Chapter 63: Management of Clients with Acute Pulmonary Disorders Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 63: Management of Clients with Acute Pulmonary Disorders

MULTIPLE CHOICE

1. In the nursing care of a client recently intubated and placed on mechanical ventilation, the nursing action that would take highest priority is

a.

assessing for pedal pulses regularly.

b.

monitoring blood pressure frequently.

c.

monitoring temperature every 4 hours.

d.

turning the client every 2 hours.

ANS: B

The lowered cardiac output will be reflected in the hypotension that clients typically exhibit immediately after being placed on mechanical ventilation. It is imperative that blood pressure be monitored closely.

DIF: Application/Applying REF: p. 1643 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

2. A client who was extubated 2 hours ago is becoming increasingly restless. The last vital signs before extubation were pulse 88 beats/min, respirations 18 breaths/min, blood pressure mm Hg, and PaCO2 45 mm Hg. Current vital signs include pulse 104 beats/min, respirations 26 breaths/min, blood pressure mm Hg, and PaCO2 62 mm Hg. The nurse would

a.

administer a nebulized bronchodilator.

b.

assist with reintubation.

c.

obtain a complete blood count (CBC).

d.

prepare the client for a tracheostomy.

ANS: B

The nurse should assess the client for indications of respiratory distress and hypoxemia, as evidenced by restlessness, irritability, tachycardia, tachypnea, and decreased PaO2 or increased PaCO2. If these manifestations are noted, the nurse should notify the physician and prepare for reintubation.

DIF: Analysis/Analyzing REF: p. 1652 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Medical Emergencies

3. The nurse monitoring a client with adult respiratory distress syndrome (ARDS) would closely assess for

a.

atelectasis.

b.

cor pulmonale.

c.

pneumonia.

d.

pulmonary edema.

ANS: D

The hallmark of ARDS is increased permeability of the pulmonary endothelium and alveolar epithelium, with resultant movement of fluid into the interstitial and alveolar spaces. This leads to the development of pulmonary edema, which decreases lung compliance and impairs oxygen transport.

DIF: Application/Applying REF: pp. 1652-1653

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

4. A client admitted to the emergency department (ED) with severe chest injuries and significant hypovolemia caused by hemorrhage would be transfused to replace blood loss initially with

a.

albumin.

b.

dextrose 5% in normal saline.

c.

type AB-negative blood.

d.

type O-negative blood.

ANS: D

A chest-injured client may require large quantities of blood replacement. Until the results of typing and crossmatching are available, the client is given O-negative blood.

DIF: Knowledge/Remembering REF: p. 1658 OBJ: Intervention

MSC: Physiological Adaptation Pharmacological and Parenteral Therapies-Blood and Blood Products

5. When a client is admitted to the ED with tension pneumothorax and mediastinal shift following an automobile accident, the nurse would know that the client would exhibit

a.

a sucking chest wound.

b.

bradycardia.

c.

mediastinal flutter.

d.

severe hypotension.

ANS: D

Mediastinal shift may cause (a) compression of the lung in the direction of the shift and (b) compression, traction, torsion, or kinking of the great vessels; thus blood return to the heart is dangerously impaired. The latter causes a subsequent decrease in cardiac output and blood pressure.

DIF: Comprehension/Understanding REF: p. 1663 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Medical Emergencies

6. The nurse would explain that emergency treatment of a tension pneumothorax requires

a.

a small stab wound with a skin blade made into the pleural space.

b.

covering the chest wall wound with gauze.

c.

immediate tracheostomy.

d.

insertion of an 18-gauge needle into the pleural space.

ANS: D

The immediate intervention is to convert tension pneumothorax into open pneumothorax (a less serious disorder). If a delay is anticipated (with chest tube insertion), a 14- to 18-gauge needle is inserted into the pleural space of the affected side at the level of the second intercostal space at the midclavicular line.

DIF: Knowledge/Remembering REF: p. 1663 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Medical Emergencies

7. When a client is admitted to the ED with a sucking chest wound, the nurse initially would

a.

cover the wound with whatever is available.

b.

leave the wound open.

c.

notify the physician.

d.

obtain a sterile gauze petroleum dressing to cover the wound.

ANS: A

When an open sucking chest wound is detected, emergency intervention includes immediately covering the wound securely with anything available. The nurse should not waste time looking for a sterile gauze petroleum dressing if it is not immediately available.

DIF: Application/Applying REF: p. 1662 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Medical Emergencies

8. After dressing a sucking chest wound, the nurse notes that the client is developing severe dyspnea, tachypnea, cyanosis, tachycardia, and asymmetrical chest movements. The nurse would

a.

check the chest dressing for any air leakage.

b.

insert an 18-gauge needle into the pleural space.

c.

notify the physician.

d.

remove the chest dressing.

ANS: D

If a tension pneumothorax appears to be developing after the wound is sealed, the nurse should immediately unplug the seal to allow the air to escape.

DIF: Application/Applying REF: p. 1662 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Medical Emergencies

9. When a client developed a hemothorax, the physician inserted a chest catheter connected to a drainage system. In the first 2 hours, 900 ml of blood drainage was collected. The nurse would

a.

clamp the tubing.

b.

continue observation of the drainage.

c.

monitor the clients vital signs.

d.

report this to the physician immediately.

ANS: D

Large amounts of drainage (200 ml/hr or more) should be reported the physician immediately.

DIF: Application/Applying REF: p. 1663 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

10. Once a near-drowning victim is stabilized, the nurse would continue to assess the client for

a.

bronchospasm.

b.

dyspnea.

c.

electrolyte imbalances.

d.

shock.

ANS: B

Clients are at high risk for pulmonary edema even several hours after a near-drowning incident.

DIF: Application/Applying REF: p. 1664 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications from Surgical Procedures and Health Alteration

11. The nurse would explain that the use of positive end-expiratory pressure (PEEP) assists the client on mechanical ventilation by

a.

gradually increasing the amount of oxygen delivered.

b.

increasing the amount of expired carbon dioxide.

c.

keeping the alveoli open.

d.

using a pressure of 30 cm H2O.

ANS: C

PEEP keeps the alveoli open to offer more ventilation surface by using pressures of 5 to 20 cm H2O.

DIF: Comprehension/Understanding REF: p. 1643 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

12. As part of the immediate care plan for a client with pulmonary edema and a nursing diagnosis of Impaired Gas Exchange, the nurse would

a.

administer oxygen as ordered using a high-flow rebreather bag.

b.

bring a tracheostomy set to the bedside.

c.

monitor vital signs every 30 to 45 minutes until stable.

d.

position the clients legs above heart level.

ANS: A

The nurse should monitor vital signs every 15 minutes initially until the client is stable and administer oxygen as ordered using a high-flow rebreather bag to maintain oxygenation (oxygen saturation above 90%). Mechanical ventilation and intubation equipment should be nearby. To reduce preload, the client should be positioned with the legs dependent. Raising edematous legs increases venous return and will stress the overtaxed left ventricle.

DIF: Application/Applying REF: p. 1637 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Medical Emergencies

13. A client with respiratory failure was intubated with an oral endotracheal (ET) tube 2 hours ago. Suspecting that the tube has changed position slightly since insertion, the nurse would assess the

a.

results of the chest x-ray film taken 2 hours earlier.

b.

current oxygen saturation readings.

c.

status of the clients breath sounds.

d.

position of the numbers on the ET tube at the lip line.

ANS: D

The nurse records in the nursing notes and on the respiratory flow sheet the point at which the ET tube meets the lips or nostrils by using the numbers listed on the tubes side. If the tube slips, its correct position can be quickly established. Then the nurse should listen to lung sounds.

DIF: Application/Applying REF: pp. 1639-1640

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

14. A client who sustained a head injury is intubated and receiving volume-cycled mechanical ventilation via the controlled mechanical ventilation (CMV) mode. The nurse would explain that this means

a.

a preset amount of pressure stays in the clients lungs at the end of exhalation.

b.

spontaneous inspiratory effort triggers the ventilator to deliver a preset tidal volume.

c.

the clients own breaths can become stacked with the ventilator breaths.

d.

the ventilator delivers the preset volume regardless of the clients efforts.

ANS: D

In the CMV mode the volume-cycled ventilator delivers a preset tidal volume. No allowance is made for spontaneous breaths. Because the ventilator is not responsive to the clients efforts, the CMV mode can lead to agitation and asynchrony.

DIF: Comprehension/Understanding REF: pp. 1642, 1643

OBJ: Comprehension/Understanding

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

15. A client who underwent surgery is intubated and receiving mechanical ventilation. The client is receiving a neuromuscular blocking agent to stop spontaneous breathing that is not in synchrony with the ventilator. The appropriate approach by the nurse to the clients postoperative pain control would be

a.

a sedative should be given with an anxiolytic and the neuromuscular blocker to control pain.

b.

an analgesic is needed specifically for pain control and must be given as needed along with the neuromuscular blocker and a sedative or anxiolytic.

c.

sedatives should be given with the neuromuscular blocking agent, and together these will control pain.

d.

the neuromuscular blocking agent will prevent pain impulse transmission, so the prn analgesic order is unnecessary.

ANS: B

Because the neuromuscular blocking agent does not inhibit pain or awareness, it is combined with a sedative or an anti-anxiety agent (anxiolytic). Pain medication may also be required if the client has pain.

DIF: Application/Applying REF: p. 1645 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

16. The nurse would determine that a client is having a dysfunctional ventilatory weaning response if the clients respiratory rate rises to

a.

20 breaths per minute.

b.

25 breaths per minute.

c.

30 breaths per minute.

d.

35 breaths per minute.

ANS: D

Manifestations of respiratory muscle fatigue include a respiratory rate of more than 30 breaths per minute or higher, increased PaCO2, abnormal patterns of breathing, hemodynamic changes (e.g., dysrhythmias), diaphoresis, anxiety, and dyspnea.

DIF: Comprehension/Understanding REF: p. 1652 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Unexpected Response to Therapies

17. When the ED nurse receives a radio call from an ambulance transporting a client who sustained chest trauma and has a severe flail chest, the nurse would set up the treatment area with

a.

an intubation tray.

b.

petroleum jelly gauze.

c.

a pulse oximeter.

d.

rib spreaders.

ANS: A

Treatment is usually with intubation and mechanical ventilation, which can (a) restore adequate ventilation, thus reducing hypoxia and hypercapnea; (b) decrease paradoxical motion by using positive pressure to stabilize the chest wall internally; (c) relieve pain by decreasing movement of the fractured ribs; and (d) provide an avenue for removal of secretions.

DIF: Application/Applying REF: p. 1660 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Medical Emergencies

18. The nurse would determine that a client with fractured ribs needs further self-care instructions when the client says

a.

I can take pain medication every 4 hours if I need it.

b.

Ill be sure to take it really easy for the next several weeks.

c.

Ill strap the ribs snugly so they cant move around.

d.

That heating pad in the closet at home will come in handy now.

ANS: C

Fractured ribs are generally treated conservatively with rest, local heat, and analgesics. Strapping the ribs is no longer recommended because it restricts deep breathing and can increase the incidence of atelectasis and pneumonia.

DIF: Application/Applying REF: p. 1658 OBJ: Evaluation

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

19. A client is being transported to the ED after sustaining carbon monoxide (CO) poisoning in a house fire. The nurse would prepare to administer

a.

100% oxygen therapy.

b.

intermittent positive-pressure breathing.

c.

suctioning.

d.

ventilation with 50% oxygen by manual resuscitation bag.

ANS: A

CO poisoning is treated by inhalation of 100% oxygen to shorten the half-life of CO to about an hour. Hyperbaric oxygen may be required to reduce the half-life of CO to minutes by forcing it off of the hemoglobin molecule.

DIF: Application/Applying REF: p. 1665 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Medical Emergencies

20. When a client with a cuffed ET tube reports shortness of breath, the nurse would

a.

give the ordered pain medication.

b.

assess for a cuff leak.

c.

increase the level of O2 delivery.

d.

elevate the head of the bed.

ANS: B

If the client can talk, the cuff is not inflated. The complaint of shortness of breath is also related to the ET tube not being tightly fitted.

DIF: Application/Applying REF: p. 1641 OBJ: Assessment

MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment

21. As part of the care of a mechanically ventilated client, the nursing action that would be inappropriate is

a.

providing oral care every 2 hours.

b.

keeping the head of the bed flat while intubated.

c.

using aseptic technique for suctioning.

d.

washing the hands before and after care.

ANS: B

Ventilator-acquired pneumonia (VAP) is a preventable nosocomial infection that occurs as early as 48 hours after intubation. Interventions to prevent VAP include performing meticulous oral care (a major cause is colonization by oropharyngeal secretions), using aseptic technique to suction, employing good hand-washing technique, and keeping the head of the bed elevated to 30 degrees or higher.

DIF: Application/Applying REF: p. 1645 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

22. A clients ventilator alarm begins to ring. The nurse enters the room and notes that the low expired minute volume alarm is sounding. After quickly determining that the client is in no acute distress, the nurse would

a.

add more water to the humidifier.

b.

look for a kink in the tubing.

c.

look for a leak or disconnection in the system.

d.

suction the clients secretions.

ANS: C

Possible causes of low expired minute volume include low spontaneous client breathing activity, leakage in the cuff, leakage in the client circuit, and improper alarm limit setting. The nurse should check cuff pressure and the client circuit, performing a leakage test if necessary, and check pause time and graphics to verify, while considering more ventilatory support for the client.

DIF: Application/Applying REF: pp. 1643, 1644

OBJ: Assessment

MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment

23. A nurse is providing community education on home safety. An important safety measure to prevent carbon monoxide poisoning is to instruct clients to

a.

have furnaces maintained professionally on a regular basis.

b.

inspect all electrical plugs before using them.

c.

install smoke detectors on each floor of the house.

d.

store a fire extinguisher near or in the kitchen.

ANS: A

Carbon monoxide (CO) is a colorless, odorless, tasteless gas that is formed by incomplete combustion of carbon fuels. CO poisoning is associated with being in an enclosed space with gases or fire. Faulty furnaces also are a risk factor; therefore furnaces should be professionally maintained on an annual basis.

DIF: Application/Applying REF: p. 1664 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

24. A client has severe adult (acute) respiratory distress syndrome (ARDS) and has not responded to several different treatments. An independent nursing action that might help the client would be to

a.

administer antioxidants as ordered.

b.

place the client in a prone position.

c.

turn the client every 2 hours.

d.

use meticulous hand-washing before client care.

ANS: B

Prone positioning improves oxygenation by changing the distribution of perfusion in the lungs. ARDS is thought to damage the most dependent parts of the lung, so by positioning the client prone, there is a change in the dependent portions and increased perfusion to the less damaged part. Positioning is an independent nursing function. Administering medications is a dependent nursing function. Hand-washing is always an important intervention, but will not improve oxygenation in a client with ARDS.

DIF: Analysis/Analyzing REF: p. 1655 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

25. A client with pulmonary edema is receiving intravenous nitroglycerin. The spouse becomes upset and says Nobody told me my spouse had a heart attack! The best response by the nurse is to say The nitroglycerin

a.

can prevent a heart attack brought on by the stress to the heart.

b.

helps get rid of extra fluid in the body.

c.

helps the heart to not work so hard.

d.

treats the chest pain that goes along with pulmonary edema.

ANS: C

Nitroglycerin reduces preload, thereby reducing the hearts workload. It does not prevent a heart attack in the setting of pulmonary edema, it does not diurese the client, and it does not treat chest pain associated with pulmonary edema.

DIF: Comprehension/Understanding REF: p. 1637 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Expected Effects/Outcomes

26. A client with ARDS has severe air hunger and is extremely anxious. The nurse would administer which medication to help both problems?

a.

Lorazepam (Ativan)

b.

Morphine sulfate (morphine)

c.

Furosemide (Lasix)

d.

Nitroglycerin (Tridil)

ANS: B

Morphine helps reduce preload and also will mildly sedate the client, relieving both the air hunger and the anxiety.

DIF: Application/Applying REF: p. 1637 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Expected Effects/Outcomes

MULTIPLE RESPONSE

1. A client has rapidly progressing ARDS. Which actions by the nurse can help the family during this crisis? (Select all that apply.)

a.

Avoid disturbing them in the waiting room.

b.

Limit visiting time so the family does not fatigue.

c.

Provide frequent condition updates.

d.

Use clear communication.

ANS: C, D

ARDS can progress rapidly and still has a high death rate, leaving the family unprepared and in crisis. Nursing actions that can assist the family in this situation include providing frequent updates on their loved ones condition and using clear communication.

DIF: Application/Applying REF: p. 1657 OBJ: Intervention

MSC: Psychological Integrity Coping and Adaptation-Coping Mechanisms

2. The nurse planning care for an intubated client includes which interventions to prevent accidental extubation? (Select all that apply.)

a.

Avoid opioid analgesics to prevent confusion and sedation.

b.

Do not reposition the client unless absolutely necessary.

c.

Keep tubing out of the clients reach.

d.

Provide adequate sedation and pain control.

e.

Use wrist restraints according to hospital policy.

ANS: C, D, E

There are several suggested actions to prevent accidental extubation. See Box 63-2 for a comprehensive list. Option a is wrong because the client may need pain control and withholding analgesia is unethical. Option b is wrong because all clients need to be repositioned at least every 2 hours.

DIF: Application/Applying REF: p. 1651 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Safe Use of Equipment

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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