MedSurg Ch. 32 NCLEX Questions

A client is receiving mechanical ventilation via an endotracheal tube. Despite several attempts to extubate the client, the client remains ventilator-dependent for 2 weeks after the initial intubation. What does the nurse plan to tell the client's family about the plan of care?

"A tracheostomy will be performed to minimize complications."

A patient is being discharged to home on warfarin (Coumadin) therapy to manage an acute pulmonary embolism. Which patient response indicates a need for further teaching by the nurse?

"I should eat more green leafy vegetables like spinach."

The nurse is providing teaching for a client who will be discharged home to continue therapy with warfarin (Coumadin). Which statement by the client indicates a correct understanding of the teaching?

"I'll use a soft-bristled toothbrush to brush my teeth."

A client is refusing to allow the nurse to apply pneumatic compression stockings while in bed, stating he doesn't like how they feel and they keep him awake. What is the nurse's best response?

"It is important to wear them in bed so don't develop a blood clot in your legs"

Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)?

24-year-old male admitted with blunt chest trauma and aspiration

A client is receiving mechanical ventilation via an endotracheal tube. Despite several attempts to extubate the client, the client remains ventilator-dependent for 2 weeks after the initial intubation. What does the nurse plan to tell the client's family about the plan of care?

A tracheostomy will be performed to minimize complications

A newly admitted client with respiratory distress has a chest x-ray that shows a ground-glass appearance in both lungs. The nurse notifies the provider and anticipates orders to treat which condition?

Acute Respiratory Distress Syndrome (ARDS)

Which risk factors increase a client's risk for venous thromboembolism that may progress to a pulmonary embolism? Select all that apply.

Age 72 years Admission weight of 290 lbs Presence of central venous catheter

The nurse notifies the Rapid Response Team for a client who develops distended neck veins, severe dyspnea, cyanosis, and syncope. The client is hypoxic and hypotensive and has an abnormal electrocardiogram. Which medication does the nurse anticipate will be ordered immediately?

Alteplase (Activase)

The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurse's first step in the suctioning process?

Assess the patient's lungs sounds and SAO2 via pulse ox

Which expected client outcome is the priority during the initial phase of treatment for a pulmonary embolism?

Attain adequate gas exchange and oxygenation

A client recovering from a pulmonary embolism after surgery is receiving low-molecular-weight heparin (Lovenox) and warfarin (Coumadin). The client's international normalized ratio (INR) is 2.4 today. After reporting this lab value to the provider, which order does the nurse anticipate?

Discontinue the heparin and continue the warfarin

A client with a pulmonary embolism has begun taking oral warfarin (Coumadin) while still receiving intravenous heparin. The nurse notifies the provider that the client has an international normalized ratio (INR) of 2.5. What order does the nurse anticipate?

Discontinuing the Heparin

Which critically ill client has the greatest risk for developing acute respiratory distress syndrome (ARDS)?

Client w/ aspiration pneumonia

The nurse hears the ventilator alarm come from the room of a client who is receiving mechanical ventilation. When arriving in the client's room, which assessment does the nurse perform first?

Client's color, perfusion, and chest rise

Which intervention for a client in the intensive care unit will decrease the incidence of "ICU psychosis?"

Decreasing Nighttime disruptions

A client who is taking warfarin (Coumadin) after an acute a pulmonary embolism is transferred from the ICU after 5 days of heparin therapy. The nurse reviews the client's electronic medical record and notes an international normalized ratio (INR) of 3.4. After notifying the provider of this result, which order does the nurse expect for this client?

Give Phytonadione

The client w/ which condition is in the greatest need of immediate intubation?

Hypoventilation and decreased breath sounds

The nurse is teaching a client recovering from a pulmonary embolism who will take warfarin (Coumadin) for several weeks about long-term management of medications. Which statement by the client indicates a need for further teaching?

I may use enemas to help w/ constipation

The nurse is teaching a client receiving warfarin sodium (Coumadin) about avoiding certain foods during this drug therapy. Which client statement indicates a correct understanding of the teaching?

I will be careful to avoid anything w/ Vitamin K in it

A client who is a lifetime smoker, obese, and has a previous history of thromboembolism is preparing to have major surgery that will require prolonged immobility. Past treatments with anticoagulant medications caused serious bleeding. Which management strategy will be best for this client?

Inferior Vena Cava Filtration

A client sitting upright and receiving high-flow oxygen with a nonrebreather mask appears anxious and has a respiratory rate of 30 breaths/min, a heart rate of 110 beats/min, and an oxygen saturation of 88%. The client is using accessory muscles to breathe and appears fatigued. The nurse notifies the provider and prepares to receive an order for which intervention?

Intubation & mechanical ventilation

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?

Listen to the client's breath sounds

A family member of a client who has acute respiratory distress syndrome (ARDS) asks the nurse how long it will take for the client to get better. The nurse reviews the medical record and notes that the client has been receiving mechanical ventilation for 2 weeks. What does the nurse tell the family member?

Lung changes have occurred that are irreversible

A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this?

Maintaining a patent airway

A patient in acute respiratory failure is classified as having ventilatory failure. The nurse understands that which finding is a potential cause of ventilatory failure?

Opioid Analgesic Overdose

A client with acute respiratory distress syndrome (ARDS) is being mechanically ventilated. The provider has ordered 10 cm H2O of positive end-expiratory pressure (PEEP) to be used with mechanical ventilation. What assessment will inform the nurse that the PEEP was effective in supporting the client's respiratory needs?

Oxygen saturation increaes from 85% to 92%

A client has a Pao2 of 55 mm Hg, an arterial oxygen saturation of 85%, and a hemoglobin of 9.2 g/dL. The client also has normal lung function and clear breath sounds, but has exertional dyspnea. What does the nurse suspect the client is experiencing?

Oxygenation Failure

Which assessment finding best indicates that the endotracheal tube remains correctly placed in the client's trachea and is not in the esophagus?

PACO2 level is 38mm Hg

What are the manifestations of hypoxemia

Pallor, Cyanosis, Restlessness

The nurse is teaching the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate?

Paralysis and sedatives help decrease the demand for oxygen

A client has developed a pulmonary embolism. The nurse anticipates orders for which lab values before beginning heparin therapy for this condition?

Partial Thromboplastin Time (PTT)

The nurse receives a report about a client with chronic obstructive pulmonary disease (COPD) and learns that the client has orthopnea. The nurse plans to perform which comfort measure for this client?

Place the client in an upright position to facilitate breathing

A client has been receiving heparin subcutaneously for 4 days. Which laboratory blood test value does the nurse report immediately to the provider?

Platelet count of 50,000mm

A client with chronic obstructive pulmonary disease (COPD) reports acute difficulty breathing and right-side pleuritic pain. Auscultation reveals decreased breath sounds in the right lung field compared to the left lung field. Which possible condition does the nurse contact the provider for based on these assessment data?

Pneumothorax

A client is receiving heparin sodium (Hepalean) therapy for a pulmonary embolism. Which antidote does the nurse confirm is available on the unit?

Protamine Sulfate

The nurse assesses extreme shortness of breath, agitation, and apprehension in a client who had knee surgery. A heart rate of 119 beats/min and a respiratory rate of 24 breaths/min with an oxygen saturation of 84% are also noted. The nurse suspects which postoperative complication?

Pulmonary Embolism

A client recovering from an osteotomy and pin fixation for a femur fracture suddenly experiences shortness of breath, chest pain, and tachycardia. What does the nurse suspect is causing the client's symptoms?

Pulmonary embolism

The nurse expects which changes in a client with acute respiratory distress syndrome (ARDS)? Select all that apply.

Reduction in surfactant activity, damage to type II pneumocytes, Edema around terminal airways

Which intervention will be most effective in reducing anxiety in a client with a pulmonary embolism (PE)?

Remain with the client and provide oxygen in a calm manner

A 17-year-old client was ejected from a car after hitting a tree at a fast speed. The client was believed to have aspirated at the scene and a nasogastric tube was placed. The client underwent emergent surgery to control bleeding from a lacerated liver and several long bone fractures. Four units of packed red blood cells were given during the surgery. The nurse monitors the client for the development of acute lung injury based on which risk factors? Select all that apply.

Shock Trauma Blood Transfusions Aspiration

An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed with a small flail chest injury. Which intervention should the nurse include in the patient's plan of care?

Suction the patient's airway secretions

A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?

To remove air from the pleural space

While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often?

When adventitious breath sounds are auscultated