Critical Care Exam 1
Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?
"Because I had a previous reaction to the test, this time I need to get a chest X-ray."
The nurse is preparing to perform chest physiotherapy (CPT) on a client. Which statement by the client tells the nurse that the procedure is contraindicated.
"I just finished eating my lunch, I'm ready for my CPT now." When performing CPT, the nurse ensures that the client is comfortable, is not wearing restrictive clothing, and has not just eaten. The nurse gives medication for pain, as prescribed, before percussion and vibration, splints any incision, and provides pillows for support, as needed. A goal of CPT is for the client to be able to mobilize secretions; the client who has an unproductive cough is a candidate for CPT.
A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care
"You must consume a diet rich in protein, such as chicken, fish, and beans."
A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What should the nurse tell the patient?
"You should switch to wearing your glasses while taking this medication." The nurse informs the patient that rifampin may discolor contact lenses and that the patient may want to wear eyeglasses during treatment.
Which action should the nurse take first in caring for a client during an acute asthma attack?
Putting on an individually fitted mask when entering the client's room
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?
Routinely deflating the cuff Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.
You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?
See if there are leaks in the system.
A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for
A kink in the ventilator tubing
A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication?
0 to 4 mm The Mantoux method is used to determine whether a person has been infected with the TB bacillus and is used widely in screening for latent M. tuberculosis infection. The size of the induration determines the significance of the reaction. A reaction of 0 to 4 mm is considered not significant. A reaction of 5 mm or greater may be significant in people who are considered to be at risk.
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long
10 to 15 seconds
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?
6 to 12 months
The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient?
6 to 12 months
A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?
84 mm Hg In general, clients with respiratory conditions are given oxygen therapy only to increase the arterial oxygen pressure (PaO2) back to the client's normal baseline, which may vary from 60 to 95 mm Hg.
The nurse is assigned to care for a client with a chest tube. The nurse should ensure that which item is kept at the client's bedside?
A bottle of sterile water It is essential that the nurse ensure that a bottle of sterile water is readily available at the client's bedside. If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent the development of a pneumothorax, a temporary water seal can be established by immersing the open end of the chest tube in a bottle of sterile water. There is no need to have an Ambu bag, incentive spirometer, or a set of hemostats at the bedside.
The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?
Acute respiratory distress syndrome
The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication?
Acute respiratory distress syndrome
A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?
Airborne and contact precautions
The nursing instructor is discussing pulmonary arterial hypertension with the nursing students. What would the instructor describe as the pathophysiology of secondary pulmonary arterial hypertension?
Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed In secondary pulmonary arterial hypertension, alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed.
A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for?
Anemic hypoxia Anemic hypoxia is a result of decreased effective hemoglobin concentration, which causes a decrease in the oxygen-carrying capacity of the blood. It is rarely accompanied by hypoxemia. Carbon monoxide poisoning, because it reduces the oxygen-carrying capacity of hemoglobin, produces similar effects but is not strictly anemic hypoxia, because hemoglobin levels may be normal.
A client has a sucking stab wound to the chest. Which action should the nurse take first?
Apply a dressing over the wound and tape it on three sides The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.
A client who works construction and has been demolishing an older building is diagnosed with pneumoconiosis. This lung inflammation is most likely caused by exposure to:
Asbestosis is caused by inhalation of asbestos dust, which is frequently encountered during construction work, particularly when working with older buildings. Laws restrict asbestos use, but old materials still contain asbestos. Inhalation of silica may cause silicosis, which results from inhalation of silica dust and is seen in workers involved with mining, quarrying, stone-cutting, and tunnel building. Inhalation of coal dust and other dusts may cause black lung disease. Pollen may cause an allergic reaction, but is unlikely to cause pneumoconiosis.
A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse
Assesses the client's tracheostomy and lung sounds every 15 minutes
A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?
Auscultate the lung for adventitious sounds.
For a client with an endotracheal (ET) tube, which nursing action is the most important?
Auscultating the lungs for bilateral breath sounds
A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?
Auscultation The nurse should assess breath sounds before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function but aren't necessary to determine lung areas requiring postural drainage.
Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?
Baseline arterial blood gas (ABG) levels
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?
Before you do the exercise, I'll give you pain medication if you need it."
A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?
Blood-tinged sputum
The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse?
Chest tube drainage, 190 mL/hr
The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the community. Which of the following would be most effective?
Classes at community centers to teach about smoking cessation strategies
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse
Continues assessing the client's respiratory status frequently Yhe SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client
A patient is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this patient?
Continuous positive airway pressure Continuous positive airway pressure (CPAP) provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. To use CPAP, the patient must be breathing independently.
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?
Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer
The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema?
Crackles in the lung bases When clinically significant atelectasis develops, it is generally characterized by increased work of breathing and hypoxemia. Decreased breath sounds and crackles are heard over the affected area.
The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined?
Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.
For a client with pleural effusion, what does chest percussion over the involved area reveal?
Dullness over the involved area
A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?
Dyspnea
Which intervention does a nurse implement for clients with empyema?
Encourage breathing exercises
A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?
Encourage the patient to take approximately 10 breaths per hour, while awake.
A client is receiving mechanical ventilation. How frequently should the nurse auscultate the client's lungs to check for secretions?
Every 2 to 4 hours
The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?
Fibrotic changes in lungs For a client with occupational lung diseases, a chest radiograph may reveal fibrotic changes in the lungs. Hemorrhage, lung contusion, and damage to surrounding tissues are possibly caused by trauma due to chest injuries.
The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?
Given this patient's vital signs, he appears to be in shock. Circulatory hypoxia is hypoxia resulting from inadequate capillary circulation. It may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause.
The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result?
Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing
A nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
Ineffective airway clearance related to obstruction by a tumor or secretions
A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?
Initiate oxygen therapy. The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus.
A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?
Institute isolation precautions.
The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?
Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.
Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths?
Intermittent mandatory ventilation (IMV) IMV provides a combination of mechanically assisted breaths and spontaneous breaths. Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the client can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing
The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique?
It prolongs exhalation. The goal of pursed-lip breathing is to prolong exhalation and increase airway pressure during expiration, thus reducing the amount of trapped air and the amount of airway resistance.
The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?
Localized calf tenderness If the client were to complain of localized calf tenderness, the nurse would know this is a possible indication of a deep vein thrombosis. The area of tenderness could also be warm to touch.
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?
Measuring and documenting the drainage in the collection chamber
A nurse reading a chart notes that the client had a Mantoux skin test result with no induration and a 1-mm area of ecchymosis. How does the nurse interpret this result?
Negative
A patient has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the patient complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?
Oxygen toxicity Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours) (Urden, Stacy, & Lough, 2010). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.
The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?
PaO2
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?
Partial pressure of arterial oxygen (PaO2
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?
Pneumothorax Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.
You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure?
Progressive loss of lung function associated with chronic disease
The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation?
Shortness of breath
The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis?
Stabbing pain during respiratory movement
The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:
Symmetry of the client's chest expansion
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?
Tension pneumothorax
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?
The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?
The patient is hypoxic from suctioning. Apply suction while withdrawing and gently rotating the catheter 360 degrees (no longer than 10-15 seconds). Prolonged suctioning may result in hypoxia and dysrhythmias, leading to cardiac arrest.
Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall?
Turn onto the affected side The nurse teaches the client to splint the chest wall by turning onto the affected side
A mechanically ventilated client is receiving a combination of atracurium and the opioid analgesic morphine. The nurse monitors the client for which potential complication?
Venous thromboemboli Neuromuscular blockers predispose the client to venous thromboemboli (VTE), muscle atrophy, foot drop, peptic ulcer disease, and skin breakdown. Nursing assessment is essential to minimize the complications related to neuromuscular blockade. The client may have discomfort or pain but be unable to communicate these sensations.
Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?
Venturi mask
Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6
Which type of ventilator has a preset volume of air to be delivered with each inspiration
Volume controlled
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes
Water seal chamber Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.
Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:
a compromised skin graft. A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:
encourage coughing and deep breathing.
A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?
flail chest During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.
Conditions that trigger the high-pressure alarm
kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. **A disconnected ventilator circuit or an ET cuff leak would trigger the low-pressure alarm. **Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.
In general, chest drainage tubes are not used for a patient undergoing
pneumonectomy
Resistance to a first-line antituberculotic agent in a client who has not received previous treatment is referred to as
primary drug resistance.
