Med Surg Exam 2 Lippincott
A client diagnosed with thyroid cancer signed a living will that states the client doesn't want ventilatory support if the condition deteriorates. As the client's condition worsens, the client states, "I changed my mind. I want everything done for me." Which response by the nurse is best?
"What exactly do you mean by wanting 'everything' done for you?"
A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic shock?
"a decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume"
The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest X-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate?
A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device.
A client with sepsis begins having labored breathing, confusion, and lethargy. What complication should the nurse assess for in this client?
Acute respiratory distress syndrome (ARDS)
A nurse is caring for a client who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. The blood pressure is 80/50 mm Hg and the client reports dizziness. What is the nurse's priority action?
Administer atropine 0.5 mg I.V. push as ordered.
A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?
Administer oxygen by nasal cannula as ordered.
A nurse is preparing to teach a client recovering from an anaphylaxis reaction about the prevention and management of reactions. What should the nurse include in the teaching? Select all that apply.
Antigens that should be avoided. How to administer emergency medications.
A client has a sucking stab wound to the chest. Which action should the nurse take first?
Apply a dressing over the wound and tape it on three sides.
A client with a recent diagnosis of deep vein thrombosis (DVT) has sudden-onset shortness of breath and chest pain that increases with a deep breath. What should the nurse do first?
Assess the oxygen saturation.
The nurse is caring for a client 1 day after having a colectomy. The client is lethargic and difficult to arouse; the temperature is 101.5°F (38.6°C), blood pressure is 92/36 mm Hg (mean arterial pressure [MAP 55 mm Hg]), and heart rate is 114 bpm, with a percutaneous oxygen saturation (SpO2) of 88% on oxygen at 2 L per minute per nasal cannula (previously 94%). A saline lock has been established and is patent. Which prescription should the nurse implement first?
Draw blood cultures.
A client who underwent surgery 12 hours ago has difficulty breathing. The client has petechiae over their chest and complains of acute chest pain. What action should the nurse take first?
Initiate oxygen therapy.
Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?
Instruct the client to breathe into a paper bag.
A client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. What should the nurse do?
Notify the health care provider (HCP) of the client's breathing pattern.
The nurse is caring for a client who is 30 years of age with a fracture of the right femur and left tibia. Both legs have casts. The nurse assesses that the client's respiration rate is 30 breaths/min and respirations are rapid and shallow; there is the presence of a faint expiratory wheeze; and coughing produces thin pink sputum. The client is yelling at the nurse and wants to be released from the hospital; this is behavior unlike that previously reported. The last pain medication was administered 3 hours ago. What should the nurse do first?
Notify the health care provider (HCP).
A client arrives via ambulance with a suspected pelvic fracture from a motor vehicle collision. The client's vital signs are: blood pressure 85/50 mm Hg, heart rate 120 beats/min, respiratory rate 22 breaths/min, and an oxygen saturation of 98% on room air. The client is afebrile. The health care provider has written several prescriptions. What is the nurse's priority action?
Obtain STAT hemoglobin and group and match.
A nurse is caring for a newborn who has developed sepsis. The health care provider has given the following orders. Which order will the nurse implement first?
Obtain blood cultures.
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?
Suction the client's artificial airway.
After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises?
The alveoli expand and increase the lung surface available for ventilation.
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation?
The chest tube system is functioning properly.
A client with end-stage chronic obstructive pulmonary disease (COPD) requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is best associated with restraint use in the client who requires BiPAP?
The client will maintain adequate oxygenation.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
The system has an air leak.
The client is admitted in septic shock. Which assessment data warrants immediate intervention by the nurse?
a urinary output of 50 mL in the past 3 hours
Which finding would suggest pneumothorax in a trauma victim?
absent breath sounds
The nurse receives a report on the assigned clients at the beginning of the second shift. Which client should the nurse plan to assess first after receiving the report?
an older adult client with pneumonia who is exhibiting periods of confusion
A client with unresolved hemothorax is febrile, with chills and sweating. The client has a nonproductive cough and chest pain. The chest tube drainage is turbid. What should the nurse request in SBAR communication with the health care provider?
antibiotic therapy
A client diagnosed with acute pancreatitis 5 days ago is experiencing respiratory distress. Which finding should the nurse report to the health care provider (HCP)?
arterial oxygen level of 46 mm Hg (6.1 kPa)
Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?
baseline arterial blood gas (ABG) levels
A client has been diagnosed with septic shock. The nurse would anticipate implementing which order?
blood chemistry of serum lactate
A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:
cover the opening with petroleum gauze.
A client with severe acute respiratory syndrome privately informs the nurse of a desire not to be placed on a ventilator if the condition worsens. The client's partner and children have repeatedly expressed their desire that every measure be taken for the client. The most appropriate intervention by the nurse would be to:
encourage the client to consider a living will or power of attorney.
A nurse is teaching a client who has a severe allergy to bee stings how to manage a reaction. What medication does the nurse encourage the client to take first after being stung by a bee?
epinephrine
Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?
extreme anxiety
The client sustained an open fracture of the femur from an automobile accident. The nurse should assess the client for which type of shock?
hypovolemic
A client is admitted to the hospital with a diagnosis of a pulmonary embolism. Which problem should the nurse address first?
impaired gas exchange
A client requires long-term ventilator therapy. The client has a tracheostomy in place and requires frequent suctioning. Which technique should the nurse use?
intermittent suction while withdrawing the catheter
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?
kinking of the ventilator tubing
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
light-headedness or paresthesia
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?
manual resuscitation bag
When assessing a client for early sepsis, which assessment finding would most concern the nurse?
mean arterial pressure less than 70 mmHg
A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?
metabolic acidosis
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?
partial pressure of arterial oxygen (PaO2)
A client who has just had a triple-lumen catheter placed in their right subclavian vein complains of chest pain and shortness of breath. The client's blood pressure is decreased from baseline and, on auscultation of the chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?
pneumothorax
A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn, yielding the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?
respiratory acidosis
A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects
respiratory alkalosis.
The nurse is assessing a client whose blood pressure is dropping and heart rate and respiratory rate are increasing. Which finding indicates the client is at risk for hypovolemic shock?
severe hemorrhage
The health care provider (HCP) has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube:
to remove air and fluid.
The nurse is planning care for an older adult with an indwelling catheter who is at risk for septic shock. Which nursing action will be most important for this client?
using aseptic technique when caring for the catheter
A client recovering from a pulmonary embolism is receiving warfarin. To counteract a warfarin overdose, the nurse should administer
vitamin K1 (phytonadione).
The nurse is caring for a client who has been diagnosed with deep vein thrombosis. When assessing the client's vital signs, the nurse notes an apical pulse of 150 bpm, a respiratory rate of 46 breaths/minute, and blood pressure of 100/60 mm Hg. The client appears anxious and restless. What should be the nurse's first course of action?
Call the rapid response team.