CH 32
Which intervention for a client in the intensive care unit (ICU) will decrease the incidence of "ICU psychosis?" A. Decreasing nighttime disruptions B. Keeping the lights on to promote orientation C. Administering sedation D. Providing television or radio for stimulation
A ICU psychosis can be minimized not only by encouraging sleep, but also by keeping to a regular routine. Keeping the lights on or providing TV or radio will not encourage sleep. Sedation can promote confusion and disorientation.
Which client has the highest risk for developing a pulmonary embolism (PE)? A. A 25-year-old woman who frequently flies to different countries B. A 67-year-old man who works on a farm C. A 45-year-old man admitted for a heart attack D. A 23-year-old woman with a bleeding disorder
A People who engage in prolonged and frequent air travel are at higher risk for PE. A 67-year-old man who works on a farm is not at high risk because he has an active lifestyle. A heart attack is usually caused by a thrombus or occlusion of the coronary arteries, not of the legs; if on prolonged bedrest, the client's risk is increased. PE is a clotting disorder, not a bleeding disorder.
All of these nursing actions are included in the plan of care for a client who has just been extubated. Which action should the nurse delegate to unlicensed assistive personnel (UAP)? A. Keep the head of the bed elevated. B. Teach about incentive spirometer use. C. Monitor vital signs every 5 minutes. D. Adjust the nasal oxygen flow rate.
A Positioning of clients is included in UAP education and scope of practice and can be delegated. Client teaching is an activity performed by the professional nurse. Although taking vital signs is an activity of the UAP, monitoring a potentially unstable client is done by the professional nurse. Adjusting oxygen flow rates requires complex decision making and should be done by the RN.
The medical-surgical unit nurse should call the Rapid Response Team to assess which client? A. Client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis B. Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain C. Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry of 94% D. Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs
A The client with a diagnosed pulmonary embolism is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin; this indicates a significant decline in status and warrants activation of the Rapid Response Team. The client with deep vein thrombosis requires ongoing monitoring and is receiving appropriate treatment; calf pain is expected in this situation. The client with a right pneumothorax requires ongoing monitoring but has normal oxygen saturation. The client who was extubated 3 days ago requires ongoing monitoring or nursing intervention, but does not have evidence of acute deterioration or severe complications.
Which intervention will be most effective in reducing anxiety in a client with a pulmonary embolism (PE)? A) Remain with the client and provide oxygen in a calm manner. B) Have the client breathe into a brown paper bag using pursed lips. C) Offer the client a mild sedative. D) Allow a family member to remain in the room.
A The underlying cause for anxiety with a PE is hypoxemia, which will be alleviated by oxygen; remaining with the client in distress is appropriate. Rebreathing from a brown paper bag is an intervention that increases PaCO2 during hyperventilation, as in a panic attack; it will not provide needed oxygen. Sedation and/or allowing a family member to stay may calm the client, but will not improve oxygenation.
The nurse is caring for a group of clients. Which clients should be monitored closely for respiratory failure? (Select all that apply.) A. Client with a brainstem tumor B. Client with acute pancreatitis C. Client with a T3 spinal cord injury D. Client using patient-controlled analgesia E. Client experiencing cocaine intoxication
ABCD Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome; abdominal distention also ensues, which can limit respiratory excursion. Clients with cervical and thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect intercostal muscles are affected. Opiates, which can depress the brainstem, present risk factors for respiratory failure. All of these clients should be monitored closely for respiratory failure. Cocaine is a stimulant, which would not cause respiratory failure unless a stroke ensued.
The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms should the nurse assess? (Select all that apply.) A. Dizziness and fainting B. Shortness of breath (SOB) worsening over the last 2 weeks C. Inspiratory chest pain D. Productive cough E. Pink, frothy sputum
AC Syncope, hypotension, and fainting are symptoms associated with PE. Sharp, pleuritic, inspiratory chest pain is also characteristic of PE. Sudden, not gradual, SOB occurs with PE. Productive cough is associated with infection; PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema; PE may cause hemoptysis.
The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which method provides an alternative to mechanical ventilation? A. Oropharyngeal airway B. Bi-level positive airway pressure (BiPAP) C. Non-rebreather mask with 100% oxygen D. Positive end-expiratory pressure (PEEP)
B BiPAP ventilation is a noninvasive method that may provide short-term ventilation without intubation. An oropharyngeal airway is used to prevent the tongue from occluding the airway or the client from biting the endotracheal tube. A non-rebreather mask will assist with oxygenation; however, muscle fatigue and hypoventilation may occur as causes of respiratory failure. The need for PEEP indicates a severe gas-exchange problem; this modality is "dialed in" on the mechanical ventilator.
A client has been admitted for a pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? A. Teach the client to avoid using dental floss. B. Monitor the platelet count daily. C. Ensure adequate staffing for the unit. D. Notify radiology of an impending scan.
B Daily platelet counts are a safety priority in assessing for thrombocytopenia; heparin-induced thrombocytopenia is a possible side effect. Avoiding the use of dental floss is important during anticoagulation therapy, but it is not the priority. Adequate staffing and notifying radiology are not the priority.
When caring for a client with pulmonary embolism (PE), which arterial blood gas results does the nurse anticipate early in the course of the disease? A) pH 7.24, PaCO2 55 mm Hg, HCO3- 26 mEq/L, PaO2 56 mm Hg B) pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L, PaO2 68 mm Hg C) pH 7.35, PaCO2 45 mm Hg, HCO3- 24 mEq/L, PaO2 80 mm Hg D) pH 7.47, PaCO2 35 mm Hg, HCO3- 30 mEq/L, PaO2 75 mm Hg
B Hyperventilation triggered by hypoxia and pain first leads to respiratory alkalosis, indicated by a low partial pressure of arterial carbon dioxide (PaCO2 of 30 mm Hg) and a high pH (7.46). No compensation is present as the bicarbonate (HCO3-) (26 mEq/L) is normal, and hypoxemia is present, consistent with PE. A pH of 7.24 is acidotic, a partial pressure of arterial oxygen (PaO2) of 56 mm Hg reflects hypoxemia, and no compensation is present with a normal HCO3- (26 mEq/L); this blood would be found in a person in acute respiratory failure owing to hypoventilation and hypoxemia. A pH between 7.35 and 7.45, PaCO2 of 35 to 45 mm Hg, HCO3- of 22 to 26 mEq/L, and PaO2 greater than 75 mm Hg all reflect normal blood gas results. A pH of 7.47 and an HCO3- of 30 mEq/L are alkalotic, indicating metabolic alkalosis; a PaCO2 of 35 mm Hg is normal (indicating lack of compensation) and a PaO2 of 75 mm Hg is normal.
The client with which condition is in greatest need of immediate intubation? A. Difficulty swallowing oral secretions B. Hypoventilation and decreased breath sounds C. O2 saturation of 90% D. Thick, purulent secretions and crackles
B Intubation may be indicated for the client who is hypoventilating and has decreased breath sounds. Suctioning, rather than intubation, is indicated for difficulty swallowing secretions, as well as for thick, purulent secretions and crackles (consistent with pneumonia). Intubation is indicated for the client with an O2 saturation of less than 90% and other symptoms of hypoxemia or hypercarbia.
A ventilated client in the intensive care unit (ICU) begins to pick at the bedcovers. Which action should the nurse take next? A. Increase the sedation. B. Assess for adequate oxygenation. C. Explain to the client that he has a tube in his throat to help him breathe. D. Request that the family leave to decrease the client's agitation.
B Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia. Increasing sedation is not indicated for this client and may mask symptoms such as hypoxemia or worsening respiratory failure. Although the nurse may explain to the client that he or she is intubated, it does not take priority over assessing for hypoxemia. The presence of family members may decrease the chances of "ICU psychosis" and anxiety, but it does not take priority over assessing for hypoxemia.
The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure. Which findings would cause the nurse to suspect a left-sided tension pneumothorax? A. The chest caves in on inspiration and "puffs out" on expiration. B. The trachea is deviated to the right side and cyanosis is present. C. The left lung field is dull to percussion with crackles present on auscultation. D. The client has bloody sputum and wheezes.
B Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention, cyanosis, and hyperresonance to percussion over the affected area. Flail chest is manifested by paradoxical chest movement, which consists of "sucking inward" of the loose chest area during inspiration and "puffing out" of the same area during expiration. Open pneumothorax presents with decreased breath sounds, hyperresonance, and poor respiratory excursion on the affected side. Pulmonary contusion presents with hemoptysis, dullness to percussion, and crackles or wheezes.
Which client needs immediate attention by the nurse? A) A 40-year-old who is receiving continuous positive airway pressure and has intermittent wheezing B) A 54-year-old who is mechanically ventilated and has tracheal deviation C) A 57-year-old who was recently extubated and is reporting a sore throat D) A 60-year-old who is receiving O2 by facemask and whose respiratory rate is 24 breaths/min
B The 54-year-old client is showing signs of a tension pneumothorax that could lead to decreased cardiac output and shock if not addressed promptly. The 40-year-old client has intermittent adventitious breath sounds, but is not in immediate danger or distress. The 57-year-old client has mild discomfort, but is not in danger of a life-threatening situation. The 60-year-old client has mild tachypnea, but is not in immediate distress or danger.
The nurse is overseeing a nursing student who is administering medications to a group of clients with pulmonary disorders. Which statement by the student nurse indicates a correct understanding about thrombolytic therapy? A. "You will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days." B. "Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3." C. "Once the health care provider orders warfarin (Coumadin), we will discontinue the intravenous heparin." D. "If bleeding develops, we will give you platelets to reverse the anticoagulant."
B The international normalized ratio (INR), a measurement of anticoagulation with warfarin, is in the therapeutic range between 2 and 3. Enoxaparin (Lovenox) is a low-molecular-weight heparin that is usually given by the subcutaneous route. Heparin and warfarin are overlapped until the INR is in the therapeutic range, then the heparin can be discontinued. Fresh-frozen plasma is used as an antidote for anticoagulant therapy, not platelets.
Which components belong to the ventilator bundle approach to prevent ventilator-associated pneumonia (VAP)? (Select all that apply.) A. Administering antibiotic prophylaxis B. Continuous removal of subglottic secretions C. Elevating the head of the bed at least 30 degrees whenever possible D. Handwashing before and after contact with the client E. Placing a nasogastric tube F. Placing the client in a negative-airflow room
BCD Continuous removal of subglottic secretions, elevating the head of the bed at least 30 degrees whenever possible, and handwashing before and after contact with a client are all part of a VAP bundle. Antibiotics are not given prophylactically; they are given on the basis of cultures to prevent an increase in drug-resistant organisms. A nasogastric tube is not part of the VAP bundle. If a client is going to be mechanically ventilated for a prolonged period of time, postpyloric or gastrostomy tubes are preferred over nasogastric tubes for nutrition. Placing a client in a negative-airflow room is not part of the VAP bundle. The client does not require this room.
The nurse coming on shift prepares to perform an initial assessment of a sedated, ventilated client. Which are priorities for the nurse to carry out? (Select all that apply.) A. Ask visitors to leave. B. Assess the client's color and respirations. C. Confirm alarms and ventilator settings. D. Ensure that the tube cuff is inflated and is in the proper position. E. Listen for bilateral breath sounds. F. Provide routine tracheotomy and endotracheotomy and mouth care.
BCDE The first priority when caring for a critically ill client is to assess airway and breathing. Alarm settings should be confirmed each shift, more frequently if necessary. Confirming that the client cannot speak ensures that air is going through the endotracheal tube and not around it. Auscultating for equal bilateral breath sounds assists in confirming that the tube is above the carina. Having visitors remain with the client may promote comfort and prevent confusion. Routine tracheostomy care is performed according to schedule, not necessarily as part of an initial assessment.
The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action should the nurse take first? A. Check the ventilator alarm settings. B. Assess the set tidal volume. C. Listen to the client's breath sounds. D. Call the respiratory therapist.
C A typical reason for the high-pressure alarm to sound is the need for suctioning or tension pneumothorax. The nurse should begin the assessment with the client, not with the ventilator. Although an excessively high tidal volume could contribute to sounding of the high-pressure alarm, assessment always begins with the client. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention.
Which critically ill client has the greatest risk for developing acute respiratory distress syndrome (ARDS)? A. Client with diabetic ketoacidosis (DKA) B. Client with atrial fibrillation C. Client with aspiration pneumonia D. Client with acute kidney failure
C Aspiration of acidic gastric contents is a risk for ARDS. Clients with DKA may develop metabolic acidosis, but not ARDS, which develops in lung injury. Atrial fibrillation does not cause lung injury unless embolization occurs. Acute kidney failure results in metabolic acidosis, not in acute lung injury.
The nurse is teaching the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate? A) "Sedation is needed so your loved one does not rip the breathing tube out." B) "Suctioning is important to remove organisms from the lower airway." C) "Paralysis and sedatives help decrease the demand for oxygen." D) "We are encouraging oral and IV fluids to keep your loved one hydrated."
C Paralytics and sedation decrease oxygen demand. Sedation is needed more for its effects on oxygenation than to prevent the client from ripping out the endotracheal tube. Suctioning is performed to maintain airway patency. Minimizing fluids while administering diuretics leads to better outcomes.
The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority? A. Inadequate nutrition related to food-drug interactions and anticoagulant therapy B. Potential for infection related to leukocytosis C. Hypoxemia related to ventilation-perfusion mismatch D. Insufficient knowledge related to the cause of PE
C Restoring adequate oxygenation and tissue perfusion takes priority when a client presents with a PE. Although nutrition must be addressed, priorities include airway, breathing, and circulation. The client has a leukocytosis related to lung inflammation; leukopenia places clients at risk for infection, but this is not the priority at this time. Education as to the cause of PE must be postponed until oxygenation and hemodynamic stability occur.
The nurse is caring for a group of clients. Which person does the nurse identify as having the highest risk for pulmonary embolism (PE)? A. A client with diabetes and cellulitis of the leg B. A client receiving IV fluids through a peripheral line C. A client returning from an open reduction and internal fixation of the tibia D. A client with hypokalemia receiving potassium supplements
C Surgery and immobility are risks for deep vein thrombosis and PE. No evidence suggests that the client with diabetes has been immobile, which is a risk factor for PE; the client will be treated with antibiotics. For the client with a peripheral line, no evidence indicates a problem with the IV or with breakage of the catheter, which could lead to an air embolism. For the client with hypokalemia, no evidence reveals risk for PE; no immobility or hyper-coagulability is present.
A client was intubated 30 minutes ago for acute respiratory distress syndrome and possible sepsis. The following orders have been given for the client. In what sequence would the nurse perform these orders for this client? 1. Infuse levofloxacin (Levaquin) 500 mg IV. 2. Obtain baseline aerobic and anaerobic sputum cultures. 3. Teach the client and family methods of communicating. 4. Analyze postintubation arterial blood gases (ABGs). A. 2, 1, 3, 4 B. 4, 3, 1, 2 C. 3, 4, 2, 1 D. 4, 2, 1, 3
D ABGs should be analyzed first before the other assessments/actions are carried out. A baseline of sputum cultures should then be obtained before medications are administered. Then levofloxacin can be given. Client and family education on communication methods is important, but is the lowest priority here.
The nurse is caring for a client who was discharged 3 weeks ago after a diagnosis of pulmonary embolism (PE). He is currently admitted with gastrointestinal (GI) bleeding and an international normalized ratio (INR) of 6.9. For which factors should the nurse assess this client? A. Consumption of green leafy vegetables B. Prolonged exhalation C. Client has massaged his calves D. Use of aspirin or salicylates
D Use of aspirin and salicylates will prolong the INR and cause gastric irritation. Green leafy vegetables are high in vitamin K and would antagonize warfarin, resulting in a low(er) INR. A prolonged expiratory phase is typical in chronic obstructive pulmonary disease, not GI bleeding or a prolonged INR. Massaging the calves may present a risk for PE if deep vein thrombosis is present, but does not relate to GI bleeding and prolonged INR.