MOD 7-Evolve AQ-CH 32 RESPIRATORY
The nurse is teaching a patient receiving warfarin sodium about avoiding certain foods during this drug therapy. Which patient statement indicates a correct understanding of the teaching? "I will not eat foods containing beta carotene." "I will avoid eating foods containing saturated fat." "I will be careful to avoid anything with vitamin K in it." "I will be careful not to eat anything containing vitamin D.
"I will be careful to avoid anything with vitamin K in it." Vitamin K is an antidote to warfarin. The patient should be taught to avoid foods that are high in vitamin K. Saturated fats should be limited in a diet for cardiovascular health, but they do not affect warfarin therapy. Beta carotene and vitamin D are excellent additions to a healthy diet and do not affect the drug action of warfarin.
A ventilated patient in the intensive care unit appears restless and begins to pick at the bedcovers. Which action should the nurse take next? 1. Increase the sedation. 2. Assess for adequate oxygenation. 3. Request that the family leave to decrease the patient's agitation. 4. Explain to the patient that the tube in the throat will help with breathing.
2. Assess for adequate oxygenation. Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia. Increasing sedation is not indicated for this patient and may mask symptoms like hypoxemia or worsening respiratory failure. Although the nurse may explain that the patient is intubated, it does not take priority over assessing for hypoxemia. The presence of family members may decrease the chances of "ICU psychosis" and anxiety, but it does not take priority over assessing for hypoxemia.
What is the drug of choice for a patient suffering from massive pulmonary embolism who has shock symptoms? Alteplase Enoxaparin Rivaroxaban Fondaparinux
Alteplase Fibrinolytic agents, such as alteplase, are used in the treatment of pulmonary embolism, specifically when the patient has shock and hemodynamic collapse. Enoxaparin is a low molecular weight heparin and is prescribed for a submassive pulmonary embolism. Rivaroxaban is an anticoagulant that prevents deep vein thrombosis and pulmonary embolism and it is prescribed when the patient is at low risk for pulmonary embolism. Fondaparinux is a synthetic pentasaccharide factor Xa inhibitor, which is used unless the pulmonary embolism is massive or occurs with hemodynamic instability.
A patient has deep vein thrombosis. The nurse is teaching the patient's caregiver about measures for preventing pulmonary embolism. Which statements made by the caregiver indicate effective learning? Select all that apply. "Help the patient to cross his legs." "Gently massage the patient's leg muscles." "Change the patient's position every 2 hours." "Avoid placing a pillow under the patient's knee." "Elevate the affected limb 20 degrees above the heart level.
Changing the patient's position every 2 hours may reduce the pressure in specific areas and promote blood circulation. Placing a pillow under the knees can cause pressure under the popliteal space. Elevation of the affected limb 20 degrees or more above the level of the heart improves the venous return. Crossing legs should be avoided to prevent pressure on the blood vessels in the affected limbs, which may result in emboli formation. The caregiver should refrain from massaging the leg muscles to prevent dislodging of the clot causing pulmonary embolism.
A patient recovering from a pulmonary embolism after surgery is receiving low-molecular-weight heparin and warfarin. The patient's international normalized ratio (INR) is 2.4 today. After reporting this lab value to the provider, which order does the nurse anticipate? Discontinue the heparin and continue the warfarin Discontinue the warfarin and administer phytonadione Discontinue the heparin and administer protamine sulfate Continue the heparin and warfarin, and repeat the INR in one day
Discontinue the heparin and continue the warfarin The patient will typically take both drugs until the INR is between 2.0 and 3.0, then will stop taking the heparin. Patients may take warfarin for 3-6 weeks or indefinitely. There is no need to administer protamine sulfate or phytonadione, which are antidotes for heparin and warfarin, since the INR is within normal limits.
A patient with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation, and the nurse has an order to turn the patient every 2 hours. This action is performed to achieve which outcome? Reduce lung fibrosis Increase gas exchange Prevent pressure ulcers Improve lung compliance
Increase gas exchange Positioning may be important in promoting gas exchange in patients with ARDS, but the exact position is controversial. Manually turning the patient every 2 hours has been shown to improve perfusion. Turning the patient does not affect lung compliance or reduce lung fibrosis. It does help prevent pressure ulcers, but in this patient's case, the order is given specifically to improve lung perfusion.
A family member of a patient who has acute respiratory distress syndrome (ARDS) asks the nurse how long it will take for the patient to get better. The nurse reviews the medical record and notes that the patient has been receiving mechanical ventilation for 2 weeks. What does the nurse tell the family member? Multisystem organ changes occur at 2 weeks." "Lung changes have occurred that are irreversible." "Patients who are ventilator-dependent usually die." "Recovery may be complete, but it will take months."
Lung changes have occurred that are irreversible. Pulmonary fibrosis with progression occurs after 10 days of onset of ARDS. Patients who survive to this point will have permanent lung changes and may remain ventilator-dependent indefinitely. While many die, telling the family member this initially will destroy any hope for a good outcome; this must be discussed with the provider, the nurse, and possibly the palliative care team. Multisystem organ changes are more likely but have not necessarily occurred. Recovery is rarely complete at this stage.
The nurse has extubated a patient who was receiving mechanical ventilation for several days. A few hours after extubation, the patient reports a sore throat and cough and the nurse notes a hoarse voice. Which action by the nurse is correct? Notify the Rapid Response Team. Provide extra fluids and throat lozenges. Encourage use of an incentive spirometer. Request an order for nebulized racemic epinephrine
Provide extra fluids and throat lozenges. The patient is experiencing signs of throat irritation and should be provided with measures to minimize discomfort. Incentive spirometry is necessary for lower airway problems to prevent pneumonia. The Rapid Response Team should be notified if the patient experiences stridor or other signs of airway obstruction. Racemic epinephrine is used to treat stridor.
A postoperative patient with a history of thromboembolism is obese and reports smoking a pack of cigarettes a day. What does the nurse include in this patient's plan of care to help prevent pulmonary complications? Teach the patient about smoking cessation techniques. Provide for passive and active range-of-motion exercises. Elevate the patient's legs by placing pillows under the knees. Encourage the patient to take deep breaths and cough frequently.
Provide for passive and active range-of-motion exercises This patient is at risk for deep vein thrombosis (DVT) in the legs, which can cause pulmonary complications when a blood clot breaks loose and lodges in the lungs. Passive and active range-of-motion exercises can help prevent DVTs. Placing a pillow under the knees increases the risk of DVT because it puts pressure on the popliteal space. Coughing can help clear airways in patients who are not at risk for DVT, but coughing involves the Valsalva maneuver, which can increase the risk of clots. Smoking cessation techniques are an important part of long-term management but will not help in the immediate time period to prevent clots.
A patient recovering from an osteotomy and pin fixation for a femur fracture suddenly experiences shortness of breath, chest pain, and tachycardia. What does the nurse suspect is causing the patient's symptoms? Pulmonary edema Pulmonary infection Pulmonary embolism Reaction to anesthesia
Pulmonary embolism Difficulty breathing, tachycardia, chest pain, fainting, and cyanosis are some of the common clinical manifestations of a pulmonary embolism. The patient also has experienced two of the major risk factors—bone fracture and surgery. A pulmonary infection and edema can cause breathing difficulties and possible cyanosis, but usually not fainting or chest pain. Respiratory difficulties and chest pain are not usual reactions to anesthesia.
A patient who is being mechanically ventilated shows increased respiratory distress, including intercostal retractions, anxiety, and restlessness, with an oxygen saturation of 86%. Which priority action by the nurse is correct? Increase the oxygen flow rate and FiO 2 levels. Remove the ventilator and provide manual ventilation. Stay with the patient and provide reassurance and support. Notify the provider and request an order for blood gas evaluation
Remove the ventilator and provide manual ventilation. Patients who develop respiratory distress while being mechanically ventilated should be manually ventilated to allow quick determination of whether the problem is with the ventilator or the patient. Increasing oxygen flow rate and Fio 2 levels, obtaining an order for blood gases, and staying with the patient to provide support may be performed next.
The nurse assesses a patient with asthma who exhibits wheezing, dyspnea, and intercostal retractions during an acute exacerbation. An arterial blood gas shows PaO 2 of 55 mm Hg, a PaCO 2 of 50 mm Hg, and a pH of 7.25. What is this patient experiencing? Ventilatory failure Oxygenation failure Acute respiratory distress Ventilatory and oxygenation failure
Ventilatory and oxygenation failure Patients with chronic obstructive diseases such as asthma will develop oxygenation failure because of diseased airways and subsequent increased work of breathing that progresses to ventilatory failure. This patient is not compensating as evidenced by hypercapnia and hypoxia and acidosis.
