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Module B Practice Questions
Terms in this set (16)
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. Which primary purpose of the chest tube will the nurse consider when planning care?
Restores negative pressure in the pleural space
Negative pressure is exerted by gravity drainage or by suction through the closed system. Though the discomfort may be lessened as a result of the insertion of the chest tube, this is not the primary purpose. There is an accumulation of air, not fluid, when a pneumothorax occurs in a client with COPD. Subcutaneous emphysema in the chest wall is associated most commonly with clients receiving air under pressure, such as that received from a ventilator; subcutaneous emphysema can also occur with a chest tube)
A client is on mechanical ventilation. When condensation collects in the ventilator tubing, what should the nurse do?
Drain the fluid from the tubing
Emptying the fluid from the tubing is necessary to prevent flooding of the trachea with fluid; some systems have receptacles attached to the tubing to collect the fluid, and others have to be temporarily disconnected while the fluid is emptied. This circumstance does not require assistance from a respiratory therapist. Humidity is necessary to preserve moistness of the respiratory tract and to help liquefy secretions. The amount of condensation is irrelevant when recording total intake and output.)
A client has a laryngectomy. The avoidance of which activity identified by the client indicates that the nurse's teaching about activities and the stoma is understood?
Water sports pose a severe threat; should water enter the stoma, the client will drown. Strenuous exercises are not harmful; as long as there is no obstruction, adequate oxygen will be available because the respiratory rate will increase. Pillows are not contraindicated, although care should be taken not to occlude the airway by any bedding while asleep. Humidity is desirable and helpful in keeping secretions liquefied.)
The nurse is caring for a client with a pneumothorax and chest tube. To evaluate the effectiveness of a chest tube, the nurse assesses for which finding?
Return of breath sounds
: The return of breath sounds indicates that the lung has reinflated. A cough that raises sputum (productive cough) may indicate a complication, such as infection. The drainage should decrease, not increase. Constant bubbling in the water-seal chamber indicates that there is a leak in the closed chest drainage system. Bubbling may occur in this chamber when air exits the pleural space with a cough or forceful expiration; the fluid will rise and fall in this chamber with pleural pressure changes associated with inspiration and expiration (tidaling).)
A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator?
Assess the need for suctioning when the high-pressure alarm of the ventilator is activated
: The high-pressure alarm signifies increased pressure in the tubing or the respiratory tract; obstruction usually is caused by excessive secretions. Cuff should be inflated; it does not need to be tested this often. Humidification should occur, but the temperature should not be routinely changed. Regulating the PEEP according to the rate and depth of the client's respirations is a dependent function of the nurse and cannot be implemented without a healthcare provider's prescription.)
A client with late-stage dementia of the Alzheimer type aspirates gastric contents and develops acute respiratory distress syndrome (ARDS). Which phase characterized by signs of pulmonary edema and atelectasis should the nurse consider when planning care?
: Exudative (injury) phase of ARDS is the early phase. Alveoli become fluid-filled with pulmonary shunting and atelectasis. Fibrotic phase of ARDS leads to pulmonary hypertension and fibrosis. Reparative (resolution) phase starts about two weeks after injury; it is characterized by recovery. If this phase persists for a prolonged time, extensive fibrosis, death, or chronic disease may result.)
A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client?
Encouraging a fluid intake of 3 L daily
Increased fluids help to liquefy secretions, enabling the client to clear the respiratory tract by coughing. Suctioning frequently will irritate the mucosal lining of the respiratory tract, which can result in more secretions. An occlusive dressing will block air exchange; the tracheostomy is now the client's airway. The use of cotton balls around a tracheostomy introduces the risk of aspiration of one of the cotton fibers; gauze should be used.)
An RN from the orthopedic unit has been floated to the medical unit. Which client assignment for the floated RN is the best?
A) The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula
B) The client with chronic lung disease who is being evaluated for possible home oxygen use
C) The client with a newly placed tracheostomy who is receiving oxygen through a tracheostomy collar
D) The client with chronic bronchitis who is receiving oxygen at 60% through a Venturi mask
The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula
: Orthopedic nurses are familiar with pulmonary emboli and with administration of oxygen through nasal cannulas. Orthopedic nurses do not specialize in chronic lung conditions; such care is best assigned to an RN with experience in chronic lung conditions and in the use of various home oxygen delivery devices and the use of various types of oxygen delivery equipment. Orthopedic nurses do not specialize in airway surgery; such care is best assigned to an RN with experience in postoperative tracheostomy care and tracheostomy collar care.)
A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially?
A client with smoke inhalation and facial burns who requires high-flow oxygen should initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue. Although a Venturi mask and a non-rebreather mask are high-flow oxygen delivery devices, they require snug fitting on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device.)
Which client has the highest risk for developing a pulmonary embolism (PE)?
A) A 25-year-old woman who frequently flies to different countries
B) A 67-year-old man who works on a farm
C) A 45-year-old man admitted for a heart attack
D) A 23-year-old woman with a bleeding disorder
A 25-year-old woman who frequently flies to different countries
People who engage in prolonged and frequent air travel are at higher risk for PE. A 67-year-old man who works on a farm is not at high risk because he has an active lifestyle. A heart attack is usually caused by a thrombus or occlusion of the coronary arteries, not of the legs; if on prolonged bedrest, the client's risk is increased. PE is a clotting disorder, not a bleeding disorder.)
The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority?
Hypoxemia related to ventilation-perfusion mismatch
Restoring adequate oxygenation and tissue perfusion takes priority when a client presents with a PE. Although nutrition must be addressed, priorities include airway, breathing, and circulation. The client has a leukocytosis related to lung inflammation; leukopenia places clients at risk for infection, but this is not the priority at this time. Education as to the cause of PE must be postponed until oxygenation and hemodynamic stability occur.)
When caring for a client with pulmonary embolism (PE), which arterial blood gas results does the nurse anticipate early in the course of the disease?
A) pH 7.24, PaCO2 55 mm Hg, HCO3- 26 mEq/L, PaO2 56 mm Hg
B) pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L, PaO2 68 mm Hg
C) pH 7.35, PaCO2 45 mm Hg, HCO3- 24 mEq/L, PaO2 80 mm Hg
D) pH 7.47, PaCO2 35 mm Hg, HCO3- 30 mEq/L, PaO2 75 mm Hg
pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L, PaO2 68 mm Hg
Hyperventilation triggered by hypoxia and pain first leads to respiratory alkalosis, indicated by a low partial pressure of arterial carbon dioxide (PaCO2 of 30 mm Hg) and a high pH (7.46). No compensation is present as the bicarbonate (HCO3-) (26 mEq/L) is normal, and hypoxemia is present, consistent with PE. A pH of 7.24 is acidotic, a partial pressure of arterial oxygen (PaO2) of 56 mm Hg reflects hypoxemia, and no compensation is present with a normal HCO3- (26 mEq/L); this blood would be found in a person in acute respiratory failure owing to hypoventilation and hypoxemia. A pH between 7.35 and 7.45, PaCO2 of 35 to 45 mm Hg, HCO3- of 22 to 26 mEq/L, and PaO2 greater than 75 mm Hg all reflect normal blood gas results. A pH of 7.47 and an HCO3- of 30 mEq/L are alkalotic, indicating metabolic alkalosis; a PaCO2 of 35 mm Hg is normal (indicating lack of compensation) and a PaO2 of 75 mm Hg is normal.)
The medical-surgical unit nurse should call the Rapid Response Team to assess which client?
A) Client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis
B) Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain
C) Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry of 94%
D) Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs
Client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis
The client with a diagnosed pulmonary embolism is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin; this indicates a significant decline in status and warrants activation of the Rapid Response Team. The client with deep vein thrombosis requires ongoing monitoring and is receiving appropriate treatment; calf pain is expected in this situation. The client with a right pneumothorax requires ongoing monitoring but has normal oxygen saturation. The client who was extubated 3 days ago requires ongoing monitoring or nursing intervention, but does not have evidence of acute deterioration or severe complications.)
The nurse is teaching the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate?
"Paralysis and sedatives help decrease the demand for oxygen."
Paralytics and sedation decrease oxygen demand. Sedation is needed more for its effects on oxygenation than to prevent the client from ripping out the endotracheal tube. Suctioning is performed to maintain airway patency. Minimizing fluids while administering diuretics leads to better outcomes.)
The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which method provides an alternative to mechanical ventilation?
Bi-level positive airway pressure (BiPAP)
BiPAP ventilation is a noninvasive method that may provide short-term ventilation without intubation. An oropharyngeal airway is used to prevent the tongue from occluding the airway or the client from biting the endotracheal tube. A non-rebreather mask will assist with oxygenation; however, muscle fatigue and hypoventilation may occur as causes of respiratory failure. The need for PEEP indicates a severe gas-exchange problem; this modality is "dialed in" on the mechanical ventilator.)
The nurse is caring for a group of clients. Which clients should be monitored closely for respiratory failure? (Select all that apply.)
A) Client with a brainstem tumor
B) Client with acute pancreatitis
C) Client with a T3 spinal cord injury
D) Client using patient-controlled analgesia
E) Client experiencing cocaine intoxication
Client with a brainstem tumor, Client with acute pancreatitis, Client with a T3 spinal cord injury, Client using patient-controlled analgesia
: Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome; abdominal distention also ensues, which can limit respiratory excursion. Clients with cervical and thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect intercostal muscles are affected. Opiates, which can depress the brainstem, present risk factors for respiratory failure. All of these clients should be monitored closely for respiratory failure. Cocaine is a stimulant, which would not cause respiratory failure unless a stroke ensued.)
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