Chapter 29: Care of Patients with Respiratory Emergencies (PRACTICE)

The physician has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube: 1. For administration of oxygen. 2. To promote formation of lung scar tissue. 3. To insert antibiotics into the pleural space. 4. To remove air and fluid.

4. A chest tube is inserted to re-expand the lung and remove air and fl uid. Oxygen is not administered through a chest tube. Chest tubes are not inserted to promote scar tissue formation. Antibiotics are not used to treat a pneumothorax.

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing f. Chronic anemia

ANS: A, B, D Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity. Anemia can make it difficult to wean a client, but this is not a normal age-related change.

A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order would the nurse anticipate? a. Decrease the heparin rate. b. Increase the heparin rate. c. No change to the heparin rate. d. Stop heparin; start warfarin.

ANS: B For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate that the heparin is working. A normal PTT is 25 to 35 seconds, so this client's PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.

A nurse is preparing to admit a client on mechanical ventilation for acute respiratory failure from the emergency department. What action does the nurse take first? a. Assessing that the ventilator settings are correct b. Ensuring that there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room

ANS: B Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse would know and check the settings. Personal protective equipment is important, but ensuring client safety is the most important action. The client may or may not need suctioning on arrival.

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? a. Hemoglobin: 14.2 g/dL (142 g/L) b. Platelet count: 82,000/L (82 109/L) c. Red blood cell count: 4.8/mm3 (4.8 1012/L) d. White blood cell count: 8700/mm3 (8.7 109/L)

ANS: B This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-age client with an exacerbation of asthma d. Older client who is 1 day post-hip replacement surgery e. Young obese client with a fractured femur f. Middle-age adult with a history of deep vein thrombosis

ANS: B, D, E Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.

A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge nurse why the client's oxygen saturation has not significantly improved. What response by the nurse is best? a. "Breathing so rapidly interferes with oxygenation." b. "Maybe the client has respiratory distress syndrome." c. "The blood clot interferes with perfusion in the lungs." d. "The client needs immediate intubation and mechanical ventilation."

ANS: C A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Acute respiratory distress syndrome can occur, but this is not as likely soon after the client starts on oxygen plus there is no indication of how much oxygen the client is on. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases and the respirations are shallow at a rate of 28 breaths/minute. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply. 1. Monitor serum creatinine and blood urea nitrogen levels. 2. Administer a sedative. 3. Keep the head of the bed flat. 4. Administer humidified oxygen. 5. Auscultate the lungs.

1, 4, 5. Acute respiratory distress syndrome (ARDS) may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries. Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidified oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases, so the nurse should continue to assess breath sounds. Sedatives should be used with caution in clients with ARDS. The nurse should try other measures to relieve the client's restlessness and anxiety. The head of the bed should be elevated to 30 degrees to promote chest expansion and prevent atelectasis.

Which of the following are expected outcomes for a client with pulmonary disease? 1. A relatively matched ventilation-to-perfusion ratio. 2. A low ventilation-to-perfusion ratio. 3. A high ventilation-to-perfusion ratio. 4. An equal PaO2 and PaCO2 ratio.

1. In the normal lung, the volume of blood perfusing the lungs each minute is approximately equal to the amount of fresh gas that reaches the alveoli each minute. Blood gas analysis evaluates respiratory function; the level of dissolved oxygen (PaO2) should be greater than the level of dissolved carbon dioxide (PaCO2).

A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg; PaCO2, 28 mm Hg; HCO3-, 24 mEq/L. Based upon the client's PaO2, which of the following conclusions would be accurate? 1. The client is severely hypoxic. 2. The oxygen level is low but poses no risk for the client. 3. The client's PaO2 level is within normal range. 4. The client requires oxygen therapy with very low oxygen concentrations.

1. Normal PaO2 level ranges from 80 to 100 mm Hg. When the PaO2 value falls to 50 mm Hg, the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The PaO2 is not within normal range. The client will require oxygenation at a concentration that maintains the PaO2 at 55 to 60 mm Hg or more.

A client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for: 1. Sudden, sharp chest pain. 2. Wheezing breath sounds over affected side. 3. Hemoptysis. 4. Cyanosis.

1. Pneumothorax signs and symptoms include sudden, sharp chest pain; tachypnea; and tachycardia. Other signs and symptoms include diminished or absent breath sounds over the affected lung, anxiety, and restlessness. Breath sounds are diminished or absent over the affected side. Hemoptysis and cyanosis are not typically present with a moderate pneumothorax.

A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment- Recommendation) technique for communication, the nurse calls the physician with the recommendation for: 1. Initiating I.V. sedation. 2. Starting a high-protein diet. 3. Providing pain medication. 4. Increasing the ventilator rate.

1. The client may be fighting the ventilator breaths. Sedation is indicated to improve compliance with the ventilator in an attempt to lower peak inspiratory pressures. The workload of breathing does indicate the need for increased protein calories; however, this will not correct the respiratory problems with high pressures and respiratory rate. There is no indication that the client is experiencing pain. Increasing the rate on the ventilator is not indicated with the client's increased spontaneous rate.

Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)? 1. Septic shock. 2. Chronic obstructive pulmonary disease. 3. Asthma. 4. Heart failure.

1. The two risk factors most commonly associated with the development of ARDS are gramnegative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or a systemic inflammatory response syndrome (which can be caused by any physiologic insult that leads to widespread infl ammation). Chronic obstructive pulmonary disease, asthma, and heart failure are not direct causes of ARDS.

A 21-year-old male client is transported by ambulance to the emergency department after a serious automobile accident. He complains of severe pain in his right chest where he struck the steering wheel. Which is the primary client goal at this time? 1. Reduce the client's anxiety. 2. Maintain adequate oxygenation. 3. Decrease chest pain. 4. Maintain adequate circulating volume.

2. Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation.

A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following? 1. Respiratory rate greater than 16 breaths/minute. 2. Continuous bubbling in the water-seal chamber. 3. Fluid in the chest tube. 4. Fluctuation of fluid in the water-seal chamber.

2. Continuous bubbling in the water-seal chamber indicates a leak in the system, and the client needs to be instructed to notify the physician if continuous bubbling occurs. A respiratory rate of more than 16 breaths/minute may not be unusual and does not necessarily mean that the client should notify the physician. Fluid in the chest tube is expected, as is fl uctuation of the fl uid in the waterseal chamber.

A client undergoes surgery to repair lung injuries. Postoperative orders include the transfusion of one unit of packed red blood cells at a rate of 60 mL/hour. How long would this transfusion take to infuse? 1. 2 hours. 2. 4 hours. 3. 6 hours. 4. 8 hours.

2. One unit of packed red blood cells is about 250 mL. If the blood is delivered at a rate of 60 mL/hour, it will take about 4 hours to infuse the entire unit. The transfusion of a single unit of packed red blood cells should not exceed 4 hours to prevent the growth of bacteria and minimize the risk of septicemia.

A client with acute respiratory distress syndrome (ARDS) is showing signs of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived, shown below. Laboratory Results Blood chemistry Result pH 7.35 PaCO2 25 mm Hg Hco3- 22 mEq/L PaO2 95 mm Hg Which finding should the nurse report to the physician? 1. pH. 2. PaCO2. 3. HCO3-. 4. PaO2.

2. The normal range for partial pressure of arterial carbon dioxide (PaCO2) is 35 to 45 mm Hg. Thus, this client's PaCO2 level is low. The client is experiencing respiratory alkalosis (carbonic acid defi cit) due to hyperventilation. The nurse should report this fi nding to the physician because it requires intervention. The increase in ventilation decreases the PaCO2 level, which leads to decreased carbonic acid and alkalosis. The bicarbonate level is normal in uncompensated respiratory alkalosis along with the normal PaO2 level. Normal serum pH is 7.35 to 7.45; in uncompensated respiratory alkalosis, the serum pH is greater than 7.45.

The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which of the following would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. 1. The family is coming in to visit. 2. The client has increased secretions requiring frequent suctioning. 3. The SpO2 and PO2 have decreased. 4. The client is tachycardic with drop in blood pressure. 5. The face has increased skin breakdown and edema.

3, 4, 5. The prone position is used to improve oxygenation, ventilation, and perfusion. The importance of placing clients with ARDS in prone positioning should be explained to the family. The positioning allows for mobilization of secretions and the nurse can provide suctioning. Clinical judgment must be used to determine the length of time in the prone position. If the client's hemodynamic status, oxygenation, or skin is compromised, the client should be returned to the supine position for evaluation. Facial edema is expected with the prone position, but the skin breakdown is of concern.

Which of the following interventions should the nurse anticipate in a client who has been diagnosed with acute respiratory distress syndrome(ARDS)? 1. Tracheostomy. 2. Use of a nasal cannula. 3. Mechanical ventilation. 4. Insertion of a chest tube.

3. Endotracheal intubation and mechanical ventilation are required in ARDS to maintain adequate respiratory support. Endotracheal intubation, not a tracheostomy, is usually the initial method of maintaining an airway. The client requires mechanical ventilation; nasal oxygen will not provide adequate oxygenation. Chest tubes are used to remove air or fluid from intrapleural spaces.

A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? 1. An obstruction is present in the chest tube. 2. The client is developing subcutaneous emphysema. 3. The chest tube system is functioning properly. 4. There is a leak in the chest tube system.

3. Fluctuation of fl uid in the water-seal column with respirations indicates that the system is functioning properly. If an obstruction were present in the chest tube, fl uid fl uctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client's skin around the chest tube insertion site. A leak in the system is indicated when continuous bubbling occurs in the water-seal column.

A nurse should interpret which of the following as an early sign of a tension pneumothorax in a client with chest trauma? 1. Diminished bilateral breath sounds. 2. Muffled heart sounds. 3. Respiratory distress. 4. Tracheal deviation.

3. Respiratory distress or arrest is a universal finding of a tension pneumothorax. Unilateral, diminished, or absent breath sounds is a common finding. Tracheal deviation is an inconsistent and late finding. Muffled heart sounds are suggestive of pericardial tamponade.

A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg; PaCO2, 28 mm Hg; HCO3-, 24 mEq/L. The nurse determines that which of the following is a possible cause for these findings? 1. Chronic obstructive pulmonary disease (COPD). 2. Diabetic ketoacidosis with Kussmaul's respirations. 3. Myocardial infarction. 4. Pulmonary embolus.

4. A PaCO2 of 28 mm Hg and PaO2 of 50 mm Hg are both abnormal; the PaO2 of 50 mm Hg signifies acute respiratory failure. In evaluating possible causes for this disorder, the nurse should consider conditions that lead to hypoxia and hyperventilation, such as pulmonary embolus. COPD is typically associated with respiratory acidosis and elevated PaCO2. The client with diabetic ketoacidosis most often has metabolic acidosis. A myocardial infarction does not often cause an acid-base imbalance because the primary problem is cardiac in origin.

Which one of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client? 1. Assessing the client's skin color. 2. Monitoring the respiratory rate. 3. Verifying the amount of cuff inflation. 4. Auscultating breath sounds bilaterally.

4. Auscultation for bilateral breath sounds is the most appropriate method for determining cuff placement. The nurse should also look for the symmetrical rise and fall of the chest and should note the location of the exit mark on the tube. Assessments of skin color, respiratory rate, and the amount of cuff inflation cannot validate the placement of the endotracheal tube.

A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should: 1. Put all four side rails up on the bed. 2. Ask the unlicensed personnel to place restraints on the client's upper extremities. 3. Request that the client's roommate put the call light on when the client is attempting to get out of bed. 4. Check on the client at regular intervals to ascertain the need to use the bathroom.

4. Confusion and vertigo are risk factors for falls. Measures must be taken to minimize the risk of injury. The nurse or unlicensed personnel should check on the client regularly to determine needs regarding elimination. Restraints, including bed rails and extremity restraints, should be used only to ensure the person's safety or the safety of others, and there must be a written order from a physician before using them. The nurse should never ask the roommate of a client to be responsible for the client's safety.

Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress? 1. Administering oxygen every 2 hours. 2. Turning the client every 4 hours. 3. Administering sedatives to promote rest. 4. Suctioning if cough is ineffective.

4. The nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned every 2 hours to help move secretions; every 4 hours is not often enough. Administering sedatives is contraindicated in acute respiratory distress because sedatives can depress respirations.

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? (Select all that apply.) A. Assist-control B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation E. Independent lung ventilation

A. Assist-control mode takes over the work of breathing. B. CORRECT: Synchronized intermittent mandatory ventilation requires that the client generate force to take spontaneous breaths. C. CORRECT: Continuous positive airway pressure requires that the client generate force to take spontaneous breaths. D. CORRECT: Pressure support ventilation requires that the client generate force to take spontaneous breaths. E. Independent lung ventilation mode is used for unilateral lung disease to ventilate the lung individually.

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.) A. A client who experienced a near-drowning incident B. A client following coronary artery bypass graft surgery C. A client who has a hemoglobin of 15.1 mg/dL D. A client who has dysphagia E. A client who experienced acute drug toxicity

A. CORRECT: A client who experienced a near-drowning incident is at risk for developing ARDS due to trauma to the lungs and cerebral edema. B. CORRECT: A client following coronary artery bypass graft surgery is at risk for developing ARDS due to trauma to the chest. C. Hemoglobin of 15.1 mg/dL is within the expected reference range. A client who has a low hemoglobin is at risk for developing ARDS. D. CORRECT: A client who has dysphagia is at risk for developing ARDS due to difficulty swallowing and risk for aspiration. E. CORRECT: A client who experienced acute drug toxicity is at risk for developing ARDS due to damage to the central nervous system.

A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply.) A. Tachypnea B. Deviation of the trachea C. Bradycardia D. Decreased use of accessory muscles E. Pleuritic pain

A. CORRECT: The client whe has apneumothorax can experience tachypnea related to respiratory distress caused by the injury. B. CORRECT: The client who has a pneumothorax can experience deviation of the trachea as tension increases within the chest. C. The client who has a pneumothorax can experience tachycardia related to respiratory distress and pain. D. The client who has a pneumothorax can experience an increase in the use of accessory muscles as respiratory distress occurs. E. CORRECT: The client who has a pneumothorax can experience pleuritic pain related to the inflammation of the pleura of the lung caused by the injury.

A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonary embolism? (Select all that apply] A. A client who has a BMI of 30 B. A female client who is postmenopausal C. A client who has a fractured femur D. A client who is a marathon runner E. A client who has chronic atrial fibrillation

A. CORRECT: The client who has a BMI of 30 is considered obese and is at increased risk for a blood clot. B. A female who is postmenopausal has decreased estrogen levels. Increased estrogen levels are a risk factor for developing a pulmonary embolism. C. CORRECT: The client who has a fractured bone, particularly in a long bone such as the femur, increases the risk of fat emboli. D. The client who is a marathon runner has increased blood flow and circulation of his body, which decreases the risk for developing a pulmonary embolism. E. CORRECT: The client who has turbulent blood flow in the heart, such as with atrial defibrillation, is also at increased risk of a blood clot.

A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recogrize as a contraindication to the therapy? A. Hip arthroplasty 2 weeks ago B. Elevated sedimentation rate C. Incident of exercise-induced asthma 1 week ago D. Elevated platelet count

A. CORRECT: The client who has undergone a major surgical procedure within the last 3 weeks should not receive thrombolytic therapy because of the risk of hemorrhage from the surgical site. B. An elevated sedimentation rate is not a contraindication to receiving heparin. C. An incident of exercise-induced asthma is not a contraindication to receiving heparin. D. An elevated platelet count is not a contraindication to receiving heparin.

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.) A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure

A. Confusion is a late manifestation of hypoxemia. B. CORRECT: Pale skin is an early manifestation of hypoxemia. C. Bradycardia is a late manifestation of hypoxemia. D. Hypotension is a late manifestation of hypoxemia. E. CORRECT: Elevated blood pressure is an early manifestation of hypoxemia.

A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A. "I am allergic to morphine." B. "I take antacids several times a day for my ulcer' C. "I had a blood clot in my leg several years ago." D. "It hurts to take a deep breath."

A. Document the client's allergy to morphine to manage the client's discomfort due to a blood clot. However, another action is the priority. B. CORRECT: The greatest risk to the client is the possibility of bleeding from a peptic ulcer. The priority intervention is to notify the provider of the finding. C. Document the client's history of a blood clot to provide preventative measures. However, another action is the priority. D. Expect the client to report pain with breathing. However, another action is the priority.

A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect? (Select all that apply) A. Bradypnea B. Pleural friction rub C. Hypertension D. Petechiae E. Tachycardia

A. Expect the client to have tachypnea. B. CORRECT: Expect the client to have a pleural friction rub. C. Expect the client to have hypotension. D. CORRECT: Expect the client to have petechiae. E. CORRECT: Expect the client to have tachycardia.

A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6° C (101.4° F), and Sa02 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest x-ray. B. Prepare for chest tube insertion. C. Administer oxygen via a high-flow mask. D. Initiate IV access.

A. Obtaining a chest x-ray to determine the level of injury to the lungs is important, but is not the priority action at this time. B. Preparing the client for chest tube insertion is important to facilitate lung expansion and restore normal intrapleural pressure, but is not the priority action at this time. C. CORRECT: According to the airway, breathing, and circulation to client care, the nurse should place the priority on administering oxygen via high-flow mask to restore optimal breathing because the client is experiencing dyspnea and has decreased lung sounds. D. Initiating I access to administer medications is important, but is not the priority action at this time.

A nurse is caring for a client receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the nurse indicates an understanding of PSV? A. "It keeps the alveoli open and prevents atelectass: B. "It allows preset pressure delivered during spontaneous ventilation." C. "It guarantees minimal minute ventilator" D. "It delivers a preset ventilatory rate and tidal volume to the client."

A. PEEP maintains pressure in the lungs to keep alveoli open or prevent atelectasis. B. CORRECT: PSV allows preset pressure delivered during spontaneous ventilation to decrease the work of breathing C. PSV does not guarantee minimal minute ventilation because no ventilator breaths are delivered. D. Assist-control (AC) mode delivers a preset ventilatory rate and tidal volume to the client.

A nurse in the emergency department is assessing a client who has sustained multiple rib fractures and has a flail chest. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Cyanosis C. Hypotension D. Dyspnea E. Paradoxical chest movement

A. The client can have tachycardia as a "manifestation when experiencing a flail chest due to inadequate oxygenation. B. CORRECT: The client can have cyanosis as a manifestation when experiencing a flail chest due to inadequate oxygenation. C. CORRECT: The client can have hypotension as a manifestation when experiencing a flail chest. D. CORRECT: The client can have dyspnea as a manifestation when experiencing a flail chest due to injury and the client's inability to effectively inhale and exhale. E. CORRECT: The client can have paradoxical chest movement as a manifestation when experiencing a flail chest due to injury to the chest and the inability to inhale and exhale.

A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. which of the following actions should the nurse take? A. Apply a vest restraint if self-extubation is attempted. B. Monitor ventilator settings every 8 hr. C. Document tube placement in centimeters at the angle of jaw. D. Assess breath sounds every 4 hr.

A. The nurse should apply soft wrist restraints to prevent self-extubation or according to facility policy. B. The nurse should monitor ventilator settings hourly. C. The nurse should document tube placement in centimeters at the client's teeth or lips. D. CORRECT: The nurse should assess the breath sounds of a client receiving mechanical ventilation every 4 hr.

A nurse is reviewing discharge instructions for a client who has COPD and experienced a pneumothorax. Which of the following statements should the nurse include? A. "Notify your provider if you experience weakness." B. "You should be able to return to work in 1 week." C. "You need to wear a mask when in crowded areas." D. "Notify your provider if you experience a productive cough."

A. Weakness is an expected finding following recovery from a pneumothorax. B. The client should expect a lengthy recovery following a pneumothorax. C. It is not necessary to wear a mask following a pneumothorax, unless the client has another condition, such as immunosuppression. D. CORRECT: The client should notify the provider of a productive or persistent cough. This can indicate that the client might need treatment of a respiratory infection.

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the client's hands. d. Sedate the client immediately.

ANS: A The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain, confusion, and hypoxia can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary but not as a first step. Ensuring the client is adequately oxygenated is the priority.

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering antiulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule f. Turning and positioning the client at least every 2 hours

ANS: A, B, C, D, F The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving antiulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, turning and positioning, and providing pulmonary hygiene measures. Suctioning is done as needed.

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the assistive personnel (AP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voice.

ANS: A, B, C, E Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia. If the client's anxiety is interfering with diagnostic testing or treatment, they can be used, but there is no evidence that this is the case.

A nurse is caring for a client in acute respiratory failure who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the client's bedside. b. Ensure that the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.

ANS: A, B, D, E There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of Communication, massaging the client's skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.

A 100-kg client has developed ARDS and needs mechanical ventilation. Which of the following are potentially correct ventilator management choices? (Select all that apply.) a. Tidal volume: 600 mL b. Volume-controlled ventilation c. PEEP based on oxygen saturation d. Suctioning every hour e. High-frequency oscillatory ventilation f. Limited turning for ventilator pressures

ANS: A, C, E The client with ARDS who needs mechanical ventilation benefits from "open lung" and lung protective strategies, such as using low tidal volumes (6 mL/kg body weight). Pressure-controlled ventilation is preferred due to the high pressures often required in these clients. PEEP usually starts at 5 cm H2O and is adjusted to keep oxygen saturations in an acceptable range. Suctioning may need to be frequent due to secretions, but is not scheduled hourly. High-frequency oscillatory ventilation is an alternative to traditional modes of ventilation. Early mobility is encouraged as is turning and positioning the client.

A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals that the client has an alteration in the gene CYP2C19. What action by the nurse is best? a. Instruct the client to eliminate all vitamin K from the diet. b. Prepare preoperative teaching for an inferior vena cava (IVC) filter. c. Refer the client to a chronic illness support group. d. Teach the client to use a soft-bristled toothbrush.

ANS: B Often clients are discharged from the hospital on warfarin after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have much higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be implanted. The other option is to lower the dose of warfarin. The nurse would prepare to do preoperative teaching on this procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy.

A client with ARDS is receiving minimal amounts of IV fluids. The new nurse notes the client is scheduled to receive a diuretic at this time. The nurse consults the Staff Development Nurse to determine the best course of action. What will the new nurse do? a. Contact the primary health care provider. b. Give the ordered diuretic as scheduled. c. Request an increase in the IV rate. d. Calculate the client's 24-hour fluid balance.

ANS: B Research has shown that clients with ARDS may benefit from conservative fluid therapy along with diuretics to maintain fluid balance. The nurse will give the ordered diuretic as scheduled. There is no reason to contact the provider or request an increased IV rate. The nurse can calculate the 24-hour fluid balance, but this will not influence the administration of the medication.

A client is being discharged to home on warfarin therapy after an acute pulmonary embolism (PE). Which client response indicates a need for further teaching by the nurse? A. "I should limit my alcohol consumption." B. "I should drink more green tea and cranberry juice." C. "I should take the medication at the same time every day." D. "I should make an appointment for weekly blood draws."

ANS: B The client should be educated to understand the risks and monitoring of this drug to include: -weekly monitoring for therapeutic levels -consistency in dosing regimens -foods to avoid (leafy green vegetables, green tea, alcohol, cranberry juice).

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and has a blood pressure of 88/52 mm Hg. What action by the nurse takes priority? a. Assess the client's lung sounds. b. Notify the Rapid Response Team. c. Provide reassurance to the client. d. Take a full set of vital signs.

ANS: B This client has signs and symptoms of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.

A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Subjective Information Shortness of breath for 20 minutes Reports feeling frightened "Can't catch my breath" Laboratory Analysis pH: 7.32 PaCO2: 28 mm Hg PaO2: 78 mm Hg SaO2: 88% Physical Assessment Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles What action by the nurse is most appropriate? a. Call respiratory therapy for a breathing treatment. b. Facilitate a STAT pulmonary angiography. c. Prepare for immediate endotracheal intubation. d. Prepare to administer intravenous anticoagulants.

ANS: B This client has signs and symptoms of pulmonary embolism (PE); however, many conditions can cause the client's presentation. The gold Standard for diagnosing a PE is pulmonary angiography. The nurse would facilitate this test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of PE.

A nurse is assisting the primary health care provider (PHCP) who is intubating a client. The PHCP has been attempting to intubate for 40 seconds. What action by the nurse is best? a. Ensure that the client has adequate sedation. b. Find another qualified provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the client's oxygen saturation.

ANS: C Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse would interrupt the intubation attempt and give the client oxygen. The nurse would also have adequate sedation during the procedure and monitor the client's oxygen saturation, but these do not take priority. Finding another qualified provider to intubate the client is not appropriate at this time.

A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a. Encourage the client to walk 5 minutes each hour. b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing. d. Tell the client that sometimes no cause for disease is found.

ANS: C Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder would be asked about family history and referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature.

A nurse is assessing a client who is suspected of having ARDS. The nurse is confused that although the client appears dyspneic and the oxygen saturation is 88% on 6 L/min of oxygen, the client's lungs are clear. What explanation does the more senior nurse provide? a. "The client is too dehydrated for moist-sounding lungs." b. "The client hasn't started having any bronchospasm yet." c. "Lung edema is in the interstitial tissues, not the airways." d. "Clients with ARDS usually have clear lung sounds."

ANS: C The clear lung sounds are due to the fact that the edema is found in the lung interstitial tissues, where it can't be auscultated, instead of in the airways. It is not related to the client being dehydrated or having bronchospasm. The statement about all clients with ARDS having clear lung sounds does not provide any information.

A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Apply oxygen at 100%. b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines.

ANS: C The priority for any chest trauma client is airway, breathing, and circulation. The nurse first ensures that the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs.

When working with women who are taking hormonal birth control, what health promotion measures does the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes.

ANS: C, D, E Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.

A client in acute respiratory failure is classified as having ventilatory failure. The nurse understands that which finding is a potential extrapulmonary cause of ventilatory failure? A.Amyloidosis B.Pneumothorax C.Pulmonary edema D.Opioid analgesic overdose

ANS: D Opioid analgesic overdose is an extrapulmonary cause of ventilatory failure. All other causes are intrapulmonary.

A new nurse asks for an explanation of "refractory hypoxemia." What answer by the staff development nurse is best? a. "It is chronic hypoxemia that accompanies restrictive airway disease." b. "It is hypoxemia from lung damage due to mechanical ventilation." c. "It is hypoxemia that continues even after the client is weaned from oxygen." d. "It is hypoxemia that persists even with 100% oxygen administration."

ANS: D Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.

A client is on mechanical ventilation and the client's spouse wonders why ranitidine is needed since the client "only has lung problems." What response by the nurse is best? a. "It will increase the motility of the gastrointestinal tract." b. "It will keep the gastrointestinal tract functioning normally." c. "It will prepare the gastrointestinal tract for enteral feedings." d. "It will prevent ulcers from the stress of mechanical ventilation."

ANS: D Stress ulcers can occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them and possible subsequent aspiration. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Ranitidine is a histamine-blocking agent.

A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what would the nurse ensure? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.

ANS: D The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent barotrauma to the lungs. Alarms are never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury.

Which of the following complications is associated with mechanical ventilation? 1. Gastrointestinal hemorrhage. 2. Immunosuppression. 3. Increased cardiac output. 4. Pulmonary emboli.

1. Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged mechanical ventilation because of the development of stress ulcers. Clients who are receiving steroid therapy and those with a previous history of ulcers are most likely to be at risk. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis.

The nurse interprets which of the following as an early sign of acute respiratory distress syndrome(ARDS) in a client at risk? 1. Elevated carbon dioxide level. 2. Hypoxia not responsive to oxygen therapy. 3. Metabolic acidosis. 4. Severe, unexplained electrolyte imbalance.

2. A hallmark of early ARDS is refractory hypoxemia. The client's PaO2 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS.

The primary reason for infusing blood at a rate of 60 mL/hour is to help prevent which of the following complications? 1. Emboli formation. 2. Fluid volume overload. 3. Red blood cell hemolysis. 4. Allergic reaction.

2. Too-rapid infusion of blood, or any intravenous fluid, can cause fluid volume overload and related problems such as pulmonary edema. Emboli formation, red blood cell hemolysis, and allergic reactions are not related to rapid infusion.

A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first? 1. Initiate gastric lavage. 2. Maintain body temperature. 3. Administer 100% oxygen by mask. 4. Obtain a psychiatric referral.

3. Carbon monoxide poisoning develops when carbon monoxide combines with hemoglobin. Because carbon monoxide combines more readily with hemoglobin than oxygen does, tissue anoxia results. The nurse should administer 100% oxygen by mask to reduce the half-life of carboxyhemoglobin. Gastric lavage is used for ingested poisons. With tissue anoxia, metabolism is diminished, with a subsequent lowering of the body's temperature, thus steps to increase body temperature would be required. Unless the carbon monoxide poisoning is intentional, a psychiatric referral would be inappropriate.

A client's chest tube is to be removed by the physician. Which of the following items should the nurse have ready to be placed directly over the wound when the chest tube is removed? 1. Butterfly dressing. 2. Montgomery strap. 3. Fine-mesh gauze dressing. 4. Petroleum gauze dressing.

4. Immediately after chest tube removal, a petroleum gauze is placed over the wound and covered with a dry sterile dressing. This serves as an airtight seal to prevent air leakage or air movement in either direction. Bandages are not applied directly over wounds. Montgomery straps are used in place of adhesive tape when a dressing requires very frequent changes and the constant removal of adhesive tape would damage the skin. Montgomery straps are not placed over open wounds. Mesh gauze would allow air movement.

A nurse is caring for a client who is receiving vecuronium during mechanical ventilation. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.) A. Fentanyl B. Furosemide C. Midazolam D. Famotidine E. Dexamethasone

A. CORRECT: Fentanyl is a pain medication administered to clients when a neuromuscular blocking agent, such as vecuronium, is administered. B. Furosemide is a diuretic used to release fluid from the body. C. CORRECT: Midazolam is a sedative medication administered to clients when a neuromuscular blocking agent, such as vecuronium, is administered. D. Famotidine is an H2 receptor antagonist given to treat upset stomach and heartburn. E. Dexamethasone is a corticosteroid used to treat inflammation, such as arthritis or an immune disorder.

A nurse is reviewing prescriptions for a client who ha acute dyspnea and diaphoresis. The client states, is anxious and unable to get enough air" Vital signs a, heart rate 117/min, respirations 38/min, temperatu 38.4° C (101.2° F), and blood pressure 100/54 mm lg Which of the following nursing actions is the pront A. Notify the provider. B. Administer heparin via I infusion. C. Administer oxygen therapy. D. Obtain a CT scan.

A. Notify the provider about the condition to obtain guidance "on treatment. However, another action is the priority. B. Administer IV heparin as a treatment to prevent growth of the existing clot and to prevent additional clots from forming. However, another action is the priority. C. CORRECT: When using the airway, breathing, circulation (ABC) priority approach to care, determine that the priority finding is related to the respiratory status. Meeting oxygenation needs by administering oxygen therapy is the priority action. D. Obtain a CT scan to detect the presence and location of the blood clot. However, another action is the priority.

The nurse is caring for four clients. Which client does the nurse identify at greatest risk of developing acute respiratory distress syndrome (ARDS)? A. 24-year-old male admitted with blunt chest trauma and aspiration B. 39-year-old male with a history of alcohol abuse and chronic pancreatitis C. 70-year-old male post heart valve surgery receiving 1 unit of packed red blood cells D. 84-year-old female on antibiotics for pneumonia

ANS: A All client scenarios create a risk for ARDS. However, the trauma client with direct chest injury and known aspiration is at greatest risk.

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication would the nurse being most beneficial? a. Alteplase b. Enoxaparin c. Unfractionated heparin d. Warfarin sodium

ANS: A Alteplase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows that this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other signs of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths.

ANS: A Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse would conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.

A client with acute respiratory failure is on a ventilator and is sedated. What care may the nurse delegate to the assistive personnel AP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools.

ANS: C The client on mechanical ventilation needs frequent oral care, which can be delegated to the AP. The other actions fall within the scope of practice of the nurse.

A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action does the nurse take first? a. Administer oxygen and reassess. b. Auscultate the client's lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.

ANS: D This client has signs and symptoms of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.

Which actions does the nurse ensure are performed for a client being mechanically ventilated to prevent ventilator-associated pneumonia (VAP)? Select all that apply. A. Assessing temperature every 4 hours B. Checking ventilator settings every 4 hours C. Getting the patient out of bed as soon as prescribed D. Keeping the head of the bed elevated to 30 degrees or above E. Maintaining the client in the prone position F. Providing adequate humidification G. Providing meticulous mouth care every 12 hours H. Suggesting that the pneumonia vaccine be prescribed

C, D, G

An attempt by a primary health care provider to intubate a client for mechanical ventilation is unsuccessful after 45 seconds. What is the nurse's priority action? A. Placing a nasotracheal tube B. Assessing for bilateral breath sounds C. Assessing oxygen saturation by pulse oximetry D. Applying oxygen with a bag-valve-mask device

D

Which of the following interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)? 1. Teaching cigarette smoking cessation. 2. Maintaining adequate serum potassium levels. 3. Monitoring clients for signs of hypercapnia. 4. Replacing fl uids adequately during hypovolemic states.

4. One of the major risk factors for development of ARDS is hypovolemic shock. Adequate fluid replacement is essential to minimize the risk of ARDS in these clients. Teaching smoking cessation does not prevent ARDS. An abnormal serum potassium level and hypercapnia are not risk factors for ARDS.

Which of the following findings would suggest pneumothorax in a trauma victim? 1. Pronounced crackles. 2. Inspiratory wheezing. 3. Dullness on percussion. 4. Absent breath sounds.

4. Pneumothorax means that the lung has collapsed and is not functioning. The nurse will hear no sounds of air movement on auscultation. The movement of air through mucus produces crackles. Wheezing occurs when airways become obstructed. Dullness on percussion indicates the increased density of lung tissue, usually caused by the accumulation of fluid.

The nurse has calculated a low PaO2/FIO2 (P/F) ratio < 150 for a client with acute respiratory distress syndrome (ARDS). The nurse should place the client in which position to improve oxygenation, ventilation distribution, and drainage of secretions? 1. Supine. 2. Semi-fowlers. 3. Lateral side. 4. Prone.

4. Prone positioning is used to improve oxygenation in clients with acute respiratory distress syndrome (ARDS) who are receiving mechanical ventilation. The positioning allows for recruitment of collapsed alveolar units, improvement in ventilation, reduction in shunting, mobilization of secretions, and improvement in functional reserve capacity (FRC). When the client is supine, side-to-side repositioning should be done every 2 hours with the head of the bed elevated at least 30 degrees.

A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask

A. A nonrebreather mask delivers an approximated amount of oxygen. B. CORRECT: A venturi mask incorporates an adapter that allows a precise amount of oxygen to be delivered. C. A nasal cannula delivers an approximated amount of oxygen. D. A simple face mask delivers an approximated amount of oxygen.

A client being mechanically ventilated has all of the following changes. Which changes are most relevant in helping the nurse determine whether suctioning is needed at this time? Select all that apply. A. Decreased SpO2 B. Elevated temperature C. Crackles auscultated over the trachea D. Crackles auscultated in the lung periphery E. High-pressure ventilator alarm sounds F. Presence of fluid within the endotracheal tube G. Presence of fluid within the ventilator tubing

A, C, E, F

A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following actions should the nurse include? (Select all that apply.) A. Administer antibiotics. B. Provide supplemental oxygen. C. Administer antiviral medications. D. Administer of bronchodilators. E. Maintain ventilatory support.

A. Antibiotics are given to treat bacterial infections. This would not be indicated for SARS. B. CORRECT: Providing supplemental oxygen should be included in the plan of care for SARS. Oxygen is administered to treat severe hypoxemia. C. SARS is caused by the coronavirus. There are no effective antiviral medications to treat this virus. D. CORRECT: Administration of bronchodilators should be included in the plan of care for SARS. Bronchodilators are used to vasodilate the client's airway. E. CORRECT: Maintaining ventilatory support should be included in the plan of care for SARS. Intubation can be required to maintain a patent airway.

A client in the emergency department has several broken ribs and reports severe pain. What care measure will best promote comfort? a. Prepare to assist with intercostal nerve block. b. Humidify the supplemental oxygen. c. Splint the chest with a large ACE wrap. d. Provide warmed blankets and warmed IV fluids.

ANS: A Uncomplicated rib fractures generally are simple to manage; however, opioids may be needed for pain. For severe pain, an intercostal nerve block is beneficial. The client needs to be able to breathe deeply and cough so as not to get atelectasis and/or pneumonia. Humidifying the oxygen will not help with the pain. Rib fractures are not wrapped or splinted in any way because this inhibits chest movement. Warmed blankets and warm IV fluids are nice comfort measures, but do not help with severe pain.

An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b. Ensure that all connections are patent. c. Listen to the client's lung sounds. d. Suction the endotracheal tube.

ANS: C When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), Pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and perform suction if needed, assess for pneumothorax, and finally check the equipment.

For a client with rib fractures and a pneumothorax, the physician prescribes morphine sulfate, 1 to 2 mg/hour, given I.V. as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which of the following outcomes would indicate successful achievement of this goal? 1. Pain rating of 0 on a scale of 0 to 10 by the client. 2. Decreased client anxiety. 3. Respiratory rate of 26 breaths/minute. 4. PaO2 of 70 mm Hg

1. If the client reports no pain, then the objective of adequate pain relief has been met. Decreased anxiety is not related only to pain control; it could also be related to other factors. A respiratory rate of 26 breaths/minute is not within normal limits. A PaO2of 70 mm Hg is not within normal limits.

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "This medication is given to treat infection." B. "This medication is given to facilitate ventilation." C. "This medication is given to decrease inflammation." D. "This medication is given to reduce anxiety."

A. Antibiotics are given to treat infection. B. CORRECT: Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption. C. Corticosteroids are given to treat inflammation. D. Benzodiazepines are given to treat anxiety.

A nurse is assisting the provider to care for a client who has developed a spontaneous preumothorax. Which of the following actions should the nurse perform first? A. Assess the client's pain. B. Obtain a large-bore IV needle for decompression. C. Administer lorazepam. D. Prepare for chest tube insertion.

A. Assessing the client's pain and administer pain medication is important. However, another action is the priority. B. CORRECT: The priority action when using the airway, breathing, circulation (ABC) approach to client care is to establish and maintain the client's respiratory function. Obtaining a large-bore IV needle for decompression is the priority action by the nurse. C. Administering a benzodiazepine wil treat the client's anxiety. However, another action is the priority. D. Gathering supplies to prepare for chest tube insertion is important. However, another action is the priority.