Module 2 Chapter 32 Care of Critically Ill Pt. With Respiratory Problems

2 Increase the oxygen flow rate to 40 L/min and reassess the client. The first step when a client becomes agitated or restless, after checking the ventilator settings, is to increase the flow rate and then reassess the client. This client's tidal volume is appropriate. Clients who are ready to be weaned from the ventilator make respiratory efforts against the ventilator. These are not necessarily signs of delirium typical of "ICU psychosis" and the nurse should first attempt to evaluate the cause of the agitation. Study Tip: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although you may have been able to enjoy regular sessions at the health club or at an exercise class several times a week, you now may have to cut down on that time without giving up a set schedule for an exercise routine. Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes for an exam. Listening to lecture recordings while doing floor exercises is another option. At least a couple of times a week, however, the exercise routine should be done without the mental connection to school; time for the mind to unwind is necessary, too.

A 70-kg client receiving manual ventilation is becoming agitated and restless. The nurse determines that the endotracheal tube is in place, notes an oxygen saturation of 97%, and ventilator settings include a pressure of 12 cm H2O, a tidal volume of 600 mL, and a flow rate of 30 L/min. Which action by the nurse is correct? 1 Contact the provider to discuss increasing the tidal volume. 2 Increase the oxygen flow rate to 40 L/min and reassess the client. 3 Notify the provider that this client is ready to be weaned from the ventilator. 4 Reassure the client that this is typical of "ICU psychosis."

3 Partial thromboplastin time (PTT) A baseline PTT should be obtained before the administration of heparin. The other actions are also important to take for the client with a pulmonary embolus, but do not have to be done before heparin administration. Kidney function tests are not indicated for this client.

A client has developed a pulmonary embolism. The nurse anticipates orders for which lab values before beginning heparin therapy for this condition? 1 Arterial blood gases (ABGs) 2 International normalized ratio (INR) 3 Partial thromboplastin time (PTT) 4 Kidney function tests

2 Intercostal nerve block Clients with severe pain often do not take deep breaths and thus do not maintain adequate ventilation. An intercostal nerve block is used for severe pain. Opioid analgesics suppress respiration and should be avoided. Splinting with tape is not done unless the fracture is complex, when seven or more ribs are involved, or if a flail chest is present. Mechanical ventilation is used as a last intervention after others have been attempted. Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam. Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best.

A client has severe pain from three rib fractures after a workplace accident. To facilitate adequate respiration, the nurse discusses which intervention with the provider? 1 Administering opioid analgesics 2 Intercostal nerve block 3 Mechanical ventilation 4 Splinting the ribs with tape

4 Stop the wean and place the client back on the recent mechanical ventilator settings. The client is showing signs of distress with the weaning process; the nurse should place the client back on the ventilator, or facilitate the process for having mechanical ventilator support reinitiated. A Rapid Response Team call is not indicated because weaning is a controlled process and the health care team works closely together to monitor the client's tolerance of weaning and reinitiating mechanical ventilation. Giving sedation agents will worsen the client's ability to breathe. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

A client is ordered to begin weaning from mechanical ventilation. The client was formerly on synchronous intermittent mandatory ventilation, but was later placed on a T-piece. Seven minutes after the client began the wean from the T-piece, the oxygen saturation decreased from 90% to 70%, and the client became tachycardic, diaphoretic, and anxious. What is the best initial nursing intervention? 1 Call the Rapid Response Team. 2 Instruct the client to breathe deeply and try to relax. 3 Give sedation medication to help the client continue the wean. 4 Stop the wean and place the client back on the recent mechanical ventilator settings.

2 Protamine sulfate Protamine sulfate is the antidote for heparin. Vitamin K is the antidote for warfarin. Antihemophilic factor and aminocaproic acid are both antidotes for fibrinolytic therapy that attempts to break up established clots.

A client is receiving heparin sodium (Hepalean) therapy for a pulmonary embolism. Which antidote does the nurse confirm is available on the unit? 1 Vitamin K 2 Protamine sulfate 3 Antihemophilic factor 4 Aminocaproic acid

1 "A tracheostomy will be performed to minimize complications." Clients who require an artificial airway longer than 10-14 days will often need a tracheostomy to help minimize tracheal and vocal cord damage and to continue to remove secretions and provide ventilation and oxygenation. BiPAP is not used to wean clients from ventilators. Nasotracheal tubes carry the same risks as endotracheal tubes and are less comfortable. It is too early to tell whether the client will be ventilator-dependent for a prolonged period of time. Test-Taking Tip: The following are crucial requisites for doing well on the NCLEX exam: (1) A sound understanding of the subject; (2) The ability to follow explicitly the directions given at the beginning of the test; (3) The ability to comprehend what is read; (4) The patience to read each question and set of options carefully before deciding how to answer the question; (5) The ability to use the computer correctly to record answers; (6) The determination to do well; (7) A degree of confidence.

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? 1 "A tracheostomy will be performed to minimize complications." 2 "The provider will order bilevel positive airway pressure (BiPAP) to help wean the client from the ventilator." 3 "We will insert a nasotracheal tube to make the client more comfortable." 4 "Your loved one may be ventilator-dependent indefinitely."

1 Decrease the oxygen flow rate. PEEP is added when clients cannot maintain adequate gas exchange even with high-flow oxygen. The effect of preventing atelectasis should increase arterial blood oxygenation and allow the oxygen flow rate to be decreased. Adding PEEP does not have a direct effect on tidal volume, which is determined by the client's weight and lung capacity. Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax.

A client is receiving mechanical ventilation with FiO2 of 85%. The provider has ordered the positive end-expiratory pressure (PEEP) to be increased from 10 cm of H2O to 15 cm of H2O after the client's oxygen saturation levels have remained less than 92%. As a result of this increase, which adjustment does the nurse plan to make? 1 Decrease the oxygen flow rate. 2 Increase the oxygen flow rate. 3 Decrease the tidal volume. 4 Increase the tidal volume.

2 "It is important to wear them in bed so you don't develop a blood clot in your legs." The continuous use of antiembolism and pneumatic compression stockings is an essential intervention in the prevention of venous thromboembolism. Providing education to clients may help with their refusal to wear compression stockings. Test-Taking Tip: Watch for grammatical inconsistencies. If one or more of the options is not grammatically consistent with the stem, the alert test taker can identify it as a probable incorrect option. When the stem is in the form of an incomplete sentence, each option should complete the sentence in a grammatically correct way.

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? 1 "I'll give you a break from them for an hour, but then I'll need to put them back on." 2 "It is important to wear them in bed so you don't develop a blood clot in your legs." 3 "Let me talk to the provider about discontinuing them."

3 Request an order for pain medication and remind the client to report discomfort. Clients who have a pulmonary embolism are usually anxious. The nurse should communicate with the client to explain interventions and offer reassurance that appropriate measures are being taken. If that is not effective, a sedative may be ordered to help the client rest. The client's anxiety is not related to pain. Telling the client's family that the client is unstable will increase the level of anxiety for everyone involved. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

A client receiving mechanical ventilation and anticoagulant medication after experiencing a pulmonary embolism appears tense and restless. Which action does the nurse take next? 1 Ask the provider if a sedative medication may be prescribed to help the client rest. 2 Explain all interventions to the client and provide reassurance that care is appropriate. 3 Request an order for pain medication and remind the client to report discomfort. 4 Tell the client's family that the client is unstable and suggest that they remain close by

4 Discontinue the heparin and continue the warfarin. The client will typically take both drugs until the INR is between 2.0 and 3.0, then will stop taking the heparin. Clients may take warfarin for 3-6 weeks or indefinitely. There is no need to administer protamine sulfate or phytonadione, which are antidotes for heparin and warfarin, since the INR is within normal limits. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question.

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? 1 Continue the heparin and warfarin, and repeat the INR in one day. 2 Discontinue the heparin and administer protamine sulfate. 3 Discontinue the warfarin and administer phytonadione (AquaMEPHYTON) 4 Discontinue the heparin and continue the warfarin.

3 Pulmonary embolism Difficulty breathing, tachycardia, chest pain, fainting, and cyanosis are some of the common clinical manifestations of a pulmonary embolism. The client also has experienced two of the major risk factors—bone fracture and surgery. A pulmonary infection and edema can cause breathing difficulties and possible cyanosis, but usually not fainting or chest pain. Respiratory difficulties and chest pain are not usual reactions to anesthesia.

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? 1 Pulmonary infection 2 Reaction to anesthesia 3 Pulmonary embolism 4 Pulmonary edema

3 Intubation and mechanical ventilation The client is hypoxic despite receiving oxygen and is showing signs of increasing distress and fatigue; intubation and mechanical ventilation are necessary to treat respiratory failure in this client. A chest x-ray and arterial blood gases may be performed once the client is stabilized as part of the ongoing assessment. An oral airway is used when the client cannot maintain a patent airway. The head of the bed should be elevated to at least 30 degrees or higher if the client prefers. Test-Taking Tip: Get a good night's sleep before an exam. Staying up all night to study before an exam rarely helps anyone. It usually interferes with the ability to concentrate.

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? 1 Chest x-ray and arterial blood gases 2 Insertion of an oral airway 3 Intubation and mechanical ventilation 4 Lowering the head of the bed to 30 degrees

1 Administer oxygen. Clients with a flail chest are initially treated with oxygen, pain management, and promotion of lung expansion through deep-breathing, positioning, and airway clearance. Oxygen is always administered first. Test-Taking Tip: Eat breakfast or lunch before an exam. Avoid greasy, heavy foods and overeating. This will help keep you calm and give you energy.

A client transported to the emergency department after a motor vehicle crash has a heart rate of 115 beats/min, blood pressure of 88/59 mm Hg, shortness of breath, cyanosis, and paradoxical chest movement. What does the nurse do first to treat this condition? 1 Administer oxygen. 2 Give analgesic medications. 3 Suction secretions from the airway. 4 Turn the client to the unaffected side.

2. Analyze postintubation arterial blood gases (ABGs). 1. Obtain baseline aerobic and anaerobic sputum cultures. 3. Infuse levofloxacin (Levaquin) 500 mg IV. 4. Teach the client and family methods of communicating. ABGs should be analyzed first before the other assessments/actions are carried out. A baseline of sputum cultures should then be obtained before medications are administered. Then levofloxacin can be given. Client and family education on communication methods is important, but is the lowest priority here. Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation.

A client was intubated 30 minutes ago for acute respiratory distress syndrome (ARDS) and possible sepsis. Place the orders for this client in the sequence the nurse should perform them. Incorrect 1. Obtain baseline aerobic and anaerobic sputum cultures. 2. Analyze postintubation arterial blood gases (ABGs). 3. Infuse levofloxacin (Levaquin) 500 mg IV. Correct 4. Teach the client and family methods of communicating.

2 Bilevel positive airway pressure

A client who does not wish to be mechanically ventilated is extremely dyspneic and is developing respiratory muscle fatigue. For comfort, what measure might the nurse suggest for this client? 1 Aerosolized bronchodilators 2 Bilevel positive airway pressure 3 Frequent repositioning 4 Venturi mask

4 Pulmonary embolism The client has symptoms of a pulmonary embolism, which do not always include hypoxemia. Clients with atelectasis and pneumonia would likely have diminished breath sounds. Deep vein thrombosis may have preceded the pulmonary embolism. Test-Taking Tip: Relax during the last hour before an exam. Your brain needs some recovery time to function effectively.

A client who had knee replacement surgery 2 days ago has a sudden onset of dyspnea and cough and reports a sharp, stabbing pain in the chest. The nurse notes a heart rate of 110 beats/min, bilateral crackles in lung fields, and an oxygen saturation of 97% on room air. Which postoperative complication does the nurse suspect the client has developed? 1 Atelectasis 2 Deep vein thrombosis 3 Pneumonia 4 Pulmonary embolism

1 Administer the medications as prescribed. Although both heparin and warfarin are anticoagulants, they have different mechanisms and onsets of action. Because warfarin has a slow onset, it must be started while the client is still receiving heparin in order to maintain a safe level of anticoagulation for effective treatment of the venous thromboembolism. It is not necessary to clarify the order because the client must take warfarin while on the heparin because the warfarin is slow-onset. Warfarin should not be held to wait for PTT because PTT is used to measure effectiveness of heparin, not warfarin. Although the nurse may implement use of a bed alarm, it is not a priority. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.

A client who has a venous thromboembolism in the upper arm is to be started on oral warfarin (Coumadin) while still receiving an intravenous heparin infusion. What is the nurse's best action? 1 Administer the medications as prescribed. 2 Clarify the warfarin and heparin orders with the provider. 3 Hold the dose of warfarin until the client's partial thromboplastin time (PTT) is within normal range. 4 Place the client on a bed alarm as a safety precaution.

3 Fibroproliferative In the fibroproliferative phase increased lung damage leads to pulmonary hypertension and fibrosis. The body attempts to repair the damage, and increasing lung involvement reduces gas exchange and oxygenation. In the exudative phase clients experience dyspnea and tachypnea and require oxygen via mask or nasal cannula. The resolution phase usually occurs after 14 days. Resolution of the injury can occur; if not, the patient either dies or has chronic disease. Fibrosis may or may not occur.

A client who has been on a ventilator for the past week has become increasingly hypoxemic and has not been responding well to the increasing oxygen settings. The nurse suspects the client is in which phase of acute respiratory distress syndrome (ARDS)? 1 Exudative 2 Resolution 3 Fibroproliferative 4 Fibrosis

4 Inferior vena cava filtration High-risk clients with a previous history of thromboembolism and bleeding with anticoagulant therapy can have a vena cava filtration device placed to prevent clots from reaching the lungs. Anticoagulant therapy is contraindicated in this client because of the previous history of bleeding. Embolectomy is a surgical procedure to remove clots when a massive clot or multiple clots are present, causing shock. Fibrinolytic therapy also carries a risk for bleeding. Test-Taking Tip: The computerized NCLEX exam is an individualized testing experience in which the computer chooses your next question based on the ability and competency you have demonstrated on previous questions. The minimum number of questions will be 75 and the maximum 265. You must answer each question before the computer will present the next question, and you cannot go back to any previously answered questions. Remember that you do not have to answer all of the questions correctly to pass.

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? 1 Anticoagulant therapy 2 Embolectomy 3 Fibrinolytic therapy 4 Inferior vena cava filtration

3 Remove the ventilator and provide manual ventilation. Clients who develop respiratory distress while being mechanically ventilated should be manually ventilated to allow quick determination of whether the problem is with the ventilator or the client. Increasing oxygen flow rate and Fio2 levels, obtaining an order for blood gases, and staying with the client to provide support may be performed next. Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. Item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints."

A client who is being mechanically ventilated shows increased respiratory distress, including intercostal retractions, anxiety, and restlessness, with an oxygen saturation of 86%. Which priority action by the nurse is correct? 1 Increase the oxygen flow rate and Fio2 levels. 2 Notify the provider and request an order for blood gas evaluation. 3 Remove the ventilator and provide manual ventilation. 4 Stay with the client and provide reassurance and support.

4 Remove the client from the ventilator and ventilate using a bag-valve-mask device. The priority is to provide ventilation using a bag-valve-mask device to determine if the problem is with the client or the ventilator. This information is necessary before calling the health care provider or the Rapid Response Team. Changing the ventilator settings does not provide immediate information about the cause of the distress (client or machine). Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer.

A client who is intubated and on mechanical ventilation begins to develop respiratory distress. What is the next priority action for the nurse? 1 Immediately notify the health care provider and monitor the client's Sao2. 2 Activate the hospital's Rapid Response Team and stay with the client. 3 Increase the ventilator rate and monitor the client's respiratory effort. 4 Remove the client from the ventilator and ventilate using a bag-valve-mask device.

3 Notify the provider of the respiratory distress. Clients receiving transfusions are at risk for transfusion-related acute lung injury (TRALI). Early signs are hyperpnea and increased work of breathing; this should be reported immediately so that treatment can be initiated. These symptoms may be signs of increased anxiety, but the nurse should report the findings to the provider since rapid treatment of TRALI is essential to prevent serious effects. Until the client is evaluated for the presence of TRALI, an anxiolytic medication is not indicated. Test-Taking Tip: Do not spend too much time on one question, because it can compromise your overall performance. There is no deduction for incorrect answers, so you are not penalized for guessing. You cannot leave an answer blank; therefore, guess. Go for it! Remember: You do not have to get all the questions correct to pass.

A client who is receiving packed red blood cells to treat anemia has a respiratory rate of 25 breaths/min, intercostal retractions with breathing, and clear breath sounds. Which action by the nurse is correct? 1 Assess the client's anxiety level. 2 Continue to monitor the client every 15 minutes. 3 Notify the provider of the respiratory distress. 4 Request an order for an anxiolytic medication.

2 Give phytonadione. Phytonadione (vitamin K) is the antidote for warfarin. This client has a prolonged coagulation time as evidenced by the increased INR, which should be between 2.5 and 3.0; this may be increased for clients with chronic pulmonary embolus. Protamine sulfate is the antidote for heparin. Increasing the warfarin dose will only increase the coagulation time, as will resuming the heparin. Study Tip: Focus your study time on the common health problems that nurses most frequently encounter.

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? 1 Administer protamine sulfate. 2 Give phytonadione. 3 Increase the warfarin dose. 4 Resume intravenous heparin.

2 Reassure the client that the treatment is working. The client is receiving appropriate treatment and has stable vital signs, so the nurse should stay with the client and provide reassurance that the measures are working. Anxiety is a common response to pulmonary embolism, even when the client is stable. The client has adequate oxygen saturation, so increasing the oxygen flow is not indicated. If reassurance is not effective, an antianxiety medication may be necessary. The client may not be able to take deep breaths, so this is not recommended as a relaxation technique. Study Tip: Do not change your pattern of study. It obviously has contributed to your being here, so it worked. If you have studied alone, continue to study alone. If you have studied in a group, form a study group.

A client who was just transferred to the ICU after developing a pulmonary embolism is receiving anticoagulant therapy and oxygen. The nurse notes clear breath sounds, an oxygen saturation of 95%, and a heart rate of 78 beats/min. The client reports feeling scared that something bad will happen. What is the nurse's priority action for this client? 1 Increase the oxygen flow to improve oxygen saturation. 2 Reassure the client that the treatment is working. 3 Request an order for an antianxiety medication. 4 Suggest that the client take deep breaths to relax.

3 Discontinuing the heparin Clients who receive IV heparin for pulmonary embolism are usually started on an oral anticoagulant such as warfarin and continue on both until the INR is between 2.0 and 3.0. Once this is reached, the heparin can be discontinued. Vitamin K and protamine sulfate are antidotes for warfarin and heparin toxicity. Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect, the latter of which is more likely. Example: If the answer you are seeking is directed to a specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the treatment-specific option.

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? 1 Administering protamine sulfate 2 Administering vitamin K 3 Discontinuing the heparin 4 Discontinuing the warfarin

2 "I can use a rectal suppository if I become constipated."

A client with a pulmonary embolism is being discharged home on warfarin (Coumadin). Which response suggests the client requires additional teaching about warfarin therapy by the nurse prior to discharge? 1 "I will not participate in my soccer club games until I'm off the warfarin." 2 "I can use a rectal suppository if I become constipated." 3 "I will have to buy myself an electric shaver." 4 "I will call my provider before I go to the dentist."

3 Pneumothorax Clients with COPD may have a spontaneous pneumothorax. Assessment findings frequently include reduced breath sounds on auscultation over the collapsed lung region, hyperresonance on percussion, deviation of the trachea, pleuritic pain, tachypnea, and subcutaneous emphysema. The provider or Rapid Response Team must be contacted immediately to evaluate the need for a chest tube to reexpand the lung.

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? 1 Tension pneumothorax 2 Flail chest 3 Pneumothorax 4 Pulmonary embolism

2 "Lung changes have occurred that are irreversible." Pulmonary fibrosis with progression occurs after 10 days of onset of ARDS. Clients who survive to this point will have permanent lung changes and may remain ventilator-dependent indefinitely. While many die, telling the family member this initially will destroy any hope for a good outcome; this must be discussed with the provider, the nurse, and possibly the palliative care team. Multisystem organ changes are more likely, but have not necessarily occurred. Recovery is rarely complete at this stage. Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late in the morning, take a high-powered snack with you to eat 20 minutes before the examination. The brain works best when it has the glucose necessary for cellular function.

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? 1 "Clients who are ventilator-dependent usually die." 2 "Lung changes have occurred that are irreversible." 3 "Multisystem organ changes occur at 2 weeks." 4 "Recovery may be complete, but will take months."

2 Assess the client's color and respirations. 3 Confirm alarms and ventilator settings. 4 Ensure that the tube cuff is inflated and is in the proper position. 5 Listen for bilateral breath sounds. The first priority when caring for a critically ill client is to assess airway and breathing. Alarm settings should be confirmed each shift, more frequently if necessary. Confirming that the client cannot speak ensures that air is going through the endotracheal tube and not around it. Auscultating for equal bilateral breath sounds assists in confirming that the tube is above the carina. Having visitors remain with the client may promote comfort and prevent confusion. Routine tracheostomy care is performed according to schedule, not necessarily as part of an initial assessment. Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam. Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best.

The nurse coming on shift prepares to perform an initial assessment of a sedated ventilated client. Which are priorities for the nurse to carry out? Select all that apply. 1 Ask visitors to leave. 2 Assess the client's color and respirations. 3 Confirm alarms and ventilator settings. 4 Ensure that the tube cuff is inflated and is in the proper position. 5 Listen for bilateral breath sounds. 6 Provide routine tracheotomy and endotracheotomy and mouth care.

3 Reduction in surfactant activity 4 Damage to type II pneumocytes 5 Edema around terminal airways ARDS occurs as a result of an acute lung injury. The injury typically happens in the alveolar-capillary membrane. As a result of the injury, surfactant is diluted by extra fluid in the lungs. Type II pneumocytes are damaged and edema forms around terminal airways. Surfactant activity is reduced due to the damage of type II pneumocytes. The collapsed alveoli cannot exchange gases and edema forms around terminal airways. In ARDS, lung volume is decreased and lung channels are compressed.

The nurse expects which changes in a client with acute respiratory distress syndrome (ARDS)? Select all that apply. 1 Increase in lung volume 2 Expansion of lung channels 3 Reduction in surfactant activity 4 Damage to type II pneumocytes 5 Edema around terminal airways

3 Provide extra fluids and throat lozenges. The client is experiencing signs of throat irritation and should be provided with measures to minimize discomfort. Incentive spirometry is necessary for lower airway problems to prevent pneumonia. The Rapid Response Team should be notified if the client experiences stridor or other signs of airway obstruction. Racemic epinephrine is used to treat stridor. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect, and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Although there is no penalty for guessing, the subsequent question will be based, to an extent, on the response you give to the question at hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based on your knowledge and skill performance on the examination up to that point.

The nurse has extubated a client who was receiving mechanical ventilation for several days. A few hours after extubation, the client reports a sore throat and cough and the nurse notes a hoarse voice. Which action by the nurse is correct? 1 Encourage use of an incentive spirometer. 2 Notify the Rapid Response Team. 3 Provide extra fluids and throat lozenges. 4 Request an order for nebulized racemic epinephrine.

2 The trachea is deviated to the right side and cyanosis is present. Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention (JVD), cyanosis, and hyperresonance to percussion over the affected area. Flail chest is manifested by paradoxical chest movement, which 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.

The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure (PEEP). Which findings would cause the nurse to suspect a left-sided tension pneumothorax? 1 The chest caves in on inspiration and "puffs out" on expiration. 2 The trachea is deviated to the right side and cyanosis is present. 3 The left lung field is dull to percussion with crackles present on auscultation. 4 The client has bloody sputum and wheezes.

1 Dizziness and fainting 3 Inspiratory chest pain Syncope, hypotension, and fainting are symptoms associated with PE. Sharp, pleuritic, inspiratory chest pain is also characteristic of PE. Sudden, not gradual, SOB occurs with PE. Productive cough is associated with infection; PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema; PE may cause hemoptysis.

The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms should the nurse assess? Select all that apply. 1 Dizziness and fainting 2 Shortness of breath (SOB) worsening over the last 2 weeks 3 Inspiratory chest pain 4 Productive cough 5 Pink, frothy sputum

1 Obesity 3 Advancing age 5 Prolonged immobility In VTE, blood tends to clot in the veins. Obesity contributes to the deposition of cholesterol in the veins, leading to clot formation. The elasticity of veins decreases with age, which leads to clot formation. Prolonged immobility increases the risk of VTE due to venous pooling. Malnutrition and vitamin deficiency are not risk factors for VTE; they are not associated with functions related to blood vessels and blood clotting mechanisms.

The nurse is assessing a client's risk for a venous thromboembolism (VTE). What are the major risk factors for VTE? Select all that apply. 1 Obesity 2 Malnutrition 3 Advancing age 4 Vitamin deficiency 5 Prolonged immobility

1 Elevate the head of the bed and assemble oxygen delivery equipment. These are signs and symptoms of pulmonary embolism. The nurse's initial intervention after activating the Rapid Response Team will be to elevate the head of the bed and prepare to give oxygen. Heparin, venous access, chest x-ray, and telemetry require an order first. Reassurance and assessment of symptoms are ongoing. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet).

The nurse is caring for a client who experiences a sudden onset of shortness of breath; a sharp, stabbing chest pain; and a feeling of apprehension. The nurse auscultates crackles in both lungs, and assesses tachypnea and an oxygen saturation of 88%. After notifying the Rapid Response Team, what does the nurse do next? 1 Elevate the head of the bed and assemble oxygen delivery equipment. 2 Prepare the client for a chest x-ray and apply telemetry monitoring equipment. 3 Prepare to give intravenous heparin and obtain venous access. 4 Reassure the client and continue to assess for other symptoms

3 Position the client in a semi-Fowler's position and continue to monitor symptoms. Coughing and difficulty clearing secretions are early signs of possible obstruction; the nurse should monitor the client closely and position the client in a semi-Fowler's position. Stridor is a late sign and signifies an emergency requiring racemic epinephrine and possible reintubation. Suctioning the client may increase irritation and cause increased swelling of the airway. Study Tip: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.

The nurse is caring for a client who has recently been extubated following ventilatory support. The nurse notes that the client is hoarse, has a cough, and has difficulty clearing secretions. Which action is correct? 1 Notify the Rapid Response Team that the client may need to be reintubated. 2 Notify the provider and request an order to administer racemic epinephrine. 3 Position the client in a semi-Fowler's position and continue to monitor symptoms. 4 Suction the client to remove secretions and encourage deep-breathing.

3 Listen to the client's breath sounds. A typical reason for the high pressure alarm to sound is the need for suctioning or tension pneumothorax. The nurse should begin the assessment with the client, not with the ventilator. Although an excessively high tidal volume could contribute to sounding of the high-pressure alarm, assessment always begins with the client. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention. Test-Taking Tip: What happens if you find yourself in a slump over the examination? Take a time-out to refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major accomplishments in life. This effort will help you regain confidence in yourself and get you back on track toward the realization of your long-anticipated goal.

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? 1 Check the ventilator alarm settings. 2 Assess the set tidal volume. 3 Listen to the client's breath sounds. 4 Call the respiratory therapist

2 Bilevel positive airway pressure (BiPAP) BiPAP ventilation is a noninvasive method that may provide short-term ventilation without intubation. An oropharyngeal airway is used to prevent the tongue from occluding the airway or the client from biting the endotracheal tube. A nonrebreathing 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 caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which method provides an alternative to mechanical ventilation? 1 Oropharyngeal airway 2 Bilevel positive airway pressure (BiPAP) 3 Nonrebreathing mask with 100% oxygen 4 Positive end-expiratory pressure (PEEP)

1 Client with a brainstem tumor 2 Client with acute pancreatitis 3 Client with a T3 spinal cord injury 4 Client using patient-controlled analgesia Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome (ARDS); abdominal distention also ensues, which can limit respiratory excursion. Opiates, which can depress the brainstem, present risk factors for respiratory failure. Clients with cervical and thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect intercostal muscles are affected. All of these clients should be monitored closely for respiratory failure. Cocaine is a stimulant, which would not cause respiratory failure unless a stroke ensued. Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer.

The nurse is caring for a group of clients. Which clients should be monitored closely for respiratory failure? Select all that apply. 1 Client with a brainstem tumor 2 Client with acute pancreatitis 3 Client with a T3 spinal cord injury 4 Client using patient-controlled analgesia 5 Client experiencing cocaine intoxication

3 Hypoxemia related to ventilation-perfusion mismatch Restoring adequate oxygenation and tissue perfusion takes priority when a client presents with a PE. Although nutrition must be addressed, priorities include airway, breathing, and circulation. The client has a leukocytosis related to lung inflammation; leukopenia places clients at risk for infection, but this is not the priority at this time. Education as to the cause of PE must be postponed until oxygenation and hemodynamic stability occur. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action.

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? 1 Inadequate nutrition related to food-drug interactions and anticoagulant therapy 2 Potential for infection related to leukocytosis 3 Hypoxemia related to ventilation-perfusion mismatch 4 Insufficient knowledge related to the cause of PE

2 Pulmonary contusion Pulmonary contusion is a common chest injury that most often occurs after a rapid deceleration during a car crash. Pulmonary contusion develops over time rather than immediately. Hemorrhage and edema in the alveoli and interstitial spaces manifest as acute respiratory distress. Test-Taking Tip: What happens if you find yourself in a slump over the examination? Take a time-out to refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major accomplishments in life. This effort will help you regain confidence in yourself and get you back on track toward the realization of your long-anticipated goal.

The nurse is reviewing the following assessment data for a client admitted after being involved in a motor vehicle crash 3 days ago in which the client was pinned against the steering wheel. Based on the client's assessment data, which condition does the nurse suspect the client may be developing? Respiratory: 32 Temp: 100.5 Heart Rate: 126 BP: 136/82 Decreased breath sounds in bilateral bases, crackles and bilateral wheezes Bloody sputum expectorated with coughing pH: 7.54 PaO2: 48 PaCO2: 28 HCO3: 25 Anxious Distressed 1 Pulmonary edema 2 Pulmonary contusion 3 Pulmonary embolism 4 Pneumonia

2 54-year-old who is mechanically ventilated and has tracheal deviation The 54-year-old client is showing signs of a tension pneumothorax that could lead to decreased cardiac output and shock if not addressed promptly. The 40-year-old client has intermittent adventitious breath sounds, but is not in immediate danger or distress. The 57-year-old client has mild discomfort, but is not in danger of a life-threatening situation. The 60-year-old client has mild tachypnea, but is not in immediate distress or danger. Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question.

Which client needs immediate attention by the nurse? 1 40-year-old who is receiving continuous positive airway pressure (CPAP) and has intermittent wheezing 2 54-year-old who is mechanically ventilated and has tracheal deviation 3 57-year-old who was recently extubated and is reporting a sore throat 4 60-year-old who is receiving O2 by facemask and whose respiratory rate is 24

2 Continuous removal of subglottic secretions 3 Elevating the head of the bed at least 30 degrees whenever possible 4 Handwashing before and after contact with the client 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 bundle. Antibiotics are not given prophylactically; they 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 a client is going to be mechanically ventilated for a prolonged period of time, postpyloric or gastrostomy tubes are preferred over nasogastric tubes for nutrition. Placing a client in a negative airflow room is not part of the VAP bundle. The client does not require this room.

Which components belong to the ventilator bundle approach to prevent ventilator-associated pneumonia (VAP)? Select all that apply. 1 Administering antibiotic prophylaxis 2 Continuous removal of subglottic secretions 3 Elevating the head of the bed at least 30 degrees whenever possible 4 Handwashing before and after contact with the client 5 Placing a nasogastric tube 6 Placing the client in a negative airflow room

3 Client with aspiration pneumonia Aspiration of acidic gastric contents is a risk for ARDS. Clients with DKA may develop metabolic acidosis, but not ARDS, which develops in lung injury. Atrial fibrillation does not cause lung injury unless embolization occurs. Acute kidney failure results in metabolic acidosis, not in acute lung injury.

Which critically ill client has the greatest risk for developing acute respiratory distress syndrome (ARDS)? 1 Client with diabetic ketoacidosis (DKA) 2 Client with atrial fibrillation 3 Client with aspiration pneumonia 4 Client with acute kidney failure

1 Decreasing nighttime disruptions ICU psychosis can be minimized not only by encouraging sleep, but also by keeping to a regular routine. Keeping the lights on or providing TV or radio will not encourage sleep. Sedation can promote confusion and disorientation.

Which intervention for a client in the intensive care unit will decrease the incidence of "ICU psychosis?" 1 Decreasing nighttime disruptions 2 Keeping the lights on to promote orientation 3 Administering sedation 4 Providing television or radio for stimulation

1 Remain with the client and provide oxygen in a calm manner. The underlying cause for anxiety with a PE is hypoxemia, which will be alleviated by oxygen; remaining with the client in distress is appropriate. Rebreathing from a brown bag is an intervention that increases Paco2 during hyperventilation, as in a panic attack; it will not provide needed oxygen. Sedation and/or allowing a family member to stay may calm the client, but will not improve oxygenation.

Which intervention will be most effective in reducing anxiety in a client with a pulmonary embolism (PE)? 1 Remain with the client and provide oxygen in a calm manner. 2 Have the client breathe into a brown paper bag using pursed lips. 3 Offer the client a mild sedative. 4 Allow a family member to remain in the room.

1 Acute respiratory distress syndrome Clients who have acute respiratory distress syndrome (ARDS) have dense pulmonary infiltrates on x-ray that resemble ground glass. The chest x-ray of a client with pulmonary embolism may have some infiltration around the embolism site or may not have any changes. A tension pneumothorax will show collapse of the affected lung. Ventilatory failure will show changes associated with the underlying cause, generally due to collapse of the alveoli.

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? 1 Acute respiratory distress syndrome 2 Pulmonary embolism 3 Tension pneumothorax 4 Ventilatory failure

4 Pulmonary embolism The client's history and clinical manifestations suggest that a pulmonary embolus may have occurred. Anaphylaxis and bronchospasm are characterized by wheezing. Pneumothorax is characterized by absent breath sounds on the affected side. Study Tip: When forming a study group, carefully select members for your group. Choose students who have abilities and motivation similar to your own. Look for students who have a different learning style than you. Exchange names, email addresses, and phone numbers. Plan a schedule for when and how often you will meet. Plan an agenda for each meeting. You may exchange lecture notes and discuss content for clarity or quiz one another on the material. You could also create your own practice tests or make flash cards that review key vocabulary terms.

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? 1 Anaphylaxis 2 Bronchospasm 3 Pneumothorax 4 Pulmonary embolism

3 A client returning from an open reduction and internal fixation of the tibia Surgery and immobility are risks for deep vein thrombosis (DVT) and PE. No evidence suggests that the client with diabetes has been immobile, which is a risk factor for PE; the client will be treated with antibiotics. For the client with a peripheral line, no evidence indicates a problem with the IV or with breakage of the catheter, which could lead to an air embolism. For the client with hypokalemia, no evidence reveals risk for PE; no immobility or hypercoagulability is present.

The nurse is caring for a group of clients. Which person does the nurse identify as having the highest risk for pulmonary embolism (PE)? 1 A client with diabetes and cellulitis of the leg 2 A client receiving IV fluids through a peripheral line 3 A client returning from an open reduction and internal fixation of the tibia 4 A client with hypokalemia receiving potassium supplements

1 Pallor 2 Cyanosis 4 Restlessness Low arterial blood oxygen level is called hypoxemia. When a client's oxygen level is low, the nurse should assess skin color for pallor and cyanosis because there is not enough oxygen perfusing the tissues. The client will be restless because decreased oxygen levels affect cerebral blood flow. Diarrhea is not a manifestation of hypoxemia. The heart rate usually increases to compensate for low perfusion in hypoxemia.

What are the manifestations of hypoxemia? Select all that apply. 1 Pallor 2 Cyanosis 3 Diarrhea 4 Restlessness 5 Bradycardia

1 Crackles 2 Diaphoresis 4 Low-grade fever A PE is a collection of particulate matter that enters venous circulation and lodges in the pulmonary vessels. Crackles, diaphoresis, and low-grade fever are some of the signs of PE. Crackles are heard because the embolism blocks pulmonary vessels and fluid accumulates. Diaphoresis occurs due to the pooling of fluid. Tachycardia occurs during a PE; the client experiences an elevated heart rate as the heart works harder to circulate blood throughout the body. A severe headache is not a sign of PE.

What are the signs and symptoms of pulmonary embolism (PE)? Select all that apply. 1 Crackles 2 Diaphoresis 3 Bradycardia 4 Low-grade fever 5 Severe headache

2 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 like 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 the chances of "ICU psychosis" and anxiety, but it does not take priority over assessing for hypoxemia.

A ventilated client in the intensive care unit begins to pick at the bedcovers. Which action should the nurse take next? 1 Increase the sedation. 2 Assess for adequate oxygenation. 3 Explain to the client that he has a tube in his throat to help him breathe. 4 Request that the family leave to decrease the client's agitation.

1 Keep the head of the bed elevated. Positioning of 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 professional nurse. Adjusting oxygen flow rates requires complex decision making and should be done by the RN. Test-Taking Tip: Look for answers that focus on the client or that are directed toward the client's feelings.

All of these nursing actions are included in the plan of care for a client who has just been extubated. Which action should the nurse delegate to unlicensed assistive personnel (UAP)? 1 Keep the head of the bed elevated. 2 Teach about incentive spirometer use. 3 Monitor vital signs every 5 minutes. 4 Adjust the nasal oxygen flow rate.

2 Good lung down To facilitate ventilation-perfusion matching, the client should be positioned with the healthy lung down. If the client's affected lung is on the left, the client should be positioned on the right side.

In order to improve oxygenation for a client with a bad left lung, how should the nurse position the client? 1 Bad lung down 2 Good lung down 3 With the head of the bed flat 4 With the head of the bed elevated to a 30-degree angle

1 "I may use enemas to help with constipation." Clients should avoid straining at stool, but should take an oral stool softener and not use an enema, which can cause trauma to rectal tissues. To prevent excessive bruising, clients should apply ice for 1 hour if bumped. Dental work should not be performed without consulting the provider. Clients on warfarin will need regular international normalized ratio (INR) levels to monitor for drug effectiveness and bleeding risk. Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in 1 to 2 minutes.

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? 1 "I may use enemas to help with constipation." 2 "I should apply an ice pack for 1 hour if I am bumped." 3 "I should not have dental work without consulting my provider." 4 "I will need weekly lab work to monitor my medication therapy."

1 Shock 2 Trauma 3 Blood transfusions 5 Aspiration Several factors place this client at increased risk for acute lung injury, including shock, trauma, multiple blood transfusions, and aspiration. The nurse should be aware of these risk factors and continually monitor the client for early signs of respiratory distress. Age is not a risk factor for this client

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. 1 Shock 2 Trauma 3 Blood transfusions 4 Age 5 Aspiration 6 Antibiotic administration

1 Client's color, perfusion, and chest rise The first assessment should always be the client, and not the ventilator or the monitor readings.

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? 1 Client's color, perfusion, and chest rise 2 Low-pressure and low-exhaled volume settings 3 Oxygen saturation, heart rate, and blood pressure readings 4 Tidal volume and respiratory rate settings

2 Hypoventilation and decreased breath sounds Intubation may be indicated for the client who is hypoventilating and has decreased breath sounds. Suctioning, rather than intubation, is indicated for difficulty swallowing secretions, as well as for thick, purulent secretions and crackles (consistent with pneumonia). Intubation is indicated for the client with an O2 saturation of less than 90% and other symptoms of hypoxemia or hypercarbia. Test-Taking Tip: Eat breakfast or lunch before an exam. Avoid greasy, heavy foods and overeating. This will help keep you calm and give you energy.

The client with which condition is in greatest need of immediate intubation? 1 Difficulty swallowing oral secretions 2 Hypoventilation and decreased breath sounds 3 O2 saturation of 90% 4 Thick, purulent secretions and crackles

2 Aminocaproic acid (Amicar) Fibrinolytic therapy is used to break up an existing clot, but these agents may cause excessive bleeding; it may be necessary to block the activity of fibrinolytic agents by using its antidote to prevent further excessive bleeding. Aminocaproic acid (Amicar) is the antidote for fibrinolytic therapy. Alteplase (Activase) is a fibrinolytic drug that increases the risk of bleeding. Vitamin K1 is an antidote for warfarin (Coumadin), an oral anticoagulant used for the long-term prevention of venous thrombi. Protamine sulfate is used to block the activity of heparin.

Which antidote is used for blocking fibrinolytic therapy? 1 Alteplase (Activase) 2 Aminocaproic acid (Amicar) 3 Vitamin K1 (AquaMEPHYTON) 4 Protamine sulfate

1 Alteplase (Activase) This client is displaying symptoms of a pulmonary embolism (PE). Clients who are hemodynamically unstable will need a fibrinolytic drug to break up the clot causing the PE. Heparin is used when the client is stable to prevent the clot from getting larger. Clopidogrel is used to prevent PE in nonhospitalized clients. Coumadin is used after the client is stable, as it generally takes 72 hours to produce anticoagulation. Test-Taking Tip: Work with a study group to create and take practice tests. Think of the kinds of questions you would ask if you were composing the test. Consider what would be a good question, what would be the right answer, and what would be other answers that would appear right but would in fact be incorrect.

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? 1 Alteplase (Activase) 2 Clopidogrel (Plavix) 3 Coumadin (Warfarin) 4 Low-molecular-weight heparin (Lovenox)

2 Place the client in an upright position to facilitate breathing.

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? 1 Encourage frequent ambulation to improve exercise tolerance. 2 Place the client in an upright position to facilitate breathing. 3 Provide low-flow oxygen by nasal cannula to alleviate hypoxia. 4 Suggest an order for a bronchodilator to open narrow airways.

2 pH 7.46, Paco2 30, HCO3- 26, Pao2 68 Hyperventilation triggered by hypoxia and pain first leads to respiratory alkalosis, indicated by a low partial pressure of arterial carbon dioxide (Paco2 of 30) and a high pH (7.46). No compensation is present as the HCO3- (26) is normal, and hypoxemia is present, consistent with PE. A pH of 7.24 is acidotic, a Pao2 of 56 reflects hypoxemia, and no compensation is present with a normal HCO3- (26); this blood would be found in a person in acute respiratory failure owing to hypoventilation and hypoxemia. A pH between 7.35 and 7.45, Paco2 of 35 to 45, HCO3- of 22 to 26, and Pao2 greater than 75 all reflect a normal blood gas. A pH of 7.47 and an HCO3- of 30 are alkalotic, indicating metabolic alkalosis; a Paco2 of 35 is normal (indicating lack of compensation) and a Pao2 of 75 is normal. Test-Taking Tip: Watch for grammatical inconsistencies. If one or more of the options is not grammatically consistent with the stem, the alert test taker can identify it as a probable incorrect option. When the stem is in the form of an incomplete sentence, each option should complete the sentence in a grammatically correct way.

When caring for a client with pulmonary embolism, which blood gas result does the nurse anticipate early in the course of the disease? 1 pH 7.24, Paco2 55, HCO3- 26, Pao2 56 2 pH 7.46, Paco2 30, HCO3- 26, Pao2 68 3 pH 7.35, Paco2 45, HCO3- 24, Pao2 80 4 pH 7.47, Paco2 35, HCO3- 30, Pao2 75

4. Tension pneumothorax PEEP is used to prevent the alveoli from collapsing at the end of expiration. The most serious side effect of PEEP is tension pneumothorax, in which the alveoli rupture and air accumulates in the pleura. Infection is not associated with application of PEEP. PEEP is used for prevention of ventilatory failure. PEEP does not affect the clotting mechanism of the body; pulmonary embolism is not a side effect associated with PEEP.

Which is a serious side effect associated with positive end-expiratory pressure (PEEP)? 1 Lung infection 2 Ventilatory failure 3 Pulmonary embolism 4. Tension pneumothorax

1 Age 72 years 2 Admission weight of 290 lb (131.8 kg) 4 Presence of a central venous catheter Several factors place a client at increased for developing a venous thromboembolism that may progress to a pulmonary embolism. Risk factors that should be assessed include prolonged immobility, central venous catheter, surgery, obesity, advanced age, history of thromboembolism, smoking history, pregnancy, estrogen therapy, heart failure, stroke, and cancer. Text Reference - p.604

Which risk factors increase a client's risk for venous thromboembolism that may progress to a pulmonary embolism? Select all that apply. 1 Age 72 years 2 Admission weight of 290 lb (131.8 kg) 3 Ability to ambulate with assistance of one person 4 Presence of a central venous catheter 5 Nonsmoker

1 Auscultate bilateral breath sounds to check endotracheal tube placement. Tidal volume may be calculated by multiplying the client's body weight in kilograms by 7 or 10 or by adding a zero to the weight in kg. This client weighs 50 kg, so an adequate tidal volume would be 350 to 500 mL. The settings of the ventilator are correct, but the client continues to exhibit respiratory acidosis as evidenced by a low pH, low Pao2, and elevated Paco2. The nurse should auscultate breath sounds and check placement of the endotracheal tube to see if both lungs are being ventilated. Because the client has respiratory acidosis, she is not compensating and not stable. Until the nurse completely assesses the client and ensures adequate ventilation, requesting sodium bicarbonate is not warranted. Weaning is not begun until clients are stable and making attempts to breathe on their own. Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of resources over an extended period of time ensures your understanding and increases your confidence about your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited, yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but excessive anxiety has the opposite effect, acting as a barrier and keeping you from reaching your goal. Your attitude about yourself and your goals will help keep you focused, adding to your strength and inner conviction to achieve success.

A 5-foot, 2-inch tall 38-year-old woman who weighs 110 lb is being mechanically ventilated at a tidal volume of 400 mL and a respiratory rate of 16 breaths per minute. Her most recent arterial blood gas (ABG) results are: pH = 7.33; Pao2 = 85 mm Hg; Paco2 = 55 mm Hg. What is the nurse's next action? 1 Auscultate bilateral breath sounds to check endotracheal tube placement. 2 Continue to monitor the client's stable status. 3 Notify the health care provider about the need for sodium bicarbonate. 4 Request an order to begin weaning the client from the ventilator.

3 Ventilation is inadequate; respiratory acidosis is present. Synchronized intermittent mandatory ventilation mode provides a set number of mechanical breaths, but spontaneous breathing to assist with ventilation is also possible. The Paco2 indicates the client is not effectively ventilating and more frequent or larger breaths are necessary. The settings of the ventilator are causing hypoventilation and respiratory acidosis. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action

A client is being mechanically ventilated after abdominal surgery via synchronized intermittent mandatory ventilation with a set rate of 10 breaths per minute. The client is sedated and not breathing spontaneously. His most recent arterial blood gas (ABG) results are: pH = 7.32; Pao2 = 85 mm Hg; Paco2 = 55 mm Hg. What is the nurse's interpretation of these results? 1 Ventilation is adequate to maintain oxygenation. 2 Ventilation is excessive; respiratory alkalosis is present. 3 Ventilation is inadequate; respiratory acidosis is present. 4 Ventilation status cannot be determined from the information presented.

1 Aminocaproic acid (Amicar) The antidote for excessive bleeding for clients receiving alteplase is aminocaproic acid. Packed red blood cells may be given if blood loss is excessive to treat anemia, but they are not used as an antidote. Phytonadione is the antidote for warfarin. Protamine sulfate is the antidote for heparin.

A client receiving intravenous alteplase (tPA) after developing a pulmonary embolism develops bloody stools and bleeding gums. The nurse notifies the provider and obtains an order for which antidote? 1 Aminocaproic acid (Amicar) 2 Packed red blood cells 3 Phytonadione (AquaMEPHYTON) 4 Protamine sulfate

2 Dobutamine (Dobutrex) Clients who have persistent hypotension with a pulmonary embolism may be given an inotropic agent such as dobutamine to improve cardiac output. Vitamin K is the antidote for warfarin (Coumadin), protamine sulfate is the antidote for heparin, and aminocaproic acid (Amicar) is the antidote for fibrinolytic therapy. Test-Taking Tip: Look for answers that focus on the client or that are directed toward the client's feelings.

A client being treated for a pulmonary embolism is receiving heparin, oxygen, and intravenous fluids. The nurse notes a persistent blood pressure of 88/58 mm Hg and a urine output of 20 mL/hr. Which medication does the nurse anticipate will be ordered by the provider? 1 Aminocaproic acid (Amicar) 2 Dobutamine (Dobutrex) 3 Protamine sulfate 4 Vitamin K

1 Oxygenation failure Clients with normal lung function who are hypoxic most likely have ventilatory failure. This client is anemic, which results in decreased oxygen-carrying capability due to a deficiency in red blood cells and hemoglobin. Clients with pulmonary embolism have changes in lung function. Respiratory distress occurs when there is increased work of breathing, but without hypercapnea or hypoxia. Ventilatory failure occurs when there is lung dysfunction with normal perfusion. Test-Taking Tip: Do not read information into questions, and avoid speculating. Reading into questions creates errors in judgment.

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? 1 Oxygenation failure 2 Pulmonary embolism 3 Respiratory distress 4 Ventilatory failure

2 Monitor the platelet count daily.

A client has been admitted for a pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? 1 Teach the client to avoid using dental floss. 2 Monitor the platelet count daily. 3 Ensure adequate staffing for the unit. 4 Notify radiology of an impending V/Q scan.

3 Obtain an order for arterial blood gases The client has developed respiratory distress. Even though the oxygen saturation level is within normal limits, a more accurate assessment of hypoxemia is with arterial blood gases. Giving high-flow oxygen with a Venturi mask may increase anxiety and cause oxygen-induced hypercapnea in clients with COPD. Unless the client exhibits signs of respiratory failure with hypoxemia and cyanosis, notifying the Rapid Response Team is not necessary. A chest x-ray may be indicated after the client is stabilized to help determine the cause of the respiratory distress. Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early.

A client with chronic obstructive pulmonary disease (COPD) suddenly becomes dyspneic with a respiratory rate of 32 breaths/min and an oxygen saturation of 94%. The client appears pale and anxious and is using accessory muscles to breathe. What is the nurse's priority action? 1 Apply high-flow oxygen with a Venturi mask 2 Notify the Rapid Response Team 3 Obtain an order for arterial blood gases 4 Request an order for a chest x-ray

3 Oxygen saturation has decreased from 95% to 80% at an Fio2 of 40%. Positive end-expiratory pressure (PEEP) is used to improve oxygenation and reduce atelectasis. A drop in oxygen saturation when PEEP is reduced should be reported to the provider because oxygenation may not be effective. The decrease in breath sounds may be related to the reduction in PEEP, but is less urgent than the change in oxygenation. Increased secretions and coughing are not abnormal when PEEP is reduced during mechanical ventilation. Test-Taking Tip: Look for answers that focus on the client or are directed toward feelings.

At the hourly assessment of an intubated client, after positive end-expiratory pressure (PEEP) has been reduced from 10 cm H2O to 5 cm H2O, the nurse notes all of the following changes. For which change does the nurse notify the provider? 1 The client is requiring more suctioning to remove secretions. 2 Breath sounds are distant over bases in both lung fields. 3 Oxygen saturation has decreased from 95% to 80% at an Fio2 of 40%. 4 The client is coughing more, requiring increased PRN sedation to tolerate the mechanical ventilator.

2 Milrinone (Primacor) Milrinone (Primacor) is a positive inotropic drug that increases the contractility of the cardiac musculature, thereby increasing cardiac output. Alteplase (Activase) is a fibrinolytic drug that prevents the formation of clots in blood vessels. Nitroprusside (Nipride) is a vasodilator that is used for lowering blood pressure. Phytonadione (Mephyton) is an antidote for warfarin and is administered in cases of warfarin overdose.

Which drug increases cardiac output by improving myocardial contractility? 1 Alteplase (Activase) 2 Milrinone (Primacor) 3 Nitroprusside (Nipride) 4 Phytonadione (Mephyton)

1 Attain adequate gas exchange and oxygenation During the initial phase of treatment oxygenation and gas exchange is the primary concern. After anticoagulant therapy is initiated, and for the duration of anticoagulant therapy, bleeding is a concern. Anxiety and coping are a concern at all times, but do not represent life-threatening problems.

Which expected client outcome is the priority during the initial phase of treatment for a pulmonary embolism? 1 Attain adequate gas exchange and oxygenation 2 Remain free from bleeding episodes 3 Reduce the level of anxiety 4 Use effective coping strategies

1 Client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis The client with a diagnosed pulmonary embolism is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin; this indicates a significant decline in status and warrants activation of the Rapid Response Team. 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 has normal oxygen saturation. The client who was extubated 3 days ago requires ongoing monitoring or nursing intervention, but does not have evidence of acute deterioration or severe complications. Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.

The medical-surgical unit nurse should call the Rapid Response Team to assess which client? 1 Client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis 2 Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain 3 Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry of 94% 4 Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs

1 Respiratory distress Respiratory failure, oxygenation failure, and ventilatory failure are all characterized by hypoxemia, which is any Pao2 less than 90%. This client has increased work of breathing and dyspnea characteristic of respiratory distress, but is still compensating to maintain oxygenation. Study Tip: You have a great resource in your classmates. We all have different learning styles, strengths, and perspectives on the material. Participating in a study group can be a valuable addition to your nursing school experience.

The nurse assesses a client with pneumonia and notes a productive cough, dyspnea with ambulation, and increased work of breathing. The client's oxygen saturation is 96% and an arterial blood gas reveals a Pao2 of 93%. The nurse contacts the provider to report which condition based on these findings? 1 Respiratory distress 2 Respiratory failure 3 Oxygenation failure 4 Ventilatory failure

3 Paco2 level is 38 mm Hg. The Paco2 level is normal. If the endotracheal tube was in the esophagus or stomach rather than the trachea, the Paco2 level would be below normal (i.e., less than 35 mm Hg). The fact that air cannot be heard in the stomach or that a suction catheter is easily passed are not conclusive assessments of a correctly placed endotracheal tube. The oxygen saturation is also not the best assessment parameter for determining endotracheal tube placement. Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or degrading responses.

Which assessment finding best indicates that the endotracheal tube remains correctly placed in the client's trachea and is not in the esophagus? 1 A suction catheter is easily passed through the endotracheal tube. 2 Oxygen saturation by pulse oximetry is greater than 85%. 3 Paco2 level is 38 mm Hg. 4 No air is heard in the stomach when auscultated with a stethoscope.

3 PEEP pressure between 5 and 15 cm H2O Clients receiving PEEP ventilation should have pressure settings between 5 and 15 cm H2O. Because prolonged use of high Fio2 can damage lungs, the Fio2 should be lowered to the lowest possible amount. The oxygen flow rate should be 40 L/min. The client's tidal volume should be 7-10 mL/kg; for this client, the range would be 560-800 mL.

The nurse assists with the intubation of an 80-kg client who will receive mechanical ventilation with positive end-expiratory pressure (PEEP) ventilation. When monitoring the client, the nurse ensures that which settings are maintained? 1 Fio2 as high as possible 2 Oxygen flow rate of 20 L/min 3 PEEP pressure between 5 and 15 cm H2O 4 Tidal volume of 400 mL

1 25-year-old woman who frequently flies to different countries People who engage in prolonged and frequent air travel are at higher risk for PE. A 67-year-old man who works on a farm is not at high risk because he has an active lifestyle. A heart attack is usually caused by a thrombus or occlusion of the coronary arteries, not of the legs; if on prolonged bedrest, the client's risk is increased. PE is a clotting disorder, not a bleeding disorder.

Which client has the highest risk for developing a pulmonary embolism (PE)? 1 25-year-old woman who frequently flies to different countries 2 67-year-old man who works on a farm 3 45-year-old man admitted for a heart attack 4 23-year-old woman with a bleeding disorder

4 Platelet count of 50,000/mm3 The normal range for platelets is 200,000-400,000/mm3. Platelets are needed for blood clotting. This client's platelet count is extremely low and he or she is at risk for bleeding. The low platelet count may be an indication of an adverse reaction to heparin known as heparin-induced thrombocytopenia (HIT). The heparin must be discontinued and the client may need to receive platelet therapy before life-threatening hemorrhage occurs. Safety measures should also be implemented to prevent bleeding.

A client has been receiving heparin subcutaneously for 4 days. Which laboratory blood test value does the nurse report immediately to the provider? 1 Activated partial thromboplastin time of 46 seconds 2 International normalized ratio (INR) of 1.7 3 Hemoglobin of 14.2 g/dL 4 Platelet count of 50,000/mm3

1 Acute respiratory distress syndrome Clients who have these symptoms most likely have acute respiratory distress syndrome (ARDS). The ground-glass appearance on the x-ray confirms this diagnosis. Clients with pulmonary embolism may have normal chest x-rays or may have infiltrates localized to the area around the embolism. Clients with pneumonia typically have infiltration or consolidation of one or more lobes. A tension pneumothorax is visible on x-ray with one-sided lung involvement. Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other examination questions.

A client receiving 100% oxygen after developing pneumonitis after inhaling an irritant has worsening hypoxemia confirmed with arterial blood gases, and has increasing dyspnea and work of breathing. A chest x-ray reveals a ground-glass appearance in both lungs. Which condition does the nurse suspect this client has developed? 1 Acute respiratory distress syndrome 2 Oil or fat embolism 3 Pneumonia 4 Tension pneumothorax

2 Oxygen saturation increases from 85% to 92% The client with ARDS often requires intubation and mechanical ventilation with PEEP. PEEP improves oxygenation by enhancing gas exchange and preventing atelectasis. An improvement in oxygen saturation would be used to evaluate the effectiveness of adding PEEP to the client's mechanical ventilation mode. Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect, the latter of which is more likely. Example: If the answer you are seeking is directed to a specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the treatment-specific option.

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? 1 Blood pressure decreases from 120/80 mm Hg to 92/65 mm Hg. 2 Oxygen saturation increases from 85% to 92%. 3 Urine output increases to 45 mL/hour. 4 Heart rate increases from 96 to 110 beats/min.

2 Oxygen saturation increases from 85% to 92%.

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? 1 Blood pressure decreases from 120/80 mm Hg to 92/65 mm Hg. 2 Oxygen saturation increases from 85% to 92%. 3 Urine output increases to 45 mL/hour. 4 Heart rate increases from 96 to 110 beats/min.

2 Increase gas exchange Positioning may be important in promoting gas exchange in clients with ARDS, but the exact position is controversial. Manually turning the client every 2 hours has been shown to improve perfusion. Turning the client does not affect lung compliance or reduce lung fibrosis. It does help prevent pressure ulcers, but in this client's case, the order is given specifically to improve lung perfusion.

A client with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation, and the nurse has an order to turn the client every 2 hours. This action is performed to achieve which outcome? 1 Improve lung compliance 2 Increase gas exchange 3 Prevent pressure ulcers 4 Reduce lung fibrosis

3 Provide for passive and active range-of-motion exercises. This client is at risk for deep vein thrombosis (DVT) in the legs, which can cause pulmonary complications when a blood clot breaks loose and lodges in the lungs. Passive and active range-of-motion exercises can help prevent DVTs. Placing a pillow under the knees increases the risk of DVT because it puts pressure on the popliteal space. Coughing can help clear airways in clients who are not at risk for DVT, but coughing involves the Valsalva maneuver, which can increase the risk of clots. Smoking cessation techniques are an important part of long-term management, but will not help in the immediate time period to prevent clots.

A postoperative client with a history of thromboembolism is obese and reports smoking a pack of cigarettes a day. What does the nurse include in this client's plan of care to help prevent pulmonary complications? 1 Elevate the client's legs by placing pillows under the knees. 2 Encourage the client to take deep breaths and cough frequently. 3 Provide for passive and active range-of-motion exercises. 4 Teach the client about smoking cessation techniques.

2 "Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3." The international normalized ratio (INR), a measurement of anticoagulation with warfarin, is in the therapeutic range between 2 and 3. Enoxaparin (Lovenox) is a low-molecular-weight heparin that is usually given by the subcutaneous 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 nurse is overseeing a nursing student who is administering medications to a group of clients with pulmonary disorders. Which statement by the student nurse indicates a correct understanding about thrombolytic therapy? 1 "You will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days." 2 "Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3." 3 "Once the health care provider orders warfarin (Coumadin), we will discontinue the intravenous heparin." 4 "If bleeding develops, we will give you platelets to reverse the anticoagulant."

4 "I'll use a soft-bristled toothbrush to brush my teeth." The client taking warfarin is at risk for bleeding and should avoid all activities that increase this risk. Enemas are not recommended. Clients are instructed to wear hard-soled shoes. Clients should avoid hard foods that might scrape the inside of the mouth. Study Tip: Enhance your organizational skills by developing a checklist and creating ways to improve your ability to retain information, such as using index cards with essential data, which are easy to carry and review whenever you have a spare moment.

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? 1 "I should use enemas to help keep my stools soft." 2 "I need to wear soft-soled shoes to protect my feet." 3 "I will eat plenty of raw fruits and vegetables." 4 "I'll use a soft-bristled toothbrush to brush my teeth."

4 "I will be careful to avoid anything with vitamin K in it." Vitamin K is an antidote to warfarin. The client should be taught to avoid foods that are high in vitamin K. Saturated fats should be limited in a diet for cardiovascular health, but they do not affect warfarin therapy. Beta carotene and vitamin D are excellent additions to a healthy diet and do not affect the drug action of warfarin. Test-Taking Tip: Once you have decided on an answer, look at the stem again. Does your choice answer the question that was asked? If the question stem asks "why," be sure the response you have chosen is a reason. If the question stem is singular, then be sure the option is singular, and the same for plural stems and plural responses. Many times, checking to make sure that the choice makes sense in relation to the stem will reveal the correct answer.

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? 1 "I will avoid eating foods containing saturated fat." 2 "I will be careful not to eat anything containing vitamin D." 3 "I will not eat foods containing beta carotene." 4 "I will be careful to avoid anything with vitamin K in it."