Unit 6 - Complex Respiratory, Shock, Sepsis, and MODS

You're providing care to four patients. Select all the patients who are at risk for developing sepsis: A. A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place. B. A 55-year-old male who is a recent kidney transplant recipient. C. A 78-year-old female with diabetes mellitus who is recovering from colon surgery. D. A 65-year-old male recovering from right lobectomy for treatment of lung cancer.

A, B, C, D All the patients have risk factors for developing sepsis. Remember the mnemonic: Septic.....Suppressed immune system (AIDS/HIV, immunosuppressive therapy, steroids, chemo, pregnancy, malnutrition)....Extreme age (infants and elderly)...Post-op (surgical/invasive procedures)....Transplant recipients.....Indwelling devices (Foley catheter, central lines, trachs).....Chronic diseases (diabetes, hepatitis, alcoholism, renal insufficiency)

Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? a. Use aseptic technique when caring for invasive lines or devices. b. Ambulate postoperative patients as soon as possible after surgery. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Advocate for parenteral nutrition for patients who cannot take oral feedings. e. Administer prescribed antibiotics within 1 hour for patients with possible sepsis

A, B, C, E Because sepsis is the most frequent etiology for SIRS, measures to avoid infection such as removing indwelling urinary catheters as soon as possible, use of aseptic technique, and early ambulation should be included in the plan of care. Adequate nutrition is important in preventing SIRS. Enteral, rather than parenteral, nutrition is preferred when patients are unable to take oral feedings because enteral nutrition helps maintain the integrity of the intestine, thus decreasing infection risk. Antibiotics should be administered within 1 hour after being prescribed to decrease the risk of sepsis progressing to SIRS

Your patient is receiving aggressive treatment for septic shock. Which findings demonstrate treatment is NOT being successful? Select all that apply: A. MAP (mean arterial pressure) 40 mmHg B. Urinary output of 10 mL over 2 hours C. Serum Lactate 15 mmol/L D. Blood glucose 120 mg/dL E. CVP (central venous pressure) less than 2 mmHg

A, B, C, E The answers are A, B, C, and E. When answering this question, select the options that would indicate the body's organs/tissues are NOT being perfused adequately. A MAP should be 65 or greater for proper tissue perfusion to occur. Urinary output should be at least 30 mL/hr. Serum lactate should be less than 2 mmoL/L....if it's high this indicates cells are not receiving enough oxygen due to low tissue perfusion. A central venous pressure (CVP) should be greater than 2 mmHg. This shows the filling pressure in the right side of the heart. If this number is low there is not enough fluid filling in the heart to maintain cardiac output. This occurs in septic shock due to hypovolemia from increased capillary permeability where fluid shifted from the intravascular to the interstitial space.

Your patient, who is post-op from a gastrointestinal surgery, is presenting with a temperature of 103.6 'F, heart rate 120, blood pressure 72/42, increased white blood cell count, and respirations of 21. An IV fluid bolus is ordered STAT. Which findings below indicate that the patient is progressing to septic shock? Select all that apply: A. Blood pressure of 70/34 after the fluid bolus B. Serum lactate less than 2 mmol/L C. Patient needs Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement D. Central venous pressure (CVP) of 18

A, C To know if the patient is progressing to septic shock, you need to think about the hallmark findings associated with this condition. Septic shock is characterized by major persistent hypotension (<90 SBP) that doesn't respond to IV fluids (refractory hypotension), and the patient needs vasopressors (ex: Norepinephrine) to maintain a mean arterial pressure greater than 65 and their serum lactate is greater than 2 mmol/L. A serum lactate greater than 2 indicates the cell's tissue/organs are not functioning properly due to low oxygen; hence tissue perfusion is poor due to the low blood pressure and mean arterial pressure.

You're assessing a patient who is post-opt from a chest tube insertion. On assessment, you note there is 50 cc of serosanguinous fluid in the drainage chamber, fluctuation of water in the water seal chamber when the patient breathes in and out, and bubbling in the suction control chamber. Which of the following is the most appropriate nursing intervention? A. Document your findings as normal. B. Assess for an air leak due to bubbling noted in the suction chamber. C. Notify the physician about the drainage. D. Milk the tubing to ensure patency of the tubes.

A. Document your findings as normal. The assessment findings are normal. All the other options are incorrect.

A patient is recovering from a pneumothorax and has a chest tube present. Which of the following is an appropriate finding when assessing the chest tube drainage system? A. Intermittent bubbling may be noted in the water seal chamber. B. 200 cc of drainage per hour is expected during recovery of a pneumothorax. C. The chest tube is positioned at the patient's chest level to facilitate drainage. D. All of these options are appropriate findings.

A. Intermittent bubbling may be noted in the water seal chamber. It is normal to find intermittent (NOT CONTINUOUS) bubbling in the water seal chamber if the patient is recovery from a pneumothorax. Remember that a pneumothorax is an AIR leak between the lung and chest wall....therefore air will escape into the water seal chamber causing intermittent bubbles.

You're providing care to a patient who was just transferred to your unit for the treatment of ARDS. The patient is in the exudative phase. The patient is ordered arterial blood gases. The results are back. Which results are expected during this early phase of acute respiratory distress syndrome that correlates with this diagnosis? A. PaO2 40, pH 7.59, PaCO2 30, HCO3 23 B. PaO2 85, pH 7.42, PaCO2 37, HCO3 26 C. PaO2 50, pH 7.20, PaCO2 48, HCO3 29 D. PaO2 55, pH 7.26, PaCO2 58, HCO3 19

A. PaO2 40, pH 7.59, PaCO2 30, HCO3 23 This option demonstrates respiratory alkalosis. In the early stages of ARDS (exudative) the patient will start to enter in respiratory alkalosis. The patient starts to have tachypnea (the body's way of trying to increase the oxygen level but it can't). They will have a very low PaO2 level (normal PaO2 is 80 mmHg), the blood pH will become high (normal is 7.35-7.45) (alkalotic). In the late stage, the patient can enter into respiratory acidosis.

The physician orders a patient in septic shock to receive a large IV fluid bolus. How would the nurse know if this treatment was successful for this patient? A. The patient's blood pressure changes from 75/48 to 110/82. B. Patient's CVP 2 mmHg C. Patient's skin is warm and flushed. D. Patient's urinary output is 20 mL/hr.

A. The patient's blood pressure changes from 75/48 to 110/82. In septic shock, the first treatment is to try to maintain tissue perfusion with fluids. If that doesn't work to increase the blood pressure and maintain perfusion, vasopressors will be used next. In septic shock, the intravascular space will be depleted of fluid due to an increase in capillary permeability. This will lead to hypovolemia, which will decrease blood pressure and lead to a decrease in blood flow to organs/tissue. If the blood pressure increases to a normal state, that tells us the fluids are working.

A patient is about to have their chest tube removed by the physician. As the nurse assisting with the removal, which of the following actions will you perform? Select-all-that-apply: A. Educate the patient how to take a deep breath out and inhale rapidly while the tube in being removed. B. Gather supplies needed which will include a petroleum gauze dressing per physician preference. C. Place the patient in Semi-Fowler's position. D. Have the patient take a deep breath, exhale, and bear down during removal of the tube. E. Pre-medicate prior to removal as ordered by the physician. F. Place the patient is prone position after removal.

B, C, D, E Option A: is wrong because this is not how the Valsalva Maneuver is performed (the correct way is detailed in option D). Option F: is wrong as well because this position would not faciltate breathing...Fowler's position is best after removal.

A patient with a severe infection has developed septic shock. The patient's blood pressure is 72/44, heart rate 130, respiration 22, oxygen saturation 96% on high-flow oxygen, and temperature 103.6 'F. The patient's mean arterial pressure (MAP) is 53 mmHg. Based on these findings, you know this patient is experiencing diminished tissue perfusion and needs treatment to improve tissue perfusion to prevent organ dysfunction. In regards to the pathophysiology of septic shock, what is occurring in the body that is leading to this decrease in tissue perfusion? Select all that apply: A. Absolute hypovolemia B. Vasodilation C. Increased capillary permeability D. Increased systemic vascular resistance E. Clot formation in microcirculation F. A significantly decreased cardiac output

B, C, E Septic shock occurs due to sepsis. Sepsis is the body's reaction to an infection and will lead to septic shock if this reaction is not treated. This reaction is the activation of the body's inflammatory system, but it's MAJORLY amplified and system wide. Cardiac output is not the problem in septic shock as with other types of shocks like hypovolemic or cardiogenic. CO is actually high or normal during the early stages of septic shock. It only decreases to the end of septic shock when heart function fails. The issue is with what is going on beyond the heart in the vessels. Substances are released by the microorganism that has invaded the body. This causes the immune system to release substances that will cause system wide vasodilation of the vessels (this will cause a DECREASE in systemic vascular resistance, blood to pool, and this decreases blood flow to the organs/tissues) along with an increase in capillary permeability (this causes fluid to leave the intravascular system and depletes the circulatory system of fluid and further decreases blood flow to the organs/fluids...this is RELATIVE (not absolute) hypovolemia). Furthermore, clots will form in the microcirculation due to plasma activating factor being released. This will cause platelets to aggregate and block blood flow even more to the organs/tissues. All of this will lead to decreased tissue perfusion and deprive cells of oxygen.

A patient is on IV Norepinephrine for treatment of septic shock. Which statement is FALSE about this medication? A. "The nurse should titrate this medication to maintain a MAP of 65 mmHg or greater." B. "This medication causes vasodilation and decreases systemic vascular resistance." C. "It is used when fluid replacement is not unsuccessful." D. "It is considered a vasopressor."

B. "This medication causes vasodilation and decreases systemic vascular resistance." This statement is FALSE because this medication causes vasoconstriction (not vasodilation) which INCREASES systemic vascular resistance.

A patient is on mechanical ventilation with PEEP (positive end-expiratory pressure). Which finding below indicates the patient is developing a complication related to their therapy and requires immediate treatment? A. HCO3 26 mmHg B. Blood pressure 70/45 C. PaO2 80 mmHg D. PaCO2 38 mmHg

B. Blood pressure 70/45 Mechanical ventilation with PEEP can cause issues with intrathoracic pressure and decrease the cardiac output (watch out for a low blood pressure) along with hyperinflation of the lungs (possible pneumothorax or subq emphysema which is air that escapes into the skin because the lungs are leaking air).

Your patient, who is post-op from a kidney transplant, has developed septic shock. Which statement below best reflects the interventions you will perform for this patient? A. Administer Norepinephrine before attempting a fluid resuscitation. B. Collect cultures and then administer IV antibiotics. C. Check blood glucose levels before starting any other treatments. D. Administer Drotrecogin Alpha within 48-72 hours.

B. Collect cultures and then administer IV antibiotics. Option A is wrong because fluids are administered first, and if they don't work vasopressors (Norepinephrine) is administered. Option C is wrong because although blood glucose levels should be measured, it does not take precedence over other treatments. Option D is wrong because Drotrecogin alpha should be given within 24-48 hours of septic shock to be the most effective.

Your patient's blood pressure is 72/56, heart rate 126, and respiration 24. The patient has a fungal infection in the lungs. The patient also has a fever, warm/flushed skin, and is restless. You notify the physician who suspects septic shock. You anticipate that the physician will order what treatment FIRST? A. Low-dose corticosteroids B. Crystalloids IV fluid bolus C. Norepinephrine D. 2 units of Packed Red Blood Cells

B. Crystalloids IV fluid bolus The first treatment in regards to helping maintain tissue perfusion is fluid replacement with either crystalloid or colloid solutions. THEN vasopressors like Norepinephrine are ordered if the fluids don't help.

While helping a patient with a chest tube reposition in the bed, the chest tube becomes dislodged. What is your immediate nursing intervention? A. Stay with the patient and monitor their vital signs while another nurse notifies the physician. B. Place a sterile dressing over the site and tape it on three sides and notify the physician. C. Attempt to re-insert the tube. D. Keep the site open to air and notify the physician.

B. Place a sterile dressing over the site and tape it on three sides and notify the physician.

A patient with a chest tube has no fluctuation of water in the water seal chamber. What could be the cause of this? A. This is an expected finding. B. The lung may have re-expanded or there is a kink in the system. C. The system is broken and needs to be replaced. D. There is an air leak in the tubing.

B. The lung may have re-expanded or there is a kink in the system.

A patient with a fever is lethargic and has a blood pressure of 89/56. The patient's white blood cell count is elevated. The physician suspects the patient is developing septic shock. What other findings indicate this patient is in the "early" or "compensated" stage of septic shock? Select all that apply: A. Urinary output of 60 mL over 4 hours B. Warm and flushed skin C. Tachycardia D. Bradypnea

B. Warm and flushed skin C. Tachycardia The answers are B and C. In the early or compensated stage of septic shock, the patient is in a hyperdynamic state. This is different from the other types of shock like hypovolemic or cardiogenic (vasoconstriction is occurring in these types of shock). In septic shock, vasodilation is occurring and this leads to WARM and FLUSHED skin in the early stage. However, in the late stage the skin will be cool and clammy. Tachycardia and TACHYpnea (not bradypnea) occurs in the early stage too as a compensatory mechanism. Oliguria (option A) is in the late stage or uncompensated when the kidneys are starting to fail.

During the exudative phase of acute respiratory distress syndrome (ARDS), the patient's lung cells that produce surfactant have become damaged. As the nurse you know this will lead to? A. bronchoconstriction B. atelectasis C. upper airway blockage D. pulmonary edema

B. atelectasis Surfactant decreases surface tension in the lungs. Therefore, the alveoli sacs will stay stable when a person exhales (hence the sac won't collapse). If there is a decrease in surfactant production this creates an unpredictable alveoli sac that can easily collapse, hence a condition called ATELETASIS will occur (collapse of the lung tissue) when there is a decrease production in surfactant.

A patient is diagnosed with septic shock. As the nurse you know this is a __________ form of shock. In addition, you're aware that __________ and _________ are also this form of shock. A. obstructive; hypovolemic and anaphylactic B. distributive; anaphylactic and neurogenic C. obstructive; cardiogenic and neurogenic D. distributive; anaphylactic and cardiogenic

B. distributive; anaphylactic and neurogenic Septic shock is a form of distributive shock. This means there is an issue with the distribution of blood flow in the small blood vessels of the body. This results in a diminished supply of blood to the body's tissues and organs. Anaphylactic and neurogenic shock are also a type of distributive form of shock. Septic shock isn't occurring due to an issue with cardiac output, which occurs in hypovolemic and cardiogenic shock.

Which patient below is at MOST risk for developing ARDS and has the worst prognosis? A. A 52-year-old male patient with a pneumothorax. B. A 48-year-old male being treated for diabetic ketoacidosis. C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection. D. A 30-year-old female with cystic fibrosis.

C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection. Sepsis is the MOST common cause of ARDS because of systemic inflammation experienced. This is also true if the cause of the sepsis is a gram-negative bacterium (this also makes the infection harder to treat...hence poor prognosis). With sepsis, the immune cells that are present with the inflammation travel to the lungs and damage the alveolar capillary membrane leading to fluid to leak in the alveolar sacs.

The patient in room 2569 calls on the call light to tell you something is wrong with his chest tube. When you arrive to the room you note that the drainage system has fallen on its side and is leaking drainage onto the floor from a crack in the system. What is your next PRIORITY? A. Place the patient in supine position and clamp the tubing. B. Notify the physician immediately. C. Disconnect the drainage system and get a new one. D. Disconnect the tubing from the drainage system and insert the tubing 1 inch into a bottle of sterile water and obtain a new system.

C. Disconnect the drainage system and get a new one. A new system needs to be obtained, however, in order to maintain a water seal until the new system arrives you will need to place the tubing 1 inch in sterile water or sterile saline to regain a water seal.

As the nurse you know that acute respiratory distress syndrome (ARDS) can be caused by direct or indirect lung injury. Select below all the INDIRECT causes of ARDS: A. Drowning B. Aspiration C. Sepsis D. Blood transfusion E. Pneumonia F. Pancreatitis

C. Sepsis D. Blood transfusion F. Pancreatitis C, D, F Indirect causes are processes that can cause inflammation OUTSIDE of the lungs....so the issue arises somewhere outside the lungs. Therefore, sepsis (infection...as long as it is outside the lungs), blood transfusion, and pancreatitis are INDIRECT causes. Drowning, aspiration, and pneumonia are issues that arise in the lungs (therefore, they are DIRECT causes of lung injury).

You're providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the patient is developing acute respiratory distress syndrome (ARDS)? A. The patient is experiencing bradypnea. B. The patient is tired and confused. C. The patient's PaO2 remains at 45 mmHg. D. The patient's blood pressure is 180/96.

C. The patient's PaO2 remains at 45 mmHg. A hallmark sign and symptom found in ARDS is refractory hypoxemia. This is where that although the patient is receiving a high amount of oxygen (here a 100% non-rebreather mask) the patient is STILL hypoxic. Option C is the answer because it states the patient's arterial oxygen level is remaining at 45 mmHg (a normal is 80 mmHg but when treating patients with ARDS a goal is at least 60 mmHg). Yes, the patient can be tired and confused from a low oxygen level BUT this question wants to know the HALLMARK sign and symptom.

A patient is receiving positive pressure mechanical ventilation and has a chest tube. When assessing the water seal chamber what do you expect to find? A. The water in the chamber will increase during inspiration and decrease during expiration. B. There will be continuous bubbling noted in the chamber. C. The water in the chamber will decrease during inspiration and increase during expiration. D. The water in the chamber will not move.

C. The water in the chamber will decrease during inspiration and increase during expiration. When a patient is receiving mechanical ventilation the water in the water seal chamber will oscillate oppositely than if the patient were breathing on their own. Therefore, the water in the chamber will decrease during inspiration and increase during expiration.

A patient has been hospitalized in the ICU for a near drowning event. The patient's respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS? A. infiltrates only on the upper lobes B. enlargement of the heart with bilateral lower lobe infiltrates C. white-out infiltrates bilaterally D. normal chest x-ray

C. white-out infiltrates bilaterally This is a finding found in ARDS....pronounce white-out infiltrates bilaterally.

You're teaching a class on critical care concepts to a group of new nurses. You're discussing the topic of acute respiratory distress syndrome (ARDS). At the beginning of the lecture, you assess the new nurses understanding about this condition. Which statement by a new nurse demonstrates he understands the condition? A. "This condition develops because the exocrine glands start to work incorrectly leading to thick, copious mucous to collect in the alveoli sacs." B. "ARDS is a pulmonary disease that gradually causes chronic obstruction of airflow from the lungs." C. "Acute respiratory distress syndrome occurs due to the collapsing of a lung because air has accumulated in the pleural space." D. "This condition develops because alveolar capillary membrane permeability has changed leading to fluid collecting in the alveoli sacs."

D. "This condition develops because alveolar capillary membrane permeability has changed leading to fluid collecting in the alveoli sacs." ARDS is a type of respiratory failure that occurs when the capillary membrane that surrounds the alveoli sac becomes damaged, which causes fluid to leak into the alveoli sac. Option A describes cystic fibrosis, option B describes COPD, and option C describes a pneumothorax.

A patient is experiencing respiratory failure due to pulmonary edema. The physician suspects ARDS but wants to rule out a cardiac cause. A pulmonary artery wedge pressure is obtained. As the nurse you know that what measurement reading obtained indicates that this type of respiratory failure is NOT cardiac related? A. >25 mmHg B. <10 mmHg C. >50 mmHg D. <18 mmHg

D. <18 mmHg A pulmonary artery wedge pressure measures the left atrial pressure. A pulmonary catheter is "wedged" with a balloon in the pulmonary arterial branch to measure the pressure. If the reading is less than 18 mmHg it indicates this is NOT a cardiac issue but most likely ARDS. Therefore, the pulmonary edema is due to damage to the alveolar capillary membrane leaking fluid into the alveolar sac....NOT a heart problem ex: heart failure.

A patient in septic shock is experiencing hyperglycemia. The patient is started on an insulin drip. A blood glucose goal for this patient would be: A. <110 mg/dL B. <80 mg/dL C. >200 mg/dL D. <180 mg/dL

D. <180 mg/dL If a patient is experiencing hyperglycemia an insulin drip may be ordered to control glucose levels. Hyperglycemia affects the immune system and healing. A blood glucose goal in this patient is <180 mg/dL.

A patient is at risk for septic shock when a microorganism invades the body. Which microorganism is the MOST common cause of sepsis? A. Fungus B. Virus C. Parasite D. Bacteria

D. Bacteria Gram-positive or gram-negative bacteria are the MOST common cause of sepsis.

You are providing care to a patient with a chest tube. On assessment of the drainage system, you note continuous bubbling in the water seal chamber and oscillation. Which of the following is the CORRECT nursing intervention for this type of finding? A. Reposition the patient because the tubing is kinked. B. Continue to monitor the drainage system. C. Increase the suction to the drainage system until the bubbling stops. D. Check the drainage system for an air leak.

D. Check the drainage system for an air leak. Continuous bubbling in the water seal chamber is NOT normal and indicates there is an air leak. However, oscillation of the water in the water seal chamber is normal.

A patient in septic shock receives large amounts of IV fluids. However, this was unsuccessful in maintaining tissue perfusion. As the nurse, you would anticipate the physician to order what NEXT? A. IV corticosteroids B. Colloids C. Dobutamine D. Norepinephrine

D. Norepinephrine Fluids are ordered FIRST in septic shock. If this is unsuccessful, then vasopressors are ordered NEXT. Norepinephrine is used as a first-line agent. Dobutamine may sometimes be used but for its inotropic effects on the heart.

True or False: Septic shock causes system wide vasodilation which leads to an increase in systemic vascular resistance. In addition, septic shock causes increased capillary permeability and clot formation in the microcirculation throughout the body. True False

False This statement is incorrect because there is a DECREASE (not increased) systemic vascular resistance in septic shock due to vasodilation. In septic shock, vasodilation is system wide. In addition, septic shock causes increased capillary permeability and thrombi formation in the microcirculation throughout the body. The vasodilation, increased capillary permeability, and clot formation in the microcirculation all leads to a decrease in tissue perfusion. This causes organ and tissue dysfunction, hence septic shock.

What is the difference between SIRS and sepsis?

SIRS is caused by a NONinfectious insult Sepsis is cause by an INFECTIOUS insult

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.) a. Severe dyspnea b. Nausea c. Decreased level of consciousness d. Headache e. Hypotension

a, c, d, e a. Severe dyspnea is correct. Severe dyspnea is a manifestation of ARF that occurs as a result of hypoxemia. c. Decreased level of consciousness is correct. Decreased level of consciousness is a manifestation of ARF that occurs due to hypercapnia. d. Headache is correct. Headache is a manifestation of ARF that occurs due to hypercapnia. e. Hypotension is correct. Hypotension is a manifestation of ARF that occurs due to acidosis.

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patients oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take next? a. Increase the oxygen flow rate. b. Suction the patients oropharynx. c. Instruct the patient to cough and deep breathe. d. Help the patient to sit in a more upright position

a. Increase the oxygen flow rate. Chapter 67: Acute Respiratory Failure and Acute Respiratory Distress Syndrome Test Bank MULTIPLE CHOICE 1. To evaluate the effectiveness of ordered interventions for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse? a. Chest x-ray b. Oxygen saturation c. Arterial blood gas analysis d. Central venous pressure monitoring ANS: C Arterial blood gas (ABG) analysis is most useful in this setting because ventilatory failure causes problems with CO 2 retention, and ABGs provide information about the PaCO 2 and pH. The other tests may also be done to help in assessing oxygenation or determining the cause of the patients ventilatory failure. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patients oxygen saturation (SpO 2 ) from 94% to 88%. Which action should the nurse take next ? a. Increase the oxygen flow rate. b. Suction the patients oropharynx. c. Instruct the patient to cough and deep breathe. d. Help the patient to sit in a more upright position. ANS: A Increasing oxygen flow rate will usually improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion b. Heart rate 112 beats/minute c. Decreased bowel sounds d. Pale, cool, and dry extremities

a. New onset of confusion The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock

When admitting a patient with possible respiratory failure with a high PaCO2, which assessment information should be immediately reported to the health care provider? a. The patient is somnolent. b. The patient complains of weakness. c. The patients blood pressure is 164/98. d. The patients oxygen saturation is 90%

a. The patient is somnolent. Increasing somnolence will decrease the patients respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect? a. Mottled skin b. Blood pressure 115/68 mmHg c. Heart rate 160/min d. Hypokalemia

b. Blood pressure 115/68 mmHg MY ANSWER The sympathetic nervous system is stimulated, resulting in the release of epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure remains within normal limits during the compensatory stage of shock.

The nurse is caring for a 33-year-old patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? a. The patients PaO2 is 45 mm Hg. b. The patients PaCO2 is 33 mm Hg. c. The patients respirations are shallow. d. The patients respiratory rate is 32 breaths/minute

a. The patients PaO2 is 45 mm Hg. The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patients poor oxygenation

A patient with acute respiratory distress syndrome (ARDS) is placed in the prone position. When prone positioning is used, which information obtained by the nurse indicates that the positioning is effective? a. The patients PaO2 is 89 mm Hg, and the SaO2 is 91%. b. Endotracheal suctioning results in clear mucous return. c. Sputum and blood cultures show no growth after 48 hours. d. The skin on the patients back is intact and without redness

a. The patients PaO2 is 89 mm Hg, and the SaO2 is 91%. The purpose of prone positioning is to improve the patients oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective

A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a. administer oxygen. b. obtain a 12-lead electrocardiogram (ECG). c. obtain the blood pressure. d. check the level of consciousnes

a. administer oxygen. The initial actions of the nurse are focused on the ABCsairway, breathing, and circulationand administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration

A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to? a. Arterial blood gases b. Urinary output c. Chest tube drainage d. Pain level

a. Arterial blood gases According to the ABC priority-setting framework, the postoperative surgical client may need supplemental oxygen in order to maintain normal blood oxygen levels. The effectiveness of oxygenation is monitored using pulse oximetry and arterial blood gases.

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? a. Confusion b. Blood pressure 84/50 mm Hg c. Anuria d. Petechiae

a. Confusion Confusion is a manifestation of the compensatory stage of shock. Other manifestations include decreased urinary output, cold and clammy skin, and respiratory alkalosis.

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? a. Continue to monitor the client. b. Immediately notify the provider. c. Reposition the client toward the left side. d. Clamp the chest tube near the water seal.

a. Continue to monitor the client. The fluid in the water seal chamber rises 2 to 4 inches during inhalation and falls during exhalation. This is a process called tidaling. An absence of tidaling might indicate a fully expanded lung or an obstruction in the chest tube.

A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.) a. Elevate the head of the bed to at least 30°. b. Verify the prescribed ventilator settings daily. c. Apply restraints if the client becomes agitated. d. Administer pantoprazole as prescribed. e. Reposition the endotracheal tube to the opposite side of the mouth daily.

a. Elevate the head of the bed to at least 30° is correct. A client who is intubated is at risk for aspiration and ventilator-associated pneumonia. To minimize these risks, the nurse should maintain the head of the bed at 30° or higher. d.Administer pantoprazole as prescribed is correct. Stress ulcers occur in many patients receiving mechanical ventilation. Antacids, histamine blockers, or proton-pump inhibitors are often prescribed as soon as a client is intubated. e. Reposition the endotracheal tube to the opposite side of the mouth daily is correct. The nurse should assess the area around the endotracheal tube frequently for color, tenderness, skin irritation, and drainage. The nurse should perform oral care every 2 hr. To prevent skin breakdown, the oral endotracheal tube should be moved to the opposite side on the mouth once daily.

A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104 F, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Give acetaminophen (Tylenol) 650 mg rectally. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg

a. Give normal saline IV at 500 mL/hr. Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider? a. Movement of the trachea toward the unaffected side b. Bubbling of the water in the water seal chamber with exhalation c. Crepitus in the area above and surrounding the insertion site d. Eyelets are not visible

a. Movement of the trachea toward the unaffected side A chest tube inserted for a spontaneous pneumothorax may result in the development of a tension pneumothorax, a medical emergency. This results from air in the pleural space compressing the blood vessels of the thorax and limiting blood return to the heart. An assessment of tracheal deviation, or movement of the trachea toward the unaffected side, is indicative of tension pneumothorax and should be reported to the provider immediately.

A nurse is caring for a client who is postoperative following a laryngectomy. Which of the following actions should the nurse take? a. Provide humidified air for the client. b.Position the head of the client's bed in the flat position. c. Suction the client's mouth toward the surgical side. d. Clean the client's sutures every 8 hr.

a. Provide humidified air for the client. The nurse should provide humidification to loosen secretions and prevent crust formation.

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs?pH 7.22PaCO2 68 mm HgBase excess -2PaO2 78 mm HgSaturation 80%Bicarbonate 26 mEq/L a. Respiratory acidosis b. Metabolic acidosis c. Metabolic alkalosis d. Respiratory alkalosis

a. Respiratory acidosis Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory function. It can be the result of respiratory depression, seen with anesthesia or opioid administration; inadequate chest expansion, due to a weakness of the respiratory muscles or constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction, or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2), resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli. Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 - 7.45) and a CO2 level that is higher than the normal reference range (35 - 45 mm Hg).

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? a. Suction two to three times with a 60-second pause between passes. b. Perform chest physiotherapy prior to suctioning. c. Lubricate the suction catheter tip with sterile saline. d. Hyperventilate the client on 100% oxygen prior to suctioning.

a. Suction two to three times with a 60-second pause between passes. MY ANSWER Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia.

Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patients serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patients extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields

a. The patients serum creatinine level is elevated. The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all consistent with the patients diagnosis of cardiogenic shock

A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see? a. pH below 7.35 b.HCO3 above 26 mEq/L c. PaO2 below 70 mm Hg d. PaCO2 above 45 mm Hg

a. pH below 7.35 With acidosis, the pH is below 7.35. However, the pH alone does not indicate whether the problem is metabolic or respiratory. A pH above 7.45 indicates alkalosis.

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first? a. Prepare the client for reintubation. b. Assess the client's airway. c. Suction the client's mouth. d. Elevate the client's head of bed.

b. Assess the client's airway. The first action the nurse should take using the nursing process is to assess the client's airway for obstruction, listen to the client's lungs for air movement, and provide mechanical ventilation with a bag-valve-mask device to reduce the risk for hypoxia.

A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? a. Administration of 100% oxygen by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of continuous positive pressure ventilation (CPAP

b. Endotracheal intubation and positive pressure ventilation The patients lethargy, low respiratory rate, and SpO 2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patients respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patients respiratory rate or oxygenation. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange

A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following medications ordered. Which medication should the nurse discuss with the health care provider before giving? a. Pantoprazole (Protonix) 40 mg IV b. Gentamicin (Garamycin) 60 mg IV c. Sucralfate (Carafate) 1 g per nasogastric tube d. Methylprednisolone (Solu-Medrol) 60 mg IV

b. Gentamicin (Garamycin) 60 mg IV Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS

A patient admitted with acute respiratory failure has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action is a priority for the nurse to include in the plan of care? a. Encourage use of the incentive spirometer. b. Offer the patient fluids at frequent intervals. c. Teach the patient the importance of ambulation. d. Titrate oxygen level to keep O2 saturation >93%

b. Offer the patient fluids at frequent intervals. Because the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. Patients should be instructed to use the incentive spirometer on a regular basis (e.g., every hour) in order to facilitate the clearance of the secretions. The other actions may also be helpful in improving the patients gas exchange, but they do not address the thick secretions that are causing the poor airway clearance

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is accurate? a. PEEP will push more air into the lungs during inhalation. b. PEEP prevents the lung air sacs from collapsing during exhalation. c. PEEP will prevent lung damage while the patient is on the ventilator. d. PEEP allows the breathing machine to deliver 100% oxygen to the lungs

b. PEEP prevents the lung air sacs from collapsing during exhalation. By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage (e.g., fibrotic changes that occur with ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient

The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider? a. Blood pressure (BP) 92/56 mm Hg b. Skin cool and clammy c. Oxygen saturation 92% d. Heart rate 118 beats/minute

b. Skin cool and clammy Because patients in the early stage of septic shock have warm and dry skin, the patients cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patients status

A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? a. The patients PaO2 is 50 mm Hg and the SaO2 is 88%. b. The patient has subcutaneous emphysema on the upper thorax. c. The patient has bronchial breath sounds in both the lung fields. d. The patient has a first-degree atrioventricular heart block with a rate of 5

b. The patient has subcutaneous emphysema on the upper thorax. The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not specific indications that PEEP should be reduce

A nurse is caring for a client who is 9 days postoperative following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make? a. "Tuck your chin when you swallow so you won't choke." b. "It is no longer possible for you to choke on or aspirate food." c. "You should have no trouble swallowing fluids." d. "I will add a thickener to your liquids to prevent aspiration."

b. "It is no longer possible for you to choke on or aspirate food." The surgical procedure of total laryngectomy provides complete anatomical separation of the trachea and esophagus. Choking and aspiration of food and liquids is no longer possible.

A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which of the following? a. 300 mL b. 480 mL c. 800 mL d. 950 mL

b. 480 mL The average tidal volume is 7 to 9 mL/kg. 60 kg x 8 mL/kg = 480. Therefore, this setting is within the average range.

A nurse is caring for a client who has lung cancer and is scheduled for a lobectomy. The nurse should prepare the client to expect which of the following after the procedure? a. A sternal incision b. A chest tube c. Moderate pain d. Pulmonary function studies

b. A chest tube A lobectomy is major surgery that involves a large posterolateral or anterolateral incision into bone, muscle, and cartilage. Chest tubes are placed to drain air and fluid and remain in place for several days postoperatively.

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? a. Atelectasis b. Flail chest c. Hemothorax d. Pneumothorax

b. Flail chest Flail chest is the result of multiple rib fractures that cause instability. During inspiration, the thorax moves inward and during expiration it bulges out.

A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations 28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The nurse will anticipate an order for which medication? a. 5% human albumin b. Furosemide (Lasix) IV c. Epinephrine (Adrenalin) drip d. Hydrocortisone (Solu-Cortef)

b. Furosemide (Lasix) IV The PAWP indicates that the patients preload is elevated, and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase heart rate and myocardial oxygen demand. 5% human albumin would also increase the PAWP. Hydrocortisone might be considered for septic or anaphylactic shock.

A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take? a. Review laboratory test results for low hemoglobin. b. Observe for signs of infection. c. Monitor the mouth for signs of xerostomia. d. Examine the skin for generalized urticaria.

b. Observe for signs of infection.

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes? a. Decrease chest wall compliance b. Suppress respiratory effort c. Induce sedation d. Decrease respiratory secretions

b. Suppress respiratory effort Neuromuscular blocking agents, such as pancuronium, induce paralysis by relaxing skeletal muscles, which improves chest wall compliance.

Which finding is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 60 mL over the last hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm Hg

b. Urine output is 60 mL over the last hour. Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, CVP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.

A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was a. dysphagia. b. hoarseness. c. dyspnea. d.weight loss.

b. hoarseness. Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long exposure to tobacco and alcohol. Hoarseness that does not resolve for several weeks is the earliest manifestation of cancer of the larynx because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh and lower in pitch than normal.

After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for a. nitroglycerine (Tridil). b. norepinephrine (Levophed). c. sodium nitroprusside (Nipride). d. methylprednisolone (Solu-Medrol).

b. norepinephrine (Levophed). When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and blood pressure, and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Methylprednisolone (Solu-Medrol) is considered if blood pressure does not respond first to fluids and vasopressors. Nitroprusside is an arterial vasodilator and would further decrease SVR

To evaluate the effectiveness of ordered interventions for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse? a. Chest x-ray b. Oxygen saturation c. Arterial blood gas analysis d. Central venous pressure monitoring

c. Arterial blood gas analysis Arterial blood gas (ABG) analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs provide information about the PaCO2 and pH. The other tests may also be done to help in assessing oxygenation or determining the cause of the patients ventilatory failure

The nurse documents the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2 F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? a. Give the scheduled IV antibiotic. b. Give the PRN acetaminophen (Tylenol) c. Obtain oxygen saturation using pulse oximetry. d. Notify the health care provider of the patients vital signs

c. Obtain oxygen saturation using pulse oximetry. The patients increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Giving the scheduled antibiotic and the PRN acetaminophen will also be done, but they are not the highest priority for a patient who may be developing ARDS

Which finding about a patient who is receiving vasopressin (Pitressin) to treat septic shock is most important for the nurse to communicate to the health care provider? a. The patients urine output is 18 mL/hr. b. The patients heart rate is 110 beats/minute. c. The patient is complaining of chest pain. d. The patients peripheral pulses are weak

c. The patient is complaining of chest pain. Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery perfusion. The other information is consistent with the patients diagnosis and should be reported to the health care provider but does not indicate a need for a change in therapy

A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with a. obtaining a ventilation-perfusion scan. b. drawing blood for arterial blood gases. c. insertion of a pulmonary artery catheter. d. positioning the patient for a chest x-ray

c. insertion of a pulmonary artery catheter. Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema

A 19-year-old patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Inspiratory crackles. b. Cool, clammy extremities. c. Apical heart rate 45 beats/min. d. Temperature 101.2 F (38.4 C)

c. Apical heart rate 45 beats/min. Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? a. Hypotension b. Anuria c. Increased respiratory rate d. Decreased level of consciousness

c. Increased respiratory rate When shock occurs, the body attempts to compensate for the decreased level of oxygenation and tissue perfusion. Initially, the client will display an increased respiratory rate as the body tries to increase oxygen delivery to the tissues. Additional compensatory manifestations of shock include increased heart rate, decreased urine output, and cold, clammy skin.

A nurse is monitoring the pulmonary artery wedge pressure (PAWP) for a client. The nurse should identity that a reading of 15 mm Hg is an indication of which of the following conditions? a. Fluid volume deficit b. Right ventricular failure c. Mitral regurgitation d. Afterload reduction

c. Mitral regurgitation Hemodynamic monitoring allows the nurse to monitor the pressures within the heart and the great vessels. The PAWP reflects left atrial pressure. A reading of 15 mm Hg is above the expected reference range, which can indicate mitral regurgitation, hypervolemia, or left ventricular failure. The nurse should monitor for trends in value, which can be more reliable than individual values.

A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge? a. Attending a class given about tracheostomy care b. Verbalizing all steps in the procedure c. Performing the procedure independently d. Asking appropriate questions about suctioning

c. Performing the procedure independently The nurse should recognize that the client is ready for discharge when the spouse demonstrates an ability to perform the procedure that will need to be performed independently at home.

A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? a. Continue to monitor the client as this is an expected finding. b. Add more water to the suction control chamber of the drainage system. c. Verify that the suction regulator is on and check the tubing for leaks. d. Milk the chest tube and dislodge any clots in the tubing that are occluding it.

c. Verify that the suction regulator is on and check the tubing for leaks. A lack of bubbling may indicate that either the suction regulator is turned off or that there is a leak in the tubing.

After receiving change-of-shift report on a medical unit, which patient should the nurse assess first? a. A patient with cystic fibrosis who has thick, green-colored sputum b. A patient with pneumonia who has crackles bilaterally in the lung bases c. A patient with emphysema who has an oxygen saturation of 90% to 92% d. A patient with septicemia who has intercostal and suprasternal retraction

d. A patient with septicemia who has intercostal and suprasternal retraction This patients history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation. The other patients should also be assessed as quickly as possible, but their assessment data are typical of their disease processes and do not suggest deterioration in their status

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which action will the nurse anticipate taking next? a. Increase the tidal volume and respiratory rate. b. Increase the fraction of inspired oxygen (FIO2). c. Perform endotracheal suctioning more frequently. d. Lower the positive end-expiratory pressure (PEEP)

d. Lower the positive end-expiratory pressure (PEEP) Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for pneumothorax

A nurse is caring for a client who is 1-day postoperative following a total laryngectomy and has begun a soft diet. The client is not eating well and tells the nurse that the hospital food has no taste. Which of the following responses is appropriate for the nurse to make? a. "You should ask your family to bring you some food from home." b. "Clients frequently complain about the taste of hospital food." c. "I would be happy to get you food that you prefer to eat." d. "Because of your surgery, you have an altered ability to smell and taste."

d. "Because of your surgery, you have an altered ability to smell and taste." Clients who have lost their larynx commonly complain of poor ability to smell and taste. This is because they now breathe through the tracheal stoma, rather than the mouth and nose, which bypasses the location of the olfactory and gustatory nerve cells.

A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first? a. Pain severity b. Wound drainage c. Tissue integrity d. Airway patency

d. Airway patency When using the airway, breathing, circulation approach to client care, the nurse determines that the priority assessment is airway patency. After head and neck surgery, a major, life-threatening complication is airway obstruction. The priority actions involve airway maintenance and gas exchange.

To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. b. Palpate for abdominal pain. c. Ask the patient about nausea. d. Check stools for occult blood.

d. Check stools for occult blood. Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments also will be done, but these will not help in determining the effectiveness of the pantoprazole administration

A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the client's care? a. Patency of the intravenous line. b. Level of pain. c. Integrity of the dressing. d. Need for suctioning.

d. Need for suctioning. Using the airway, breathing, circulation (ABC) priority-setting framework, confirming a patent airway is the priority observation for a postoperative client after a total laryngectomy.

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? a. Obtain a cardiology consult. b. Suction the client less frequently. c. Administer an antidysrhythmic medication. d. Perform pre-oxygenation prior to suctionining

d. Perform pre-oxygenation prior to suctionining Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury. . In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual resuscitator bag set at 100% oxygen.

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan? a. Administer low-flow oxygen continuously via nasal cannula. b. Encourage oral intake of at least 3,000 mL of fluids per day. c. Offer high-protein and high-carbohydrate foods frequently. d. Place in a prone position.

d. Place in a prone position. Oxygenation in clients who have ARDS is improved when placed in the prone position. Frequent and consistent turning of the client is also beneficial and can be accomplished by the use of specialty beds.

A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take? a. Increase the client's wall suction. b. Strip the client's chest tube. c. Clamp the client's chest tube. d. Reposition the client.

d. Reposition the client. The nurse repositioning the client is an appropriate action to relieve chest burning from the chest tube.

A nurse is caring for a client scheduled to receive external radiation to the neck for cancer of the larynx. During a pre-treatment exam, the nurse explains to the client that the most likely side effect would be a. infertility. b. diarrhea. c. dyspnea. d. dysphagia.

d. dysphagia.