258 test 2
The nurse is caring for a client on a mechanical ventilator. The high pressure alarm sounds. The nurse assesses the client and attempts to determine the cause of the alarm. Which initial nursing action would be appropriate if the nurse is unable to determine the cause of the ventilator alarm?
Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device
What should the nurse suspect when hourly assessment of urine output on a patient postcraniotomy exhibits a urine output from a catheter of 1,500 mL for 2 consecutive hours?
Diabetes insipidus
The low exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication?
Displacement of the endotracheal tube
The nurse is assessing a client with possible pulmonary embolism. For which symptom should the nurse assess?
Dizziness and fainting Inspiratory chest pain
The nurse is assessing a patient who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the patients respirations. How should the nurse best respond to this assessment finding?
Document that the chest drainage system is operating as it is intended
Which activities would the client with a T4 spinal cord injury be able to perform independently?
Eating Breathing Transferring to a wheelchair Writing
To decrease the risk for ventilator associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation?
Elevate head of bed to 30 to 45 degrees
The nurse is assessing a patient who has been admitted with possible ARDS. What findings would distinguish ARDS from cardiogenic pulmonary edema?
Elevated B type natriuretic peptide BNP levels
When caring for a patient who has had a stroke, a priority is reduction of ICP. What patient position is most consistent with this goal?
Elevation of the head of the bed [this promotes venous drainage and lowers ICP. The head should be in a neutral midline position]
Acute respiratory failure is defined as:
- a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) - increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), - with an arterial pH of less than 7.35
Chest tube procedures to relieve
- lung abscesses, lung cancer, cysts, benign tumors, emphysema
Acute respiratory failure occurs when oxygen tension PaO2 falls to less than ______ mm Hg (Hypoxemia) and carbon dioxide tension PaCO2 rises to greater than ______ mm Hg (hypercapnia)
50 and 50 [Acute respiratory failure is defined as a decrease in the arterial oxygen tension to less than 50 mm Hg and an increase in the arterial carbon dioxide tension to greater than 50 mm Hg with an arterial pH of less than 7.35]
The nurse is caring for four patients on the unit. Which patient should the nurse consider to be at highest risk for developing acute respiratory distress syndrome ARDS?
A 72 year old man with a history of liver failure who became septic shock after pneumonia
Although his oxygen saturation is above 92%, an orally intubated, mechanically ventilated patient is restless and very anxious. What interventions will most likely decrease the risk of accidental extubation?
Administer sedatives Have a caregiver stay with the patient
The nurse is caring for a client with acute respiratory distress syndrome ARDS who is receiving mechanical ventilation and positive end expiratory pressure PEEP. The alarm sounds, indicating decreased pressure in the system. What is the nurse's best action?
Assess lung sounds
*ARDS Diagnostic tests
BNP, Echocardiography, and pulmonary artery cath.
The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess?
Baseline arterial blood gas levels [ABG levels checked to assess how patient is tolerating the procedure, prior attempts at weaning and ECG results are documented on the patients record, and the nurse can refer to them before the weaning process begins]
Pleural effusion
Blood, fluid, air, bacteria
The nurse recognizes the presence of Cushing's triad in the patient with which vitals? ]
Decreased pulse, irregular respiration, widened pulse pressure
A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform he client that the lower chest tube is placed for which of the following reasons?
Draining blood and fluid from the pleural space
A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient?
Ineffective breathing patterns related to weakness of the intercostal muscles
Pleurisy
Inflammaion
A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely?
Level of consciousness Arterial blood gases Vital signs
The nurse is caring for a client who is receiving mechanical ventilation and hears the high pressure alarm. Which action should the nurse take first?
Listen to the clients breath sounds.
Which conditions are related to acute respiratory distress syndrome ARDS?
Lung fluid increases A systemic inflammatory response occurs Lung volume is decreased Hypoxemia resultsLung fluid increases
A nurse is caring for a client who has a spinal cord injury at T4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?
Prevent bladder distention
Empyema
Pus/ purulent fluid
'The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order?
Removal from the ventilator, tube, and then oxygen
A family member brings the patient to the clinic for a follow up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What should be the nurses best answer?
Stop smoking as soon as possible
The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes?
The cough reflex is depressed [thickening of secretions, depressed swallow reflexes. Ulceration and stricture of larynx or trachea may develop]
Care for a patient with ARF:
assisting with intubation and maintain mechanical ventilation. Nurses asses ABGs, vital signs, and pulse ox.
Risk Factors for Infection With Pseudomonas aeruginosa
o Structural lung disease (e.g., bronchiectasis) o Corticosteroid therapy o Broad-spectrum antibiotic therapy (>7 days in the past month) o Malnutrition
Low pressure alarm-
either the ventilator tubing has come apart OR the tubing detached from the client. They are a result of malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator
Risk Factors for Infection With Penicillin-Resistant and Drug-Resistant Pneumococci
o Age >65 years o Alcoholism o Beta-lactam therapy (e.g., cephalosporins) in past 3 months o Immunosuppressive disorders o Multiple medical comorbidities o Exposure to a child in a day care facility o Risk Factors for Infection With Enteric Gram-Negative Bacteria o Residency in a long-term care facility o Underlying cardiopulmonary disease o Multiple medical comorbidities o Recent antibiotic therapy
The nurse is assessing arterial blood gases ABGs. The client with which ABG reading requires the nurse's immediate attention?
pH 7.55, PaCO2 32 mmHg, PaO2 50 mm Hg [this client has the most severe hypoxia and respiratory alkalosis,
What can lead to ARF:
pneumonia, ARDs, heart failure, COPD, PE, and restrictive lung diseases.
Excessive airway secretions-
triggers a high pressure alarm because there is an increase in resistance each time the ventilator administers a breath to the client]
Which patient has the greatest risk for developing ARDS?
74 year old who aspirates a tube feeding
Which patient below is at MOST risk for developing ARDS and has the worst prognosis?
A 69 year old female with sepsis caused by a gram negative bacterial infection
The nurse caring for a client who is mechanically ventilated is monitored for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow up?
A blood pressure of 90/60 mm Hg decreased from 112/78 mm Hg
A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low pressure alarm on the ventilator sounds, it indicates which of the following to the nurse?
A leak within the ventilator's circuitry
What would the critical care nurse recognize as a condition that may indicate a patients need to have a tracheostomy?
A patient requires permanent ventilation [long term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed patient]
After receiving change of shift report on a medical unit, which patient should the nurse assess first?
A patient with septicemia who has intercostal and substernal retractions
A patient with thoracic trauma is admitted to the ICU. The nurse notes the patients chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated?
A tracheostomy
What is an advantage of a tracheostomy over an endotracheal tube for long term management of an upper airway obstruction?
A tracheostomy tube allows for more comfort and mobility
A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure ICP. What nursing intervention would be most appropriate for this patient?
Absolute bed rest in a quiet, nonstimulating environment
A patient with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure. What nursing intervention would be most appropriate for this patient?
Absolute bed rest in a quiet, nonstimulating environment
A nurse is caring for a client on a mechanical ventilator. The high pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which finding?
Accumulation of respiratory secretions
The nurse is caring for a patient with permanent neurologic impairments resulting from traumatic head injury. When working with this patient and family, what mutual goal should be prioritized?
Achieve as high a level of function as possible
The nurse is reviewing the ABG results for a patient. The latest ABG shows pH 7.48, hco3 23 mEq/L, PACO2 98 mm Hg. What's the correct interpretation of these lab findings?
Acute respiratory alkalosis and hyperventilation
A patient presents to the ED stating she was in a boating accident about 3 hours ago. Now the patient has complaints of headache, fatigue, and the feeling that he just can't breathe enough. The nurse notes that the patient is restless and tachycardic with an elevated BP. This patient may be in the early stages of what respiratory problem?
Acute respiratory failure
A nurse is caring for a client on a mechanical ventilator who has a nasogastric tube in place. The nurse is assessing the pH of the gastric aspirate and notes that the pH is 4.5. Based on this finding, which nursing action is appropriate?
Administer a dose of a prescribed antacid
Paramedics have brought an intubated patient to the RD following a head injury due to acceleration deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following?
Administer benzodiazepines on a PRN basis
Paramedics have brought an intubated patient to the RD following a head injury due to acceleration deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following?
Administer benzodiazepines on a PRN basis [this is a sedative that doesn't affect cerebral blood flow or ICP. Head of Bed should be elevated 30 degrees)
A client with a pulmonary embolus has the following ABG values: pH 7.49, partial pressure of arterial oxygen PaO2 60 mm Hg, partial pressure of arterial carbon dioxide PaCO2 30 mm Hg, bicarbonate HCO3 25 mEq/L. What should the nurse do first?
Administer oxygen by nasal cannula as ordered
The nurse is caring for a client who is in the process of weaning off of mechanical ventilations. Which assessment findings should the nurse report to the healthcare provider?
Agitation Pallor Abdominal breathing
When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of which the nurse should be aware?
Alteration in level of consciousness LOC [early signs: mild drowsiness, slur of speech, sluggish papillary reactions, sudden headaches]
To prevent pneumonia and promote the integrity of the pulmonary system, an essential postoperative nursing intervention includes
Ambulating the client as soon as possible
A nurse is caring for several clients in the intensive care unit. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome?
Aspirating gastric contents
The nurse is reviewing the medication administration record of a female patient who possesses numerous risk factors for stroke. Which of the womans medications carries the greatest potential for reducing her risk of stroke?
Aspirin 81 mg PO o.d. Manage BP - Better nutrition - Control cholesterol - Weight loss - Manage blood glucose- Quit smoking - Physical activity
The nurse notes that each time the mechanical ventilator delivers a breath to a client with acute respiratory distress syndrome, the peak inspiratory pressure alarm sounds. What is the nurse's best intervention?
Assess the airway
The peak pressure alarm is sounding on the ventilator of the client with a recent tracheostomy. What intervention should be done first?
Assess the client's respiratory status
A patient is being treated for a hemorrhagic stroke. The patient is alert and able to verbalize basic needs and wants. The patient is currently able to use the bathroom with assistance but continues to have facial paralysis. Which patient care goals are most appropriate for this patient before discharge?
Assess the patient for dysphagia
The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurses first step in the suctioning process?
Assess the patients lung sounds and SAO2 via pulse oximeter
The nurse is caring for a patient who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the patient is hypoxemic?
Assess the patients oxygen saturation level
The nurse is caring for a client on a ventilator when the high pressure alarm sounds. What actions are most appropriate?
Assess the tubing for kinks Determine the need for suctioning Auscultate the client's lungs
What ventilation setting delivers preset tidal volume whenever the patient exerts inspiration, and still ensures that the patient receives a breath if they do not spontaneously trigger the ventilator?
Assist control
A patients plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy?
Assist the patient into a position that will allow gravity to move secretions
A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the patients cardiac and neurologic status, the nurse monitors the patient for signs of what complication?
Bleeding
A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad?
Bradycardia Bradypnea Hypertension
What are the three parts of the Cushing's triad? Cheyne stokes respirations (irregular, shallow respirations secondary to impaired brainstem function)
Bradycardia Hypertension, widening pulse pressure
A patient is just admitted to the hospital following a spinal cord injury at the level of T4. A priority of nursing care for the patient is monitoring for
Bradycardia with hypoxemia
The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the patients symptoms from those of a cardiac etiology?
Brain natriuretic peptide BNP level
A nurse is teaching a patient how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the patient?
Breathe in deeply through the spirometer, hold your breath briefly, and the exhale
A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse?
Call the physician immediately
It is suspected that the clients oxygenation status is deteriorating. The nurse is aware that abnormal assessment finding that represents the most serious indication of the clients decreased oxygenation is
Central Cyanosis (hypoxemia)
Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what health assessment?
Chest auscultation
Postural drainage has been ordered for a patient who is having difficulty mobilizing her bronchial secretions. Before repositioning the patient and beginning treatment, the nurse should perform what heath assessment?
Chest auscultation
A client comes to the emergency department in severe respiratory distress following left sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client?
Chest tube insertion [Manifestations indicate pneumothorax and nurse should prepare to insert a chest tube and connect it to a water- seal drainage system]
The nurse is caring for a group of clients. Which client should be monitored closely for respiratory failure? SATA
Client with a brainstem tumor Client with acute pancreatitis Client with a T3 spinal cord injury Client using a patient controlled analgesia
On admission a patient presents as follows pH 7.38, respiratory rate 24 breaths/min, regular, pursed lip breathing, PaO2 66 mm Hg, heart rate 112 beats/min, sinus tachycardia, PaCO2 52 mm Hg, blood pressure 110/68 mm Hg, HCO3 34 mEq/L, and SpO2 90% on O2, 2L/min nasal cannula. These gases should
Compensated respiratory acidosis
In what ventilation setting does the vent deliver tidal volume at a present rate because the patient is not breathing spontaneously?
Controlled Mandatory Ventilation
A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what?
Corrective use of incentive spirometry
The high pressure alarm of a patient's mechanical ventilator goes off. What are potential causes for this occurrence?
Cuff leak in the endotracheal or tracheostomy tube Pt has stopped bleeding Leak in the circuit
What does the nurse monitor for in a patient with a PE?
Cyanosis Rapid HR Dyspnea Crackles in the lung fields
Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease COPD, the patients arterial blood gas results include pH of 7.50, PaO2 of 80 mm Hg, PaCO2 of 29 mm Hg, and HCO3 of 23 mEq/L. The nurse will anticipate the need to
Decrease the respiratory rate
The nurse is caring for a patient who was just placed on mechanical ventilation and is observing the paitent's vital signs because positive pressure ventilation can lead to
Decreased cardiac output Decreased venous return Decreased intracranial pressure
The nurse is planning the care for a patient at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan?
Encouraging a liberal fluid intake Assisting the patient to do leg elevations about the level of the heart Using elastic stockings, especially when decreased mobility would promote venous stasis Applying a sequential compression device
A nurse is caring for a patient undergoing mechanical ventilation who is also receiving positive end expiratory pressure PEEP. What is the outcome that the nurse hopes to achieve with PEEP
Expand collapse alveoli
When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone SIADH. What nursing interventions should the nurse most likely initiate if the patient developed SIADH?
Fluid restriction
When preparing to discharge a patient home, the nurse has met with the family and warned them that the patient may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause?
Frustration around changes in function and communication
A health care provider writes a prescription to begin to wean the client form the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation IMV/SIMV. The nurse determines that the process of weaning will occur by which mechanism?
Gradually decreasing the respiratory rate until the client can assume the work of breathing without ventilatory assistance
Which assessment finding for a client requires the nurse's immediate action?
Having the endotracheal tube taped to the lower jaw
Which manifestations in a patient with a thoracic spinal cord injury T4 should alert the nurse to possible autonomic dysreflexia? Headache and rising blood pressure
Headache and rising blood pressure
Which option indicates a sign of Cushing's triad, an indication of increased intracranial pressure?
Heart rate decreases from 75 to 55 beats/minute
Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus?
Hemoptysis Sharp chest pain Hypotension
A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the patient and family needs to begin as soon as the patient is settled on the unit and will continue until the patient is discharged. What will family education need to include?
How to correctly modify the home environment
A patient with a T4 spinal cord injury experiences neurogenic shock as a result of SNS dysfunction. What would the nurse recognize as characteristic of this condition?
Hypotension
The nurse is caring for a patient at risk for atelectasis. The nurse implements a first line measure to prevent atelectasis development in the patient. What is an example of a first line measure to minimize atelectasis?
Incentive spirometry
The purpose of adding PEEP to positive pressure ventilation is to
Increase functional residual capacity and improve oxygenation
Actions of PEEP?
Increased driving pressure of oxygen Decreases surface tension to prevent alveolar collapse at end expiration Decreases intrapulmonary shunt by opening alveoli that are collapsed (alveolar recruitment) increases functional residual capacity Minimizes the risk of VILI by stabilizing the lung units and reducing the repeated opening and collapsing of alveoli
The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the patients respiratory effort has increased. What is the nurses most appropriate response?
Inform the care team and assess for further signs of possible increased ICP
A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first?
Initiate bag-valve-mask ventilation
Which assessment finding is considered an early sign of ARDS?
Intercostal & suprasternal retractions
A nurse is caring for a client who has had an accident. Which responses produced by the sympathetic division of the autonomic nervous system should the nurse identify in the client?
Involuntary defecation or urination
A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely?
Level of consciousness Arterial blood gases Vital signs
A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patients plan of care, what goal should be prioritized?
Maintain and improve cerebral tissue perfusion
The neurologic ICU nurse is admitting a patient following a craniotomy using the supratentorial approach. How should the nurse best position the patient?
Maintain head of bed elevated 30 to 45 degrees
A patient has been admitted to the ICU after being recently diagnosed with an aneurysm and the patients admission orders include specific aneurysm precautions. What nursing action will the nurse incorporate into the patients plan of care?
Maintain the patient on complete bed rest
A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this?
Maintaining a patent airway
The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority?
Maintaining a patent airway
A patient in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter does the nurse monitor most closely on a patient who is postoperative following an embolectomy?
Pulmonary arterial pressure
The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic diuretic use. What would be an appropriate intervention for this diagnosis?
Monitor serum electrolytes
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?
Monitor the pressure in the cuff at least every 8 hours
The high pressure alarm of a patient's mechanical ventilator goes off. What are the potential causes for this occurrence?
Mucus plus Patient's fighting the ventilator Bronchospasm Patient is coughing
During a patients recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help patients and families set realistic goals. What are the predictors of stroke outcome?
National Institutes of Health Stroke Scale score NIHSS LOC at time of admission Age
A firefighter was trapped in a fire and is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of ARDS and is intubated. What other supportive measures are initiated in a patient with ARDS?
Nutritional support
The nurse is caring for several clients on the respiratory floor. Which client does the nurse assess most carefully for the development of acute respiratory distress syndrome?
Older adult who has aspirated his tube feeding
Which clients are at highest risk for pulmonary embolism?
Older adult with a 20 pack year history of smoking Client who has been on bedrest for 3 weeks Obese client who has elevated platelets Older adult who has just had abdominal surgery
A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe?
Older adults often lack the classic signs and symptoms of pneumonia
A student nurse asks why chlorhexidine gluconate was ordered twice daily for a patient with an ET tube. Which response should the nurse preceptor provide?
Oral decontamination reduces pathogenic bacterial colonization in the oral cavity, which may cause VAP if contaminated secretions are aspirated
A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome?
Oxygen administered at 100%, PaO2 60 Increased dyspnea Anxiety
Which statement by the nurse when explaining the purpose of positive end expiratory pressure PEEP to the family members of a patient with ARDS is accurate?
PEEP prevents the lung air sacs from collapsing during exhalation
A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome?
PaO2 50 mmHg
The nurse is caring for a 65 year old man with acute respiratory distress synd'rome ARDS who is on pressure support ventilation PSV, fraction of inspired oxygen FIO2 at 80% and positive end expiratory pressure PEEP at 15 cm H2O. The patient weighs 72 kg. What finding would indicate that the treatment is effective?
PaO2 of 60 mm Hg
A patient with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurses best intervention for preventing injury?
Pad the side rails of the patients bed
The nurse is teaching the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate?
Paralysis and sedatives help decrease the demand for oxygen
The nursing student is assisting in the care of a patient on mechanical ventilator. Which action by the student contributes to the prevention of ventilator assisted pneumonia?
Performs oral care every 2 hours
A client who is diagnosed with acute respiratory distress syndrome requires mechanical ventilation. Which ventilator mode should the nurse expect to implement to promote pressure throughout the respiratory cycle?
Positive end expiratory pressure PEEP
A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurse identify?
Post thoracotomy Spontaneous pneumothorax Chest trauma resulting in pneumothorax
A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify?
Post thoracotomy Spontaneous pneumothorax Chest trauma resulting in pneumothorax
The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurses most appropriate action?
Prepare for interventions to increase the patients BP
A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What intervention should the nurse first anticipate?
Preparing to assist with intubating the patient [ARDS requires intubation and mechanical ventilation, priority is to secure the airway]
When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end expiratory pressure PEEP to the ventilator settings has which therapeutic effect?
Prevention of alveolar collapse during expiration
A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patients increased risk for what complication?
Pulmonary Embolism
A nurse is educating a patient in anticipation of a procedure that will require a water sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for?
Removing excess air and fluid [Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood]
The home care nurse is monitoring a patient discharged home after resolution of a pulmonary embolus. For what potential complication would the home care nurse be most closely monitoring this patient?
Residual effects of compromised oxygenation
indicated by low partial pressure of arterial carbon dioxide PaCO2 values on ABG analysis A patient demonstrates chest pain, dyspnea, dry cough, and change in level of consciousness. The nurse suspects PE and notifies the HCP who orders an arterial blood gas. In the early stage of a PE, what would ABG results probably indicate?
Respiratory alkalosis
A patient who involved in a workplace accident suffered a penetrating wound of the chest that led to acute respiratory failure. What goal of treatment should the care team prioritize when planning this patient's care?
Restoration of adequate gas exchange
A patient who involved in a workplace accident suffered a penetrating wound of the chest that led to acute respiratory failure. What goal of treatment should the care team prioritize when planning this patients care?
Restoration of adequate gas exchange
The decision has been made to discharge a ventilator dependent patient home. The nurse is developing a teaching plan for this patient and his family. What would be most important to include in this teaching plan?
Signs of pulmonary infection [teach: about the ventilator, suctioning, tracheostomy care, cuff inflation/deflation, assessment of vital signs
Which of the following is the primary risk factor for pulmonary embolism?
Smoking Heart disease DVT Malignancy
A nurse in a med-surg unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism?
Stabbing chest pain [Chest pain that is sharp/stabbing, dyspnea, coughing, hemoptysis (cough up blood), tachypnea, tachycardia, diaphoresis, feeling of impending doom]
The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify?
Stable vital signs and ABGs
A nurse is caring for a client immediately FOLLOWING extubation. Which of the following manifestations indicates that the nurse should call the rapid response team?
Stridor
The nurse is preparing for removal of an endotracheal tube from a client. In assisting the health care provider in this procedure, which is the initial nursing action?
Suction the ET tube
An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed with a small flail chest injury. Which intervention should the nurse include in the patients plan of care?
Suction the patients airway secretions
A nurse is reviewing the plan of care for a client who is receiving mechanical ventilation. Which of the following ventilator modes will increase the client's work of breathing?
Synchronized intermittent mandatory ventilation Continuous positive airway pressure Pressure support ventilation
The nurse is caring for a client who has been using mechanical ventilation for several months after an episode of sepsis and acute respiratory distress syndrome. Which ventilator setting should the nurse anticipate the healthcare provider ordering for weaning?
Synchronized intermittent mandatory ventilation SIMV [BEST for patient trying to wean from mechanical ventilation]
A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure?
Tachycardia [dyspnea, restlessness, headaches, increased BP]
A 58 year old patient with a left brain stroke suddenly bursts into tears when family members visit. The nurse should
Teach the family that emotional outbursts are common after strokes
A rehabilitation nurse caring for a patient who has had a stroke is approached by the patients family and asked why the patient has to do so much for herself when she is obviously struggling. What would be the nurses best answer?
The focus on care in a rehabilitation facility is to help the patient to resume as much self care as possible
A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place. 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make?
The lower tube will drain blood, and the higher tube will remove air
A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions?
The nurse auscultates coarse crackles in the lung fields
Beep Beep Beep. The high pressure alarm is sound in the patient's room. Which of the following is the most likely cause?
The patient is trying to talk to his friend
A patient who has experienced an ischemic stroke has been admitted to the medical unit. The patients family is adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurses response to the family?
The patient should mobilize as soon as she is physically able
While assessing the patient, the nurse observes constant bubbling in the water seal chamber of the patients closed chest drainage system. What should the nurse conclude?
The system has an air leak
The nurse is providing preoperative teaching to a client scheduled for surgery. The nurse is instructing the client on the use of deep breathing, coughing, and the use of incentive spirometry when the client states, I don't know why you're focusing on my breathing. My surgery is on my hip, not my chest. What rationale for these instructions should the nurse provide?
To promote optimal lung expansion
A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?
To remove air from the pleural space
A patient is exhibiting signs of a pneumothorax (air in chest/lungs) following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?
To remove the air from the pleural space
The nurse is assessing a patient who sustained significant chest trauma during a motor vehicle accident. What significant assessment finding suggest tension pneumothorax?
Tracheal deviation to the unaffected side
What are the risk factors for pulmonary embolism PE and DVT?
Trauma HF Cancer (particularly lung or prostate)
A patient presents with the following values pH 7.20, PaO2 106 mm Hg, PaCO2 35 mm Hg, and HCO3 11 mEq/L. These values are most consistent with
Uncompensated metabolic acidosis
A patient's assessment data presents as follows: pH 7.10, PaCO2 60 mm Hg, PaO2 40 mm Hg, HCO3 24 mEq/L, RR 34 breaths/min, HR 128 beats/min, and BP 180/92 mm Hg. This condition is best described as
Uncompensated respiratory acidosis
A nurse is aware that the diagnostic feature of ARDS is sudden
Unresponsive arterial hypoxemia [Marked by rapid onset of severe dyspnea that occurs 12 to 48 hours after the initiating event]
The nurse is performing oral hygiene for a critically ill patient with an artificial airway and who is on mechanical ventilation. Which action reduces the risk of ventilator associated pneumonia? Using chlorhexidine mouthwash
Using chlorhexidine mouthwash
The low pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action?
Ventilate the client manually
A patient has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication?
Vigilant monitoring of fluid balances
The nurse is caring for a client who is mechanically ventilated and the high pressure ventilator alarm is sounding. The nurse understands that which complication may cause this alarm?
Water or a kink in the tubing Biting on the endotracheal tube Increased secretions in the airway
While caring for a patient with an endotracheal tube, the nurse recognizes that suctioning is required how often?
When adventitious breath sounds are auscultated
A patient in the ICU has had an endotracheal tube in place for 3 weeks. The physician has ordered that a tracheostomy tube be placed. The patients family wants to know why the endotracheal tube cannot be left in place. What would be the nurses best response?
When an endotracheal tube is left in too long it can damage the lining of the windpipe
Extubation (Removal of Endotracheal Tube)
• Explain procedure. • Have self-inflating bag and mask ready in case ventilatory assistance is required immediately after extubation. • Suction the tracheobronchial tree and oropharynx, remove tape, and then deflate the cuff. • Give 100% oxygen for a few breaths, then insert a new, sterile suction catheter inside tube. • Have the patient inhale. At peak inspiration, remove the tube, suctioning the airway through the tube as it is pulled out.
