hypocapnia b. Hypercapnia, hypoventilation, and hypoxemia c. Hyperoxemia, hypocapnia, and hyperventilation d. Hypotension, hyperoxemia, and hypercapnia

Correct Answer: b. Hypercapnia, hypoventilation, and hypoxemia

A client is admitted to the hospital with a diagnosis of a pulmonary embolism. Which problem should the nurse address first? a. Nonproductive cough b. Impaired gas exchange c. Activity intolerance d. Difficulty breathing

Correct Answer: b. Impaired gas exchange

The nurse is taking care of a client who is receiving chlordiazepoxide as needed for signs and symptoms of alcohol withdrawal. The nurse assesses the client and determines the need for medication with the client displays: a. Hypothermia, mild tremors, slurred speech b. Mild tremors, hypertension, tachycardia c. Bradycardia, hyperthermia, sedation d. Hypotension, decreased reflexes, drowsiness

Correct Answer: b. Mild tremors, hypertension, tachycardia

The ICU nurse is preparing to suction a client's tracheostomy. When suctioning a client's tracheostomy tube, what should the nurse do? a. Suction the tracheostomy for at least 20 seconds b. Oxygenate the client before suctioning c. Use clean gloves during the procedure d. Use a bolus of sterile water to stimulate cough

Correct Answer: b. Oxygenate the client before suctioning

A client's chest tube is connected to a drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that: a. There is an obstruction in the chest tube b. The chest tube system is functioning properly c. The client is developing crepitus d. There is a leak in the chest tube system

Correct Answer: b. The chest tube system is functioning properly

Which assessment finding by the nurse when caring for a client with ARDS who is being treated with mechanical ventilation and high levels of PEEP indicates that the PEEP may need to be decreased? a. The client has a sinus bradycardia with a rate of 52 b. The client has subcutaneous emphysema c. The client has bronchial breath sounds in lung fields bilaterally d. The client's PaO2 is 50 mmHg and the SaO2 is 88%

Correct Answer: b. The client has subcutaneous emphysema

The nurse is taking care of a client in the ICU on mechanical ventilation who becomes very frustrated when trying to communicate. Which intervention should the nurse perform to assist the client? a. Encourage pulmonary toiletry to expedite extubation b. Reassure the client that everything will be alright and that that the client is getting better c. Ask the client to write or spell words with an alphabet board d. Ask family members to stay with the client whenever they can

Correct Answer: c. Ask the client to write or spell words with an alphabet board

A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. What action should the nurse take FIRST? a. Administer midazolam 5mg by IV push immediately b. Apply soft wrist restraints to keep him from pulling out the endotracheal tube c. Assess the patient to see if a physiologic reason exists for his agitation d. Obtain an arterial blood gas level to ensure the patient is not hypoxemic

Correct Answer: c. Assess the patient to see if a physiologic reason exists for his agitation

The nurse hears the low tidal volume alarming on a client's ventilator in one of the nurse's assigned ICU rooms. What is the nurse's FIRST action? a. Manually ventilate the client b. Call the physician c. Check the ventilator connections d. Put air into the endotracheal tube cuff

Correct Answer: c. Check the ventilator connections

The nurse is caring for a client who is experiencing cardiogenic shock. Which medication would the nurse anticipate giving? a. Phenylephrine (Neo-Synephrine) b. Epinephrine (Adrenaline) c. Dobutamine (Dobutrex) d. Norepinephrine (Levophed)

Correct Answer: c. Dobutamine (Dobutrex)

The nurse interprets which findings as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? a. Elevated carbon dioxide level b. Metabolic acidosis c. Hypoxia not responsive to oxygen therapy d. Sever, unexplained electrolyte imbalance

Correct Answer: c. Hypoxia not responsive to oxygen therapy

The nurse is taking care of a client that presented to the ER in possible septic shock. The nurse knows which blood test is most helpful in determining the severity of septic shock? a. Urinalysis b. Troponin c. Lactate d. Kentones

Correct Answer: c. Lactate

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? a. Stripping the chest tube every hour b. Keeping the collection chamber at chest level c. Measuring and documenting the drainage in the collection chamber d. Maintaining continuous bubbling in the water-seal chamber

Correct Answer: c. Measuring and documenting the drainage in the collection chamber

A client in the ICU is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a. Bicarbonate (HCO3-) b. Partial pressure of arterial carbon dioxide (PaCO2) c. Partial pressure of arterial oxygen (PaO2) d. pH

Correct Answer: c. Partial pressure of arterial oxygen (PaO2)

A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic shock? a. A decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces b. It is due to severe hypersensitivity reaction resulting in massive systemic vasodilation c. Generally caused by decreased blood volume d. A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume

Correct Answer: d. A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume

The client is admitted to the ICU in septic shock. Which assessment data warrants immediate intervention by the nurse? a. A white blood cell count of 19,000 b. Vital signs T 100.4, P 104, R 26, and BP 112/65 c. A SaO2 reading 92% d. A urinary output of 50ml in the past 3 hours

Correct Answer: d. A urinary output of 50ml in the past 3 hours

The nurse is taking care of an intubated client in the ICU. For a client with an endotracheal tube, the nurse knows which nursing action is the MOST important? a. Turning the client from side to side q2h b. Monitoring serial blood gas values q4h c. Providing frequent oral hygiene d. Auscultating the lungs for bilateral breath sounds

Correct Answer: d. Auscultating the lungs for bilateral breath sounds

A client presents with absent lung sounds in the left lower lung fields, moderate shortness of breath, and dyspnea. The nurse suspects pneumothorax and notifies the ER physician. Which findings best support the nurse's suspicions? a. Elevated left diaphragm b. Whiteness in the left lower lung area c. Blackness in the right lower lung area d. Blackness in the left lower lung area

Correct Answer: d. Blackness in the left lower lung area

The nurse is caring for a client with a deep vein thrombosis. Which change in assessment findings does the nurse find most concerning? a. Hypertension and lack of fever b. Bradypnea and bradycardia c. Nonproductive cough and abdominal pain d. Chest pain and dyspnea

Correct Answer: d. Chest pain and dyspnea

The nurse is caring for a client in the ICU. Which drug is most commonly used to treat cardiogenic shock? a. Enalapril b. Furosemide c. Metoprolol d. Dopamine

Correct Answer: d. Dopamine

The nurse is taking care of a client has been hospitalized for 3 days in the ICU and is now experiencing symptoms of pneumonia, confirmed by chest x-ray. Which of the following is a priority for preventing this type of pneumonia? a. Prophylactic antibiotics for all hospitalized clients b. Pneumovax injection at the first sign of pneumonia in the hospitalized client c. Staff education for early recognition of community-acquired pneumonia (CAP) on admitted clients d. Staff education for prevention of hospital-acquired pneumonia (HAP)

Correct Answer: d. Staff education for prevention of hospital-acquired pneumonia (HAP)

The ICU nurse is taking care of a client diagnosed with acute lung failure receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? a. Increase the oxygen percentage b. Ventilate the client with a portable mechanical ventilator c. Chest the clients radial pulse d. Suction the client's artificial airway

Correct Answer: d. Suction the client's artificial airway

The nurse is taking care of a client in the ER whose arterial blood gas values on room air are PaO2, 40 mm Hg; pH, 7.10; PaCO2, 44 mm Hg; and HCO3, 16 mEq/L. What is the interpretation of the client's ABG? a. Uncompensated respiratory acidosis b. Compensated metabolic acidosis c. Compensated respiratory acidosis d. Uncompensated metabolic acidosis

Correct Answer: d. Uncompensated metabolic acidosis

A nurse is caring for a client in the ICU who is at high risk for developing pneumonia. Which interventions should the nurse include on the client's care plan? a. Turning the client q4h to prevent fatigue b. Keeping the HOB at 15 degrees or less c. Providing oral hygiene daily d. Using strict hand hygiene

Correct Answer: d. Using strict hand hygiene

A client presents to the emergency department in anaphylactic shock. Which medication would the nurse administer first? a. Epinephrine b. Atropine c. Propofol d. Methylprednisolone

Correct Answer: a. Epinephrine

A nurse is working in the emergency receives the following arterial blood gas results on four clients. Which of the following laboratory results requires immediate nursing intervention? a.pH 7.33, PaCO2 58 mm Hg, and PaO2 64mm Hg b.pH 7.48, PaCO2 35 mm Hg, and PaO2 65 mm Hg c.pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg d.pH 7.34, Pa CO2 33 mm Hg, and PaO2 80 mm Hg

Correct Answer: c. pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg

The nurse is caring for a client in the emergency department who has experienced severe multiple trauma. The client's arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. This finding is an indicator of the development of which following conditions? a. Hypovolemic shock b.Asthma c.Community-acquired pneumonia d.Acute respiratory distress syndrome (ARDS)

Correct Answer: d. Acute respiratory distress syndrome (ARDS)

The client sustained an open fracture of the femur from an automobile accident. the nurse assess the client for which type of shock? a. Anaphylactic b. Cardiogenic c. Neurogenic d. Hypovolemic

Correct Answer: d. Hypovolemic