Exam 4

A nurse is caring for a client with a new order of heparin weight-based protocol intravenously. Which of the following statements is most concerning for the nurse?

"I take antacids several times a day for my stomach ulcer"

A nurse is providing teaching for a client who has stage 3 HIV/AIDS. Which of the following statement by the client should indicate to the nurse an understanding of the teaching?

"I will cook vegetables before eating them"

The nurse is providing patient education for newly diagnosed human immunodeficiency virus (HIV)-infected patient. Which of these statements by the patient reflects a need for further teaching?

"Once my tests show that the virus has decreased, I cannot give HIV to another person"

Which clinical findings of a critical care nurse suggest that a patient in the respiratory critical care unit has cor-pulmonale. SATA

- Ascites - Jugular vein distention - Pedal edema - Hepatomegaly

A nurse is performing the admission assessment of a client who has AIDS. Which nursing intervention should the nurse implement to promote skin integrity. SATA

- Identify factors that may exacerbate diarrhea, if present, reduce the number of stools per day. - Instruct to keep the perineal region as clean as possible. - Open lesions can be cultured as ordered if infection is suspected. - Skin and oral mucosa are assessed routinely for evidence of infection or breakdown.

Which findings are AIDS defining characteristics for a patient with HIV (human immunodeficiency virus). SATA

- Infection with pulmonary tuberculosis - presence of HIV wasting syndrome - CD4 cell count less than 200/mm3

The nurse is applying standard precautions in the care for a patient who has an immunodeficiency. what are key elements of standard precautions? Select all that apply

- using appropriate PPE - using injection safe practices - performing hand hygiene

A student nurse is discussing the pathophysiology of HIV in class. How will the student nurse describe the correct sequence of events in the development of HIV infection and how it affects the T lymphocytes?

1. -HIV glycoproteins bind to CD4 receptors on T lymphocytes (Attachment/Binding) 2. -Contents of the HIVs viral core (RNA and enzymes) are emptied into the T lymphocytes (Uncoating/fusion) 3. -HIV changes genetic material from RNA to DNA through the action of reverse transcriptase (DNA synthesis) 4. -New viral DNA enters the nucleus of the infected T lymphocytes leading to permanent lifelong infection (integration)

A client was tested for HIV as part of a screening process and has just been told the results were positive. What anticipatory guidance should the nurse provide to the client?

A follow-up exam using a different type of test will be promptly performed to confirm the result

The ICU is preparing to wean a patient from the ventilator. What parameter is most important for the nurse to assess?

AGB level of PaO2 greater than 60 mmHg with FiO2 less than 40%

A client is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What nursing action is most likely to increases the likelihood of successful therapy?

Address possible barrier to adherence

The nurse responds to a ventilator alarm and finds the the client who is disoriented lying in bed holding the endotracheal tube. Which action should the nurse take next?

Assess airway and manually ventilate with 100% oxygen as needed

Four hours after mechanical ventilation (MV) is initiated for a client with chest injuries, the arterial blood gas (ABG) results showed a pH of 7.51, PaO2 of 90 mmHg, PaCO2 of 26 mmHg, and HCO3 of 23 mEq/L (23 mmol/L). what changes in the setting of the MV will the nurse anticipate?

Decreased the respiratory rate

COVID-19 can trigger an immune response called a "cytokine storm" leading to ARDS. Which of the following medications have shown sufficient evidence of benefit in suppressing the exaggerated immune response among hospitalized covid patients with respiratory complications?

Dexamethasone (Decadron) corticosteroid-decrease inflammation

Which of the following statement is correct about T lymphocytes

Differentiate to cytotoxic T-cells directly attacking antigens

The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the nurse implement to greatly decrease the patient's risk of developing pulmonary emboli?

Early ambulation

The nurse notes thick, white secretions in the endotracheal tube (ET) of a client who is receiving mechanical ventilation. Which intervention will be most effective in addressing this problem?

Ensure adequate humidification is provided

The emergency room nurse can use the following techniques to identify correct placement of the ET tube in a newly intubated patient, except:

Ensuring cuff pressure between 10-15 mmHg

An older adult client has experienced a severe respiratory condition and requires mechanical ventilation (MV). Which of the following mechanical settings of the MV will be specified and ordered by the primary provider?

Fraction of inspired oxygen (FiO2); tidal volume; positive and expiratory pressure (PEEP)

A clinic nurse is caring for a client admitted with AIDS. The nurse has assessed the client is experiencing progressive decline in cognitive, behavior, and motor function. The nurse will further assess for the presence of

HIV encephalopathy

A nurse is providing teaching for a client who is immunocompromised. which statement indicated by the client indicates the need for additional teaching?

I can eat whatever I want as long as it is low in fat

The chest xray result of a semi-conscious trauma patient reveals rib fracture with diagnosis of severe flail chest injury. Which intervention is the most appropriate for the nurse to anticipate next?

Immediate sedation and endotracheal intubation

A patient is on supplemental nasal cannula at 4 L/min due to right pulmonary contusion. The nurse assess patient with the following findings: diminished breath sounds on affected side, pulse oximeter of 89%, soft abdomen, respiratory rate 26/min, heart rate of 115 bpm, and blood pressure of 108/64 mmHg. Which would be the nurse's priority.

Increase the fraction of inspired oxygen (FiO2) as ordered

A patient with severe shortness of breath has the following chest x-ray result showing right sided lucency and leftward mediastinal shift. What will the nurse anticipate to be performed next?

Insertion of a chest tube

COVID-19 can trigger an immune response called a "Cytokine storm" leading to ARDS. Which of the following will the nurse anticipate be included in the priority management of care for patient with respiratory failure refractory to O2 therapy?

Mechanical ventilation

A critical care client is on mechanical ventilation with positive and expiratory pressure (PEEP). Which among the following clinical manifestations noticed by the nurse suggests that a client is developing tension pneumothorax as a complication of mechanical ventilation?

New onset of absent breath sounds over the right lung (Diminished breath sounds over the right lung)

A patient has the following arterial blood gas (ABG) results. Based on your analysis, the patient has? ABG Results pH 7.31 PaCO2 50 paO2 78 HCO3 26

Respiratory acidosis

A nurse is preparing to discharge a client with an immunodeficiency. When preparing the patient for self-infusion of IVIG in the home setting, what education should the nurse prioritize?

Signs and symptoms of adverse reactions

To evaluate effectiveness of antiretroviral therapy (ART), which laboratory test will the nurse review?

Viral load testing (Viral RNA load testing)

A patient with pulmonary embolism just recently received a bolus dose of heparin, after which heparin drip was initiated. The nurse will anticipate to order which of the following laboratory test in 6 hours to monitor the effectiveness of the treatment and possible need for titration?

aPPT

A client with AIDs is admitted to the hospital with AIDs related wasting syndrome and AIDs related anorexia. What drug has been found to promote significant weight gain in clients with AIDs, by increasing body fat stores.

megestrol (megace)

The nurse's plan of care for a client with stage 3 HIV addresses the diagnosis of risk for impaired skin integrity related to candidiasis. what nursing intervention best addresses this risk?

providing oral care before and after meals

A male patient post-motor vehicular accident sustained a transverse right 5th rib fracture but is awake, alert and stable. The patient is asking the nurse what will be likely management for his situation. The nurse will be correct in stating all of the following, except:

surgery will most likely be scheduled in the coming days

The nurse is caring for a patient for acute respiratory distress syndrome (ARDS). Which collaborative care should the nurse anticipate will be included in the plan of care? Select all that apply.

* Prone position * ABG monitoring * Sedation * Inhaled nitric oxide

A patient was admitted in the unit who has been diagnosed with AIDS complicated by chronic diarrhea. What priority interventions should be included int the plan of care after assessing the patient? Select all that apply

- Administer Antispasmodic medication as prescribed - Identify food irritants and avoid them - Obtain stool culture to identify possible pathogens (*Discourage smoking if indicated * Obtain stool culture to identify possible pathogens * Administer opioids and anticholinergic medication as prescribed)

Which of the following are AIDS defining characteristics for a patient with HIV (human immunodeficiency virus)? Select all that apply

- CD4+ cell count less than 200/mm3 - Infection with pulmonary tuberculosis - Presence of HIV wasting syndrome

Post endotracheal intubation, which of the following interventions should the nurse implement? SATA

- Check cuff pressure and maintain at 20-25 mmHg - Provide oral hygiene as prescribed and whenever necessary - Check symmetry of chest expansion and auscultate breath sounds

Immediately after intubation, which of the following interventions should the nurse implement? SATA

- Check symmetry of chest expansion and auscultate breath sounds - Check cuff pressure q6-8 hrs - Provide oral hygiene as prescribed and whenever necessary - administer oxygen concentration as prescribed

Which clinical findings observed by a critical care nurse suggest that a client in the respiratory critical care unit has cor pulmonale right sided heart failure due to severe pulmonary hypertension

- Edema of the lower extremities - dyspnea - hepatomegaly - JVD

A patient is diagnosed with a tension pneumothorax. What should the nurse expect to assess in this patient? Select all that apply

- Hypotension - Distended neck veins - Increasing hypoxemia - Absent breath sounds on the affected side - Tracheal deviation to the unaffected side

A client hospitalized with HIV cachexia due to wasting syndrome. The client reports shortness of breath with activity, pallor, and extreme fatigue. What intervention is best to address patient activity intolerance? SATA

- Instruct patient about energy conservation techniques - Assess client's hemoglobin and hematocrit levels - Pace activities, allowing for adequate rest

The nurse has assisted they physician to intubate the patient. What ways will the nurse use to assure proper placement of the endotracheal tube without complications? Select all that apply

- Monitor for S&S of aspiration - Auscultate for equality of breath sounds - Observe rise and fall of the chest - Portable chest x-ray (*Obtain an order of portable CXR *Auscultate for anterior breath sounds bilaterally * Observe symmetrical rise and fall of chest)

A patient with AIDS is admitted to the hospital with AIDS-related wasting syndrome leading to nutritional deficit. Which intervention should the nurse implement related to nutrition? SATA

- Monitor serum albumin and electrolyte levels - Administer viscous lidocaine for oral lesions - Assess oral intake and may require enteral feeding - Provide oral hygiene before and after meals

The nurse is caring for a patient intubated for acute respiratory distress syndrome (ARDS). Which collaborative care should the nurse anticipate will be included in the plan of care? Select all that apply

- Prone position - Inhaled nitric oxide - Ventilatory PEEP support - Sedation

A nurse is caring for a client with a medical diagnosis of pulmonary embolism. Which of the following client's have a high risk for pulmonary embolism?

- a client who undergone open cholecystectomy 2 days ago - a client who has chronic atrial fibrillation - a client who has a fractured femur

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? SATA

- check for gentle continuous bubbling in the suction control chamber - observe for rise and fall in the level of water in the water seal chamber with inspiration and expiration - obtain an order for CXR - Encourage client to cough and take deep breaths

Which of the following manifestations can be seen in a patient with COVID-19 infection? SATA

- cough - sore throat - fatigue - diarrhea - Anosmia - fever

A nurse in the emergency department is assessing a client who has sustained multiple rib fractures and has a flail chest. Which of the following findings should the nurse expect? Select all that apply

- hypotension - paradoxical chest movement

A patient is diagnosed with pulmonary embolism with sudden shortness of breath and hypoxemia. Collaborative care is implemented. What nursing actions are appropriate for this patient? Select all that apply.

- maintain oxygen therapy as prescribed - prepare and assist for emergent endotracheal intubation if severely hypoxemic - continuous cardiac monitoring to detect dysrhythmias associated with pulmonary emboli - assess lung sounds and pulse oximetry reading - monitor the patient for complications of anticoagulant therapy

Which of the following are adverse effects the nurse would associate with all HIV treatment regimens? Select all that apply.

- osteopenia - hepatotoxicity - nephrotoxicity - increased risk of cardiovascular disease

Similar: The RN is reviewing medication treatment. Which medication treatment needs clarification?

- patient with sudden dyspnea, crackles breath sounds and elevated D-dimer test results. Treatment: calcium channel blockers - Patient with pulmonary embolism and tachycardia. Treatment: beta blockers (metoprolol) - A patient with chest trauma and loud squeaking sounds while inspiration. Treatment: opioids

The intensive care unit nurse is caring for a patient who went into septic shock and now on a mechanical ventilator via endotracheal tube. To promote evidence-based practice interventions to prevent ventilator associated pneumonia, which nursing action should be included in the care plan? SATA

- perform sedation vacation and assess readiness of patient for extubation - DVT prophylaxis - Elevate the patient's head of bed 45 degrees - Administration of pantoprazole 40 mg IV as prescribed

The ICU nurse is assisting in a bedside chest tube insertion for a patient with left hemothorax. The pulmonologist asks the nurse where will the chest tube be inserted. Mark the area on the accompanying diagram where the nurse should identify as the posible tube insertion site?

5th intercostal space

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

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

A nurse is caring for a client who has pulmonary condition and is receiving 100% non-rebreather mask. Arterial blood Gasses: Ph = 7.28; PaO2 = 58; PaCO2 = 55; HcO3 = 26 VS: P = 120; BP = 95/45; RR = 4; O2Sat = 88% With the above finding, which action should the nurse take first?

Activate the code blue team and provide ventilation support

A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include diminished breath sounds in the right lower lobe with dyspnea, blood pressure 115/70 mm Hg, heart rate 118/min, respirations of 32/min, and SaO2 92% on room air. Which of the following actions should the nurse take first?

Administer oxygen via a high-flow mask

A nurse is evaluating a client's arterial blood gas values (ABGs):pH 7.30, PaO2 86 mmhg, PaCO2 55mm hg, and HCO3 -22mEq/L. Which nursing intervention should the nurse implement first?

Assess the airway

The nurse is caring for a patient with an endotracheal tube with mechanical ventilation. What should be the nurse's first step before implementing suctioning process?

Assess the patient's lung sounds and SAO2 via pulse oximeter

The nurse is caring for a patient suspected of having acute respiratory distress syndrome (ARDS). What is the most likely test ordered in the early stages of this disease to differentiate the patient's symptoms from those of a cardiac etiology?

Brain natriuretic peptide (BNP) level

A nurse is caring for a patient, diagnosed with COVID-19, now with ARDS on BIPAP. The nurse observes a rapid progression of dyspnea, increased work of breathing with tachycardia with respiratory rate between 35 and 40 per minute. What intervention should nurse perform next?

Call rapid response team for possible intubation

The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the patient?

Can you tell me what concerns you most about dying

A new nurse is observed caring for a patient who has a chest tube in place after a partial lobectomy. Which action by the nurse is inappropriate and requires a more experienced nurse to intervene?

Clamping the chest tube while the patient is ambulating to the bathroom

Nurse is working in the emergency department with a client who had endotracheal intubation placement. The nurse must verify tube placement....

E, A, D, C, B E: check end-tidal carbon dioxide detector A: Auscultate the chest during the ventilation D: Confirm that breath sounds are equal bilaterally C: Secure the tube in place B: Obtain an order for a chest xray to document tube placement

A patient who is orally intubated and receiving mechanical ventilation is anxious and is "fighting" the ventilator. Which action should the nurse take next?

Increase the rate of the ordered sedative (propofol [Diprivan]) infusion as prescribed *(consider administering sedatives as prescribed)

A patient with systemic lupus erythematosus has come to the clinic for a routine checkup. When auscultating the patient's apical heart rate, the nurse notes the presence of a distinct scratching sound. What is the nurse's most appropriate action?

Inform health care provider that a friction rub may be present

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

Noted 600 mL of blood in the collection chamber

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 in the emergency department is notified that a person who sustained a gunshot wound to the right side of the chest will arrive soon. What should the nurse plan to do for the priority management of care?

Obtain equipment for chest tube insertion

A client is admitted to the hospital because of chronic severe diarrhea. The nurse caring for this client should expect the health care provider to prescribe what medication for the management of the clients diarrhea?

Octreotide acetate (sandostatin)

A male patient with pneumonia developed acute respiratory failure. He will be a candidate for mechanical ventilation based on which of the following criteria:

PaO2: 50 mmHg

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

Patient reports decreased exertional dyspnea

Which of these patients being seen at the human immunodeficiency virus (HIV) clinic should the nurse assess first?

Patient who has had 10 liquid stools in the last 24 hours and oral lesions

The RN is reviewing medical treatment. Which medication treatment needs clarification?

Patient with chest trauma and chest wall tenderness. Treatment opioid (morphine) - suppress breathing

After change-of-shift report in the progressive care unit, who should the nurse care for first?

Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics

A nurse is caring for a client with Acute Respiratory Distress Syndrome (ARDS) and is receiving mechanical ventilation via an endotracheal tube. Which actions should the nurse take?

Perform lung auscultation at least every 2-4 hours

The nurse is caring for a client who has been admitted for the treatment of AIDS. In the morning, the client tells the nurse that he experienced night sweats and recently "coughed up some blood". What is the nurse's most appropriate action?

Place the client on appropriate respiratory isolation and inform the physician

A client comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having COVID-19. Which of these prescribed actions should be taken first?

Place the client on contact and airborne precautions in the negative-pressure room

A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82% and the client is cyanotic. What action by the nurse is priority?

Prepare to assist with intubation

A patient with acute respiratory failure intubated with endotracheal tube and mechanically ventilated in the emergency room. The ventilator alarm reads high peak airway pressure. The nurse notes patient coughing while on semi fowler position. The nurse noted rhonchi in the bilateral upper anterior chest upon auscultation. What is the next priority nursing action?

Prepare to suction airway for secretions

The nurse is caring for a patient with respiratory distress. Understanding the ventilation and perfusion concept of respiratory function is important for a nurse to identify underlying etiology. Using the image below what disease process is a possible cause of a patient showing signs and symptoms of impaired gas exchange?

Pulmonary embolism

A client with dyspnea and chest pain has the following diagnostic study results. The nurse will anticipate that the patient will undergo further work-up and management for what possible conditions? Plasma D-dimer-elevated; ECG-nonspecific t-wave change; pH-7.49; PaO2 74; PaCO2-30

Pulmonary embolism with respiratory alkalosis

A hospital nurse has experienced percutaneous exposure to an HIV-positive client's blood as a result of a needle stick injury. What action should the nurse take immediately?

Report to the immediate supervisor and initiate the occupation exposure system as per facility protocol.

The nurse notes thin, white secretions in the endotracheal tube (ET) of a client who is receiving mechanical ventilation. Which intervention will be most effective in addressing this problem?

Suction once every 1-2 hours

A patient who is intubated is exhibiting rhonchi and has a pulse oximeter reading of 93%, soft abd, heart rate of 88 BPM and blood pressure of 98/54. Which would be the nurse's priority?

Suction the patient

A nurse is assessing a 28-year- old man with HIV who has been admitted with pneumonia. In assessing the patient, which of the following observations takes immediate priority?

Tachycardia and restlessness

A patient arrived at the emergency room (ER) and is diagnosed with massive pulmonary embolism. The patient has also developed hypotension and hypoxemia. What medication will most likely be given for the patient?

Tissue plasminogen activator (TPA)

A nurse is caring for an AIDS patient with a CD4 cell count of 100 cells/mm3. Which of the following medication will the nurse anticipate to be recommended as prophylaxis treatment against pneumocystis pneumonia?

Trimethoprim/sulfamethoxazole (Bactrim)

An older patient with an infected stage IV pressure ulcer is lethargic. What additional finding should the nurse expect to assess in possible systemic inflammatory response syndrome (SIRS)?

WBC 11,000; HR 98; Temp 96F

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

Patient who was successfully weaned and extubated 2 hours ago and noted with frequent episodes of cough.

A client is hospitalized with Pneumocystis Jiroveci pneumonia. The client reports SOB with activity and extreme fatigue. What interventions are best to address patient activity intolerance? SATA

* Instruct about energy conservation techniques * Pace activities allowing for adequate rest * Check hemoglobin and hematocrit level * Assist to a fowler's position

A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first?

Client with AIDS with CD4+ cell count of 210/mm3 and a temp of 102.4F

Patient with dyspnea on exertion was diagnosed with pulmonary hypertension. The nurse anticipate which collaborative therapies for this patient?

Oxygen and calcium-channel blocker (Oxygen, digoxin, and prostacyclin)