Evolve Chap 32
The nurse is caring for a client who has just been extubated after receiving mechanical ventilation. Which action will the nurse delegate to unlicensed assistive personnel (UAP)? a. keep head of bed elevated b. teach about incentive spirometer use c. monitor v/c q 5 min d. adjust the nasal oxygen flow rate
a Positioning 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 RN. Adjusting oxygen flow rates requires complex decision making and should be done by the RN.
When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse calls the Rapid Response Team (RRT) for intervention for which client? a.Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia 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 reading of 94% d.Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs
a The RRT needs to quickly assess the client with a diagnosed pulmonary embolism who is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin. Tachycardia, along with bloody sputum (hemoptysis), may be a symptom of hypoxemia or hemorrhagic shock, which requires immediate intervention.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 demonstrates adequate pulse oximetry of 94%. The client who was extubated 3 days ago requires ongoing nursing assessment, but does not have evidence of acute deterioration or severe complications.
When caring for a client with a pulmonary embolism, which priority intervention will the nurse use to reduce anxiety? 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 priority nursing intervention is to correct hypoxemia, the underlying cause of anxiety. The nurse will stay with the client and provide oxygen in a calm manner. Anxiety, agitation, tachycardia, and restlessness are early symptoms of hypoxemia, which occurs with a PE. Oxygen will help to alleviate this problem. Remaining with the client in distress is also 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 and tissue perfusion. Sedation and/or allowing a family member to stay may calm the client, but will not improve oxygenation and may delay appropriate treatment.
The nurse is caring for a group of clients on a medical surgical unit. Which clients will the nurse monitor closely for respiratory failure?select all that apply a. Client with a brainstem tumor b. Client with acute pancreatitis c. Client with a C5 spinal cord injury d. Client using client-controlled analgesia e. Client experiencing cocaine intoxication
a, b, c, d 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 high thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect the diaphragm and intercostal muscles are affected. Opiates used in client controlled analgesia are respiratory depressants and can depress the breathing center in the brainstem causing 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 consistent with PE will the nurse assess? select all a.Dizziness and syncope b.Shortness of breath (SOB) worsening over the last 2 weeks c.Inspiratory chest pain d.Productive cough e.Pink, frothy sputum f.tachycardia
a, c, f Symptoms consistent with PE include: dizziness, syncope, hypotension, and fainting. Sharp, pleuritic, inspiratory chest pain, hemoptysis, and tachycardia are also characteristic of PE.Typically SOB and dyspnea associated with PE develops abruptly rather than gradually over two weeks. Productive cough is associated with infection. PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema.
The intensive care nurse is working on a unit-based project to prevent intensive care unit (ICU) psychosis. Which intervention does the nurse recommend to best decrease the incidence of ICU psychosis? a.Providing frequent explanations and reassurance b. Keeping the lights on to promote orientation c.Administering sedation d.Providing television or radio for stimulation
a. Clients with ICU psychosis need frequent, repeated explanations and reassurance. ICU psychosis or delirium can occur in clients undergoing mechanical ventilation in ICUs. It can also be minimized by encouraging sleep, and keeping to a regular routine.Keeping the lights on or providing TV or radio will not encourage sleep. Rather, these activities provide stimulation. Sedation can promote confusion and disorientation. It should be used when necessary to promote oxygenation and compliance with the ventilator.
The nurse is caring for a group of clients on a Telemetry unit. When providing client education, which client will the nurse determine most needs information regarding preventing pulmonary embolism (PE)? a. A woman who frequently flies to Europe b. A man who works on a farm c. A man admitted for a myocardial infarction d. A woman with a bleeding disorder
a. A woman who frequently flies to Europe Individuals who engage in prolonged and frequent air travel are at higher risk for PE due to the dependent position of the legs during long air flights.A 67-year-old man who works on a farm poses a low risk due to his active lifestyle. A myocardial infarction is caused by a thrombus or occlusion of the coronary arteries, not of the leg veins. If the MI client is on prolonged bedrest, the client's risk is increased. PE is a clotting disorder, not a bleeding disorder.
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 left chest caves in on inspiration and "puffs out" on expiration. b.Chest asymmetry and jugular vein distention are 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. If not promptly detected and treated, tension pneumothorax is quickly fatal.Flail chest is generally the result of fractures of at least two neighboring ribs in two or more places and is manifested by paradoxical chest movement. This 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.
A client in the intensive care unit (ICU) who is receiving mechanical ventilation begins to pick at the bedcovers. Which action will the nurse take next? a. inc the sedation b. assess for adequate oxygenation c. explain that the tube in the pt's throat helps with breathing d. request that the family leave to decrease the pt's agitation
b The next action by the nurse would be to assess for adequate oxygenation. 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, not increase, the chances of "ICU psychosis" and anxiety.
When receiving report on a group of clients on the step down unit, which client needs immediate attention by the nurse? a. A client who is receiving continuous positive airway pressure (CPAP) and has intermittent wheezing b.A client receiving mechanical ventilation who has tracheal deviation c.A client who was recently extubated and is reporting a sore throat d.A client who is receiving O2 by facemask and whose respiratory rate is 24 breaths/min
b The nurse needs to immediately attend to the mechanically ventilated client with a tracheal deviation. This client is showing signs of a tension pneumothorax that could lead to hypoxemia, decreased cardiac output, and shock.The client receiving CPAP has intermittent wheezing, but is not in immediate danger or distress. The client recently extubated has sore throat which is anticipated after intubation. There is no indication this client is in need of immediate intervention. The client wearing oxygen has mild tachypnea, but is not in immediate distress or danger.
The nurse is caring for a group of clients with respiratory disorders. For which of these clients does the nurse plan for immediate intubation? a.Client who requires suctioning of oral secretions b.Client with hypoventilation and decreased breath sounds c.Client with O2 saturation of 90% d.Client with thick, purulent secretions and crackles
b The nurse plans for immediate intubation for the client who demonstrates hypoventilation and has decreased breath sounds.There is no indication that the client with difficulty handling oral secretions or who has purulent sputum has hypoxemia or airway obstruction interfering with swallowing. Suctioning of oral secretions, rather than intubation, is indicated while continuing to monitor for hypoxemia, aspiration, and pneumonia. Intubation may be indicated for the client with an O2 saturation of less than 90% and other symptoms of hypoxemia or hypercarbia.
The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which respiratory modality does the nurse suggest to the interdisciplinary team as 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 The nurse suggests bi-level positive airway pressure (BiPAP) because this type of ventilation provides noninvasive pressure support ventilation by nasal mask or facemask rather than by endotracheal intubation. Generally, it used for clients with sleep apnea but can also be used for clients with respiratory muscle fatigue or impending respiratory failure to avoid more invasive ventilation methods; this may provide short-term relief of an acute problem.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.
The nurse is reviewing the medical record of a client with pulmonary embolism (PE). What priority does the nurse set after reviewing the blood gas result below? pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L (26 mmol/L), PaO2 62 mm Hg a.Have the client breathe rapidly and deeply b.Apply oxygen c.Administer sodium bicarbonate d.Collaborate with the provider to increase the pH
b The priority action taken by the nurse is to administer oxygen. Hypoxemia is present, demonstrated by PaO2 below 75 mmHg. This is consistent with PE and supplementary oxygen is needed to improve tissue perfusion.Hyperventilation triggered by hypoxemia 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). Breathing more rapidly and deeply will continue to "blow off" CO2 and cause further alkalosis. The bicarbonate level (HCO3-) (26 mEq/L) (26 mmol/L) is normal and requires no intervention. The pH level is already high.
When caring for the client receiving mechanical ventilation, the nurse includes which of these interventions to prevent ventilator-associated pneumonia (VAP)? Select all 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
b, c, d 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 prevention bundle.Antibiotics are not given prophylactically, but 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 the stomach is distended, decompression with a NG tube after intubation may be used. If a client is going to receive mechanical ventilation for a prolonged period of time, postpyloric or gastrostomy tubes are preferred over nasogastric tubes for nutrition. Placing the client in a negative-airflow room may be used in a surgical suite or for care of clients with TB, but 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 client receiving sedation and mechanical ventilation through a tracheostomy. Which are priorities for the nurse to carry out? select all a.Ask visitors to leave the room. b.Assess the client's color and respirations. c.Confirm alarms and ventilator settings. d.Ensure that the tube is in proper position. e.Auscultate for bilateral breath sounds. f.Provide routine tracheostomy and mouth care.
b,c,d,e Initial priorities when assessing the critically ill client are to assess airway and breathing. Alarm settings should be confirmed each shift, more frequently if necessary. Markings on the endotracheal tube should be compared to previous records to ensure the tube remains in appropriate position. Auscultating for equal bilateral breath sounds assists in confirming that the tube is in the proper position above the carina.It is not necessary to ask visitors to leave. Having visitors remain with the client may promote comfort and prevent confusion.Routine tracheostomy care, an intervention, is performed according to schedule and as needed, and is not necessarily part of an initial assessment.
A client has been admitted with a diagnosis of 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 heparin induced thrombocytopenia, a potential side effect of heparin.Avoiding the use of dental floss is important during anticoagulation therapy, but it is not the priority. The nurse would work with the manager to ensure adequate staffing but this is not a priority. Notifying radiology of needed scans is not a safety priority.
The nurse is overseeing a nursing student who is administering medications to a group of clients receiving treatment for pulmonary embolism. The nurse recognizes the student understands safety and administration of anticoagulant therapy when the student makes which of these statements? a.The client will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days." b. "Therapy with warfarin (Coumadin) is effective when the INR is between 2 and 3." c."Once the health care provider orders warfarin (Coumadin), the intravenous heparin can be discontinued d.If bleeding develops, we will give platelets to reverse the anticoagulant."
b. The nursing student correctly understands safety and effectiveness of Coumadin therapy when the student states that the international normalized ratio or INR reflects a therapeutic level when between 2 and 3. The INR is the diagnostic test used to measure effectiveness of anticoagulation with warfarin. Subtherapeutic levels below 2 pose a risk for clots to develop; values above 3 pose a risk for bleeding.Enoxaparin (Lovenox) is a low-molecular-weight heparin that is given by the subcutaneous, not intramuscular 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.
The charge nurse in the intensive care unit is overseeing care for a group of clients. The nurse is especially vigilant in collaboration with the primary nurse and interprofessional team in assessing for acute respiratory distress syndrome (ARDS) in which of these clients? a. pt with DKA b. pt with atrial fibrillation c. pt with aspiration pneumonia d. pt with acute kidney failure
c The nurse will carefully watch the client with aspiration pneumonia for signs of ARDS. Acute Respiratory Distress Syndrome also called noncardiac-associated bilateral pulmonary edema is characterized by widespread inflammation in the lungs. Aspiration of acidic gastric contents promotes inflammation and is a risk for ARDS.Clients with DKA may develop metabolic acidosis, but do not typically ARDS, which develops as a result of 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 providing education about the management of respiratory failure to the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse will 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.Paralytics and sedatives help decrease the demand for oxygen." d."We are encouraging oral and IV fluids to keep your loved one hydrated."
c The nurse will tell the family that paralytics and sedation are administered to decrease oxygen demand and promote compliance with mechanical ventilation.Sedation is needed more for its effects on oxygenation than to prevent the client from ripping out the endotracheal tube. Suctioning is performed to remove upper airway secretions and maintain airway patency. Clients receiving mechanical ventilation typically receive hydration by enteral tube or parenteral route and not orally.
The nurse is caring for a group of clients on a medical surgical unit. For which of these individuals does the nurse provide immediate interventions to reduce the risk for pulmonary embolism (PE)? a. a pt with diabetes and cellulitis of the leg b.a pt receiving IV fluids through a peripheral line c. a pt returning from an open reduction and internal fixation of the tibia d. a pt with fluid volume deficit and hypokalemia receiving potassium supplements
c To reduce the risk for developing PE, the nurse provides immediate interventions for the client returning from an open reduction and internal fixation of the tibia. Surgery and perioperative immobility are very high risks for deep vein thrombosis and PE. Orthopedic surgery compounds this risk.No evidence suggests that the client with diabetes has been immobile, which is a risk factor for PE. Cellulitis is treated with antibiotics. Diabetic vascular disease is typically arterial in nature, rather than venous. The client receiving IV fluids through a peripheral line who evidences no problem with the IV or with breakage of the catheter appears to require no immediate nursing intervention. While severe fluid volume deficit and resulting hemoconcentration may pose a risk for thrombosis, this is not as common as thromboembolic complications after orthopedic surgery, and for the client with hypokalemia, no evidence reveals risk for PE.
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 with anticoagulant therapy b.Risk for infection related to leukocytosis c.Hypoxemia related to ventilation-perfusion mismatch d. Insufficient knowledge related to the cause of PE
c. The client problem given priority by the nurse is hypoxia related to ventilation-perfusion mismatch. Restoring adequate oxygenation and tissue perfusion takes priority. Obstruction of blood flow through the pulmonary artery or branches impairs ability of the alveolus to deliver oxygen to the left side of the heart; the resulting hypoxemia may be profound. Initially the client breathes more rapidly and eliminates CO2 causing respiratory alkalosis. A large PE causes hypoventilation and prolonged hyperventilation causes muscle fatigue and hypoventilation; hypoventilation leads to respiratory acidosis.Although nutrition must be addressed, priorities include airway, breathing, and circulation. The client has a leukocytosis, elevated WBC count, an expected response to lung inflammation. Leukopenia places clients at risk for infection, but neither is the priority at this time. Education as to the cause of PE must be postponed until oxygenation and hemodynamic stability are ensured.
The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action will the nurse take first? a.Check the ventilator alarm settings. b.assess the set tidal volume c. listen to breath sounds d.call respiratory therapist
c. The nurse will first listen to the client's breath sounds. Assessment always begins with the client. A typical reason for the high-pressure alarm to sound is obstruction of airflow through the ventilator circuit, usually indicating the need for suctioning. Other reasons for the high pressure alarm to be triggered included biting the endotracheal tube or tension pneumothorax.The nurse is behind the assessment with the client, not with the ventilator or ventilator settings. Although an excessively high tidal volume could contribute to the high-pressure alarm sounding, this is not the nurse's first concern. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention.
The nurse is caring for a client who developed GI bleeding 3 weeks after a diagnosis of pulmonary embolism (PE). The international normalized ratio (INR) is 6.9. Which one of these questions is most appropriate for the nurse to ask at this time? a. have you eaten a lot of green leafy vegetables b.Have you experienced swelling of your legs?" c. Were you massaging your calves?" d.Have you taken any aspirin or salicylates?
d. Have you taken any aspirin or salicylates? It is most appropriate for the nurse to ask about the use of aspirin and salicylates. Use of aspirin and salicylates will prolong the INR and cause gastric irritation and bleeding.Green leafy vegetables are high in vitamin K and would antagonize warfarin, resulting in a low(er) INR; bleeding would be unlikely. Unilateral swelling rather than bilateral swelling is typically present in DVT, which may lead to PE, but is not present in this situation. 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.
A client was intubated 30 minutes ago for acute respiratory distress syndrome (ARDS) and possible sepsis. The following prescriptions have been given for the client. In what sequence will the nurse perform these actions? 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 post-intubation 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.4,2,1,3 ABGs which evaluate oxygenation, ventilation, and pH would be analyzed first before the other assessments/actions are carried out. A baseline of sputum cultures would then be obtained before anti-infective medications are administered. Then levofloxacin can be given. Client and family education on communication methods is important, but is the lowest priority.
