TEST 1
how to avoid alarms going off with ECG
- proper placement of leads that do not go over bony areas or hair or a wet chest - Check alarm settings at the start of every shift, with any change in patient condition and with any change in caregiver. - Customize alarm parameter settings for individual patients in accordance with unit or hospital policy.
how do we prevent VAP ?
- sedation vacation - oral care - suction oral kits - keep bed elevated from 30-45 degrees - use peptic ulcer prophylaxis
what are complications that can arise with TPN?
- sepsis/infection - electrolyte imbalance - fluid imbalance - hyperglycemia
what are causes of metabolic alkalosis
- steroid or diuretic use - overuse of bicarb - prolong vomit or Ng tube which decrease acid
what are s/s of metabolic acidosis
- warm * - flushed * - Kusmal RR * - discomfort - lethargy - decrease BP * - headache
if the ARDS is a respiratory issue what is the main way to treat it?
-mecahnical ventilation with high PEEP and O2 - maintain ABC
hypotonic solution examples
0.45% NS
TPN orders must be in by when and why?
1 pm because it takes a very long time to put everything together in the formula
What is the Chovstek sign and Trousseau sign?
1) Chvostek sign --> Tapping on facial nerve elicits twitching of nose and lips 2) Trousseau sign --> Inflation of blood pressure cuff leads to carpal spams
what is the main assessment tool for assessing ventilation ARF
EtCO2
t/f: EN feedings need 2 nurses to check
FALSE - TPN orders need 2 nurses to check because it is a high alert medication
t/f: you only flush before giving medications with an NG tube
FALSE - you flush before and after
how often should you change TPN tubing that has lipid in it?
Q12 to reduce risk of infection
how often should you change TPN tubing
Q24
what is Dumping syndrome - s/s?
Rapid emptying of gastric contents into small intestines and youre getting fed too fast and your GI cannot absorb the nutrients from food and you can lose weight. s/s: ab pain, nausea, vomiting, explosive diarrhea, weakness, dizziness, palpitations & tachycardia.
what are S/S of ARDS
SOB, Shallow Rapid Breathing, Atelectasis (aveoli close), Dyspnea, Inspiratory Crackles, Respiratory Alkalosis, Decreased Lung Compliance, Hypoxemia
what is the main assessment tool for assessing oxygenation ARF
Spo2
In addition to residual stomach volume, what other evidence suggests feeding intolerance? a. Abdominal distention b. Absence of tympany on percussion c. Active bowel sounds d. Elevated blood glucose by fingerstick
a
The nurse is working on a progressive care unit (PCU) the monitor alarms a crisis alarm. The nurse checks the alarm and monitor which shows AFIB. What is the next action of the nurse? a. Check the patient b. Deliver 15L O2 NRM c. Start CPR d. Check for a pulse
a
The patient arrives to the ER from an MVC. The patient is stabilized and the nurse is on G of the TNP and placing the patient on the monitor who has a very hair chest. What is the next action of the nurse? a. Shave the hair of the areas where the electrode(s) is being placed b. Shave the whole chest c. Place the electrodes on anyway since the patient is in the ER d. Get an order not to monitor the EKG rhythm since the patient is stable
a
The patient is intubated and placed on a ventilator for respiratory acidosis with the following ventilator settings of a respiratory rate 22, tidal volume 650 mL and FiO2 80%. An ABG was obtained: pH 7.50 PaCO2 30 HCO3- 22 PaO2 150 What would be the recommendations from the nurse in relation to the ABG results? A. Decrease the respiratory rate, tidal volume and FiO2 B. Increase the respiratory rate and FiO2 C. Decrease the FiO2 D. Increase the tidal volume
a
What statement by the new nurse to the preceptor would best represent what tidal volume represents on the ventilator? A. The tidal volume represents the volume of air being instilled by the ventilator B. The tidal volume represents the rate of air being instilled by the ventilator C. The tidal volume represents the amount of oxygen being instilled by the ventilator D. The tidal volume represents the amount of end airway pressure
a
Which of the following would be most appropriate for a male client with an arterial blood gas (ABG) of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3 24 mEq/L, and PaO2 94 mm Hg? a. Instruct the client to breathe into a paper bag b. Administer a prescribed decongestant c. Offer the client fluids frequently d. Administer prescribed supplemental oxygen.
a
Which patient would benefit from a Nasogastric Tube? a. A stroke victim who failed their swallow evaulation b. A patient with Congestive Heart Failure c. A patient who had a left leg amputation d. A patient with a Platelet count of 50
a
You are assisting a MD with the removal of a chest tube. What activity may the MD have the patient perform while the chest tube is being removed? a. Valsalva Maneuver b. Leopold Maneuver c. Chest Physiotherapy d. Huff Cough Techniqure
a
You just inserted a Nasogastric tube. Which of the following is NOT A correct way to check correct placement of the tube? a. Administering a 100cc Water flush and assessing for patient coughing b. Obtaining a sample of GI contents through the tube by aspirating c. Following the MD order for an X-ray to confirm placement d. Checking pH of GI contents to be at 1 to 3.5
a
Your patient has a PEG tube and you are about to administer a feeding. While checking residual you obtain 95 ml of stomach contents. What would be your next nursing intervention? a. Administered the scheduled feeding b. Wait 30 minutes and reassess residual c. Skip this scheduled feeding and administer the next feeding due in 6 hours
a
Your patient has a PEG tube and you are about to administer a tube feeding using the feeding pump. You note that the last feeding tube hanging on the pole is labeled Aug 16 and today's date is Aug 18. Which nursing action is correct. a. Immediately discard the tubing and open a new package of tubing before proceeding with the feeding b. Continue to administer the feeding because the tubing is good for 4 days c. Change the adapter cap at the end of the tubing d. Notify the MD for further orders
a
Your patient has an endotracheal tube. You are assessing placement by listening to the lung sounds and you notice that the breath sounds and chest wall movement are absent on the left side? What is usually the cause of this? a. The tube may be displaced in the right main stem bronchus b. A pneumothorax may be developing and a STAT chest x-ray should be ordered c. The incorrect size tubing was used d. The tube is not above the carina and must be re-inserted
a
the patient care technician in the Critical Care Unit comes running to the nurses' station yelling "call a code blue, call a code blue". The nurse evaluates the central monitor for any crisis alarms. The patient that is alarming is reading a crisis alarm of V fib. What is the next action by the nurse? a. Go and check the patient b. Call the monitor tech to fix the alarm c. Silence the alarms and resume charting d. Move the A fib alarm to alarm status and not crisis
a
what is the first step when the patient is experiencing a pulmonary embolism a. apply O2 b. increase the rate of IV fluids c. administer pain meds d. initiate cardiac monitoring
a
which client is at the greatest risk for a pulmonary embolism a. a client who is 48 hours post op with a total hip surgery b. a client who is 8 hours post op an open surgery for the appendix c. a client who is 2 hours post op following fixation of the right radius
a
which of the following is not an indirect ARDs lung injury cause a. pneumonia b. TRALI c. severe trauma d. UTI
a
The intubated patient is receiving TPN and Lipids via central line. Which of the following is true about TPN and Lipids? a. Supplies high level of proteins b. Provides superior nutrition compared to enteral feedings c. Provides more aspiration risks than enteral feedings d. Puts the patient at higher risk of infection
d
what is the purpose of prone positioning with ARD patients?
pulls things forward and out of the lungs
respiratory alkalosis or respiratory acidosis? low Ph and when ventilation is depressed and Co2 is retained causing hypercapnia
respiratory acidosis
what is this? ABG interpretation: pH 7.25 PaCO2 68 PaO2 75 HCO3- 22
respiratory acidosis
what is this? ABG interpretation: pH 7.50 PaCO2 25 PaO2 90 HCO3- 26
respiratory alkalosis
the delay in response to the alarm going off leads to what?
risk of patient safety
how can oxygenation be altered?
something can block it like vasoconstriction or mucus
what is the first vein that we attempt to use with TPN?
subclavian
how do we monitor patients with TPN for hyperglycemia?
take blood sugar Q8
how long can TPN with lipids and other nutrients be hung for
they are continuous - make sure to monitor site closely
what is the treatment of metabolic alkalosis
treat underlying cause; decrease settings on a ventilator if they are on one; partial rebreather mask at a low setting - inject bicarb and dialysis
t/f: TPN feeding is used when the patient cannot receive feeding PO/NG
true
t/f: We should meet the patient requirements in regards to what the alarm setting should be
true
t/f: there are barriers to giving nutrition due to all patients being different and high risk patients are complex
true
t/f: ventilation has to do with air getting into your lungs and is a sign with acidotic ph
true
what is the Allens test?
used to find out if the blood flow to your hand is normal. For the Allen test, the health professional drawing your blood will apply pressure to the arteries in your wrist for several seconds.
if the patient is at risk for aspiration and is getting an NGT placed, where do we place it, lower or higher?
we would place the NG tube lower in the stomach so if they cough it doesnt become dislodged and go into the lungs
how do we treat ventillation ARF
with a bipap or ventilator
what should you be careful about when flushing the EN/NG tube?
with an increase in Na that can lead to a SEIZURE - so if you see a large amount of fluid, pause and check electrolytes
are hypotonic or isotonic solutions better for hydration of the cells
hypotonic
are hypotonic solutions or isotonic solutions good for central IV administration of TPN
hypotonic
when should enteral feeding be intiated?
if a patient is in the ICU and unable to maintain PO
how on an ABG can you tell if a patient is a CO2 retainer ?
if they have a HIGH pCO2 and a low PH
what are S/S of metabolic alkalosis
- N/V - tachycardia - hypoventillaiton - hyperactive reflexes - confusion - mm cramps - anxiety - confusion
ventilation - is O2 or Co2 the issue we are looking at - what would reflect this
- co2 is the issue - PH would reflect it
ventilation ARF causes what
- hypercapnia - hypoxemia - type 2 ARF - respiratory acidosis
what are the causes of respiratory alkalosis
- hyperventilation - anxiety - PE - ventilation too high
what are S/S of respiratory acidosis
- hypoventilation - Decreased Bp and RR - mm weakness - drowsy and dizzy - skin pale and dry
oxygenation ARF causes what?
- hypoxemia - ARF type 1 - respiratory alkalosis
what are the causes of metabolic acidosis
- impaired kidney - severe diahrea - shock - ketoacidosis - increase in potassium
what are s/s of respiratory alkalosis
- low k - numbness and tingling - light headed - tachycardia - decrease BP
if the ARDS is a circulatory issue, what is the main way to treat it?
- monitor hemodynamics and fluids - give inotropes to maintain CO - vasodilators to treat pulmonary HTN
poor nutrition can lead to what?
- mortality - skin breakdown - increased length of stay
Isotonic solution examples
- 0.9% NS - lactated ringers - D5W
what are causes of respiratory acidosis
- LOC - infection - immobility - over sedation - trauma to brain
how do we treat respiratory acidosis
+ pressure ventilation
what is the criteria to diagnose a patient with acute respiratory distress syndrome
1. acute onset with 1 week after clinical insult 2. B/L pulmonary opacities that is not explained b another condition (like white out on CXR) 3. altered PaO2/FiO2 ratio : when you give O2 and still doesnt improve
how long can TPN lipid based feedings be hung for
12 hours
how soon should we initiate EN feeding?
24-48 hours of onset of illness
if we notice that the ECG looks different and the monitor alarm goes off, what should we do?
look at patient before determining if it is an artifact or a serious issue
You are caring for a patient with acute respiratory distress syndrome. As the nurse you know that prone positioning can be beneficial for some patients with this condition. Which findings below indicate this type of positioning was beneficial for your patient with ARDS? (select all that apply) A. Improvement in lung sounds B. Development of a V/Q mismatch C. PaO2 increased from 59 mmHg to 82 mmHg D. PEEP needs to be titrated to 15 mmHg of water
A and C
what else is a sign when looking at the NG tube that it is not in the correct place anymore?
looking at a change in the length of the external portion of the feeding tube, which may help detect tube dislocation
rhonci
loud rumbling sounds heard on auscultation of bronchi obstructed by sputum - coughing can help this
what is this? ABG interpretation: pH 7.15 PaCO2 41 PaO2 90 HCO3- 15
metabolic acidosis
what is this? ABG interpretation: pH 7.50 PaCO2 36 PaO2 90 HCO3- 40
metabolic alkalosis
Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
C
a nurse is assessing a client who has bacterial pneumonia, which manifestation should the nurse expect a. decreased fremitius b. SAo2 of 95% on room air c. temperature of 101.8 F d. braydpnea
C - increase fremitus and tachypnea are expected as well
if the patient who has ARDS needs fluid and electrolyte to be managed, what should we give them?
phosphorus with either K or Na
a nurse is the ED is caring for a patient with ARF, what is an expected finding a. PH 7.50 b. PAco2 25 c. SAO2 92% d. PaO2 58
D - the nurse should expected the PH to decrease - the nurse should expect the CO2 to rise - the nurse should expect the SAO2 to drop
what measures this? Measures the partial pressure or maximum concentration of CO2 at the end of an exhaled breath
ETCO2
how do we treat respiratory alkalosis
positive ventilation pressure
if the patient has severe ARDS and is on a venillator what drug is best to give?
NMB
what is the pathophysiology behind ARDS
There is increased permeability of the alveolar capillary membranes. --> leads to development of protein-rosh pulmonary edema that impairs gas exchange
A female client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a. PaO2 b. pH c. PaCO2 d. HCO3
a
A male client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? a. pH, 7.25; PaCO2 50 mm Hg b. pH, 5.0; PaCO2 30 mm Hg c. pH, 7.35; PaCO2 40 mm Hg d. pH, 7.40; PaCO2 35 mm Hg
a
which of the following patients should not receive nasopharyngeal suction? a. epistaxis (bleeding) patient b. a client who has amyotrophic lateral sclerosis c. a client who has pneumonia d. a client who has emphysema
a - avoid it with bleeding patients!!!
a nurse is preparing a client for discharge following a bronchoscope with the use of moderate sedation, the nurse should make sure which is present? a. a gag reflex b. no pain c. hydrated well
a - since the patient was slightly sedated to make sure they dont choke or aspirate
Which components assess and monitor for ventilation of a patient? (select all that apply) a. EtCO2 b. PaO2 c. HCO3- d. PaCO2 e. pH
a and d
what is a sign in the chest Xray that we have ARF
a white out! - meaning instead of seeing a black screen it is all white that shows pulmonary edema and poor gas exchange
The nurse is assisting with endotracheal intubation and understands correct placement of the endotracheal tube in the trachea would be identified by which of the following? (Select all that apply.) A. Equal lung sounds B. Yellow/tan color noted on the CO2 detector (bc doesn't this mean ur in the lungs) C. CXR confirmation D. Purple color noted on the CO2 detector E. Unequal symmetry of the chest
a, b, c
The patient is in the Critical Care Unit intubated for Acute Respiratory Failure from pneumonia. The patient is receiving enteral feedings. Which of the following interventions should the nurse incorporate into the plan of care? (Select all that apply) a. Oral Care b. HOB > 30 degrees c. Place the patient OOB d. Checking residual tube feeding volume e. Frequent ambulation
a, b, d
Which of the following medication orders would the nurse clarify before administering via NGT? (Select all that apply) a. ASA EC 81 mg b. Lopressor XL 50 mg c. Pepcid 20 mg d. Heparin 5000 units e. Prednisone 10 mg
a, b, d
how do we help keep acidosis low
add oxygen by ventilation through positive pressure
what precautions is TB?
airborne - if on medications for it expect that your urine to change color to orange
in the hospitals, what is the #1 safety issue?
alarms going off and no nurses reacting and fixing and checking the patient
is alkalosis or acidosis much easier to correct?
alkalosis
what is the background of respiratory alkalosis
an increase in Ph and we need to get more acid into the body
A client receiving parenteral nutrition (PN) complains of a headache. A nurse notes that the client has an increased blood pressure, bounding pulse, jugular distension, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy? a. Air embolism. b. Hypervolemia. c. Hyperglycemia. d. Sepsis.
b
choose the option that does NOT cause oxygenation ARF a. pulmonary edema b. NM disorders c. alveolar hemorrhage d. pneumonia
b
when teaching nursing students about suctioning an endotracheal tube, which of the following statements indicates an understanding? a. I will use clean technique b. I will use a rotating motion when removing the suction catheter c. I will suction the oropharyngeal cavity prior to suctioning d. I will suctions the client every 2 hours
b
A newly RN nurse is about to insert a nasogastric tube to a client with Guillan Barre Syndrome. To determine the accurate measurement of the length of the tube be inserted, the nurse should: a. Place the tube at the tip of the nose, and measure by extending the tube to the earlobe and then down to the top of the sternum. b. Place the tube at the tip of the nose, and measure by extending the tube to the earlobe and then down to the xiphoid process. c. Place the tube at the tip of the nose, and measure by extending the tube down to the chin and then down to the top of the xiphoid process.
b
A patient is on mechanical ventilation with PEEP (positive end-expiratory pressure). Which finding below indicates the patient is developing a complication related to their therapy and requires immediate treatment? A. HCO3 26 mmHg B. Blood pressure 70/45 C. PaO2 80 mmHg D. PaCO2 38 mmHg
b
Oxygen saturation (SaO2) represents: a. alveolar oxygen tension. b. oxygen that is chemically combined with hemoglobin. c. oxygen that is physically dissolved in plasma. d. total oxygen consumption.
b
The lung cancer/COPD patient is brought to the ER found at home unresponsive with 5 Fentanyl patches noted on the patient. The patient's SpO2 is 88% and EtCO2 is 70. An ABG is obtained: pH 7.1 PaCO2 102 PaO2 60 HCO3- 32 The patient is diagnosed with acute respiratory failure. What should the nurse prepare for this patient? a. BiPap b. Intubation c. CPAP d. High flow nasal cannula
b
The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration? a. Hyperventilation and respiratory acidosis b. Hypoventilation and respiratory acidosis c. Hypoventilation and respiratory alkalosis d. Respiratory acidosis and normal oxygen levels
b
The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia? a. Bradycardia b. Change in sputum characteristics c. Hypoventilation and respiratory acidosis d. Pursed-lip breathing
b
The nurse would anticipate which of the following arterial blood gas results in a client experiencing a prolonged, severe asthma attack? a. Decreased CO2, increased pO2, and decreased pH b. Increased CO2, decreased pO2, and decreased pH c. Increased CO2, increased pO2, and increased pH d. Decreased CO2, decreased pO2, and increased pH
b
The patient is admitted for sepsis related to pneumonia. The patient has the following ABG: pH 7.10 PaCO2 53 HCO3 - 26 PaO2 60 What is the interpretation of this ABG? A. Compensated Metabolic Acidosis B. Uncompensated Respiratory Acidosis C. Partial compensation Respiratory Alkalosis D. Uncompensated Metabolic Acidosis
b
The patient is admitted to the ER for stroke and unable to manage their airway, the nurse understands the patient with this condition can contribute to which of the following with respiratory physiology? a. Respiration b. Ventilation c. Oxygenation d. Hypoxia
b
The patient is admitted to the Progressive Care Unit in a COPD exacerbation. The pulmonologist has a specific order for titrate oxygen to a SpO2 of 88 - 94%. What is the best action by the nurse to help with management of this type of patient and alarm fatigue? a. Turn the SpO2 alarms off b. Adjust the SpO2 alarms to a high of 95% and a low of 87% c. Adjust the SpO2 alarms to a high of 100% and a low of 87% d. Adjust the SpO2 alarms to a high of 100% and a low of 90%
b
The patient is admitted with a COPD with known CO2 retainer. The nurse knows this patient needs a higher SpO2. Which of the following would be proper use of the monitor alarm for the SpO2? A. Alarm less than 93% B. Alarm between 88-94% C. Alarm less than 90% D. Alarm less than 85%
b
The patient is admitted with septic shock with a lactic acid of 10.5. The ABG reveals: pH 6.85 PaCO2 35 HCO3- 10 PaO2 60 Which of the following interventions would the nurse prepare to administer? A. Vancomycin B. Sodium Bicarbonate C. One liter Normal Saline Solution D. Blood cultures
b
The patient was admitted from the ER with the diagnosis of upper GI bleed with coffee ground emesis. VS Temp 98.9, HR 105, RR 22, B/P 112/50, SpO2 94%. The patient's chest is saturated with emesis and the leads are not fully adhered to the skin. The nurse notes on the monitor. What is the next action by the nurse? a. Check the H&H levels b. Clean, dry the chest and reapply the electrodes c. Place A fib rhythm to alert mode on the monitor d. Give a liter of crystalloids
b
When fluid is present in the alveoli: a. alveoli collapse and atelectasis occurs. b. diffusion of oxygen and carbon dioxide is impaired. c. hypoventilation occurs. d. the patient is in heart failure.
b
Which ABG component would reflect a RR of 8/min? a. pH 7.42 b. PaCO2 55 c. HCO3- 23 d. PaCO2 30
b
Which is the evidence-based method for determining nasogastric tube placement before feeding initiation? a. Aspirating the gastric contents b. CXR confirmation c. Testing the pH of the gastric contents d. Injection of air and listening over the epigastric area
b
a nurse is taking care of a patient who has COPD, which of the following findings should be priority to tell the provider? a. increased AP diameter b. productive cough with green sputum c. clubbing of fingers d. pursed lip breathing
b
A client is receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse next assesses the client to identify the presence of which of the following? a. Hypotension. b. Crackles upon auscultation of the lungs. c. Thirst. d. Polyuria
b - Normally, the weight gain of a client receiving PN is about 1-2 pound a week. A weight gain of 5 pounds over a week indicates a client is experiencing fluid retention that can result to hypervolemia. Signs of hypervolemia includes weight gain more than desired, headache, jugular vein distention, bounding pulse, and crackles on lung auscultation
the nurse is caring for a client with respiratory distress. which of the following low flow devices should the nurse use? a. nasal cannula b. nonrebreather mask c. simple face mask
b - provides the most O2
During the exudative phase of acute respiratory distress syndrome (ARDS), the patient's lung cells that produce surfactant have become damaged. As the nurse you know this will lead to? A. bronchoconstriction B. atelectasis C. upper airway blockage D. pulmonary edema
b -Surfactant decreases surface tension in the lungs. Therefore, the alveoli sacs will stay stable when a person exhales (hence the sac won't collapse). If there is a decrease in surfactant production this creates an unpredictable alveoli sac that can easily collapse, hence a condition called ATELETASIS will occur (collapse of the lung tissue) when there is a decrease production in surfactant.
a nurse is assessing a patient who has emphysema, which of the findings should the nurse report? a. Rhonci b. elevated temperature c. barrel shaped chest d. diminished breath sounds
b - all the other choices are expected
what components assess and monitor oxygenation of a patient? (Select all that apply) a. PaCO2 b. SpO2 c. HCO3- d. PaO2 e. pH
b and d
why is infection risk so high with TPN?
because of the lipid feeding ! - bacteria LOVES lipids so be careful
how do we treat metabolic acidosis
bicarb injection and dialysis
for the ABG, what is the buffer?
bicarbonate
A 72 y/o diabetic man presents with dyspnea at rest for 1 hour. RR 26/min, HR 110/min, BP 156/95 mm Hg, SpO2 90%. He is in respiratory distress and is unable to complete full sentences. He has JVD, pedal edema, and crackles. The telemetry monitor shows AFIB Which of the following interventions would be priority for this patient? A. Place the patient on O2 6L NC (not enough) B. Get an order for Furosemide stat (NO) C. Prepare for BiPap on this patient D. Place the patient on 42% Venturi Mask
c
What are the main components of alarm fatigue? (Select all that apply) a. Over education on alarms b. Underuse of alarms c. Devaluing alarms d. Desensitization of alarms e. Distrust in alarms
c, d, e
A client with a small bowel obstruction has had a nasogastric tube connected to low intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder? a. Respiratory Alkalosis b. Respiratory Acidosis c. Metabolic Alkalosis d. Metabolic Acidosis
c
A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention?a. Administer a sedative b. Place client in left lateral position c. Place client in high-Fowler's position d. Assist the client to breathe into a paper bag
c
A client with renal failure enters the emergency room after skipping three dialysis treatment to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis? a. pH of 7.43, PCO2 of 36, HCO3 of 26 b. pH of 7.41, PCO2 of 49, HCO3 of 30 c. pH of 7.33, PCO2 of 35, HCO3 of 17 d.pH of 7.25, PCO2 of 56, HCO3 of 28
c
A patient has been hospitalized in the ICU for a near drowning event. The patient's respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS? A. infiltrates only on the upper lobes B. enlargement of the heart with bilateral lower lobe infiltrates C. white-out infiltrates bilaterally D. normal chest x-ray
c
A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min. He receives a dose of morphine sulfate, and his respirations decrease to 4 breaths/min. Which acid-base disturbance will likely occur? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
c
A patients feeding tube has been successfully placed in the small intestine with continuous flow tube feeding. The nurse knows that this approach was chosen because: a. intermittent feedings cause increased nausea and vomiting. b. the increased filling of the stomach increases absorption. c. the intestinal mucosa normally receives nutrients from the stomach in peristaltic waves. d. this will prevent malabsorption syndrome.
c
Before seeing a newly assigned female client with respiratory alkalosis, the nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? a. Type 1 Diabetes Mellitus b. Myasthenia gravis c. Extreme anxiety d. Narcotic overdose
c
Continuous type of feedings is administered over a __ hour period.? a. 4. b. 12. c. 24. d. 36.
c
Nurse Spencer is caring for an anorexic client who is having total parenteral nutrition solution for the first time. Which of the following assessments requires the most immediate attention? a. Dry sticky mouth. b. Temperature of 100° Fahrenheit. c. Blood glucose of 210 mg/dl. d. Fasting blood sugar of 98 mg/dl
c
The charge nurse is walking up the hallway and hears the IV pump going off in a room that has a Heparin drip infusing. What is the best action by the charge nurse? a. Walk by the room and tell the primary nurse in person b. Call the primary nurse and notify them of the IV pump alarm c. Go into the patient's room to address the alarm d. Call the patient care technician to address the IV pump
c
The new nurse is caring for the patient. The current setting on the monitor for blood pressure alarms is high 150 and low 80. The monitor is constantly alarming for the B/P. The preceptor asks the new nurse how to manage this patient. What is the appropriate response by the new nurse is in regards to alarm fatigue? a. I should adjust how often I take the blood pressure not to set the alarms off as often b. I should adjust the EKG alarm to all rhythms to alert mode c. I should adjust my blood pressure settings to the patient so the monitor does not constantly alarm d. I did not even hear the alarms going off
c
The nurse is assessing a patient as part of the initial head to toe assessment. The nurse finished heart sounds and notes that the EKG leads has the black lead to the right lower rib area, white lead to the left lower rib area, red lead to the left clavicular area and green lead to the right clavicular area. The nurse notes this is not correct but is unsure of the proper placement. What is the next action by the nurse? a. Call the patient care technician b. Google it c. Look at the back of the telemetry box d. Call the charge nurse
c
The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The physician orders a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the physician of this assessment and anticipates an order for: a. continuous lateral rotation therapy. b. guided imagery. c. neuromuscular blockade. d. prone positioning.
c
The patient in ARDS is not synchronous with the ventilator. The physician orders a neuromuscular blocking agent. The nurse knows which of the following class of medications needs to be ordered with neuromuscular blocking agents? a. Calcium Channel Blockers b. Beta Blockers c. Sedation d. Enteral Nutrition
c
The patient in severe ARDS and needs to be placed in the prone position. Which of the following rationales for the prone position? a. helps with spinal cord injuries b. helps relieve pressure injuries c. helps with aeration of the lungs d. helps with the pulmonary edema
c
The patient is admitted for exacerbation of COPD. Which ABG result would concern the nurse? a. pH 7.35, PaCO2 60, HCO3- 26, PaO2 65 b. pH 7.34, PaCO2 78, PaO2 55, HCO3- 27 c. pH 7.30 PaCO2 88, HCO3- 28, PaO2 60 d. pH 7.47, PaCO2 35, HCO3- 20, PaO2 65
c
Which of the following equipment is needed with neuromuscular blocking agents? a. High flow nasal cannula b. Telemetry monitor c. Train of four d. BiPap machine
c
You're providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the patient is developing acute respiratory distress syndrome (ARDS)? A. The patient is experiencing bradypnea. B. The patient is tired and confused. C. The patient's PaO2 remains at 45 mmHg. D. The patient's blood pressure is 180/96.
c
a nurse is caring for a client who has a chest tube following a lobectomy, what should the nurse keep near? a. extra drainage system b. suture removal set c. container of sterile water d. nonadhere pads
c
a nurse is providing discharge to a patient who just had a temporary tracheostomy put in, which of the following shows that the patient understands the teaching? a. I should dip a cotton tipped applicator into full strength hydrogen peroxide to clean my stoma b. I should cut a 4 inch gauze dressing and place it around my tracheostomy tube to absorb drainage c. I should remove the old twill ties after the new ties are in place d. I should apply suction while inserting the catheter into my tracheostomy's tube
c
choose the option that does NOT cause ventilation ARF a. CNS disorders b. OSA c. sepsis d. drug OD
c
the nurse is caring for a patient with ARF and is on mechanical ventilation, which of the following is the best method to determine the effectiveness of mechanical ventillation? a. blood pressure b. capillary refill c. ABG d. heart rate
c
what intervention should the nurse provide for a patient who has COPD a. schedule respiratory treatments following meals b. have the client sit up in a chair for 2 hours period 3 times a day c. provide a diet that is high in calories and protein
c
which of the following is a possible cause of the low pressure alarms going off with mechanical ventilation a. excess secretions b. kinks in the tube c. artificial airway cuff leak
c
nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse next assesses which of the following items? a. Time of last dressing change. b. Tightness of the tuning connections. c. Client's temperature. d. Expiration date on the bag
c - Redness at the catheter insertion site is a possible sign of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess.
Which patient below is at MOST risk for developing ARDS and has the worst prognosis? A. A 52-year-old male patient with a pneumothorax. B. A 48-year-old male being treated for diabetic ketoacidosis. C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection. D. A 30-year-old female with cystic fibrosis.
c -Sepsis is the MOST common cause of ARDS because of systemic inflammation experienced. This is also true if the cause of the sepsis is a gram-negative bacterium (this also makes the infection harder to treat...hence poor prognosis). With sepsis, the immune cells that are present with the inflammation travel to the lungs and damage the alveolar capillary membrane leading to fluid to leak in the alveolar sacs.
Excessive use of oral antacids containing sodium or calcium HCO3 can result in which of the following acid-base disturbances? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis
d
The Acute Respiratory failure patient was intubated. When is the best time to insert the NGT for feeding? a. Before the intubation b. Right after the CXR c. After the patient stabilizes d. Right after intubation and before the CXR
d
what is important to do if a patient is on a venilator?
oral care and ween off ventilators
if suction is needed with the Salem sump, what do we do?
connect the large bore to suction
A client has an order to have a set of arterial blood gases (ABGs) drawn. The intended site is the radial artery. The nurse ensures that which of the following is positive before the ABGs are drawn? a. Homan sign b. Chovstek sign c. Trousseau test d. Allen test
d
A patient has coronary artery bypass graft surgery and is transported to the surgical intensive care unit at noon. He is placed on mechanical ventilation. Interpret his initial arterial blood gas levels: pH 7.31 PaCO2 48 mm Hg Bicarbonate 22 mEq/L PaO2 115 mm Hg O2 saturation 99% a. Normal arterial blood gas levels with a high oxygen level b. Partly compensated respiratory acidosis, normal oxygen c. Uncompensated metabolic acidosis with high oxygen levels d. Uncompensated respiratory acidosis; hyperoxygenated
d
A patient receiving parenteral nutrition is administered via the following routes except: a. Subclavian line. b. Central Venous Catheter. c. PICC (Peripherally inserted central catheter) line. d. PEG tube
d
A patient who is receiving continuous enteral feedings has just vomited 250 mL of milky green fluid. This is a concern because this most likely demonstrates that the patient has: a. a bowel obstruction. b. developed an ileus. c. gastrointestinal bleeding. d. tube feeding intolerance.
d
The nurse is assessing a client with an endotracheal tube and observes that the client can make verbal sounds. What is the most likely cause of this? a. This is a normal finding. b. There is a leak. c. There is an occlusion. d. The endotracheal tube is displaced.
d
The nurse is caring for a patient with acute respiratory failure and identifies Risk for Ineffective Airway Clearance as a nursing diagnosis. A nursing intervention relevant to this diagnosis is: a. Elevate head of bed to 30 degrees. b. Obtain order for venous thromboembolism prophylaxis. c. Provide adequate sedation. d. Reposition patient every 2 hours.
d
The patient has had a nasogastric tube (NGT) on suction for 5 days. When his arterial blood gases are tested, which pH result might be associated with the use of the NGT? application a. 7.28 pH b. 7.35 pH c. 7.44 pH d. 7.49 pH
d
The patient returned from PACU from an ORIF of the femur from an MVC. The patient develops severe respiratory distress petechiae rash on the chest, and CXR reveals "white out". The patient is on 15 L NRM with a SpO2 of 80%. Which of the following conditions would the nurse hypothesize is happening with the patient? a. Acute Respiratory Failure from heart failure b. ARDS from pneumonia from the OR c. ARDS from anesthesia d. ARDS from fat emboli
d
The physician orders the following mechanical ventilation settings for a patient who weighs 75 kg. The patients spontaneous respiratory rate is 22 breaths/min. What arterial blood gas abnormality may occur if the patient continues to be tachypneic at these ventilator settings? Settings: Tidal volume: 600 mL (8 mL per kg) FiO2: 0.5 Respiratory rate: 14 breaths/min Mode assist/control Positive end-expiratory pressure: 10 cm H2O a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
d
The preceptor is training a new nurse to the ICU. The assigned patient is intubated with an ETT #8.0 22 cm at the right lip and remains on a ventilator. Which of the following statements by the new nurse would indicate an understanding of Ventilatory Associated Pneumonia (VAP)? A. I would keep the HOB at 20 degrees at all times, even turning B. I would set the patient up for oral care C. I will ask the family to bring in a toothbrush and toothpaste D. I will use the suction oral kits for ventilated patients
d
Which ABG component would reflect full compensation? a. PaCO2 46 b. pH 7.30 c. HCO3- 22 d. pH 7.36
d
You're precepting a nursing student who is assisting you care for a patient on mechanical ventilation with PEEP for treatment of ARDS. The student asks you why the PEEP setting is at 10 mmHg. Your response is: A. "This pressure setting assists the patient with breathing in and out and helps improve air flow." B. "This pressure setting will help prevent a decrease in cardiac output and hyperinflation of the lungs." C. "This pressure setting helps prevent fluid from filling the alveoli sacs." D. "This pressure setting helps open the alveoli sacs that are collapsed during exhalation."
d
You're teaching a class on critical care concepts to a group of new nurses. You're discussing the topic of acute respiratory distress syndrome (ARDS). At the beginning of the lecture, you assess the new nurses understanding about this condition. Which statement by a new nurse demonstrates he understands the condition? A. "This condition develops because the exocrine glands start to work incorrectly leading to thick, copious mucous to collect in the alveoli sacs." B. "ARDS is a pulmonary disease that gradually causes chronic obstruction of airflow from the lungs." C. "Acute respiratory distress syndrome occurs due to the collapsing of a lung because air has accumulated in the pleural space." D. "This condition develops because alveolar capillary membrane permeability has changed leading to fluid collecting in the alveoli sacs."
d
a nurse if caring for a client who has a pulmonary embolism, what kind of care should the nurse do a. provide a quiet environment b. encourage the use of incentive spirometer every 1-2 hour c. obtain a blood sample d. administer heparin via IV infusion
d
ames has been brought in by ambulance for increased shortness of breath and extreme fatigue for three days. His wife states she has noticed some "black, tar-like" stools but thought it was related to something he ate. Your first impression of James is that he is incredibly pale, lethargic and has a weak, thready and rapid pulse. He's telling you he just can't catch his breath and he's beginning to get a bit confused. You check James' vital signs and notice that his SpO2 is 88% on room air, his heart rate is 123 and his blood pressure is 98/52. While you wait for the CBC, the MD orders a fluid bolus to address the low BP and oxygen to maintain levels above 92%. What do you grab first? a. STAT CBC b. MTP c. Fluid bolus d. O2 mask
d
before feeding a client via NGT, the nurse checks for residual and obtains a residual amount of 90ml. What is the appropriate action for the nurse to take? a. Discard the residual amount. b. Hold the due feeding. c. Skip the feeding and administer the next feeding due in 4 hours. d. Reinstill the amount and continue with administering the feeding.
d
which of the following is a sign of tension pneunomthorax a. collapsed neck veins on the affected side b. collapsed neck veins on the unaffected side c. tracheal deviation to the affected side d. tracheal deviation to the unaffected side
d
A client with COPD feels short of breath after walking into the bathroom on 2 liters of oxygen nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention? a. Call the physician and report the change in client's condition b. Turn the client's O2 up to 4 liters nasal cannula c. Encourage the client to sit down and to take deep breaths d. Encourage the client to rest and to use pursed-lip breathing technique
d - Encourage the client to rest and to use pursed-lip breathing technique (d) Clients with COPD, especially those who are in a chronic compensated respiratory acidosis, are very sensitive to changes in O2 flow, because hypoxemia rather than high CO2 levels stimulates respirations. Deep breaths are not helpful because clients with COPD have difficulty with air trapping in alveoli. There is no need to call the physician, since the client is presently most likely at baseline
A patient is receiving enteral feedings and has just vomited 250 mL of milky green liquid. The nurse holds the tube feeding, which had been infusing at 100 mL/hr. The nurse knows that the next action should be: a. connect the feeding tube to suction. b. continue the tube feeding. c. decrease the tube feeding. d. recheck the residual in 2 hours.
d - The patient is not tolerating the tube feeding. It should be held until he has absorbed the remaining tube feeding. Feedings may resume when residuals are less than 250 mL.
In assessing a patient, the nurse understands that an early sign of hypoxemia is: a. clubbing of nail beds b. cyanosis c. hypotension d. restlessness
d - cyanosis is a late sign
The nurse is preparing to give bolus enteral feedings via a nasogastric tube to a unconscious client. Which of the following actions is an inappropriate practice by the nurse? a. If bowel sounds are absent, hold the feeding and notify the physician. b. Assess tube placement by aspirating gastric content and check the PH level. c. Warm the feeding to room temperature to prevent the occurrence of diarrhea and cramps. d. Elevate the head of the bed to 45 degrees and maintains for 30 minutes after instillation of feeding.
d -If the client is unconscious, place in a high-fowlers which is in a 90-degree level.
A nurse is preparing to hang the initial bag of the parenteral nutrition (PN) solution via the central line of a malnourished client. The nurse ensure the availability of which medical equipment before hanging the solution? a. Glucometer. b. Dressing tray. c. Nebulizer. d. Infusion pump.
d -Question 3 Explanation: The nurse should prepare an infusion pump prior hanging a parenteral solution. The use of an infusion pump is important to make sure that the solution does not infuse too quickly or delayed since the parenteral nutrition has a high glucose content.
A nurse is conducting a follow-up home visit to a client who has been discharged with a parenteral nutrition(PN). Which of the following should the nurse most closely monitor in this kind of therapy? a. Blood pressure and temperature. b. Blood pressure and pulse rate. c. Height and weight. d. Temperature and weight
d -The client's temperature is monitored to identify signs of infection which is one of the complications of this therapy. While the weight is monitored to detect hypervolemia and to determine the effectiveness of this nutritional therapy.
A client who suffers from an anxiety disorder is very upset, has a respiratory rate of 32, and is complaining of lightheadedness and tingling in the fingers. ABG values are pH of 7.48, PaCO2 of 29, HCO3 of 24 and O2 is at 93% on room air. The nurse performs which of the following as a priority nursing intervention? a. Monitor intake and output b. Encourage client to increase activity c. Institute deep breathing exercises every hour d. Provide reassurance to the client and administer sedatives
d -This client is in a state of respiratory alkalosis. Administering sedatives will assist the client to slow breathe and retain more CO2, thus bringing the pH back into normal range. Deep breathing exercises may worsen the client's condition. Encourage the client to increase activity is contraindicated because clients are often exhausted and require rest after expending so much energy breathing. Monitor intake and output is not a priority.
what is the background of metabolic acidosis
it is a decrease in Ph that we see in a lot of renal patents where acid accumulates in the body and bicarb is lost
what is the purpose of SpO2rt for patients with ARD?
it is a rotational bed to help move things in the lungs
what is the background of metabolic alkalosis
it is an increase in Ph because of too much bicarb and not enough acid
What is ECMO used for with ARD patients ?
it is like dialysis and brings O2 into the body and filters out CO2
a nurse if assessing a patient who has ARDS, which of the following findings should the nurse report to the provider? a. decreased bowel sounds b. O2 of 92% c. CO2 of 24 d. intercostal retractions
d - this represents respiratory compromise - the CO2 level is expected for ARDS patients
severe acute respiratory distress syndrome is defined by what
less than 100 PaO2 even with increased FiO2
What is an artifact?
electrocardiographic alterations, not related to cardiac electrical activity. As a result of artifacts, the components of the electrocardiogram (ECG) such as the baseline and waves can be distorted. Motion artifacts are due to shaking with rhythmic movement
t/f: to asses an NG tube, osculating is more accurate than observing the patient for respiratory distress
false!!!
crackles
fine, crackling sounds made as air moves through wet secretions in the lungs - coughing won't clear this its too deep
how do we treat oxygenation ARF?
giving O2
a nurse is caring for a patient who has emphysema, what is the proper position for this patient?
high fowlers position with the arms supported on the overbed table or on top of pillows
Increasing H+ leads to an increase of extracellular K+ which can lead to what
hyperkalemia - If H+ is elevated than potassium will leave the cell because it like a magnet