Chapter 32 - Exam 1
A 242-lb patient is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.) ___ mL
660
A nurse is caring for a patient on mechanical ventilation and finds the patient agitated and thrashing about. What action by the nurse is most appropriate? A. Assess the cause of the agitation. B. Reassure the patient that he or she is safe. C. Restrain the patient's hands. D. Sedate the patient immediately.
A
The nurse caring for mechanically ventilated patients uses best practices to prevent ventilator- associated pneumonia. What actions are included in this practice? (Select all that apply.) A. Adherence to proper hand hygiene B. Administering antiulcer medication C. Elevating the head of the bed D. Providing oral care per protocol E. Suctioning the patient on a regular schedule
A, B, C, D
A patient with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) A. Acknowledge the frightening nature of the illness. B. Delegate a back rub to the unlicensed assistive personnel (UAP). C. Give simple explanations of what is happening. D. Request a prescription for antianxiety medication. E. Stay with the patient and speak in a quiet, calm voice.
A, B, C, E
A patient is being discharged soon on warfarin. What menu selection for dinner indicates that the patient needs more education regarding this medication? A. Hamburger and French fries B. Large chef's salad and muffin C. No selection; spouse brings pizza D. Tuna salad sandwich and chips
B
A patient has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? A. Apply oxygen at 100%. B. Assess the respiratory rate. C. Ensure a patent airway. D. Start two large-bore IV lines.
C
A patient is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? A. Assess the patient for sedation needs. B. Get family permission for restraints. C. Provide frequent oral care per protocol. D. Use nonverbal pain assessment tools.
C
An intubated patient's oxygen saturation has dropped to 88%. What action by the nurse takes priority? A. Determine if the tube is kinked. B. Ensure that all connections are patent. C. Listen to the patient's lung sounds. D. Suction the endotracheal tube.
C
When working with women who are taking hormonal birth control, what health promotion measures does the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) A. Avoid drinking alcohol. B. Eat more omega-3 fatty acids. C. Exercise on a regular basis. D. Maintain a healthy weight. E. Stop smoking cigarettes.
C, D, E
A patient is on mechanical ventilation and the patient's spouse wonders why ranitidine (Zantac) is needed since the patient "only has lung problems." What response by the nurse is best? A. "It will increase the motility of the gastrointestinal tract." B. "It will keep the gastrointestinal tract functioning normally." C. "It will prepare the gastrointestinal tract for enteral feedings." D. "It will prevent ulcers from the stress of mechanical ventilation."
D
A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best? A. "It is chronic hypoxemia that accompanies restrictive airway disease." B. "It is hypoxemia from lung damage due to mechanical ventilation." C. "It is hypoxemia that continues even after the patient is weaned from oxygen." D. "It is hypoxemia that persists even with 100% oxygen administration."
D
A patient appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? A. Assess for other manifestations of hypoxia. B. Change the sensor on the pulse oximeter. C. Obtain a new oximeter from central supply. D. Tell the patient to take slow, deep breaths.
A
A patient has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the patient will need as the priority? A. Alteplase B. Enoxaparin C. Unfractionated heparin D. Warfarin sodium
A
A patient in the emergency department has several broken ribs. What care measure will best promote comfort? A. Allowing the patient to choose the position in bed B. Humidifying the supplemental oxygen C. Offering frequent, small drinks of water D. Providing warmed blankets
A
The nurse caring for mechanically ventilated patients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) A. Chest wall stiffness B. Decreased muscle strength C. Inability to cooperate D. Less lung elasticity E. Poor vision and hearing
A, B, D
A nurse is caring for a patient who is on mechanical ventilation. What actions will promote comfort in this patient? (Select all that apply.) A. Allow visitors at the patient's bedside. B. Ensure that the patient can communicate if awake. C. Keep the television tuned to a favorite channel. D. Provide back and hand massages when turning. E. Turn the patient every 2 hours or more.
A, B, D, E
A nurse answers a call light and finds a patient anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg. What action by the nurse takes priority? A. Assess the patient's lung sounds. B. Notify the Rapid Response Team. C. Provide reassurance to the patient. D. Take a full set of vital signs.
B
A nurse is caring for a patient on the medical stepdown unit. The following data are related to this patient: Subjective Info S.O.B. for 20 minutes, Feels frightened, "Can't catch my breath" Lab Analysis pH: 7.12, PaCO2: 28 mm Hg, PaO2: 58 mm Hg, SaO2: 88% Physical Assessment Pulse: 120 beats/min, RR: 34 breaths/min, BP: 158/92 mm Hg, Lungs have crackles What action by the nurse is most appropriate? A. Call respiratory therapy for a breathing treatment. B. Facilitate a STAT pulmonary angiography. C. Prepare for immediate endotracheal intubation. D. Prepare to administer intravenous anticoagulants.
B
A nurse is caring for four patients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? A. Hemoglobin: 14.2 g/dL (142 g/L) B. Platelet count: 82,000/L (82 × 109/L) C. Red blood cell count: 4.8/mm3 (4.8 × 1012/L) D. White blood cell count: 8700/mm3 (8.7 × 109/L)
B
A nurse is preparing to admit a patient on mechanical ventilation from the emergency department. What action by the nurse takes priority? A. Assessing that the ventilator settings are correct. B. Ensuring that there is a bag-valve-mask in the room. C. Obtaining personal protective equipment. D. Planning to suction the patient upon arrival to the room.
B
A nurse is teaching a patient about warfarin. What assessment finding by the nurse indicates a possible barrier to self-management? A. Poor visual acuity B. Strict vegetarian C. Refusal to stop smoking D. Wants weight loss surgery
B
A patient is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals that the patient has an alteration in the gene CYP2C19. What action by the nurse is best? A. Instruct the patient to eliminate all vitamin K from the diet. B. Prepare preoperative teaching for an inferior vena cava (IVC) filter. C. Refer the patient to a chronic illness support group. D. Teach the patient to use a soft-bristled toothbrush.
B
A patient is on intravenous heparin to treat a pulmonary embolism. The patient's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? A. Decrease the heparin rate. B. Increase the heparin rate. C. No change to the heparin rate. D. Stop heparin; start warfarin.
B
A student nurse is preparing to administer enoxaparin to a patient. What action by the student requires immediate intervention by the supervising nurse? A. Assessing the patient's platelet count B. Choosing an 18-gauge, 2-inch (5 cm) needle C. Not aspirating prior to injection D. Swabbing the injection site with alcohol
B
A nurse is caring for five patients. For which patients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) A. Patient who had a reaction to contrast dye yesterday B. Patient with a new spinal cord injury on a rotating bed C. Middle-aged man with an exacerbation of asthma D. Older patient who is 1 day post-hip replacement surgery E. Young obese patient with a fractured femur
B, D, E
A nurse is assisting the healthcare provider who is intubating a patient. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? A. Ensure that the patient has adequate sedation. B. Find another provider to intubate. C. Interrupt the procedure to give oxygen. D. Monitor the patient's oxygen saturation.
C
A patient has a pulmonary embolism and is started on oxygen. The student nurse asks why the patient's oxygen saturation has not significantly improved. What response by the nurse is best? A. "Breathing so rapidly interferes with oxygenation." B. "Maybe the patient has respiratory distress syndrome." C. "The blood clot interferes with perfusion in the lungs." D. "The patient needs immediate intubation and mechanical ventilation."
C
A patient is admitted with a pulmonary embolism (PE). The patient is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? A. Encourage the patient to walk 5 minutes each hour. B. Refer the patient to smoking cessation classes. C. Teach the patient about factor V Leiden testing. D. Tell the patient that sometimes no cause for disease is found.
C
A nurse is caring for a patient on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? A. The patient is able to initiate spontaneous breaths. B. The inspired oxygen has adequate humidification. C. The upper peak airway pressure limit alarm is off. D. The upper peak airway pressure limit alarm is on.
D
A patient is brought to the emergency department after sustaining injuries in a severe car crash. The patient's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the patient is cyanotic. What action by the nurse is the priority? A. Administer oxygen and reassess. B. Auscultate the patient's lung sounds. C. Facilitate a portable chest x-ray. D. Prepare to assist with intubation.
D
