Iggy Chapter 32: Care of Critically Ill Patients with Respiratory Problems

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?
a. Assess the client's lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs.
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A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?
a. Assess the client's lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs.
b. Notify the Rapid Response Team.
A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?
a. "Breathing so rapidly interferes with oxygenation."
b. "Maybe the client has respiratory distress syndrome."
c. "The blood clot interferes with perfusion in the lungs."
d. "The client needs immediate intubation and mechanical ventilation.
c. "The blood clot interferes with perfusion in the lungs."
A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
a. Decrease the heparin rate.
b. Increase the heparin rate.
c. No change to the heparin rate.
d. Stop heparin; start warfarin (Coumadin).
b. Increase the heparin rate.
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
a. Assess for other manifestations of hypoxia.
b. Change the sensor on the pulse oximeter.
c. Obtain a new oximeter from central supply.
d. Tell the client to take slow, deep breaths.
a. Assess for other manifestations of hypoxia.
An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority?
a. Determine if the tube is kinked.
b. Ensure all connections are patent.
c. Listen to the client's lung sounds.
d. Suction the endotracheal tube.
c. Listen to the client's lung sounds.
A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?
a. Assessing that the ventilator settings are correct
b. Ensuring there is a bag-valve-mask in the room
c. Obtaining personal protective equipment
d. Planning to suction the client upon arrival to the room
b. Ensuring there is a bag-valve-mask in the room
A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best?
a. "It will increase the motility of the gastrointestinal tract."
b. "It will keep the gastrointestinal tract functioning normally."
c. "It will prepare the gastrointestinal tract for enteral feedings."
d. "It will prevent ulcers from the stress of mechanical ventilation."
d. "It will prevent ulcers from the stress of mechanical ventilation."
A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?
a. Apply oxygen at 100%.
b. Assess the respiratory rate.
c. Ensure a patent airway.
d. Start two large-bore IV lines
c. Ensure a patent airway.
A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?
a. Hamburger and French fries
b. Large chef's salad and muffin
c. No selection; spouse brings pizza
d. Tuna salad sandwich and chips
b. Large chef's salad and muffin
A client in the emergency department has several broken ribs. What care measure will best promote comfort?
a. Allowing the client to choose the position in bed
b. Humidifying the supplemental oxygen
c. Offering frequent, small drinks of water
d. Providing warmed blankets
a. Allowing the client to choose the position in bed
A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin)a. Alteplase (Activase)A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority? a. Administer oxygen and reassess. b. Auscultate the client's lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.d. Prepare to assist with intubation.A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best? a. "It is chronic hypoxemia that accompanies restrictive airway disease." b. "It is hypoxemia from lung damage due to mechanical ventilation." c. "It is hypoxemia that continues even after the client is weaned from oxygen." d. "It is hypoxemia that persists even with 100% oxygen administration."d. "It is hypoxemia that persists even with 100% oxygen administration."A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a. Client who had a reaction to contrast dye yesterday b. Client with a new spinal cord injury on a rotating bed c. Middle-aged man with an exacerbation of asthma d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femurb. Client with a new spinal cord injury on a rotating bed d. Older client who is 1-day post hip replacement surgery e. Young obese client with a fractured femurWhen working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) a. Avoid drinking alcohol. b. Eat more omega-3 fatty acids. c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes.c. Exercise on a regular basis. d. Maintain a healthy weight. e. Stop smoking cigarettes.A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) a. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. d. Request a prescription for antianxiety medication. e. Stay with the client and speak in a quiet, calm voicea. Acknowledge the frightening nature of the illness. b. Delegate a back rub to the unlicensed assistive personnel (UAP). c. Give simple explanations of what is happening. e. Stay with the client and speak in a quiet, calm voiceThe nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedulea. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocolA nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the client's bedside. b. Ensure the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.a. Allow visitors at the client's bedside. b. Ensure the client can communicate if awake. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.