practice ?s Exam 2
A patient is refusing to wear pneumatic compression stockings while in bed, stating he does not like how they feel and they keep him awake. Which response would the nurse provide? "Let me talk to the health care provider about discontinuing them." "Would you like me to give you medication to help you sleep?" "It is important to wear them in bed so you don't develop a blood clot in your legs." "I'll give you a break from them for an hour, but then I'll need to put them back on."
"It is important to wear them in bed so you don't develop a blood clot in your legs." Rationale The continuous use of antiembolism and pneumatic compression stockings is an essential intervention in the prevention of venous thromboembolism. Providing education to patients may help with their refusal to wear compression stockings. It may be necessary to request a prescription for a sleep aid, but this is not the best response.
The nurse is teaching a patient with acute kidney injury how to take prescribed ferrous sulfate. Which statement made by the patient indicates a need for further teaching? "I have to take the drug after dialysis." "The drug should be taken along with meals." "I must take a stool softener daily along with this drug." "My pulse should be taken daily before I take this drug."
"My pulse should be taken daily before I take this drug." Rationale The patient taking ferrous sulfate is not required to take his or her pulse daily because the drug does not alter heart rate. Patients taking cardiac glycosides should take their pulses daily because the drug slows the heart rate. Because dialysis can remove ferrous sulfate from the blood, it is taken after the procedure. It is taken along with meals because food reduces nausea and abdominal discomfort. Ferrous sulfate is an oral iron preparation. Because it causes constipation, it is taken along with a stool softener. p. 1391
Which information would the nurse communicate to the family of a patient who is receiving mechanical ventilation? "Paralytic and sedative medications help decrease the demand for oxygen." "Suctioning is important to remove organisms from the lower airway." "We are encouraging oral and IV fluids to keep your loved one hydrated." "Sedation is needed so your loved one does not remove the breathing tube."
"Paralytic and sedative medications help decrease the demand for oxygen." Rationale Paralytics and sedation decrease oxygen demand. Sedation is needed more for its effects on oxygenation than to prevent the patient from removing the endotracheal tube. Suctioning is performed to maintain airway patency. Oral fluids would increase the risk for aspiration and pneumonia while an artificial airway and mechanical ventilation are in use. p. 596
A patient is receiving mechanical ventilation after developing acute respiratory distress syndrome (ARDS) from aspiration pneumonia. The patient's spouse asks the nurse how long it will take the patient to recover. Which response would the nurse provide? "Patients eventually recover but require medications indefinitely." "Recovery time depends on the severity and progression of symptoms." "With appropriate medications and treatments, most patients recover fully." "Patients with ARDS have permanent lung damage and require long-term care.
"Recovery time depends on the severity and progression of symptoms." Rationale The most accurate answer is to tell the family member that the severity and progression of symptoms can indicate recovery chances and length of time to recovery. Not all patients will eventually recover or need medication indefinitely, nor do all patients recover fully, even with aggressive medical and nursing treatment. Permanent lung damage is not always the result of ARDS. Permanent damage is typically seen in those who progress to stage 4 disease.
The nurse is explaining thrombolytic therapy to a patient. Which information would the nurse include? "You will receive a dose of enoxaparin IM for 3 days." "Therapy with warfarin is effective when your international normalized ratio (INR) is between 2 and 3." "If bleeding develops, we will give you platelets to reverse the anticoagulant." "As soon as the health care provider prescribes warfarin, we will stop the IV heparin."
"Therapy with warfarin is effective when your international normalized ratio (INR) is between 2 and 3." Rationale The INR, a measurement of anticoagulation with warfarin, is in the therapeutic range between 2 and 3. Enoxaparin is a low-molecular-weight heparin that is usually given by the subcutaneous route. Heparin and warfarin are overlapped until the INR is in the therapeutic range; then the heparin can be discontinued. Freshfrozen plasma is used as an antidote for anticoagulant therapy, not platelets. p. 591
Which expiratory volume value signifies a poor prognosis in patients with deep chest trauma? 10 mL/kg 15 mL/kg 20 mL/kg 25 mL/kg
10 mL/kg Rationale An expiratory volume of less than 15 mL/kg is considered to be a sign of poor prognosis. The chances of survival are very bleak. An expiratory volume of 15 mL/kg, 20 mL/kg, and 25 mL/kg indicate fair prognosis in patients with chest trauma. p. 607
Which patient is at high risk for a pulmonary embolism (PE)? A patient with diabetes admitted with cellulitis of the arm A patient receiving IV fluids through a peripheral line A patient with hypokalemia receiving oral potassium supplements A patient who had an open reduction and internal fixation of the tibia
A patient who had an open reduction and internal fixation of the tibia Rationale Surgery and immobility are risks for deep vein thrombosis (DVT) and PE. No evidence suggests that the patient with diabetes has been immobile, which is a risk factor for PE; the patient will be treated with antibiotics. For the patient with a peripheral line, no evidence indicates a problem with the IV or with breakage of the catheter, which could lead to an air embolism. For the patient with hypokalemia, no evidence reveals a risk for PE; no immobility or hypercoagulability is present. p. 587
Which patient is more susceptible to acute kidney injury (AKI)? A patient with fever A patient with anemia A patient with hypertension A patient who has sustained a humerus fracture
A patient with hypertension Rationale The risk for AKI is increased in patients with pre-existing hypertension, diabetes, peripheral vascular disease, liver disease, or chronic kidney disease. Fever, anemia, and a humerus fracture are conditions not related to AKI. p. 1377
Which finding in the first 24 hours after kidney transplantation requires immediate intervention? Incisional pain Blood-tinged urine Increase in urine output Abrupt decrease in urine output
Abrupt decrease in urine output Rationale An abrupt decrease in urine output may indicate complications such as rejection, acute kidney injury, thrombosis, or obstruction. Blood-tinged urine, incisional pain, and an increase in urine output are expected findings after kidney transplantation. p. 1406
Which treatment is the focus during the management of an uncomplicated rib fracture? Splinting the chest Administering analgesics Stabilizing the chest surgically Applying positive-pressure ventilation
Administering analgesics Rationale An uncomplicated rib fracture can be managed by the administration of analgesics. Splinting the chest by tape or any other material is not preferred. Surgical stabilization is indicated for extreme cases of flail chest. Positive-pressure ventilation is usually a preferred treatment modality to stabilize a flail chest. p. 607
Which step would the nurse consider first in the emergency approach to a patient with chest injuries? Airway Breathing Circulation Disability
Airway Rationale The first step in the ABC emergency approach to all chest injuries is to clear the patient's airway, followed by addressing breathing and circulation. Assessment of disability follows the other steps.
Which chemical is directly associated with reduced urine volume in the renin-angiotensinaldosterone pathway during an acute kidney injury? Renin Aldosterone Angiotensin I Angiotensin II
Aldosterone Rationale Aldosterone acts on the kidney's tubules to increase the reabsorption of sodium and water into the blood; this chemical is directly associated with reduced urine output. When blood perfusion to the kidneys is reduced, the juxtaglomerular cells convert prorenin to renin. This converts angiotensinogen to angiotensin I. Angiotensin I is subsequently converted to angiotensin II in the lungs. Angiotensin II increases blood pressure and also stimulates the secretion of aldosterone. p. 1385
Which drug is an antidote to fibrinolytic therapy? Alteplase Vitamin K 1 Protamine sulfate Aminocaproic acid
Aminocaproic acid Rationale Aminocaproic acid is the antidote for fibrinolytic therapy. Fibrinolytic therapy is used to break up an existing clot, but these agents may cause excessive bleeding; it may be necessary to block the activity of fibrinolytic agents by using its antidote to prevent further excessive bleeding. Alteplase is a fibrinolytic drug that increases the risk for bleeding. Vitamin K is an antidote for warfarin, an oral anticoagulant used for the long-term prevention of venous thrombi. Protamine sulfate is used to block the activity of heparin. p. 591
A patient in the ICU on mechanical ventilation appears increasingly restless and picks at the bedcovers. Which action would the nurse take? Increase the sedation. Assess for adequate oxygenation. Request that the family members leave. Explain the breathing tube to the patient
Assess for adequate oxygenation. Rationale Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia. Increasing sedation 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 comfort the patient. p. 594
A patient with a recently created vascular access for hemodialysis is being discharged. Which information would the nurse include in discharge teaching to prevent complications with the graft? How to practice proper nutrition How to assess for a bruit in the affected arm Modifications to allow for complete rest of the affected arm Avoiding venipuncture and blood pressure measurements in the affected arm
Avoiding venipuncture and blood pressure measurements in the affected arm Rationale Compression of vascular access causes decreased blood flow and may cause occlusion; if this occurs, dialysis will not be possible. The nurse should take every opportunity to discuss nutrition with patients, but this intervention does not specifically address prevention of graft complications. The patient can palpate for a thrill; a stethoscope is not needed to auscultate the bruit at home. The arm should be exercised, not rested, to encourage venous dilation.
Which finding in a CT report of a patient with chest trauma indicates a flail chest? Hemorrhage and edema Deviation of trachea away from the side of injury Tear in the tracheobronchial tree Bilateral separation of ribs from cartilage
Bilateral separation of ribs from cartilage Rationale A flail chest may occur because of bilateral separation of the ribs from the cartilage connections, which would be revealed in the CT scan. A pneumothorax is associated with the deviation of trachea away from the side of injury. The CT scan also reveals hemorrhage and edema in patients with pulmonary contusion, but bilateral rib separation from the cartilage is not associated with pulmonary contusion. Tracheobronchial trauma is associated with a tear in the tracheobronchial tree of the patient's respiratory system. p. 607
The nurse is caring for a patient with impending respiratory failure who declines intubation. Which option could provide ventilatory support to the patient without requiring intubation? Oropharyngeal airway Positive end-expiratory pressure (PEEP) Nonrebreathing mask with 100% oxygen Bilevel positive airway pressure (BiPAP)
Bilevel positive airway pressure (BiPAP) Rationale BiPAP ventilation is a noninvasive method that may provide short-term ventilation without intubation. An oropharyngeal airway is used to prevent the tongue from occluding the airway or the patient from biting the endotracheal tube. A nonrebreathing mask will assist with oxygenation; however, muscle fatigue and hypoventilation may occur as causes of respiratory failure. The need for PEEP indicates a severe gas exchange problem; this modality is "dialed in" on the mechanical ventilator. p. 600
Which term is used to refer to alveolar damage from an inflammatory response? Biotrauma Barotrauma Volutrauma Atelectrauma
Biotrauma Rationale Biotrauma is a lung problem that occurs when a patient is on mechanical ventilation; it is the damage to the alveoli that is mediated by an inflammatory response. When the damage to the lungs is caused by excessive pressure, it is referred to as barotrauma. When excess volume of ventilation is delivered to only one lung, it is referred to as volutrauma. A shear injury to alveoli while opening and closing is termed atelectrauma. p. 604
Which complication would the nurse identify as a possible cause of postrenal acute kidney injury (AKI) in a patient? Bladder cancer Acute tubular necrosis Pulmonary embolism Exposure to nephrotoxins
Bladder cancer Rationale Bladder cancer is a cause of postrenal AKI. Postrenal AKI is the obstruction of the urine-collecting system. Exposure to nephrotoxins and acute tubular necrosis are causes of intrarenal AKI. Intrarenal AKI is actual physical, chemical, hypoxic, or immunologic damage directly to the kidney tissue. Pulmonary embolism is a cause of prerenal AKI. Prerenal AKI is a decrease in blood flow to the kidneys, leading to ischemia in the nephrons. p. 1377
Which parameter would be considered normal in a patient who underwent renal transplantation 48 hours ago? Oliguria Diuresis Blood-tinged urine Presence of acetone bodies in urine
Blood-tinged urine Rationale The color of urine is pink to blood red immediately after renal transplantation surgery; the urine will gradually turn pale yellow after several weeks. Oliguria indicates that the transplanted kidney experienced an acute injury. Diuresis (increased urine volume) may result in hypotension, causing decreased blood perfusion in the transplanted kidney. The presence of acetone bodies is a sign of uncontrolled diabetes mellitus. p. 1406
Which finding indicates that the endotracheal tube remains correctly placed in the patient's trachea and is not in the esophagus? Breath sounds are present equally over bilateral lung fields. Oxygen saturation by pulse oximetry is greater than 85%. A suction catheter is easily passed through the endotracheal tube. No air is heard in the stomach when auscultated with a stethoscope.
Breath sounds are present equally over bilateral lung fields. Rationale Bilateral positive breath sounds indicate the endotracheal tube is in the proper placement. If breath sounds are heard on the right but not the left, the breathing tube may be in the right mainstem bronchus and may need to be retracted until breath sounds are heard equally. The gold standard for endotracheal tube placement verification is a chest x-ray. If the endotracheal tube was in the esophagus or stomach, breath sounds would be heard over the stomach rather than the bilateral lung fields. Other indications of proper tube placement include positive end-tidal carbon dioxide (CO ) readings and condensation in the tube. The fact that air cannot be heard in the stomach or that a suction catheter is easily passed are not conclusive assessments of a correctly placed endotracheal tube. Although an increase in oxygen saturation after intubation and ventilation indicates that the patient has improved oxygenation, the saturation value alone does not assure correct tube location.
Which finding is characteristic of hypoxic respiratory failure? Select all that apply. One, some, or all responses may be correct. Confusion Diarrhea Irritability Restlessness Tachycardia
Confusion Irritability Restlessness Rationale When a patient's oxygen level is low, the patient may be restless, irritable, or confused because decreased oxygen levels affect cerebral blood flow. The heart rate usually increases to compensate for low perfusion in hypoxemia. Diarrhea is not a manifestation of hypoxemia. p. 594
To prevent prerenal acute kidney injury, which person is encouraged to increase fluid consumption? Taxicab driver Schoolteacher Office secretary Construction worker
Construction worker Rationale Physical labor and working outdoors, especially in warm weather, cause diaphoresis and place the construction worker at risk for dehydration and prerenal azotemia. The taxicab driver, even without air conditioning, will not experience diaphoresis and fluid loss like the construction worker. The office secretary and schoolteacher work indoors and, even without air conditioning, will not lose as much fluid to diaphoresis as someone performing physical labor.
Which early manifestation is expected for a patient with pulmonary edema? Lethargy Thick white sputum Decreased heart rate Crackles at the base of the lungs
Crackles at the base of the lungs Rationale Crackles heard on auscultation at the base of the lungs is an early manifestation of pulmonary edema. Fluid leakage from the pulmonary circulation into the lung tissue and alveoli cause increased heart rate; bloodtinged, frothy sputum; and restlessness. p. 1390
Which findings would support that a patient may have a tension pneumothorax? Tachycardia and hypotension Cyanosis and distended neck veins Massive air leaks and tracheal lacerations Wheezes and crackles on auscultation
Cyanosis and distended neck veins Rationale The assessment findings of a tension pneumothorax include cyanosis and distended neck veins. A flail chest may develop as a complication of cardiopulmonary resuscitation and may manifest as cyanosis, dyspnea, tachycardia, and hypotension. Subcutaneous emphysema and air leaks may occur in patients with tracheal lacerations. Wheezes and crackles on auscultation may indicate edema or an infectious process in the airways. p. 608
Which assessment finding is consistent with the patient having a large pneumothorax? Dull percussion notes Paradoxic chest movement Increased breath sounds on auscultation Deviated trachea away from the side of injury
Deviated trachea away from the side of injury Rationale In patients with a pneumothorax, the trachea deviates away from the affected side. Hyperresonance is noticed on percussion. Dull sounds on percussion are noticed in patients with a pulmonary contusion. Paradoxic chest movements are a characteristic feature of flail chest. Breath sounds are decreased on auscultation in patients with a pneumothorax.
A patient requiring mechanical ventilation for treatment of pneumonia becomes agitated, restless, and shows symptoms of respiratory distress. The mechanical ventilator highpressure alarm has been activated. Which action would the nurse take? Medicate the patient with a sedating agent. Increase oxygen delivery to 100% through the ventilator. Check the mechanical ventilator data for possible causes of the alarm. Disconnect the ventilator, and provide ventilation with a self-inflating bag.
Disconnect the ventilator, and provide ventilation with a self-inflating bag Rationale When a patient shows signs of respiratory distress while being mechanically ventilated, the nurse should focus on the patient, not the mechanical ventilator. The first best action is to disconnect the ventilator and use a self-inflating bag to ventilate the patient while problem solving the cause of the alarm. Although it may be necessary to administer sedation to the patient, the nurse must attempt to stabilize the patient first. The nurse should not increase oxygen through the ventilator until the cause of the alarm is determined
Which finding supports the nurse's suspicion that a patient with rib fractures has a flail chest? Select all that apply. One, some, or all responses may be correct. Dyspnea Dry cough Bradycardia Hypotension Paradoxic chest movement
Dyspnea, hypotension, Paradoxic chest movement Rationale Patients with a flail chest may develop respiratory distress that leads to dyspnea. Hypotension is also seen in these patients. Paradoxic chest movements are observed in patients with a flail chest because of fractures of two neighboring ribs in two or more places. A dry cough is a symptom associated with pulmonary contusions. Bradycardia is not seen in patients with a flail chest; however, tachycardia is predominantly found in patients with a flail chest. p. 607
A patient receiving mechanical ventilation and anticoagulant medication after experiencing a pulmonary embolism appears tense and is unable to sleep or rest. Which action should the nurse take? Request a prescription for pain medication, and remind the patient to report discomfort. Ask the health care provider if conscious sedation may be administered to help the patient rest. Explain all interventions to the patient, and provide reassurance that care is appropriate. Tell the patient's family that the patient is unstable, and suggest that they remain close by.
Explain all interventions to the patient, and provide reassurance that care is appropriate. Rationale Patients who have a pulmonary embolism are usually anxious. The nurse should communicate with the patient to explain interventions and offer reassurance that appropriate measures are being taken. The patient's anxiety is not related to pain. A sedative may be prescribed if other comfort measures are not effective; however, conscious sedation is a specific level of analgesia recommended during uncomfortable or painful procedures or when a mechanically ventilated patient is unable to be oxygenated adequately. Family presence may provide comfort; however, telling the patient's family that the patient is unstable will increase the level of anxiety for everyone involved.
Which diet would the nurse suggest for a patient with acute kidney injury who reports a loss of appetite, nausea, vomiting, itching, and white salt-like frosty deposits on the skin? Fiber-rich diet Protein-rich diet Glucose infusion Fat emulsion infusion
Fat emulsion infusion Rationale White salt-like frosty deposits on the skin indicate uremic frost, a specific dermatologic manifestation of uremia. Patients with uremia have high blood urea levels because of renal failure. These patients should be given a fat emulsion infusion instead of glucose to provide a nonprotein high-calorie diet. A fiber-rich diet does not have any specific role in the diet of patients with uremia. A protein-rich diet should not be administered because it can lead to fluid retention.
Which condition is consistent with an x-ray report of three adjacent ribs each fractured in three different places? Flail chest Pulmonary contusion Tension pneumothorax Tracheobronchial trauma
Flail chest Rationale Flail chest appears in CT as the fracture of at least three neighboring ribs in two or more places. The chest xray of a patient with a pulmonary contusion reveals hazy opacity in the lobes or parenchyma. A tension pneumothorax is indicated by the asymmetry of the thorax in the x-ray. In tracheobronchial trauma, the chest x-ray shows a tracheobronchial tear.
Which drug would the nurse recognize as a loop diuretic? Digoxin Folic acid Epoetin alfa Furosemide
Furosemide Rationale Furosemide is a loop diuretic used to manage volume overload when urinary elimination is still present. Digoxin is a cardiac drug that may be used in chronic kidney disease. Folic acid is a vitamin B supplement and is used to help replace essential vitamins removed from the blood to prevent deficiencies. Patients also may use epoetin alfa, a synthetic erythropoietin, to prevent anemia. It stimulates the growth of red blood cells and facilitates their maturation in the bone marrow. pp. 1391, 1392
Which dialyzable drug would the nurse expect to be administered to the patient after hemodialysis is performed? Quinidine Captopril Ganciclovir Nifedipine
Ganciclovir Rationale Ganciclovir is an antiviral dialyzable drug. Dialyzable drugs can be partially removed from the blood during dialysis, so they must be administered after the procedure. Quinidine, captopril, and nifedipine are not dialyzable drugs; they are vasoactive drugs that can cause hypotension during hemodialysis and are administered after dialysis. p. 1400
In which order do physiologic changes occur in a patient with pulmonary contusion?
Hemorrhage and edema Reduction in lung movement Hypoxia and dyspnea Hazy opacity in the lobes or lung parenchyma Rationale Respiratory failure may develop in a patient with pulmonary contusion. Hemorrhage and edema occur in and between the alveoli first, thereby reducing both lung movement and the area available for gas exchange. The patient will then experience hypoxia and dyspnea. Hazy opacity in the lobes or lung parenchyma can develop over time.
Which term describes bleeding into the chest cavity? Stridor Hemothorax Thoracotomy Pneumothorax
Hemothorax Rationale Hemothorax is bleeding into the chest cavity. Stridor is a high-pitched, crowing noise during inspiration caused by laryngospasm or edema around the glottis. Thoracotomy is a surgical incision into the chest wall. Pneumothorax is air in the pleural space causing a loss of negative pressure in chest cavity, a rise in chest pressure, and a reduction in vital capacity, which can lead to lung collapse. p. 608
Which condition may require the use of a chest tube to drain fluid from the pleura? Flail chest Hemothorax Pneumothorax Tension pneumothorax
Hemothorax Rationale Chest tubes may be used in a patient with a hemothorax to empty the pleural space of accumulated blood. A pneumothorax and a tension pneumothorax may require a chest tube for removal of air from the pleural space. A flail chest does not require a chest tube unless other injuries are also present. p. 608
Which assessment finding would the nurse expect in a patient with a tension pneumothorax? Dry, nonproductive cough Crackles in the lung bases Reduced breath sounds bilaterally Hyperresonant sounds on percussion
Hyperresonant sounds on percussion Rationale A common assessment finding in a patient with a tension pneumothorax is hyperresonant sounds on percussion. This occurs because of the trapped air in the pleural space. A dry cough, crackles over the affected area, and reduced breath sounds bilaterally are findings associated with a pulmonary contusion.
A patient with a pulmonary embolism is experiencing anxiety and asks the nurse for a sedative. Which risk would be increased by administering a sedative? Increased clotting Hypoventilation Hyperventilation Abnormal bleeding
Hypoventilation Rationale Although a sedative can help manage a patient's anxiety, a health care provider is unlikely to prescribe it to a patient with a pulmonary embolism because sedatives carry the risk for hypoventilation as a side effect. Sedative agents do not carry a risk for increasing clots. Anticoagulants, not sedatives, may cause abnormal bleeding. Sedative agents slow, not quicken, breathing, so they are unlikely to cause hyperventilation.
Which instruction would the nurse give to a patient at discharge after hospitalization for an acute kidney injury (AKI)? Select all that apply. One, some, or all responses may be correct. Increase the intake of foods rich in sodium. Increase the intake of potassium-rich foods. Increase fluid consumption to flush waste. Limit the intake of foods containing phosphorus. Report a daily weight gain of 2 lb or more
Increase fluid consumption to flush waste. Report a daily weight gain of 2 lb or more Rationale Until the kidney resumes baseline normal functioning, the patient should limit the intake of foods containing phosphorus because high blood phosphate levels cause hypocalcemia. The patient must also keep a daily weight measurement log and report a weight gain of 2 lb or more over 24 hours to the health care provider. Weight gain may indicate the retention of fluids because of the deterioration of kidney function or a progression to chronic kidney disease. The patient must be taught to restrict, not increase, the consumption of dietary potassium and sodium as low urine output can cause an increase in serum sodium and serum potassium levels. Fluid consumption is also restricted, not increased, in the patient to prevent fluid overload. p. 1393
Which alteration in laboratory values would the nurse expect to see in a patient with complications of chronic kidney disease? Increased serum calcium Increased serum creatinine Decreased serum potassium Decreased serum phosphorus
Increased serum creatinine Rationale In chronic kidney disease, there is increased serum creatinine, decreased serum calcium, and increased serum potassium and phosphorus levels.
Which complication would the nurse be aware of after hemodialysis for a patient with chronic kidney disease? Select all that apply. One, some, or all responses may be correct. Infection Hypotension Weight gain Hyperglycemia from dialysate Muscle cramps and back pain
Infection Muscle cramps and back pain Hypotension Rationale Complications associated with the use of hemodialysis include disequilibrium, muscle cramps and back pain, headache, itching, adverse cardiac and hemodynamic events, and infection. Complications associated with peritoneal dialysis include hyperglycemia from dialysate and weight gain. 1395
Which postoperative intervention is the priority for a patient who underwent placement of an arteriovenous fistula? Monitor blood pressure in the extremity. Palpate the area for thrills every 2 hours. Start an IV line in the extremity with the fistula. Instruct the patient to elevate the extremity postoperatively
Instruct the patient to elevate the extremity postoperatively Rationale The patient should elevate the extremity postoperatively to prevent edema at the site. The nurse must not monitor blood pressure or start an IV line in the extremity with the fistula because repeated compression can result in loss of the vascular access. The nurse should palpate the area for thrills and auscultate for bruits every 4 hours. p. 1399
A patient has severe pain from three rib fractures after a workplace accident. Which intervention would the nurse suggest to the health care provider? Intercostal nerve block Mechanical ventilation Splinting the ribs with tape Administering opioid analgesics
Intercostal nerve block Rationale Patients with severe pain often do not take deep breaths and thus do not maintain adequate ventilation. An intercostal nerve block is used for severe pain. Opioid analgesics suppress respiration and should be avoided. Splinting with tape is not done unless the fracture is complex, when seven or more ribs are involved, or if a flail chest is present. Mechanical ventilation is used as a last intervention after others have been attempted.
A patient sitting upright and receiving high-flow oxygen with a nonrebreather mask appears anxious and has a respiratory rate of 30 breaths/min, a heart rate of 110 beats/min, and an oxygen saturation of 88%. The patient is using accessory muscles to breathe and appears fatigued. For which procedure would the nurse prepare to assist? Insertion of an oral or nasal airway Chest x-ray and arterial blood gases Intubation and mechanical ventilation Thoracostomy and chest tube insertion
Intubation and mechanical ventilation Rationale The patient is hypoxic despite receiving oxygen and is showing signs of increasing distress and fatigue; intubation and mechanical ventilation are necessary to treat respiratory failure in this patient. A chest x-ray and arterial blood gases may be performed after the patient is stabilized as part of the ongoing assessment. An oral airway is used when the patient cannot maintain a patent airway. A thoracostomy and chest tube insertion would be performed for signs of a pneumothorax.
Which action describes paradoxical chest wall movement? Bilateral separation of the ribs from their cartilage Deviation of the trachea away from the side of the injury Forceful entry of air into the chest cavity causing lung collapse Inward movement of the thorax during inspiration
Inward movement of the thorax during inspiration Rationale Flail chest results in paradoxical chest wall movement. It is the inward movement of the thorax during inspiration with outward movement during expiration. Bilateral separation of the ribs from their cartilage causes flail chest. Tension pneumothorax deviates the trachea away from the side of the injury. Forceful entry of air into the chest cavity causing collapse of the affected lung is related to tension pneumothorax. p. 607
Which term would the nurse use to document a condition where the ability to produce dilute urine is reduced, resulting in urine with a fixed osmolarity? Uremia Azotemia Isosthenuria Hyponatremia
Isosthenuria Rationale Isosthenuria is a condition where the ability to produce dilute urine is reduced, resulting in urine with a fixed osmolarity. Azotemia is a condition where nitrogen-based waste builds up in the blood. Azotemia with clinical symptoms is called uremia. Hyponatremia is a condition that causes sodium depletion in the body. p. 1384
Which assessment finding represents a positive response to erythropoietin therapy? Less fatigue Hematocrit of 26.7% Potassium within normal range Absence of spontaneous fractures
Less fatigue Rationale Treatment of anemia with erythropoietin will result in increased hemoglobin and hematocrit (H&H) and decreased shortness of breath and fatigue. A hematocrit value of 26.7% is low; erythropoietin should restore the hematocrit to at least 36% to be effective. Erythropoietin causes more red blood cells to be produced, increasing H&H; it has no effect on potassium levels. Calcium supplements and phosphate binders prevent renal osteodystrophy and subsequent fractures; erythropoietin treats anemia.
Which manifestation of pericarditis would the nurse expect to find in the patient with chronic kidney disease? Select all that apply. One, some, or all responses may be correct. Halitosis Mild chest pain Low-grade fever Decreased pulse rate Pericardial friction rub
Low-grade fever Pericardial friction rub Rationale The presence of low-grade fever is a manifestation of pericarditis, the inflammation of the pericardial sac by uremic toxins or infection. A pericardial friction rub is heard on auscultation over the left sternal border, indicating pericarditis or an inflammation of the pericardial sac. The patient experiences severe chest pain and an increased pulse rate. Halitosis, or bad breath, is caused by the breakdown of urea into ammonia. The reaction is catalyzed by the enzyme urease, present in the mouth. Halitosis is not a manifestation of pericarditis. p. 1386
Which term would the nurse use to document the presence of black and tarry stools in a patient with severe chronic kidney disease? Melena Purpura Tachypnea Hyperpnea
Melena Rationale Melena is the term used to document the presence of black and tarry stools. Tachypnea refers to the increase in the rate of breathing. Hyperpnea refers to an increase in the depth of breathing. Purpura refers to the presence of purple patches on the skin. p. 1389
For which imaging assessment would the nurse prepare a patient diagnosed with acute kidney injury (AKI) to measure the glomerular filtration rate (GFR)? CT Mercaptoacetyltriglycine (MAG3) Kidney, ureter, and bladder (KUB) MRI
Mercaptoacetyltriglycine (MAG3) Rationale A nuclear medicine study called MAG3 may be used to determine the nature of kidney failure and measure the GFR. A CT scan without contrast can determine the adequacy of kidney perfusion but cannot measure the GFR. A KUB is an x-ray of the kidneys, ureters, and bladder that may be able to determine the cause of AKI but cannot measure GFR. An MRI may be used in place of a CT scan to determine the adequacy of kidney perfusion but cannot measure GFR. p. 1379
Which drug increases cardiac output by improving myocardial contractility? Alteplase Milrinone Nitroprusside phytonadione
Milrinone Rationale Milrinone is a positive inotropic drug that increases the contractility of the cardiac musculature, thereby increasing cardiac output. Alteplase is a fibrinolytic drug that prevents the formation of clots in blood vessels. Nitroprusside is a vasodilator that is used for lowering blood pressure. Phytonadione is an antidote for warfarin and is administered in cases of warfarin overdose.
Which Fowler position is recommended for a patient with a pulmonary contusion? Low Fowler High Fowler Standard Fowler Moderate Fowler
Moderate Fowler Rationale The patient with a pulmonary contusion is placed in a moderate-Fowler position to maintain ventilation and oxygenation. Low-, high-, and standard-Fowler positions do not ensure proper respiration and are not suitable. p. 607
Which procedure would the nurse anticipate the health care provider will perform to treat a suspected tension pneumothorax in a patient with chest trauma? Intercostal block Cricothyroidotomy Bronchoscopy Needle thoracostomy
Needle thoracostomy Rationale A tension pneumothorax is a life-threatening complication in which air escapes into the chest cavity, causing a complete collapse of the affected lung. A large-bore needle thoracostomy is the initial and immediate intervention in this situation. Thoracostomy is followed by placing chest tubes. An intercostal block is used to manage pain from serious rib fractures. A cricothyroidotomy is performed to establish an airway in cases of tracheobronchial trauma. A bronchoscopy is performed for diagnostic purposes or to remove something from the airway such as mucus or a foreign object.
Which initial radiographic findings would the nurse expect in a patient with a pulmonary contusion? No opacity in the lobes or parenchyma Hazy opacity in the lobes or parenchyma Highly dense opacity in the lobes or parenchyma Moderately dense opacity in the lobes or parenchyma
No opacity in the lobes or parenchyma Rationale Initial assessment of the chest x-ray may not reveal any abnormalities, but a hazy opacity in the lobes or parenchyma may develop over several days, and the density may increase as time progresses. Highly dense opacity or moderately dense opacity is seen at later stages of a pulmonary contusion as the condition of the patient progresses. p. 607
Which action would the nurse take after noting cloudy effluent, malaise, and nausea in a patient undergoing peritoneal dialysis (PD)? Administer an antiemetic Decrease the rate of exchange Obtain a specimen from the dialysate Add a broad-spectrum antibiotic to the dialysate
Obtain a specimen from the dialysate Rationale Cloudy effluent, malaise, and nausea may indicate peritonitis (cloudy effluent is the earliest indication). In response, the nurse would send a specimen of the dialysate outflow to identify the infecting organism. Although an antiemetic may be administered for nausea, the nurse must first obtain a prescription from the health care provider. Decreasing the rate of exchange is not necessary; this patient is exhibiting signs and symptoms of a peritoneal infection, and a specimen of the effluent must be obtained. Although antibiotics may be given when peritonitis is suspected, a prescription must first be written by the health care provider; it is outside of the scope of practice of the nurse to administer antibiotics without a prescription. p. 1404
A patient with chronic obstructive pulmonary disease (COPD) suddenly becomes dyspneic with a respiratory rate of 32 breaths/min and an oxygen saturation of 94%. The patient appears pale and anxious and is using accessory muscles to breathe. Which action would the nurse take? Notify the Rapid Response Team. Request an order for a chest x-ray. Obtain an order for arterial blood gases. Apply high-flow oxygen with a Venturi mask.
Obtain an order for arterial blood gases Rationale The patient has developed respiratory distress. Even though the oxygen saturation level is within normal limits, a more accurate assessment of hypoxemia is with arterial blood gases. Giving high-flow oxygen with a Venturi mask may increase anxiety and cause oxygen-induced hypercapnia in patients with COPD. Unless the patient exhibits signs of respiratory failure with hypoxemia or cyanosis, notifying the Rapid Response Team is not necessary. A chest x-ray may be indicated after the patient is stabilized to help determine the cause of the respiratory distress.
What pretreatment would be given to a patient with a known history of renal failure while administering ibuprofen? Oral or IV antibiotics Oral or IV diuretic medication Oral or IV bolus of fluid volume Oral or IV H -receptor antagonist
Oral or IV bolus of fluid volume Rationale Pretreatment hydration is proven to reduce the nephrotoxic potential of many drugs. Therefore fluid intake is advised before the administration of ibuprofen, which is potentially nephrotoxic. Antibiotics are not necessarily administered unless there is an infection. Diuretic medicines are used to treat renal failure cases, but they do not reduce the nephrotoxicity of ibuprofen. H -receptor antagonists may also be administered, but they have no effect on renal health.
The nurse assists with the intubation of an 176-lb (80-kg) patient who will receive mechanical ventilation on assist/control mode with positive end-expiratory pressure (PEEP).Which ventilator setting would the nurse expect to be maintained over the next shift? Fraction of inspired oxygen (Fio 2) as high as possible Tidal volume of 400 mL Oxygen flow rate of 20 L/min PEEP between 5 and 15 cm H 2O
PEEP between 5 and 15 cm H 2O Rationale Patients receiving PEEP ventilation should have pressure settings between 5 and 15 cm H O. Because prolonged use of high Fio2 can damage lungs, the Fio should be lowered to the lowest possible amount. The oxygen flow rate should be 40 L/min. The patient's tidal volume should be 6 to 8 mL/kg; for this patient, the range would be 480 to 640 mL. p. 601
Which statement is accurate about a patient with chest trauma? Patients with a lung contusion should be restricted from IV fluids. Patients with severe hypoxemia respond to treatment with humidified oxygen. Patients with rib fractures are primarily treated by surgical stabilization. Patients with a flail chest are stabilized by using positive-pressure ventilation.
Patients with a flail chest are stabilized by using positive-pressure ventilation. Rationale Patients with a flail chest are generally stabilized with positive-pressure ventilation. Patients with severe hypoxemia are managed with positive end-expiratory pressure. Surgical stabilization is performed only in extreme cases of multiple rib fractures that cause flail chest. Patients with a lung contusion should be given IV fluids as prescribed. p. 608
Which procedure would help identify a hemothorax in a patient who experienced blunt chest trauma? Palpation Inspection Percussion Auscultation
Percussion Rationale Percussion produces a dull sound over the area of a hemothorax. A hemothorax is characterized by blood in the pleural space and is confirmed by x-ray or a CT scan. A thoracentesis is then performed to remove the blood from the pleural space. A thoracentesis is not performed before radiographic confirmation because of the risks associated with the procedure if a pneumothorax is not present. Palpation is a physical assessment method used to examine the size, tenderness, and location of organs in the body and would not detect blood in the pleural space. Inspection involves observing the appearance of the body and would not detect hemothorax. Auscultation is listening to internal sounds of the body. p. 608
A patient with an acute kidney injury is often managed in the ICU by an interprofessional health care team. During the acute phase, the team would include which professional? Select all that apply. One, some, or all responses may be correct. Pharmacist Nephrologist Physical therapist Nephrology nurse Registered dietitian nutritionist Occupational therapist
Pharmacist Nephrologist Nephrology nurse Registered dietitian nutritionist Rationale The most crucial members of the interprofessional team for managing a patient with acute kidney injury during the acute phase are a pharmacist, nephrologist, nephrology nurse, and registered dietitian nutritionist. Physical and occupational therapists are not crucial during the acute phase of the illness.
A patient formerly on synchronous intermittent mandatory ventilation is placed on a T-piece to begin weaning from mechanical ventilation. Seven minutes later, the patient's oxygen saturation decreases from 90% to 70%, and the patient becomes tachycardic, diaphoretic, and anxious. Which action would the nurse take? Call the Rapid Response Team. Instruct the patient to breathe deeply and try to relax. Give sedation medication to help the patient continue the weaning. Place the patient back on the recent mechanical ventilator settings.
Place the patient back on the recent mechanical ventilator settings. Rationale The patient is showing signs of distress with the weaning process; the nurse should place the patient back on the ventilator or facilitate the process for having mechanical ventilator support reinitiated. The anxiety is a response to hypoxemia; a patient who has reached this level of distress is unlikely to be able to breathe more deeply or relax in response to instructions. A Rapid Response Team call is not indicated because weaning is a controlled process and the health care team works closely together to monitor the patient's tolerance of weaning and reinitiating mechanical ventilation. Giving sedation agents will decrease the patient's drive to breathe.
Which immediate action would the nurse take when a patient experiences hypotension while undergoing dialysis? Discontinue the treatment. Administer a large fluid bolus. Increase the temperature of the dialysate. Place the patient in the Trendelenburg position.
Place the patient in the Trendelenburg position. Rationale When a patient experiences hypotension during dialysis, which is common, the nurse should immediately respond by placing the patient in a legs-up position (Trendelenburg) to increase the blood pressure. Discontinuing treatment for hypotension during dialysis is normally a last resort when hypotension continues despite appropriate interventions, so this would not be the immediate action. The nurse should administer one to two small fluid boluses (100 to 250 mL) if hypotension occurs during dialysis. The nurse should decrease, not increase, the temperature of the dialysate during hypotension; heat transfer from warm solutions can cause vasodilation and a drop in blood pressure.
A patient who has been admitted for a pulmonary embolism is receiving a heparin infusion. Which laboratory result would the nurse monitor to detect a possible complication of heparin therapy? Platelet count International normalized ratio (INR) Blood urea nitrogen (BUN) Serum prealbumin
Platelet count Rationale Daily platelet counts are a safety priority in assessing for thrombocytopenia; heparin-induced thrombocytopenia is a possible side effect. The INR would be monitored for a patient taking warfarin. BUN is a measure of hydration and renal function. Serum albumin is used as a measure of nutritional status. p. 591
A patient has been receiving heparin subcutaneously for 4 days. For which laboratory value would the nurse contact the health care provider? Hemoglobin of 14.2 g/dL Platelet count of 50,000/mm 3 International normalized ratio (INR) of 1.1 Activated partial thromboplastin time of 35 seconds
Platelet count of 50,000/mm 3 Rationale The normal range for platelets is 200,000/mm to 400,000/mm . Platelets are needed for blood clotting. This patient's platelet count is extremely low, and he or she is at risk for bleeding. The low platelet count may be an indication of an adverse reaction to heparin known as heparin-induced thrombocytopenia (HIT). The heparin must be discontinued, and the patient may need to receive platelet therapy before life-threatening hemorrhage occurs. The hemoglobin, INR, and activated partial thromboplastin time values are is normal. p. 591
Which condition is likely to require preparing a patient for chest tube insertion? Flail chest Rib fractures Pneumothorax Pulmonary contusion
Pneumothorax Rationale Chest tubes may be employed in patients with a pneumothorax to facilitate the escape of air, which will allow the lung to reinflate. Humidified oxygen, pain management, and promotion of lung expansion are beneficial interventions in patients with a flail chest. Pain management is the main focus of treatment in patients with rib fractures. Oxygen, IV fluids, and moderate-Fowler position are advocated in patients with pulmonary contusion. p. 608
Which term describes air in the pleural space? Stridor Hemothorax Thoracotomy Pneumothorax
Pneumothorax Rationale Pneumothorax is air in the pleural space causing a loss of negative pressure in chest cavity, a rise in chest pressure, and a reduction in vital capacity, which can lead to a lung collapse. Stridor is a high-pitched, crowing noise during inspiration caused by laryngospasm or edema around the glottis. Hemothorax is bleeding into the chest cavity. Thoracotomy is a surgical incision into the chest wall. p. 608
A patient who just underwent a central venous access catheter insertion has a deviated trachea and absence of breath sounds on one side. Which complication would the nurse suspect? Flail chest Hemothorax Pulmonary contusion Pneumothorax
Pneumothorax Rationale A deviated trachea and absence of breath sounds on one side are findings in patients with a pneumothorax. Patients with a flail chest may experience paradoxic chest movements. Patients with a hemothorax may have massive blood loss. Patients with pulmonary contusions would have decreased breath sounds or crackles and wheezes. p. 608
Several hours after extubation, the patient reports a sore throat and cough, and the nurse notes a hoarse voice. Which action would the nurse take? Notify the Rapid Response Team. Prepare for reintubation at the bedside. Encourage use of an incentive spirometer. Request a prescription for nebulized racemic epinephrine.
Prepare for reintubation at the bedside. Rationale The patient is experiencing signs of throat irritation, which are common after extubation. Incentive spirometry is used to prevent atelectasis and 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. Reintubation would be used if the patient could not maintain ventilation.
Which problem excludes a patient hoping to receive a kidney transplant from undergoing the procedure? History of hiatal hernia Presence of tuberculosis Presence of diabetes and hemoglobin A 1c (HbA 1c) of 6.8% History of basal cell carcinoma on the nose 5 years ago
Presence of tuberculosis Rationale Long-standing pulmonary disease and chronic infection, such as tuberculosis, typically exclude patients from transplantation; these conditions worsen with the immunosuppressants that are required to prevent rejection. A patient with a history of hiatal hernia is not exempt from undergoing a kidney transplant. Good control of diabetes is a positive point and would not exclude the patient from transplantation. Basal cell carcinoma is considered curable and occurred 5 years ago, consistent with appropriate candidates for transplantation. p. 1405
The nurse is caring for a patient injured in a car crash. The patient has bruising on the chest, dry cough, and decreased breath sounds. The chest x-ray on admission shows no abnormalities. Which collaborative actions would the nurse expect for this patient? Administer an intercostal nerve block. Administer antibiotics. Perform an immediate needle thoracostomy followed by insertion of a chest tube. Provide oxygen and IV fluids.
Provide oxygen and IV fluids. Rationale The patient injured in a car crash with chest bruising, dry cough, decreased breath sounds, and no chest x-ray abnormalities most likely has a pulmonary contusion, which is managed with oxygen, IV fluids, and placing the patient in a moderate-Fowler position. Severe pain related to rib fracture may be managed with an intercostal nerve block. Antibiotics are indicated for pneumonia. A tension pneumothorax is managed with an immediate needle thoracostomy, followed by the insertion of a chest tube.
The nurse provides care for a patient admitted with an acute kidney injury as the result of thoracic and abdominal trauma sustained in a motor vehicle accident. For which cardiovascular complications would the nurse monitor the patient? Bleeding Thrombosis Hypocalcemia Pulmonary embolism
Pulmonary embolism Rationale Pulmonary embolism is a cardiovascular complication of an acute kidney injury. Bleeding and thrombosis are hematologic complications of acute kidney injury. Hypocalcemia is a metabolic complication of acute kidney injury.
A patient who had knee surgery 2 days ago now has extreme shortness of breath, agitation, and apprehension. A heart rate of 119 beats/min and a respiratory rate of 24 breaths/min with an oxygen saturation of 84% are also noted. Which condition would the nurse suspect? Anaphylactic reaction Bronchospasm Pneumothorax Pulmonary embolism
Pulmonary embolism Rationale Venous thromboemboli are a potential complication after orthopedic surgery. Shortness of breath, agitation, apprehension, tachycardia, and a decreased oxygen saturation are findings consistent with a pulmonary embolism. Anaphylaxis and bronchospasm are characterized by wheezing. Pneumothorax is characterized by absent breath sounds on the affected side
Arrange the changes of the kidney during chronic kidney disease in order of occurrence Destruction of nephrons Fluid overload Production of urine with fixed osmolarity Pressure on healthy nephrons to maintain homeostasis Decreased ability to produce diluted urine Increased blood urea nitrogen and decreased urine output
Rationale In chronic kidney disease, diseased nephrons die, and healthy nephrons become larger and work harder to maintain essential homeostasis. As the disease progresses, the ability to produce diluted urine is reduced, resulting in urine with a fixed osmolarity (isosthenuria). As kidney function continues to decline, the blood urea nitrogen increases, and urine output decreases. At this point, the patient is at risk for fluid overload. p. 1384
In which order do physiologic changes occur with tension pneumothorax? Air is forced into the chest cavity, increasing the pressure. Major blood vessels are compressed. Venous return is limited. Cardiac filling and cardiac output are decreased.
Rationale Tension pneumothorax is a life-threatening condition that may lead to death. Air is forced into the chest cavity, and the pressure increases. This increased pressure compresses the blood vessels, resulting in the limiting of blood return. Finally, there is a decrease in the cardiac filling as well as the cardiac output. p. 608
Which instruction would the nurse give the patient about preventing kidney problems? Select all that apply. One, some, or all responses may be correct. Consume at least 1 L of fluids daily. Reduce the intake of carbonated soft drinks. Report any discomfort with the passage of urine. Have kidney function checked at least once a year. Report any change in frequency or volume of urine.
Rationale The patient should avoid carbonated soft drinks because they contain artificial sweeteners and are not beneficial to the kidney. Any discomfort with the passage of urine is not normal and must be reported to the health care provider. The patient must have kidney function checked at least once a year; changes in kidney function are often silent for many years. The patient must report any change in frequency or volume of urine because these are signals of potential problems and must be resolved at the earliest. The patient must take at least 3 L of fluids, mainly water, to flush the kidney thoroughly. p. 1387
The nurse assesses the reports of a patient with acute kidney injury (AKI). Which parameter indicates the severity of the disease? Select all that apply. One, some, or all responses may be correct. Decreased urine output Increased serum calcium Increased serum creatinine Decreased glomerular filtration rate Decreased blood urea nitrogen (BUN) levels
Rationale The severity of an AKI is based on decreased urine output and increased serum creatinine. Both these parameters occur as a result of renal dysfunction because of nephron damage. The glomerular filtration rate is not measured during acute and critical illness. In renal diseases, serum calcium levels are decreased while BUN levels are increased.
Which type of nutritional therapy may be required for a patient with acute kidney injury (AKI) who is scheduled to undergo dialysis? Select all that apply. One, some, or all responses may be correct. 40 g of protein per day Sodium intake up to 100 mEq/L Potassium intake up to 90 mEq/L Total parenteral nutrition (TPN) Fluid intake equal to urine output plus 500 mL
Rationale The very ill patient with AKI is usually administered TPN. This provides the patient with sufficient nutrition, preserves lean body mass, and maintains fluid balance. Generally, the patient is allowed fluid intake equal to urine output plus 500 mL. The patient on dialysis is prescribed 1 to 1.5 g/kg of protein in the diet, whereas 40 g/day of protein is prescribed for the patient without dialysis. The patient's diet includes a potassium intake of up to 60 to 70 mEq/L and a sodium intake of up to 60 to 90 mEq/L. p. 1381
Which patient is at risk for acute kidney injury (AKI)? Select all that apply. One, some, or all responses may be correct. Football player in preseason practice Patient who underwent contrast dye radiology Accident victim recovering from a severe hemorrhage Accountant with diabetes Patient in the ICU on high doses of antibiotics Patient recovering from GI influenza
Rationale To prevent AKI, all people should be urged to avoid dehydration by drinking at least 2 to 3 L of fluids daily, especially during strenuous exercise or work associated with diaphoresis, or when recovering from an illness, such as influenza, that reduces kidney blood flow. Contrast media may cause acute renal failure (ARF), especially in older patients with reduced kidney function. Recent surgery or trauma, transfusions, or other factors that might lead to reduced kidney blood flow may cause AKI. Certain antibiotics may cause nephrotoxicity. Diabetes may cause acute kidney failure superimposed on chronic kidney failure. p. 1377
A patient who was just transferred to the ICU after developing a pulmonary embolism is receiving anticoagulant therapy and oxygen. The nurse notes clear breath sounds, an oxygen saturation of 95%, and a heart rate of 78 beats/min. The patient reports feeling scared that something bad will happen. Which action would the nurse take? Request a prescription for an antianxiety medication. Reassure the patient that the treatment is working. Suggest that the patient take deep breaths to relax. Increase the oxygen flow to improve oxygen saturation.
Reassure the patient that the treatment is working. Rationale The patient with a pulmonary embolism is receiving appropriate treatment and has stable vital signs, so the nurse should stay with the patient and provide assurance that the measures are working. Anxiety is a common response to pulmonary embolism, even when the patient is stable. The patient has adequate oxygen saturation, so increasing the oxygen flow is not indicated. If reassurance is not effective, an antianxiety medication may be necessary at a later time. The patient may not be able to take deep breaths, so this is not recommended as a relaxation technique.
Which intervention would the nurse plan for reducing anxiety in a patient with a pulmonaryembolism (PE)? Offer the patient a mild sedative. Allow a family member to remain in the room. Remain with the patient, and provide oxygen. Have the patient breathe into a brown paper bag.
Remain with the patient, and provide oxygen. Rationale The underlying cause for anxiety with a PE is hypoxemia, which will be alleviated by oxygen; remaining with the patient in distress is appropriate. Rebreathing from a brown bag is an intervention that increases partial pressure of arterial carbon dioxide (Paco ) during hyperventilation, as in a panic attack; it will not provide needed oxygen. Sedation or allowing a family member to stay may calm the patient but will not improve oxygenation. p. 592
Which action would the nurse take when caring for a patient with a peritoneal dialysis catheter? Clean the area twice with cotton swabs. Use clean technique while cleaning the site. Remove the old dressing, and assess the area for infection. Clean the site from the abdomen toward the insertion site
Remove the old dressing, and assess the area for infection. Rationale The nurse must put on sterile gloves to remove the old dressing and assess the site for signs of infection, such as swelling, redness, or discharge around the catheter site. The nurse applies aseptic technique when caring for the wound. The site is cleaned with cotton swabs soaked in povidone-iodine. Cleaning is done in a circular motion starting from the insertion site moving toward the abdomen. The area is cleaned three times with three different cotton swabs. p. 1404
Which component of a patient's plan of care is based on the ventilator bundle approach to prevent ventilator-associated pneumonia (VAP)? Select all that apply. One, some, or all responses may be correct. Placing a nasogastric tube Administering antibiotic prophylaxis Removing subglottic secretions continuously Placing the patient in a negative airflow room Handwashing before and after contact with the patient Elevating the head of the bed at least 30 degrees when possible
Removing subglottic secretions continuously Elevating the head of the bed at least 30 degrees when possible Handwashing before and after contact with the patient Rationale Continuous removal of subglottic secretions, elevating the head of the bed at least 30 degrees whenever possible, and handwashing before and after contact with a patient are all part of a VAP bundle. Antibiotics are not given prophylactically; they are given on the basis of cultures to prevent an increase in drug-resistant organisms. A nasogastric tube is not part of the VAP bundle. If a patient is going to be mechanically ventilated for a prolonged period of time, postpyloric or gastrostomy tubes are preferred over nasogastric tubes for nutrition. Placing a patient in a negative airflow room is not part of the VAP bundle but would be used if a patient had an airborne communicable disease. p. 60
Which factor contributes to a patient with a flail chest developing atelectasis and pneumonia? Splinting the chest Performing tracheal suction Elevating the head of the patient's bed Providing positive-pressure ventilation
Splinting the chest Rationale Splinting is contraindicated in patients with a flail chest as it may further reduce the ability to exert the extra effort to breathe and may contribute later to the failure to wean off mechanical ventilation. Performing tracheal suction is beneficial in clearing nasal secretions. Elevating the head of the patient's bed does not interrupt the patient's capacity to wean from the ventilator. Providing positive-pressure ventilation is indicated for the stabilization of flail chest and helps to prevent atelectasis.
Which intervention is reserved for extreme cases of flail chest? Splinting with a tape wrap Surgical stabilization Humidified oxygenation Positive end-expiratory pressure (PEEP
Surgical stabilization Rationale Surgical stabilization is used only in extreme cases of flail chest. Splinting is not recommended because it further reduces the patient's ability to exert effectively to breathe and may contribute later to failure to wean from ventilator support. Providing humidified oxygen prevents the upper airway from drying out and may be used in patients with a flail chest, but it is the main intervention for patients with a severe flail chest. Patients with a flail chest and severe hypoxemia and hypercarbia are intubated and mechanically ventilated with PEEP
Which information would the nurse provide when teaching a patient taking folic acid while undergoing dialysis? Monitor for a slow pulse. Monitor for constipation. Take the folic acid with meals. Take the folic acid after treatment.
Take the folic acid after treatment. Rationale The nurse should teach the patient to take the folic acid after dialysis treatment to prevent the supplement from being removed from the blood during dialysis. Monitoring for a slow or irregular pulse is important for a patient taking sevelamer as it is a sign of hypophosphatemia. Monitoring for constipation is important for a patient taking sevelamer as it can lead to fecal impaction or an ileus. Patients should take iron supplements with meals to reduce nausea or abdominal discomfort. p. 1391
When caring for a patient with acute kidney injury (AKI) and a temporary subclavian hemodialysis catheter, which assessment finding would the nurse report to the health care provider immediately? Anorexia +1 ankle edema Temperature of 100.8°F (38.2°C) Mild discomfort at the catheter insertion site
Temperature of 100.8°F (38.2°C) Rationale Infection is a major complication of temporary hemodialysis catheters. All symptoms of infection, including fever, must be reported to the health care provider immediately because the catheter may have to be removed. Mild discomfort at the insertion site is expected with a subclavian hemodialysis catheter. During AKI, oliguria with resulting fluid retention and pedal edema is expected. Rising blood urea nitrogen associated with AKI may result in anorexia, nausea, and vomiting. As expected findings, these do not require immediate reporting to the health care provider.
When caring for a patient who receives peritoneal dialysis (PD), which finding would the nurse report to the health care provider immediately? Pulse oximetry reading of 95% Blood pressure of 148/90 mm Hg Temperature of 101.2°F (38.4°C) Sinus bradycardia, rate of 58 beats/min
Temperature of 101.2°F (38.4°C) Rationale The patient's fever may signal infection, which can indicate peritonitis - a major complication of PD, caused b y intra-abdominal catheter site contamination; meticulous aseptic technique must be used when caring for PD equipment. A pulse oximetry reading of 95% is a normal saturation. Although a heart rate of 58 beats/min is slightly bradycardic, the health care provider can be informed upon visiting the patient. Patients with kidney failure tend to have slightly higher blood pressures because of fluid retention; however, this is not as serious as a fever.
Which complication would the nurse suspect if a patient being mechanically ventilated with positive end-expiratory pressure (PEEP) suddenly experiences extreme respiratory distress? Flail chest Hemothorax Pulmonary contusion Tension pneumothorax
Tension pneumothorax Rationale Mechanical ventilation with PEEP may induce a tension pneumothorax in a patient with chest trauma. A flail chest may occur as a complication of cardiopulmonary resuscitation. A hemothorax occurs as a result of blunt chest trauma or penetrating injuries. Distress related to a pulmonary contusion generally develops slowly, over hours to days. p. 608
Which adverse effect is associated with the use of positive end-expiratory pressure (PEEP)? Lung infection Ventilatory failure Pulmonary embolism Tension pneumothorax
Tension pneumothorax Rationale PEEP is used to prevent the alveoli from collapsing at the end of expiration. The most serious side effect of PEEP is tension pneumothorax, in which the alveoli rupture and air accumulates in the pleura. Infection is not associated with application of PEEP. PEEP is used for prevention of ventilatory failure. PEEP does not affect the clotting mechanism of the body; pulmonary embolism is not associated with PEEP. p. 596
Which complication would the nurse expect in a patient with a torn mainstem bronchus who is rapidly intubated and ventilated with positive pressure? Flail chest Hemothorax Pneumothorax Tension pneumothorax
Tension pneumothorax Rationale A patient with a torn mainstem bronchus may develop a tension pneumothorax rapidly when intubated and ventilated with positive pressure. A flail chest may occur after cardiopulmonary resuscitation. A hemothorax is caused by lung injury and massive blood loss. A pneumothorax may occur from blunt chest trauma and with some degree of hemothorax. pp. 604, 608
Which condition involves air entering the pleural cavity under pressure? Flail chest Pulmonary contusion Tension pneumothorax Tracheobronchial trauma
Tension pneumothorax Rationale In patients with tension pneumothorax, air enters forcefully into the chest cavity, resulting in increased pressure. This rise in pressure may result in the complete collapse of the lungs. A flail chest occurs because of the fracture of two or more ribs in two or more places. A pulmonary contusion causes hemorrhage and edema between the alveoli. This reduces both lung movement and the area available for gaseous exchange, thus resulting in hypoxemia. Tracheobronchial trauma causes extensive air leakage, leading to subcutaneous emphysema. p. 608
Which nephrotoxic NSAID can cause acute kidney injury (AKI) in patients? Tolmetin Cisplatin Rifampin Vancomycin
Tolmetin Rationale Tolmetin is a nephrotoxic NSAID that can cause AKI. Cisplatin is a nephrotoxic chemotherapy agent that can cause AKI. Rifampin and vancomycin are nephrotoxic antibiotics that can cause AKI. p. 1377
While assisting a patient during peritoneal dialysis, the nurse observes the drainage discontinue after 200 mL of peritoneal effluent. What action would the nurse implement first? Reposition the catheter. Document the effluent as output. Turn the patient to the opposite side. Instruct the patient to deep breathe and cough
Turn the patient to the opposite side. Rationale With peritoneal dialysis, usually 1 to 2 L of dialysate is infused by gravity into the peritoneal space. The fluid dwells in the cavity for a specified time and then drains by gravity into a drainage bag. The dialyzing fluid is called peritoneal effluent on outflow. The outflow should be a continuous stream after the clamp is completely open. Potential causes of flow difficulty include constipation, kinked or clamped connection tubing, the patient's position, fibrin clot formation, and catheter displacement. If inflow or outflow drainage is inadequate, reposition the patient to stimulate inflow or outflow. Turning the patient to the other side or ensuring that he or she is in good body alignment may help. An x-ray is needed to identify peritoneal dialysis catheter placement. Only the physician repositions a displaced catheter. The nurse needs to measure and record the total amount of outflow after each exchange. However, the nurse should reposition the patient first to assist with complete dialysate drainage. Instructing the patient to deep breathe and cough will not promote dialysate drainage. Increased abdominal pressure from coughing contributes to leakage at the catheter site.
Which amount of daily fluid intake is recommended for a patient recovering from acute kidney injury? Urine output with an additional 300 mL Urine output with an additional 500 mL Urine output with an additional 700 mL Urine output with an additional 1000 mL
Urine output with an additional 500 mL Rationale Patients with renal failure should be very carefully monitored regarding the fluid intake. The daily intake should be 500 mL in addition to the urine volume. Less than 500 mL may lead to dehydration of the body; more than 500 mL may lead to fluid excess and excess pressure upon the healing kidneys. p. 1381
Which finding indicates that a patient has a flail chest? Select all that apply. One, some, or all responses may be correct. Cyanosis Dry cough Tachycardia Pleuritic pain Subcutaneous emphysema Paradoxic chest movement
cyanosis, paradoxic chest movement, dyspnea, and tachypnea Rationale A person with a flail chest typically presents with cyanosis, paradoxic chest movement, dyspnea, and tachypnea. A pulmonary contusion manifests as dry cough, tachycardia, tachypnea, and dullness to percussion. A pneumothorax manifests as pleuritic pain, subcutaneous emphysema, and tachypnea. p. 607
Which nursing intervention would be performed to relieve a patient's pain during the inflow of the dialysate during peritoneal dialysis? Cool the dialysate in the refrigerator. Heat the dialysate using a heating pad. Warm the dialysate in a microwave oven. Warm the dialysate using a warming chamber.
Warm the dialysate using a warming chamber. Rationale Before infusing into the peritoneal cavity, the dialysate solution should be warmed to prevent any discomfort and pain. Infusing cool dialysate will cause pain and discomfort; dialysate that is too hot will damage the properties of the dialysate in addition to the pain. Dialysate should not be placed in a microwave oven because it causes a rapid rise in temperature. p. 1403
Which complication would the nurse anticipate for a patient who splints fractured ribs? Select all that apply. One, some, or all responses may be correct. Increased pain Increased risk for flail chest Decreased breathing depth Increased risk for a pneumothorax Ineffective clearance of secretions
decreased breathing depth and ineffective clearance of secretions Rationale Complications associated with splinting fractured ribs includes decreased breathing depth and ineffective clearance of secretions. A patient splints the fracture to decrease pain. Flail chest and pneumothorax are not risk factors of splinting fractured ribs.
Which finding may signify a pulmonary contusion in a patient who was in a motor vehicle crash? Select all that apply. One, some, or all responses may be correct. Dry cough Hemoptysis Bradycardia Tachycardia Hyperresonant to percussion
dry cough and tachycardia. Rationale Patients with a pulmonary contusion have a dry cough and tachycardia. Hemoptysis may occur with a pulmonary embolism. Bradycardia does not manifest in a pulmonary contusion. The sound of percussion in a patient with a pulmonary contusion is always dull. Hyperresonance on percussion occurs in patients with a pneumothorax. p. 607
A 154-lb (70-kg) patient receiving manual ventilation is becoming agitated and restless. The nurse determines that the endotracheal tube is in place and notes an oxygen saturation of 97%. Ventilator settings include a pressure of 12 cm H O, a tidal volume of 600 mL, and a flow rate of 30 L/min. Which action would the nurse take? Reassure the patient that this is typical of "ICU psychosis." Contact the health care provider to discuss increasing the tidal volume. Increase the oxygen flow rate, and reassess the patient. Notify the health care provider that this patient is ready to be weaned from the ventilator.
increase the flow rate and then reassess the patient. Rationale The first step when a patient becomes agitated or restless, after checking the ventilator settings, is to increase the flow rate and then reassess the patient. This patient's tidal volume is appropriate. Patients who are ready to be weaned from the ventilator make respiratory efforts against the ventilator. These are not necessarily signsof delirium typical of ICU psychosis, and the nurse should first attempt to evaluate the cause of the agitation.
