Chapter 34: Care of Critically Ill Patients with Respiratory Problems Nursing School Test Banks

Chapter 34: Care of Critically Ill Patients with Respiratory Problems

Test Bank

MULTIPLE CHOICE

1. The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus. The clients international normalized ratio (INR) is 2.0. What is the nurses best action?

a.

Increase the heparin dose.

b.

Increase the warfarin dose.

c.

Continue the current therapy.

d.

Discontinue the heparin.

ANS: D

The client who is being treated for pulmonary embolism usually continues on heparin and warfarin until the INR reaches a therapeutic level between 2 and 3. Heparin can then be discontinued because warfarin is therapeutic.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapyPharmacological Agents)

MSC: Integrated Process: Nursing Process (Implementation)

2. The nurse is caring for a postoperative client who suddenly reports difficulty breathing and sharp chest pain. After notifying the Rapid Response Team, what is the nurses priority action?

a.

Elevate the head of the bed and apply oxygen.

b.

Listen to the clients lung sounds.

c.

Pull the call bell out of the wall socket.

d.

Assess the clients pulse oximetry.

ANS: A

The clients immediate need is to have oxygen applied. The nurse should then assess the clients pulse oximetry.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)

MSC: Integrated Process: Nursing Process (Implementation)

3. It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurses priority action?

a.

Monitor the clients oxygenation.

b.

Teach the client about potential side effects.

c.

Monitor the IV insertion site.

d.

Monitor for bleeding.

ANS: A

Airway and breathing are the top priority. The nurse would also need to monitor for bleeding when administering fibrinolytic therapy, and would monitor the IV site as well. Teaching the client is also a need, however. Oxygenation is the highest priority.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)

MSC: Integrated Process: Nursing Process (Implementation)

4. A client with a large pulmonary embolism is receiving alteplase (Activase). The nurse notes frank red blood in the Foley catheter drainage bag. What is the nurses first action?

a.

Irrigate the Foley.

b.

Administer an antibiotic.

c.

Clamp the Foley.

d.

Notify the health care provider.

ANS: D

Alteplase is a fibrinolytic agent that dissolves formed clots. The drug has an impact on clots outside the pulmonary embolism, and the client is at great risk for hemorrhage and shock. The nurse should realize the potential for a severe problem and should call the health care provider immediately for orders. The other actions would not be appropriate first actions in this situation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Analysis)

5. The nurse is caring for a client with a pulmonary embolus who also has right-sided heart failure. Which symptom will the nurse need to intervene for immediately?

a.

Respiratory rate of 28 breaths/min

b.

Urinary output of 10 mL/hr

c.

Heart rate of 100 beats/min

d.

Dry cough

ANS: B

Urinary output is very low; this could indicate that the client has decreased cardiac output. The nurse will need to intervene and notify the health care provider. A respiratory rate that is slightly elevated is expected in this condition. Likewise, a heart rate that is a little higher is expected in this situation. A dry cough is also commonly found with pulmonary embolus.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Analysis)

6. A client states, At night, I usually need to sleep propped up on two pillows in the chair, but now it seems I need three pillows. What is the nurses best response?

a.

You should try to rest more during the day.

b.

You should try to lie flat for short periods of time.

c.

You need to stay in the hospital for further evaluation.

d.

You can take medication at night so you can sleep.

ANS: C

Orthopnea is the sensation of dyspnea or breathlessness in the supine position. Clients feel that they cannot catch their breath in the supine position and must rest or sleep in a semi-sitting position by placing pillows behind their backs or by using a reclining chair. The degree of breathlessness can be measured roughly by the number of pillows needed to make the client less dyspneic (e.g., one-pillow orthopnea, two-pillow orthopnea). With a client who has chronic respiratory problems, a minor increase in dyspnea may indicate a severe respiratory problem. Respiratory failure is a high risk. This client needs to stay in the hospital to be evaluated more completely. The client should not be instructed to try to lie flat, or to take a sleeping pill.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

7. A client is admitted owing to difficulty breathing. The nurse assesses the clients color, lung sounds, and pulse oximetry reading. The pulse oximetry is 90%. What is the nurses next action?

a.

Give an intermittent positive-pressure breathing treatment.

b.

Administer a rescue inhaler.

c.

Call for a chest x-ray.

d.

Assess an arterial blood gas.

ANS: D

When clients with respiratory problems are assessed, an arterial blood gas is needed for the most accurate assessment of oxygenation. No indications are known for a breathing treatment or an inhaler, nor does the nurse have enough information to know whether a chest x-ray is warranted.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

8. A client with dyspnea is becoming very anxious. An arterial blood gas (ABG) shows a PaO2 of 93 mm Hg. How does the nurse best intervene?

a.

Increase the oxygen.

b.

Administer an antianxiety medication.

c.

Administer a bronchodilator.

d.

Assist with relaxation techniques.

ANS: D

The nurse should assess the clients oxygenation; however, this clients arterial blood gas documents that the clients hypoxia has resolved. At this time it is not necessary to increase the oxygen or administer a bronchodilator; both of these interventions would be appropriate if the client were hypoxic. The client with respiratory problems should not take an antianxiety medication as a first-line intervention, because this may decrease the respiratory rate and/or alertness. The best intervention at this time is to assist with relaxation techniques.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

9. The nurse notes that each time the mechanical ventilator delivers a breath to a client with acute respiratory distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the nurses best intervention?

a.

Suction the client.

b.

Perform chest physiotherapy.

c.

Administer an inhaler.

d.

Assess the airway.

ANS: D

An increase in peak inspiratory pressure (PIP) in the ARDS client is indicative of decreased lung compliance, making it more difficult to ventilate diseased lungs. The nurse first should assess the airway to make sure no sputum is present in the airway and that no kinks are noted in the tubing. The nurse is not able to make changes in the ventilator settings, so an order is needed to increase inspiratory pressure to oxygenate the client. Suctioning or performing chest physical therapy (PT) will not help the clients lung compliance; however, if mucus is impeding the airway, these interventions would be necessary and would be noticed when the airway is assessed. Administering a bronchodilator may help the client; however, an inhaler could not be used by a client on a ventilator.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

10. The nurse is caring for several clients on the respiratory floor. Which client does the nurse assess most carefully for the development of acute respiratory distress syndrome (ARDS)?

a.

Older adult with COPD

b.

Middle-aged client receiving a blood transfusion

c.

Older adult who has aspirated his tube feeding

d.

Young adult with a broken leg from a motorcycle accident

ANS: C

The older adult who has aspirated a tube feeding is at high risk and should be assessed closely for the possibility of ARDS. A client with COPD and a middle-aged client with no other risk factors are not at as high a risk for ARDS. The client who has a broken leg from an accident is not at high risk.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

11. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation and positive end-expiratory pressure (PEEP). The alarm sounds, indicating decreased pressure in the system. What is the nurses best action?

a.

Change the clients position.

b.

Suction the client.

c.

Assess lung sounds.

d.

Turn off the pressure alarm.

ANS: C

One of the biggest risks in the client with ARDS on mechanical ventilation with PEEP is tension pneumothorax. The nurse needs to assess lung sounds hourly. The alarms on a ventilator should never be turned off. If the client needed to be suctioned, the high-pressure alarm would sound. Changing the clients position would not change the pressure needed to administer a breath.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment) MSC: Integrated Process: Nursing Process (Analysis)

12. The nurse is caring for a client who has been intubated and placed on a ventilator for treatment of acute respiratory distress syndrome (ARDS). Aside from assessing oxygenation, what is the nurses priority action?

a.

Assess hemoglobin.

b.

Administer ferrous sulfate.

c.

Assess muscle strength.

d.

Consult with the registered dietitian.

ANS: D

The client who is intubated needs nutrition delivered via enteral tube feeding. If nutrition is ignored, the clients respiratory status can deteriorate, because respiratory muscle function can deteriorate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities)

MSC: Integrated Process: Nursing Process (Implementation)

13. The nurse is caring for a client who is intubated with an endotracheal tube and on a mechanical ventilator. The client is able to make sounds. What is the nurses first action?

a.

Check cuff inflation on the endotracheal tube.

b.

Listen carefully to the client.

c.

Call the health care provider.

d.

Auscultate the lungs.

ANS: A

If the client has the cuff on the endotracheal tube inflated, the cuff should prevent air from going around the cuff and through the vocal cords. If the client can talk with the cuff inflated, the cuff probably has a leak, causing it to become deflated and allowing air to pass through. The risk is that the client will not receive the prescribed tidal volume.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment)

MSC: Integrated Process: Nursing Process (Implementation)

14. Which assessment finding of a client requires the nurses immediate action?

a.

Being intubated for 4 days

b.

Uneven breath sounds

c.

Wheezing on auscultation

d.

Having the endotracheal (ET) tube taped to the lower jaw

ANS: D

The endotracheal tube can be taped to the upper lip but should never be taped to the lower jaw because the lower jaw moves too much. The other clients need to be assessed by the nurse, but the one with the ET tube taped to the jaw requires immediate action.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Evaluation)

15. The pilot balloon on the endotracheal tube of a client being mechanically ventilated is deflated. What is the nurses priority action?

a.

Nothing; this is required during ventilation.

b.

Inflate the cuff using minimal leak technique.

c.

Call the Rapid Response Team.

d.

Increase the tidal volume.

ANS: B

The pilot balloon indicates whether the endotracheal tube cuff is inflated or deflated. A deflated balloon means that the cuff is also deflated and a seal is no longer present around the tube to prevent air from escaping. Thus, some of the air being moved into the clients airway by the ventilator is escaping through the clients trachea before it reaches the lower airways and alveoli. The nurse should inflate the cuff. Calling the Rapid Response Team is not necessary, and increasing tidal volume will not improve oxygenation if the cuff is leaking.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment)

MSC: Integrated Process: Nursing Process (Implementation)

16. The nurse is caring for a client with a ventilation/perfusion mismatch who is receiving mechanical ventilation. Which intervention is a priority for this client?

a.

Administering antibiotics every 6 hours

b.

Positioning the client with the good lung dependent

c.

Making sure that the pilot balloon line on the endotracheal tube is deflated

d.

Ensuring that the client is able to speak clearly

ANS: B

Clients who are being mechanically ventilated are experiencing a problem in that their normal ventilation is not adequate. The recommended position for clients who have one lung more affected by a problem than the other lung is to place the good lung down, keeping the healthier lung dependent to the less healthy lung. Such positioning allows gravity to keep more blood in the lower lung (healthier lung) and better ventilation in the upper lung, thus helping a ventilation/perfusion mismatch. Antibiotics are not prescribed for this disorder. The pilot balloon line should be inflated to ensure that the cuff is inflated, keeping the endotracheal tube in place and directing ventilated air into the lungs. The client with an endotracheal tube that is nonfenestrated, with the cuff inflated, will not be able to speak. Communication is addressed in other ways.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Analysis)

17. The nurse is caring for a client who is receiving mechanical ventilation accompanied by positive end-expiratory pressure (PEEP). What assessment findings require immediate intervention?

a.

Blood pressure drop from 110/90 mm Hg to 80/50 mm/Hg

b.

Pulse oximetry value of 96%

c.

Arterial blood gas (ABG): pH, 7.40; PaO2, 80 mm Hg; PaCO2, 45 mm Hg; HCO3, 26 mEq/L

d.

Urinary output of 30 mL/hr

ANS: A

Increased intrathoracic pressure can inhibit blood return to the heart and cause decreased cardiac output. This manifests with a drop in blood pressure. The pulse oximetry reading, ABGs, and urinary output are all normal.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareEstablishing Priorities) MSC: Integrated Process: Nursing Process (Analysis)

18. The client receiving mechanical ventilation has become more restless over the course of the shift. Which is the nurses first action?

a.

Sedate the client.

b.

Call the health care provider.

c.

Assess the client for pain.

d.

Assess the clients oxygenation.

ANS: D

Increasing restlessness in a client being mechanically ventilated may mean that the client is not receiving sufficient oxygen. It can also be a manifestation of pain. When in doubt, determining the adequacy of ventilation has the highest priority. The nurse would not sedate the client until the cause of the restlessness has been addressed. The nurse would call the provider if the cause could not be determined and addressed, or if the clients status deteriorated.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests, Treatments, and Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

19. The pressure reading during inspiration on the ventilator of a client receiving mechanical ventilation is fluctuating widely. What is the nurses first action?

a.

Determine whether an air leak is present in the clients endotracheal tube cuff.

b.

Have the respiratory therapist check the pressure settings.

c.

Assess the clients oxygenation.

d.

Manually ventilate the client with a resuscitation bag.

ANS: C

A widely fluctuating pressure reading is one indication of inadequate airflow and oxygenation. The nurses priority is to check the clients oxygenation status. If oxygenation is inadequate, the nurse would assess for a cause while manually ventilating the client and calling for assistance.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests, Treatments, and Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

20. A client is admitted to the emergency department several hours after a motor vehicle crash. The cars driver-side airbag was activated during the accident. Which assessment requires the nurses immediate intervention?

a.

Disorientation

b.

Hemoptysis

c.

Pulse oximetry reading of 94%

d.

Chest pain with movement

ANS: B

The nurse should be concerned about possible pulmonary contusion. Interstitial hemorrhage accompanies pulmonary contusion. Bleeding may not be evident at the initial injury, but the client develops hemoptysis and decreased breath sounds up to several hours after injury as bleeding into the alveoli or airways occurs. The pulse oximetry reading is within normal limits and chest pain is expected with movement after chest trauma. Disorientation needs to be investigated, but does not take priority over a breathing problem.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

21. The nurse assesses a client admitted for chest trauma who reports dyspnea. The nurse finds tracheal deviation and a pulse oximetry reading of 86%. What is the nurses priority intervention?

a.

Notify the health care provider and document the symptoms.

b.

Intubate the client and prepare for mechanical ventilation.

c.

Administer oxygen and prepare for chest tube insertion.

d.

Administer an intermittent positive-pressure breathing treatment.

ANS: C

Blunt chest trauma can cause an air leak into the thoracic cavity, collapsing the lung on the side with the air leak (pneumothorax). More air enters the pleural space with each breath, increasing intrathoracic pressure on the affected side, moving the trachea to the unaffected side, and leading to decreased cardiac output. This condition (tension pneumothorax) is life threatening without intervention. The client will need oxygen administration right away and a chest tube inserted.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Analysis)

22. The nurse assesses a client who has a hemothorax and a chest tube inserted on the right side. What finding requires immediate attention?

a.

Pain at the chest tube insertion site

b.

Fluctuation in the water seal chamber with breathing

c.

Puffiness of the skin around the chest tube insertion site and a crackling feeling

d.

Dullness to percussion on the affected side

ANS: C

Puffiness of the skin around the chest tube and a crackling feeling indicate subcutaneous emphysema, or air leaking into the tissue around the insertion site. This must be addressed immediately. A hemothorax involves bleeding into the thoracic cavity and decreased lung inflation on the affected side, resulting in duller and less resonant percussion notes. Pain at the insertion site, fluctuation in the water seal, and dullness to percussion are all expected.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

23. The nurse is caring for a client who is taken off a ventilator and placed on continuous positive airway pressure (CPAP). What intervention is most appropriate for this client?

a.

Administering antianxiety medications PRN

b.

Administering a medication to help the client sleep

c.

Telling the client to relax and let the ventilator do the work

d.

Making sure the client is breathing spontaneously

ANS: D

A requirement for using CPAP is that the client will be able to breathe spontaneously. Antianxiety and sleep medications should not be administered to the client during weaning. Telling the client to relax may be helpful in some cases but does not take priority over ensuring the clients ability to breathe spontaneously.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareSafe Use of Equipment) MSC: Integrated Process: Nursing Process (Assessment)

24. The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation. The clients oxygen saturation has dropped from 94% to 86%. What is the priority action by the nurse?

a.

Encourage the client to take deep, controlled breaths.

b.

Document findings and continue to monitor the client.

c.

Notify the health care provider and prepare for intubation.

d.

Stabilize the chest wall with rib binders.

ANS: C

This client has a flail chest characterized by paradoxical chest wall motion. With the oxygen saturation dropping, the client is at high risk for respiratory failure and needs to be intubated. Deep-breathing exercises are not enough at this point. Rib binders are not used anymore because they limit chest wall expansion and were used only for simple rib fractures.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationMedical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)

25. The nurse auscultates the lungs of a client on mechanical ventilation and hears vesicular breath sounds throughout the right side but decreased sounds on the left side of the chest. What is the nurses best action?

a.

Turn the client to the right side.

b.

Elevate the head of the bed.

c.

Assess placement of the endotracheal (ET) tube.

d.

Suction the client.

ANS: C

The endotracheal tube is more likely to slip into the right mainstem bronchus, leading to the breath sounds described. The nurse should assess placement of the ET tube by assessing where the markings are, making sure it is taped, and confirming equal breath sounds bilaterally. If it is believed that the tube has slipped into the right mainstem bronchus, the health care provider should order a chest x-ray and reposition the tube.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests, Treatments, and Procedures)

MSC: Integrated Process: Nursing Process (Assessment)

26. What is the best way for the nurse to communicate with a client who is intubated and is receiving mechanical ventilation?

a.

Ask the client to point to words on a board.

b.

Ask the client to blink for yes and no.

c.

Have the client mouth words slowly.

d.

Teach the client some simple sign language.

ANS: A

The nurse should have the client point to words on a board to communicate needs. The endotracheal tube is positioned and placement is maintained with tape or some other type of appliance. Asking the client to move his or her mouth and lips could result in possible extubation. Communication is limited and could be misunderstood with blinking. Teaching the client sign language, even simple, would be an involved and unrealistic goal.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)

MSC: Integrated Process: Communication and Documentation

27. A client admitted with respiratory difficulty and decreased oxygen saturation keeps pulling off the oxygen mask. What action does the nurse take?

a.

Stays with the client and replaces the oxygen mask

b.

Asks the clients spouse to hold the oxygen mask in place

c.

Restrains the client per facility policy

d.

Contacts the health care provider and requests sedation

ANS: A

Restlessness and confusion are clinical manifestations of hypoxemia. It is important that the nurse stay with the client, ensure that the oxygen is maintained, and attempt to calm the client. Because of the clients restlessness, the nurse cannot delegate care to the spouse. Requesting a sedative might adversely affect the clients respiratory status further. Restraining the client could increase restlessness and increase oxygen demand.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Implementation)

28. A client with severe respiratory insufficiency becomes short of breath during activities of daily living. Which nursing intervention is best?

a.

Call the Rapid Response Team.

b.

Decrease involvement in care until the episode is past.

c.

Cluster morning activities to provide long rest periods.

d.

Space out interventions to provide for periods of rest.

ANS: B

Clients with shortness of breath and decreased oxygen saturation must be monitored closely. Minimal involvement in activities is required if the client is severely short of breath. The nurse should continue to assess the client and can increase involvement in activities if shortness of breath subsides. The Rapid Response Team is not required. Clustering or spacing of activities does nothing to decrease the clients involvement, which is the cause of shortness of breath.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Implementation)

29. The nurse is assessing arterial blood gases (ABGs). The client with which ABG reading requires the nurses immediate attention?

a.

pH, 7.32; PaCO2, 55 mm Hg; PaO2, 70 mm Hg

b.

pH, 7.45; PaCO2, 42 mm Hg; PaO2, 70 mm Hg

c.

pH, 7.48; PaCO2, 38 mm Hg; PaO2, 60 mm Hg

d.

pH, 7.55; PaCO2, 32 mm Hg; PaO2, 50 mm Hg

ANS: D

This client has the most severe hypoxia and respiratory alkalosis, indicated by low partial pressure of arterial carbon dioxide (PaCO2) values on ABG analysis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Nursing Process (Analysis)

30. The nurse auscultates the following lung sound in a client with a respiratory disorder. What is the nurses best action? (Click the media button to hear the audio clip.)

a.

Have the client use an incentive spirometer.

b.

Have the client cough and deep breathe.

c.

Suction the client after auscultating the lower lobes of the lungs.

d.

Call for the Rapid Response Team.

ANS: D

The sound heard is stridor. Stridor on inspiration is caused by laryngospasm or edema and heralds impending airway occlusion. The clients airway is in jeopardy and immediate intervention is necessary. Using the spirometer or coughing and deep breathing will not help the client in this situation. The nurse needs to call the Rapid Response Team.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation-Medical Emergencies) MSC: Integrated Process: Nursing Process (Analysis)

MULTIPLE RESPONSE

1. Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)? (Select all that apply.)

a.

Wheezes throughout lung fields

b.

Hemoptysis

c.

Sharp chest pain

d.

Flattened neck veins

e.

Hypotension

f.

Pitting edema

ANS: B, C, E

Hemoptysis, sharp chest pain, and hypotension all may be caused by pulmonary embolism and the pulmonary hypertension that results. Rather than wheezes, crackles usually occur along with a dry cough.

DIF: Cognitive Level: Knowledge/Remembering REF: Chart 34-2, p. 664

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

2. Which clients are at highest risk for pulmonary embolism (PE)? (Select all that apply)

a.

Middle-aged client awaiting surgery

b.

Older adult with a 20pack-year history of smoking

c.

Client who has been on bedrest for 3 weeks

d.

Obese client who has elevated platelets

e.

Middle-aged client with diabetes mellitus type 1

f.

Older adult who has just had abdominal surgery

ANS: B, C, D, F

Older adults, especially those with chronic lung problems, are at higher risk for pulmonary embolism. Prolonged bedrest is also a risk factor, as are abdominal surgery and smoking. Because platelets are involved in the clotting process, elevated platelets may contribute to increased clotting. Diabetes and waiting for surgery are not known risk factors.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 663

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

3. A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)? (Select all that apply.)

a.

Oxygen administered at 100%, PaO2 60

b.

Increased dyspnea

c.

Anxiety

d.

Chest pain

e.

Pitting pedal edema

f.

Clubbing of fingertips

ANS: A, B, C

A client who is developing ARDS presents with a decrease in oxygen despite an increase in the fraction of inspired oxygen. Increased dyspnea goes along with the increased hypoxemia, as does anxiety. Chest pain is not specific to ARDS; although chest pain can occur with ARDS, it occurs with many other conditions as well. Pitting edema would not be an assessment factor that confirms ARDS. Clubbing occurs in chronic, not acute, respiratory conditions.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 671

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

4. The nurse is caring for a client on a ventilator when the high-pressure alarm sounds. What actions are most appropriate? (Select all that apply.)

a.

Assess the tubing for kinks.

b.

Assess whether the tubing has become disconnected.

c.

Determine the need for suctioning.

d.

Call the health care provider.

e.

Call the Rapid Response Team.

f.

Auscultate the clients lungs.

ANS: A, C, F

Reasons for a high-pressure alarm include water or a kink impeding airflow or mucus in the airway. The nurse first should assess the client and determine whether he or she needs to be suctioned; then the nurse should auscultate the lungs. The nurse also should assess the tubing for kinks. The high-pressure alarm sounding would not be a reason to call the health care provider or the Rapid Response Team. If the tubing became disconnected, the low-pressure alarm would sound.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment) MSC: Integrated Process: Nursing Process (Assessment)

5. The nurse is prioritizing care for a client on a ventilator. What are essential nursing interventions for this client? (Select all that apply.)

a.

Change the settings in accordance with provider orders.

b.

Modify the settings for weaning the client.

c.

Assess the reasons for alarms.

d.

Compare the ventilator settings with ordered settings.

e.

Assess the water level in the humidifier.

f.

Change the ventilator tubing according to hospital policy.

ANS: C, D, E

The nurse should assess the client when an alarm sounds and should intervene accordingly. The nurse should also check the settings to make sure they are correct and should evaluate the water level to make sure the humidifier does not go dry. The nurse would not be responsible for changing ventilator settings, weaning the client, or changing the ventilator tubing.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlSafe Use of Equipment) MSC: Integrated Process: Nursing Process (Assessment)

6. The nurse is caring for a client with a high risk for pulmonary embolism (PE). Which prevention measures does the nurse add to the clients care plan? (Select all that apply.)

a.

Use antiembolism stockings.

b.

Massage calf muscles per client request.

c.

Maintain supine position with the legs flat.

d.

Turn every 2 hours if client is in bed.

e.

Refrain from active range-of-motion exercises.

ANS: A, D

Both antiembolism stockings (or sequential pressure devices) and a turning schedule can help prevent venous thromboembolism, which can lead to PE. Massaging the calves is discouraged because this can cause a clot to break loose and travel to the lungs. Legs should be elevated when in bed, and the client should perform active range of motion (ROM) if able. If the client is unable to perform active ROM, the nurse should provide passive ROM.

DIF: Cognitive Level: Knowledge/Remembering REF: Chart 34-1, p. 663

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Planning)

SHORT ANSWER

1. A nurse is making initial rounds on assigned clients at the beginning of the shift. One client is receiving a heparin infusion at 5 mL/hr. The nurse notes that 25,000 units of heparin are mixed in 250 mL of solution. How many units per hour is the client receiving? __________ units/hr

ANS:

500

25,000 units/250 mL = X units/hr/(5 mL/hr)

250X = 125,000

X = 500 units/hr

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesDosage Calculation) MSC: Integrated Process: Nursing Process (Assessment)

2. A client is ordered heparin 5000 units at 7 AM. The heparin is provided in a vial labeled 20,000 units per mL. How much does the nurse administer? ______ mL

ANS:

0.25

5000 units/20,000 units 1 mL = 0.25 mL

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesDosage Calculation) MSC: Integrated Process: Nursing Process (Assessment)

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