Chapter 32: Care of Critically Ill Patients with Respiratory Problems
83. The nurse is preparing to administer medications to the following clients. Which medication should the nurse question administering? 1. The oral coagulant warfarin (Coumadin) to the client with an INR of 1.9. 2. Regular insulin to a client with a blood glucose level of 218 mg/dL. 3. Hang the heparin bag on a client with a PT/PTT of 12.9/98. 4. A calcium channel blocker to the client with a BP of 112/82.
1. An INR of 2 to 3 is therapeutic; therefore, the nurse would administer this medication. 2. This is an elevated blood glucose level; therefore, the nurse should administer the insulin. ✅3. A normal PTT is 39 seconds, and for hepa- rin to be therapeutic, it should be 1.5 to 2 times the normal value, or 58 to 78. A PTT of 98 indicates the client is not clotting and the medication should be held. 4. This is a normal blood pressure and the nurse should administer the medication. TEST-TAKING HINT: This question is asking the test taker to select a distracter with assessment data that are unsafe for admin- istering the medication. The test taker must know normal laboratory values to administer medication safely. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level - Application: Concept - Medication
79. The nurse identified the client problem "decreased cardiac output" for the client diagnosed with a pulmonary embolus. Which intervention should be included in the plan of care? 1. Monitor the client's arterial blood gases 2. Assess skin color and temperature. 3. Check the client for signs of bleeding. 4. Keep the client in the Trendelenburg position.
1. Arterial blood gases would be included in the client problem "impaired gas exchange." ✅2. These assessment data monitor tissue perfusion, which evaluates for decreased cardiac output. 3. This would be appropriate for the client problem "high risk for bleeding." 4. The client should not be put in a position with the head lower than the legs because this would increase difficulty breathing. TEST-TAKING HINT: The test taker must think about which answer option addresses the problem of the heart's inability to pump blood. Decreased blood to the extremities results in cyanosis and cold extremities. Content - Medical: Integrated Nursing Process - Diagnosis: Client Needs - Safe Effective Care Environ- ment, Management of Care: Cognitive Level - Analysis: Concept - Oxygenation.
76. The client diagnosed with a pulmonary embolus is in the intensive care department. Which assessment data warrant immediate intervention from the nurse? 1. The client's ABGs are pH 7.36, Pao2 95, Paco2 38, Hco3 24. 2. The client's telemetry exhibits occasional premature ventricular contractions (PVCs). 3. The client's pulse oximeter reading is 90%. 4. The client's urinary output for the 12-hour shift is 800 mL.
1. The ABGs are within normal limits and would not warrant immediate intervention. 2. Occasional premature ventricular contractions are not unusual for any client and would not warrant immediate intervention. ✅3. The normal pulse oximeter reading is 93% to 100%. A reading of 90% indicates the client has an arterial oxygen level of around 60. 4. A urinary output of 800 mL over 12 hours in- dicates an output of greater than 30 mL/hour and would not warrant immediate interven- tion by the nurse. TEST-TAKING HINT: This question is asking the test taker to select abnormal, unex- pected, or life-threatening assessment data in relationship to the client's disease process. A pulse oximeter reading of less than 93% indicates severe hypoxia and requires imme- diate intervention. Content - Medical: Integrated Nursing Process - Assessment: Client Needs - Safe Effective Care Environ- ment, Management of Care: Cognitive Level - Synthesis: Concept - Oxygenation.
84. The client is getting out of bed and becomes very anxious and has a feeling of impending doom. The nurse thinks the client may be experiencing a pulmonary embolism. Which action should the nurse implement first? 1. Administer oxygen 10 L via nasal cannula. 2. Place the client in high Fowler's position. 3. Obtain a STAT pulse oximeter reading. 4. Auscultate the client's lung sounds.
1. The client needs oxygen, but the nurse can intervene to help the client before applying oxygen. ✅2. Placing the client in this position facilitates maximal lung expansion and reduces venous return to the right side of the heart, thus lowering pressures in the pulmonary vascular system. 3. A pulse oximeter reading is needed, but it is not the first intervention. 4. Assessing the client is indicated, but it is not the first intervention in this situation. TEST-TAKING HINT: The test taker must select the option that will directly help the client breathe easier. Therefore, assessment is not the first intervention and option "4" can be eliminated as the correct answer. When the client is in distress, do not assess. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Safe Effective Care Envi- ronment, Management of Care: Cognitive Level - Synthesis: Concept - Oxygenation.
81. Which statement by the client diagnosed with a pulmonary embolus indicates the discharge teaching is effective? 1. "I am going to use a regular-bristle toothbrush." 2. "I will take antibiotics prior to having my teeth cleaned." 3. "I can take enteric-coated aspirin for my headache." 4. "I will wear a Medic Alert band at all times."
1. The client should use a soft-bristle toothbrush to reduce the risk of bleeding, so the teaching is not effective. 2. This is appropriate for a client with a mechanical valve replacement, not a client receiving anticoagulant therapy, so the teaching is not effective. 3. Aspirin, enteric-coated or not, is an antiplate- let, which may increase bleeding tendencies and should be avoided, so the teaching is not effective. ✅4. The client should wear a Medic Alert band at all times so that, if any accident or situation occurs, the health-care providers will know the client is receiving antico- agulant therapy. The client understands the teaching. TEST-TAKING HINT: This is a higher level question in which the test taker must know clients with a pulmonary embolus are pre- scribed anticoagulant therapy on discharge from the hospital. If the test taker had no idea of the answer, the option stating "wear a Medic Alert band" is a good choice because many disease processes require the client to take long-term medication and a health-care provider should be aware of this. Content - Medical: Integrated Nursing Process - Evaluation: Client Needs - Physiological Integrity, Physi- ological Adaptation: Cognitive Level - Synthesis: Concept - Oxygenation
78. The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a PT/PTT of 22/39 and an INR of 2.8. What action should the nurse implement? 1. Assess the client for abnormal bleeding. 2. Prepare to administer vitamin K (AquaMephyton). 3. Administer the medication as ordered. 4. Notify the HCP to obtain an order to increase the dose.
1. The client would not be experiencing abnormal bleeding with this INR 2. This is the antidote for an overdose of anticoagulants and the INR does not indicate this. ✅3. A therapeutic INR is 2 to 3; therefore, the nurse should administer the medication. 4. There is no need to increase the dose; this result is within the therapeutic range TEST-TAKING HINT: The test taker must know normal laboratory values; this is the only way the test taker will be able to answer this question. The test taker should make a list of laboratory values that must be memorized for successful test taking. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level - Application: Concept - Medication.
77. The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention should the nurse implement? 1. Administer oral anticoagulants. 2. Assess the client's bowel sounds. 3. Prepare the client for a thoracentesis. 4. Institute and maintain bedrest.
1. The intravenous anticoagulant heparin will be administered immediately after diagnosis of a PE, not oral anticoagulants. 2. The client's respiratory system will be assessed, not the gastrointestinal system. 3. A thoracentesis is used to aspirate fluid from the pleural space; it is not a treatment for a PE. ✅4. Bedrest reduces the risk of another clot becoming an embolus leading to a pulmo- nary embolus. Bedrest reduces metabolic demands and tissue needs for oxygen in the lungs. TEST-TAKING HINT: The test taker must be aware of adjectives such as "oral" in option "1," which makes this option incorrect. The test taker should apply the body system of the disease process to eliminate option "2" as a correct answer. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Physiological Integrity, Physiological Adaptation: Cognitive Level - Application: Concept - Oxygenation.
75. Which nursing assessment data support that the client has experienced a pulmonary embolism? 1. Calf pain with dorsiflexion of the foot. 2. Sudden onset of chest pain and dyspnea. 3. Left-sided chest pain and diaphoresis. 4. Bilateral crackles and low-grade fever.
1. This is a sign of a deep vein thrombosis, which is a precursor to a pulmonary embolism, but it is not a sign of a pulmonary embolism. ✅2. The most common signs of a pulmonary embolism are sudden onset of chest pain when taking a deep breath and shortness of breath. 3. These are signs of a myocardial infarction. 4. These could be signs of pneumonia or other pulmonary complications but not specifically a pulmonary embolism. TEST-TAKING HINT: The key to selecting option "2" as the correct answer is sudden onset. The test taker would need to note "left-sided" in option "3" to eliminate this as a possible correct answer, and option "4" is nonspecific for a pulmonary embolism. Content - Medical: Integrated Nursing Process - Assessment: Client Needs - Physiological Integrity, Reduc- tion of Risk Potential: Cognitive Level - Analysis: Concept - Oxygenation.
73. The client is diagnosed with a pulmonary embolus (PE) and is receiving a heparin drip. The bag hanging is 20,000 units/500 mL of D5W infusing at 22 mL/hr. How many units of heparin is the client receiving each hour? ________
880 units. If there are 20,000 units of heparin in 500 mL of D5W, there are 40 units in each mL: 20,000 ÷ 500 = 40 units If 22 mL are infused per hour, then 880 units of heparin are infused each hour: 40 × 22 = 880 TEST-TAKING HINT: The test taker must know how to calculate heparin drips from two aspects: the question may give the mL/hr and the test taker has to determine units/hr, or the question may give units/hr and the test taker has to determine mL/hr. Remember to learn how to use the drop-down calculator on the computer. During the NCLEX-RN, the test taker can request an erase slate. Content -Medical: Integrated Nursing Process - Implementation: Client Needs - Physiological Integrity, Pharmacological and Parenteral Therapies: Cognitive Level - Application: Concept - Medication
20.A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin)
ANS: A Activase is a clot-busting agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting. DIF:Remembering/Knowledge REF: 619 KEYulmonary embolism| thromboembolic event| anticoagulants MSC:Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapy
18.A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse? a. Assessing the clients platelet count b. Choosing an 18-gauge, 2-inch needle c. Not aspirating prior to injection d. Swabbing the injection site with alcohol
ANS: B Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions are appropriate. DIF:Applying/Application REF: 620 KEY:Anticoagulants| medication administration MSC:Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4.A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial thromboplastin time (PTT) was 25 seconds. What order should 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 (Coumadin).
ANS: B For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working. A normal PTT is 25 to 35 seconds, so this clients PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation. DIF:Applying/Application REF: 619 KEY: Pulmonary embolism| thromboembolic events| anticoagulants| laboratory values MSC:Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5.A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals 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 (Coumadin) after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have 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 Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 258 filter device to be implanted. The nurse should 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. DIF:Applying/Application REF: 621 KEY: Pulmonary embolism| thromboembolic events| patient education| genetic alterations MSC:Integrated Process: Nursing Process: Analysis NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
1.A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? a. Assess the clients 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 manifestations 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. DIF:Remembering/Knowledge REF: 618 KEY: Critical rescue| Rapid Response Team| thromboembolic event| pulmonary embolism MSC:Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
6.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 b. Platelet count: 82,000/L c. Red blood cell count: 4.8/mm3 d. White blood cell count: 8.7/mm3
ANS: B This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender. DIF:Applying/Application REF: 622 KEY:Anticoagulants| laboratory values MSC:Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
17.A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management? a. Poor visual acuity b. Strict vegetarian c. Refusal to stop smoking d. Wants weight loss surgery
ANS: B Warfarin works by inhibiting the synthesis of vitamin Kdependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have trouble maintaining this diet. The nurse should explore this possibility with the client. The other options are not related. DIF:Applying/Application REF: 620 KEY:Anticoagulants| patient education| medication safety MSC:Integrated Process: Nursing Process: Assessment NOT:Client Needs Category: Health Promotion and Maintenance
16.A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication? a. Hamburger and French fries b. Large chefs salad and muffin c. No selection; spouse brings pizza d. Tuna salad sandwich and chips
ANS: B Warfarin works by inhibiting the synthesis of vitamin Kdependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. The chefs salad most likely has too many leafy green vegetables, which contain high amounts of vitamin K. The other selections, while not particularly healthy, will not interfere with the medications mechanism of action. DIF:Evaluating/Synthesis REF: 620 KEYatient education| anticoagulants| nursing process evaluation MSC:Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
3.A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients 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
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. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment. DIF:Applying/Application REF: 616 KEY: Pulmonary embolism| thromboembolic event| respiratory system| oxygen saturation MSC:Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
2.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 should be 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. DIF:Applying/Application REF: 618 KEY: Pulmonary embolism| thrombotic events| patient education| genetic testing MSC:Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
2. When shock occurs in a patient with pulmonary embolism or abdominal compartment syndrome, what type of shock would that be? a. Distributive shock b. Obstructive shock c. Cardiogenic shock d. Hypovolemic shock
a, b, e, f. Hypovolemic shock occurs when there is a loss of intravascular fluid volume from fluid 686 loss (e.g., hemorrhage or severe vomiting and diarrhea), fluid shift (e.g., burns or ascites), or internal bleeding (e.g., with a ruptured sple
25. The nurse suspects a fat embolism rather than a pulmonary embolism from a venous thrombosis when the patient with a fracture develops what? a. Tachycardia and dyspnea b. A sudden onset of chest pain c. Petechiae around the neck and upper chest d. Electrocardiographic (ECG) changes and decreased PaO2
c. Patients with fractures are at risk for both fat embolism and pulmonary embolism from VTE, but there is a difference in the time of occurrence, with fat embolism occurring shortly after the injury and thrombotic embolism occurring several days after immobilization. They both may cause pulmonary symptoms of chest pain, tachypnea, dyspnea, apprehension, tachycardia, and cyanosis. However, fat embolism may cause petechiae located around the neck, anterior chest wall, axilla, buccal membrane of the mouth, and conjunctiva of the eye, which differentiates it from thrombotic embolism.
27. The health care provider orders a pulmonary angiogram for a patient admitted with dyspnea and hemoptysis. For which problem is this test most commonly used as a diagnostic measure? a. Tuberculosis (TB) b. Cancer of the lung c. Airway obstruction d. Pulmonary embolism
d. A pulmonary angiogram outlines the pulmonary vasculature and is useful to diagnose obstructions or pathologic conditions of the pulmonary vessels, such as a pulmonary embolus. The tissue changes of TB and cancer of the lung may be diagnosed by chest x-ray or CT scan, MRI, or PET scans. Airway obstruction is most often diagnosed with pulmonary function testing.
27. The health care provider orders a pulmonary angiogram for a patient admitted with dyspnea and hemoptysis. For which problem is this test most commonly used as a diagnostic measure? a. TB b. Cancer of the lung c. Airway obstruction d. Pulmonary embolism
d. A pulmonary angiogram outlines the pulmonary vasculature and is useful to diagnose obstructions or pathologic conditions of the pulmonary vessels, such as a pulmonary embolus. The tissue changes of TB and cancer of the lung may be diagnosed by chest x-ray or CT scan, MRI, or positron emission tomography (PET) scans. Airway obstruction is most often diagnosed with pulmonary function testing.
36. A pulmonary embolus is suspected in a patient with a deep vein thrombosis who develops dyspnea, tachycardia, and chest pain. Diagnostic testing is scheduled. Which test should the nurse plan to teach the patient about? a. D-dimer b. Chest x-ray c. Spiral (helical) CT scan d. Ventilation-perfusion lung scan
✅. c. A spiral (helical) CT scan is the most frequently used test to diagnose pulmonary emboli (PE) because it allows illumination of all anatomic structures and produces a 3-dimensional picture. If a patient cannot have contrast media, a ventilation-perfusion scan is done. Although pulmonary angiography is most sensitive, it is invasive, expensive, and carries more risk for complications. D-dimer is neither specific nor sensitive for small PE, especially in this patient with deep vein thrombosis. Chest x-rays do not detect PE until necrosis or abscesses occur.
29. Collaboration: The nursing care area is very busy with new surgical patients. Which care could the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP) for a patient with VTE? a. Assess the patient's use of herbs. b. Measure the patient for elastic compression stockings. c. Remind the patient to flex and extend the legs and feet every 2 hours. d. Teach the patient to call emergency response system with signs of pulmonary embolus.
✅. c. The RN could delegate to the UAP the task to remind the patient to flex and extend the legs and feet every 2 hours while in bed. Measuring for elastic compression stockings may be delegated to the LPN. The RN must assess and teach the patient.
1. When obtaining a health history from a 72-year-old man with peripheral arterial disease (PAD) of the lower extremities, the nurse asks about a history of related conditions, including a. venous thrombosis. b. venous stasis ulcers. c. pulmonary embolism. d. coronary artery disease (CAD).
✅. d. Regardless of the location, atherosclerosis is responsible for peripheral arterial disease (PAD) and is related to other cardiovascular disease and its risk factors, such as coronary artery disease (CAD) and carotid artery disease. Venous thrombosis, venous stasis ulcers, and pulmonary embolism are diseases of the veins and are not related to atherosclerosis.
80. Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary embolus who is undergoing thrombolytic therapy? Select all that apply. 1. Keep protamine sulfate readily available. 2. Avoid applying pressure to venipuncture sites. 3. Assess for overt and covert signs of bleeding. 4. Avoid invasive procedures and injections. 5. Administer stool softeners as ordered.
✅1. Heparin is administered during thrombolytic therapy, and the antidote is protamine sulfate and should be available to reverse the effects of the anticoagulant. 2. Firm pressure reduces the risk for bleeding into the tissues. ✅3. Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for. ✅4. Invasive procedures increase the risk of tissue trauma and bleeding. ✅5. Stool softeners help prevent constipa- tion and straining, which may precipitate bleeding from hemorrhoids. TEST-TAKING HINT: Thrombolytic therapy is ordered to help dissolve the clot resulting in the PE. Therefore, all nursing interventions should address bleeding tendencies. The test taker must select all interventions applicable in these alternative questions. Content - Medical: Integrated Nursing Process - Implementation: Client Needs - Safe Effective Care Envi- ronment, Management of Care: Cognitive Level - Application: Concept - Oxygenation.
82. The client diagnosed with a pulmonary embolus is being discharged. Which intervention should the nurse discuss with the client? 1. Increase fluid intake to two (2) to three (3) L/day. 2. Eat a low-cholesterol, low-fat diet. 3. Avoid being around large crowds. 4. Receive pneumonia and flu vaccines
✅1. Increasing fluids will help increase fluid volume, which will, in turn, help prevent the development of deep vein thrombosis, the most common cause of PE. 2. Pulmonary emboli are not caused by athero- sclerosis; this is not an appropriate discharge instruction for a client with a pulmonary embolus. 3. Infection does not cause a PE; this is not an appropriate teaching instruction. 4. Pneumonia and flu do not cause pulmonary embolism. TEST-TAKING HINT: The test taker must know deep vein thrombosis is the most common cause of pulmonary embolus and preventing dehydration is an important in- tervention. The test taker can attempt to eliminate answers by trying to determine which disease process is appropriate for the intervention. Content - Medical: Integrated Nursing Process - Planning: Client Needs - Physiological Integrity, Physi- ological Adaptation: Cognitive Level - Synthesis: Concept - Oxygenation.
74. The client is suspected of having a pulmonary embolus. Which diagnostic test suggests the presence of a pulmonary embolus and requires further investigation? 1. Plasma D-dimer test. 2. Arterial blood gases. 3. Chest x-ray (CXR). 4. Magnetic resonance imaging (MRI).
✅1.The plasma D-dimer test is highly spe- cific for the presence of a thrombus; an elevated D-dimer indicates a thrombus formation and lysis. This result would require a CT or V/Q scan to then confirm the diagnosis. An ABG evaluates oxygenation level,but it does not diagnose a pulmonary embolus (PE). A CXR shows pulmonary infiltration and pleural effusions, but it does not diagnose a PE. An MRI is a noninvasive test that detects a deep vein thrombosis (DVT), but it does not diagnose a pulmonary embolus. A com- puted tomography (CT) scan or ventilation/ perfusion (V/Q) scan would be used to confirm the diagnosis. TEST-TAKING HINT: The key to answering this question is "confirms the diagnosis." The test taker should eliminate options "2" and "3" based on the fact these are diagnostic tests used for many disease processes and conditions. Content - Medical: Integrated Nursing Process - Diagnosis: Client Needs - Physiological Integrity, Reduction of Risk Potential: Cognitive Level - Analysis: Concept - Oxygenation.
A nurse is caring for a client with a new prescription for warfarin (Coumadin.) Which of the following should the nurse include when teaching the client about this medication? A. Partial thromboplastin time values determine the warfarin dosage B. Protamine is used to reverse warfarin's effects C. International Normalized Ratio (INR) is used to assess effectiveness D. Warfarin will facilitate blood clotting
Correct Answer: C. International Normalized Ratio (INR) is used to assess effectiveness INR is the value used to assess effectiveness of warfarin sodium therapy. INR reflects the prothrombin time. It is the ratio of the actual PT to the PT that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method for monitoring the effectiveness of warfarin sodium. Incorrect Answers: A. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. B. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium's anticoagulant effect. Protamine reverses the effects of heparin. D. Warfarin sodium will help to prevent blood clots. Vital Concept: Warfarin is an oral anticoagulant medication that interferes with the liver's synthesis of vitamin K-dependent clotting factors (II, VII, IX, and X). It is used for prophylaxis and treatment of: venous thrombosis, pulmonary embolism, and thromboembolism in clients with atrial fibrillation. It is also used for prevention of thrombus formation and embolization after prosthetic valve placement. Therapeutic levels can be monitored using the prothrombin time or INR.
A nurse in an ICU is caring for a client who has a pulmonary artery catheter and a pressure monitoring system. The client has a central venous pressure (CVP) of 14 mm Hg and a pulmonary artery wedge pressure (PAWP) of 17 mm Hg. Which of the following findings should the nurse expect? (Select all that apply.) A. Poor skin turgor B. Bilateral crackles in the lungs C. Jugular Vein Distention D. Dry mucous membranes E. Lower extremity edema
Correct Answers: B. Bilateral crackles in the lungs C. Jugular Vein Distention E. Lower extremity edema The nurse should expect the client to have bilateral crackles in the lungs with an increased CVP and PAWP. Crackles are the sound of excess fluid in the alveoli as a result of leakage of pulmonary capillaries. This represents left-sided heart failure, which is measured indirectly by the PAWP. The nurse should expect the client to have jugular vein distension with an increased CVP and PAWP. This is a finding in right-sided heart failure, measured by the CVP. The nurse should expect the client to have lower extremity edema with an increased CVP and PAWP. The edema is a manifestation of right-sided heart failure, measured by the CVP. Incorrect Answers: A. The client's CVP and PAWP are above the expected reference range, indicating fluid volume excess. The nurse should expect the client to have poor skin turgor when the client's CVP and PAWP are decreased. D. The client's CVP and PAWP are above the expected range, indicating fluid volume excess. The nurse should expect the client to have dry mucous membranes when the CVP and PAWP are decreased. Vital Concept: Hemodynamic assessment can be done in the ICU through a special catheter in the subclavian vein and a pressure monitoring system. Waveforms and numerical values are displayed continuously and certain measurements, such as CVP and PAWP, can be taken intermittently. This kind of monitoring provides valuable information about a client's cardiac and fluid status and response to treatment, especially in cases of heart failure, shock, acute respiratory distress syndrome (ARDS), or sepsis. Complications are uncommon but can include infection, air embolism, and pneumothorax.
A nurse is caring for a hospitalized client after hip replacement. When monitoring the client for post-operative complications, which of the following does the nurse understand is a sign of pulmonary embolism? (Select all that apply.) A. Anxiety B. Bradycardia C. Pleuritic chest pain D. Hypoventilation E. Hypertension
Correct Answers: A. Anxiety C. Pleuritic chest pain A. Anxiety Pulmonary embolism can be caused by thrombus, air emboli, or fat in the pulmonary vasculature. The most common origin of a pulmonary embolism is thrombus in the deep veins of the lower extremities, although thrombosis can develop in pelvic veins, veins of the upper extremity, or in the right atrium of the heart. Factors that promote formation of deep vein thrombosis (DVT) include damage to the blood vessels, hypercoagulability, and immobility. Clients who have undergone surgical procedures are at increased risk of DVT. PE occurs when a portion of the thrombus is dislodged and travels to the pulmonary circulation, where it becomes lodged in a small blood vessel, preventing perfusion of areas of the lung distal to the obstruction. Signs and symptoms of PE vary with the size of the embolism and include dyspnea, hypoxemia, pleuritic chest pain, tachypnea and tachycardia. Other clinical manifestations include anxiety or a sense of dread, crackles on auscultation of the lung, fever, hemoptysis, and accentuated pulmonic valve sounds. Hypotension, pallor, syncope, and hemodynamic collapse occur with large emboli. Ventilation-perfusion scan and plasma levels of D-dimer are used in concert with clinical probability to aid in diagnosis. Pulmonary angiography is a more invasive and specific test, used when the diagnosis remains unclear or to localize the embolism prior to pulmonary embolectomy. Treatment includes anticoagulation and supportive care, including supplemental oxygen. Pulmonary embolectomy is associated with a high mortality rate, so it performed only for massive PE. Incorrect Answers: B. Tachycardia is associated with PE. D. Tachypnea may occur. E. Hypotension is associated with PE. Vital Concept: The risk of formation of deep vein thrombosis is increased in post-surgical clients. When a portion of the thrombosis is dislodged, spontaneously or mechanically, it travels through the circulatory system and becomes trapped in a smaller vessel, often in the lungs. The resulting obstruction prevents perfusion of portions of the lung distal to the clot. Clinical manifestations of PE vary depending upon the size of the embolism and range from tachycardia, tachypnea, and pleuritic chest pain to hemodynamic collapse.
