MedSurg ch 29 practice questions

What is the basis for the decreased oxygen saturation the nurse assesses in a client with a pulmonary embolism (PE)?

Shunting of deoxygenated blood to the left side of the heart

Which assessment finding on a client who is being mechanically ventilated with positive end-expiratory pressure indicates to the nurse a possible left-sided tension pneumothorax?

Chest is asymmetrical and trachea deviates toward the right side.

Which assessment findings in a postoperative client suggest to the nurse the possibility of a pulmonary embolism (PE) and pulmonary infarction?

Hemoptysis and shortness of breath

Which client will the nurse consider to be at the greatest risk for developing acute respiratory distress syndrome (ARDS)?

74 year old who aspirates a tube feeding

Which clients will the nurse monitor most closely for respiratory failure? (Select all that apply.)

A 30 year old with a C-5 spinal cord injury A 35 year old using client-controlled analgesia A 40 year old with acute pancreatitis A 55 year old with a brainstem tumor A 65 year old with COVID-19 pneumonia

With which client will the nurse take immediate actions to reduce the risk for developing a pulmonary embolism (PE)?

A 36 year old who had open reduction and internal fixation of the tibia

The nurse has just received report on a group of clients. Which client is the nurse's first priority?

A 50 year old being mechanically ventilated who has tracheal deviation.

Drugs from which class will the nurse prepare to administer as first-line therapy for a client just diagnosed with pulmonary embolism (PE)?

Anticoagulants

29-1 A client who is 3 days postoperative from extensive abdominal surgery for cancer reports having a difficult time "catching her breath" and having a reddish-purple, nonitchy, rash on her chest. After assessing the client, what is the nurse's best action or response to prevent harm?

Apply oxygen and call the rapid response team

A client who is 3 days postoperative from extensive abdominal surgery for cancer reports having a difficult time "catching her breath" and having a reddish-purple, nonitchy rash on her chest. After assessing the client, what is the nurse's best action or response to prevent harm?

Apply oxygen and call the rapid response team

29-1 An attempt by a primary health care provider to intubate a client for mechanical ventilation is unsuccessful after 45 seconds. What is the nurse's priority action?

Applying oxygen with a bag-valve-mask device

Which action will the nurse take first for a client being mechanically ventilated who begins to pick at the bedcovers?

Assessing for adequate oxygenation

What is the primary emphasis for the nurse who is providing care to a client with acute respiratory distress syndrome (ARDS) currently in the exudative management stage of the disorder?

Assessing the client at least hourly for tachypnea and dyspnea

Which action will the nurse take first while caring for a client being mechanically ventilation when the high-pressure alarm sounds?

Auscultating the client's breath sounds

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?

Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia.

Which action has the highest priority for the nurse to take to prevent harm for a client being mechanically ventilated with 100% oxygen for the past 24 hours who now has new-onset crackles, decreased breath sounds, and a PaO2 level of 95 mm Hg?

Collaborating with the pulmonary health care provider to lower the FiO2 level

For which problems will the nurse specifically assess when the low-pressure alarm of a client's mechanical ventilator sounds? (Select all that apply.)

Cuff leak in the endotracheal or tracheostomy tube. Client is not breathing. Leak in the ventilator tubing circuit.

29-3 A client being mechanically ventilated has all of the following changes. Which changes are most relevant in helping the nurse determine whether suctioning is needed at this time? Select all that apply.

Decreased SpO2 Crackles auscultated over the trachea High pressure ventilator alarm sounds Presence of fluid within the endotracheal tube

Which symptom or change in assessment of a client with 4 broken ribs on the right side indicates to the nurse the possibility of a tension pneumothorax?

Distended neck veins

Which new assessment finding in a client being managed for a pulmonary embolism (PE) indicates to the nurse that the client's condition is worsening?

Distended neck veins in the high-Fowler position

Which assessment findings in a client at high risk for pulmonary embolism (PE) indicates to the nurse the probably presence of a PE? (Select all that apply.)

Dizziness and syncope Inspiratory chest pain Tachycardia

What type of percussion note or sound will the nurse expect on the affected chest side of a client who has a hemothorax?

Dull

29-2. Which condition, sign, or symptom does the nurse consider most relevant in assessing a client suspected to have ARDS? Select all that apply.

Dyspnea Intercostal retractions PaO2 84% on oxygen at 6 L/minute

Which condition, sign, or symptom does the nurse consider most relevant in assessing a client suspected to have ARDS? Select all that apply.

Dyspnea Intercostal retractions PaO2 84% on oxygen at 6 L/minute

Which action will the nurse instruct a client with an endotracheal tube to perform during the time the tube is being removed?

Exhale

29-2. Which actions does the nurse ensure are performed for a client being mechanically ventilated to prevent ventilator-associated pneumonia (VAP)? Select all that apply.

Getting the patient out of bed as soon as prescribed Keeping the head of the bed elevated to 30 degrees or above Providing meticulous mouth care every 12 hours

In addition to notifying the pulmonary health care provider, what is the most important action for the nurse to take first for a client with a pulmonary embolism (PE) whose arterial blood gas (ABG) values are pH 7.28, PaCO2 50 mm Hg, PaO2 62 mm Hg, and HCO3− 24 mEq/L (24 mmol/L)?

Increasing the oxygen flow rate

Which action is a priority for the nurse to prevent harm for a client with a pulmonary embolism who is receiving a continuous heparin infusion?

Monitoring the platelet count daily

What is the nurse's best first action when assessing a client who was intubated a few minutes ago and finds the end-tidal carbon dioxide level is 0 and the SpO2 is 38%?

Removing the endotracheal tube and ventilating the client with a bag-valve-mask

What type of acid-base problem will the nurse expect in a client who is being insufficiently mechanically ventilated for the past 4 hours and whose most recent arterial blood gas results include a pH of 7.29?

Respiratory acidosis with an acid excess

In addition to the pulmonary health care provider, which other member of the interprofessional team will the nurse expect to collaborate with most frequently when providing care to a client with a pulmonary embolism (PE)?

Respiratory therapist

What is the best first action when the nurse assesses that the respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures but the ventilator tubing is clear?

Suctioning the tracheostomy tube

Which ventilator mode does the nurse expect will be set for a client with a tracheostomy who is beginning to take spontaneous breaths at his own rate and tidal volume between set ventilator breaths?

Synchronized intermittent ventilation (SIMV)

The client is a 5 foot 11 inch tall, 176 lb (80 kg) woman who has been mechanically ventilated at a tidal volume of 400 mL and a respiratory rate of 12 breaths per minute for the past 24 hours. The most recent arterial blood gas (ABG) results for this client are: pH= 7.32; PaO2 = 84 mm Hg; PaCO2 = 56 mm Hg. What is the nurse's interpretation of these results?

Ventilation inadequate; respiratory acidosis present.