Complex skills Exam 2

After receiving change-of-shift report, which patient should the nurse assess first?

Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes

Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure?

Arterial blood gas analysis

After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?

Ask the patient whether medications have been taken as directed.

When assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse finds a new onset of agitation and confusion. Which action should the nurse take first?

Assess oxygenation using pulse oximetry

A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist?

Assess the ability to swallow before using the fenestrated tube.

A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse should take which action?

Assign the patient to a room near the nurse's station.

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?

Encourage fluid intake up to 4000 mL every day.

A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?

Endotracheal intubation and positive pressure ventilation

The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)?

Increased peak inspiratory pressure on the ventilator

The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?

Increased tactile fremitus

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?

Infuse 5% dextrose in water at 125 mL/hr.

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?

Lung sounds

The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following?

Management and protection of the airway

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first?

Medicate the patient with prescribed morphine.

The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following?

Mobility

The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?

O2 saturation is 88%.

A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider?

O2 saturation of 99%

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions?

"I will continue to do deep breathing and coughing exercises at home."

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?

"I will drink apple juice instead of orange juice for breakfast."

After change-of-shift report, which patient should the nurse assess first?

A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion

The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia?

Change in sputum characteristics

A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first?

Check the patient's blood pressure.

A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value?

Daily alcohol intake

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient complains of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?

Give the patient the PRN IV morphine sulfate 4 mg.

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next?

Monitor ionized calcium level.

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?

Na+ 154 mEq/L (154 mmol/L)

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

No sedative has been ordered for the patient.

A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first?

Piperacillin/tazobactam (Zosyn)

An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease?

Require the use of protective equipment.

Which information about prevention of lung disease should the nurse include for a patient with a 42 pack-year history of cigarette smoking?

Resources for support in smoking cessation

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?

Serum sodium level of 120 mg/dL

A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take?

Tape a nonporous dressing on three sides over the wound.

Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess?

Teach about the need for prolonged antibiotic therapy after discharge from the hospital.

Which action should the nurse plan to prevent aspiration in a high-risk patient?

Place a patient with altered consciousness in a side-lying position.

When fluid is present in the alveoli,

diffusion of oxygen and carbon dioxide is impaired.

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take?

Suggest that the health care provider order a basic metabolic panel.

The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care?

Teach patient to "swish and swallow" prescribed oral nystatin

The nurse discusses management of upper respiratory infections (URIs) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed?

"I can use nasal decongestant spray until the congestion is gone."

The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed?

"I must keep the stoma covered with an occlusive dressing."

The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%).

130; meets criteria for ARDS

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?

Administer the prescribed normal saline bolus and insulin.

The nurse reviews the electronic health record for a patient scheduled for a total hip replacement. Which assessment data shown in the accompanying figure increase the patient's risk for respiratory complications after surgery?

Albumin level and weight loss

Which action should the nurse take first when a patient develops epistaxis?

Apply squeezing pressure to the nostrils for 10 minutes

A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?

Appropriate use of cough suppressants

A patient diagnosed with active tuberculosis (TB) is homeless and has a history of alcohol abuse. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?

Arrange for a daily meal and drug administration at a community center.

A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance?

Assist the patient to splint the chest when coughing

A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?

Blood cultures from two sites

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

Blood pressure is 90/40 mm Hg.

When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

Chest tube connected to suction

After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider?

Clear nasal drainage

A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate?

Continue to monitor the collection device.

A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?

Daily weight

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved?

Decreased peripheral edema

The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms?

Decreasing PaO2 levels despite increased FiO2 administration

The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider?

Diffuse crackles in the lungs

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?

Digoxin (Lanoxin) 0.25 mg/day

The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?

Document the amount of drainage every 8 hours

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?

Edema

A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?

Elevate head of bed to 30 to 45 degrees.

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first?

Elevate the head of the bed to a semi-Fowler's position.

A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient's illness?

Explain that orange discolored urine and tears are normal while taking this medication.

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?

Gradually decreasing level of consciousness (LOC)

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?

Infuse the KCl at a rate of 10 mEq/hour.

An acute exacerbation of asthma is treated with which of the following?

Inhaled bronchodilators and intravenous corticosteroids

A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action?

Keep the patient in semi-Fowler's position.

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?

Metabolic acidosis

A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation?

Noninvasive positive-pressure ventilation (NPPV)

A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first?

Notify the patient's health care provider.

The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies?

Observe for distended neck veins.

The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2° F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action should the nurse take next?

Obtain oxygen saturation using pulse oximetry.

A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to improve gas exchange?

On the left side

An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching?

Placing the patient on droplet precautions in a private hospital room

A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?

Position the patient sitting up on the side of the bed.

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete?

Presence of the Chvostek's sign

The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take?

Put on sterile gloves and use a sterile catheter to suction.

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray?

Skim milk

The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?

Teach the patient about providing specimens for 3 consecutive days.

Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting?

Teaching patients about the need for adult pertussis immunizations

The basic underlying pathophysiology of acute respiratory distress syndrome results in

damage to the type II pneumocytes, which produce surfactant.

A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is important for the nurse to ask?

"How much alcohol do you drink in an average week?"

The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates to the nurse that the teaching has been effective?

"I will call the health care provider right away if I develop a fever."

The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful?

"I will elevate my head for 48 hours to minimize swelling."

After assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

Weak cough effort

An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?

Yellow-tinged sclera

The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the

alveolar-capillary membrane

A patient with newly diagnosed lung cancer tells the nurse, "I don't think I'm going to live to see my next birthday." Which is the best initial response by the nurse?

"Can you tell me what it is that makes you think you will die so soon?"

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?

"Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?"

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?

A 46-yr-old patient on bed rest who is complaining of sudden onset of shortness of breath

The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes, a weak cough effort, and complains of fatigue. Which action should the nurse take next?

Assist the patient with staged coughing.

The nurse is caring for a hospitalized older patient who has nasal packing in place after a nosebleed. Which assessment finding will require the most immediate action by the nurse?

The oxygen saturation is 89%.

Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/LVN) working in the intensive care unit?

Insert an indwelling urinary catheter.

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next?

Lower the positive end-expiratory pressure (PEEP).

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first?

Mental status

A patient admitted with acute respiratory failure has ineffective airway clearance related to thick secretions. Which nursing intervention would specifically address this patient problem?

Offer the patient fluids at frequent intervals.

The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider?

Oxygen saturation 90% on 100% O2 by nonrebreather mask

The nurse is assessing a patient with acute respiratory distress syndrome. An expected assessment is

PAOP of 10 mm Hg and PaO2 of 55.

Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)?

PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE.

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is accurate?

"The hypertonic solution will be more rapidly diluted when given through a central line."

A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains to the patient:

"This injection is being given to prevent blood clots from forming."

A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, "Will I be able to talk normally after surgery?" What is the most accurate response by the nurse?

"You will have a permanent opening into your neck, and you will need rehabilitation for some type of voice restoration."

The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?

400 mL of blood in the collection chamber

The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient's postoperative care?

Frequent use of an incentive spirometer

A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient's condition is improving?

Patient reports a decrease in exertional dyspnea.

The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider?

Red-brown drainage from nasogastric tube

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?

Respiratory alkalosis

During the admission process, the nurse obtains information about a patient through a physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate?

Risk for injury: seizures

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?

Serum calcium is 18 mg/dL.

During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first?

Use pulse oximetry to check the oxygen saturation

A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider's order to discontinue airborne precautions unless which assessment finding is documented?

Sputum smears for acid-fast bacilli are negative

Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy?

Suction the tracheostomy when directed.

The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse?

The epoprostenol (Flolan) infusion is disconnected.

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?

The patellar and triceps reflexes are absent.

A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse indicates that this identified problem is resolving?

The patient asks how to clean the tracheostomy stoma and tube.

Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first?

A patient who is complaining of a sore throat and has a muffled voice

After receiving change-of-shift report on a medical unit, which patient should the nurse assess first?

A patient with septicemia who has intercostal and suprasternal retractions

Identify diagnostic criteria for ARDS. (Select all that apply.)

a. Bilateral infiltrates on chest x-ray study b. Decreased cardiac output c. PaO2/ FiO2 ratio of less than 200

After a laryngectomy, a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?

Attempt to reinsert the tracheostomy tube with the obturator in place.

A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (on 0 to 10 scale) "whenever I take a deep breath." Which action will the nurse take next?

Auscultate for breath sounds.

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?

Auscultate the patient's breath sounds.

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/LVN)?

Flush a saline lock with normal saline.

Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma?

Respiratory acidosis

Which statement by the patient indicates that teaching has been effective for a patient scheduled for radiation therapy of the larynx?

"I will need to buy a water bottle to carry with me."

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?

"I will use the incentive spirometer every hour or two during the day."

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?

"Increase fluids if your mouth feels dry."

The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse instructs,

"It is important for you to get an annual influenza shot to reduce your risk of pneumonia."

The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?

"My spouse will sleep in another room."

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate?

"PEEP prevents the lung air sacs from collapsing during exhalation."

A lobectomy is scheduled for a patient with stage I non-small cell lung cancer. The patient tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate?

"Tell me what you know about the treatments available."

The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse?

A surgical face mask is applied before visiting the patient.

An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take?

Administer the prescribed morphine.

A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the priority?

Impaired gas exchange related to respiratory congestion

The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration?

Hypoventilation and respiratory acidosis

The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan?

Identifying and avoiding environmental triggers are the best way to prevent symptoms.

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take?

Increase the prescribed O2 flow rate.

A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?

Paradoxical chest movement

A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced?

The patient has subcutaneous emphysema on the upper thorax.

A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider?

The patient is being treated with antiretrovirals for HIV infection.

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?

The patient is experiencing laryngeal stridor

When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider?

The patient is very somnolent

The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action?

The patient's PaO2 is 45 mm Hg.

When prone positioning is used for a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective?

The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%.

A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding by the nurse is most important to report to the health care provider?

The patient's respirations have dropped to 10 breaths/minute.

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective?

The patient's white blood cell (WBC) count is 9000/µL.

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?

There are crackles throughout both lung fields.

Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery?

Thrombolytics

The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?

UAP lower the head of the patient's bed to 15 degrees.

The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would determine if the cuff has been properly inflated?

Use a hand-held manometer to measure cuff pressure.

When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking?

Use a swab to obtain a sample for a rapid strep antigen test.

Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse?

Use and side effects of isoniazid

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?

Use the push-pause method to flush the CVAD after giving medications.

The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)?

a. A 76-yr-old nursing home resident b. A 36-yr-old female patient who is pregnant d. A 30-yr-old patient who takes corticosteroids for rheumatoid arthritis

Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)?

a. Age d. O2 saturation b. Blood pressure e. Presence of confusion c. Respiratory rate f. Blood urea nitrogen (BUN) level

The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.)

a. Airway clearance therapies b. Antibiotic therapy c. Nutritional support e. Lung transplant

The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)?

a. Decongestants can be used to relieve swelling. c. Taking a hot shower will increase sinus drainage and decrease pain. d. Saline nasal spray can be made at home and used to wash out secretions. e. You will be more comfortable if you keep your head in an upright position.

The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.)

a. Drain condensate from the ventilator tubing away from the patient. b. Elevate the head of the bed 30 to 45 degrees. d. Perform regular oral care with chlorhexidine.

Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.)

a. Graduated compression stockings b. Heparin or low-molecular weight heparin for patients at risk c. Sequential compression devices

Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.)

a. Increases functional residual capacity b. Prevents collapse of unstable alveoli c. Improves arterial oxygenation d. Opens collapsed alveoli

Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply.)

a. Interrupt sedation each day to assess readiness to extubate. b. Maintain head of bed at least 30 degrees of elevation. c. Provide deep vein thrombosis prophylaxis. d. Provide prophylaxis for peptic ulcer disease.

The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.)

a. high Fowler's. b. side lying with head of bed elevated. c. sitting in a chair.

During rounds, the provider alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is

an optional treatment to improve ventilation

Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.)

b. Implementing a comprehensive oral care program is an intervention for preventing VAP. c. Oral care protocols should include oral suctioning and brushing teeth. d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP.

Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)?

b. Provide a "sedation holiday" daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30°. e. Provide oral care with chlorhexidine (0.12%) solution daily.

Intrapulmonary shunting refers to

blood that is shunted from the right side of the heart to the left without oxygenation.

A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being "stuck up my nose" and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first?

d. Have the patient occlude the left nare and blow the nose.

The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is

deep vein thrombosis from lower extremities.

A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following drugs ordered. Which drug should the nurse discuss with the health care provider before giving?

gentamicin 60 mg IV

A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with

insertion of a pulmonary artery catheter.

A strategy for preventing pulmonary embolism in patients at risk who cannot take anticoagulants is

insertion of a vena cava filter.

The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The provider prescribes a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the provider of this assessment and anticipates an order for

neuromuscular blockade.

A definitive diagnosis of pulmonary embolism can be made by

pulmonary angiogram.

The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this diagnosis is to

reposition the patient every 2 hours.

The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the patient to prevent exacerbation by:

taking all asthma medications as prescribed.