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Theory IV Exam 2
Terms in this set (81)
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take?
a. Suction the patient's oropharynx.
b. Increase the prescribed O2 flow rate.
c. Instruct the patient to cough and deep breathe.
d. Help the patient to sit in a more upright position.
Increasing O2 flow rate will usually improve O2 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.
A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?
a. Administration of 100% O2 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)
The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Giving high-flow O2 will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.
The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes, a weak cough effort, and complains of fatigue. Which action should the nurse take next?
a. Position the patient on the left side.
b. Assist the patient with staged coughing.
c. Place a humidifier in the patient's room.
d. Schedule a 4-hour rest period for the patient.
The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 4-hour rest period at this time may allow the O2 saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the left side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.
A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to improve gas exchange?
a. On the left side
b. On the right side
c. In the tripod position
d. In the high-Fowler's position
The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions.
When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider?
a. The patient is very somnolent.
b. The patient complains of weakness.
c. The patient's blood pressure is 164/98.
d. The patient's oxygen saturation is 90%.
Increasing somnolence (drowsiness) will decrease the patient's 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.
The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider?
a. Persistent cough of blood-tinged sputum.
b. Scattered crackles in the posterior lung bases.
c. Oxygen saturation 90% on 100% O2 by nonrebreather mask.
d. Temperature 101.5° F (38.6° C) after 2 days of IV antibiotics.
The patient's low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.
Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/LVN) working in the intensive care unit?
a. Assess breath sounds every hour.
b. Monitor central venous pressures.
c. Place patient in the prone position.
d. Insert an indwelling urinary catheter.
Insertion of indwelling urinary catheters is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff, and should be supervised by an RN. Assessment of breath sounds and obtaining central venous pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient.
A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider?
a. O2 saturation of 99%
b. Heart rate 106 beats/minute
c. Crackles audible at lung bases
d. Respiratory rate 22 breaths/minute
The FIO2 of 80% increases the risk for O2 toxicity. Because the patient's O2 saturation is 99%, a decrease in FIO2 is indicated to avoid toxicity. The other patient data would be typical for a patient with ARDS and would not be the most important data to report to the health care provider.
Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?
a. No sedative has been ordered for the patient.
b. The patient does not respond to verbal stimulation.
c. There is no cough or gag reflex when the patient is suctioned.
d. The patient's oxygen saturation remains between 90% to 93%.
Because neuromuscular blockade is extremely anxiety provoking, it is essential that patients who are receiving neuromuscular blockade receive concurrent sedation and analgesia. Absence of response to stimuli is expected in patients receiving neuromuscular blockade. The O2 saturation is adequate.
The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider?
a. Red-brown drainage from nasogastric tube
b. Blood urea nitrogen (BUN) level 32 mg/dL
c. Scattered coarse crackles heard throughout lungs
d. Arterial blood gases: pH of 7.31, PaCO2 of 50, and PaO2 of 68
The nasogastric drainage indicates possible gastrointestinal bleeding or stress ulcer and should be reported. The pH and PaCO2 are slightly abnormal, but current guidelines advocating for permissive hypercapnia indicate that these would not indicate an immediate need for a change in therapy. The BUN is slightly elevated but does not indicate an immediate need for action. Adventitious breath sounds are commonly heard in patients with ARDS.
The nurse reviews the electronic health record for a patient scheduled for a total hip replacement. Which assessment data shown in the accompanying figure increase the patient's risk for respiratory complications after surgery?History Lab Data Physical AssessmentAge 81 H&H 11.8/38% LCTAMed/Surg history: Albumin 2.7 Mildly confused:Recent 15lb weight loss, disoriented to date,Knee arthroscopy 3 oriented to person and placemonths ago
a. Older age and anemia
b. Albumin level and weight loss
c. Recent arthroscopic procedure
d. Confusion and disorientation to time
The patient's recent weight loss and low protein stores indicate possible muscle weakness, which make it more difficult for an older patient to recover from the effects of general anesthesia and immobility associated with the hip surgery. The other information will also be noted by the nurse but does not place the patient at higher risk for respiratory failure.
Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)?
a. Obtain arterial blood gases daily.
b. Provide a "sedation holiday" daily.
c. Give prescribed pantoprazole (Protonix).
d. Elevate the head of the bed to at least 30°.
e. Provide oral care with chlorhexidine (0.12%) solution daily.
ANS: B, C, D, E
The nurse is caring for a 27-yr-old man with multiple fractured ribs from a motor vehicle crash. Which clinical manifestation, if experienced by the patient, is an early indication that the patient is developing respiratory failure?
A Tachycardia and pursed lip breathing
B Kussmaul respirations and hypotension
C Frequent position changes and agitation
D Cyanosis and increased capillary refill time
A change in mental status is an early indication of respiratory failure. The brain is sensitive to variations in oxygenation, arterial carbon dioxide levels, and acid-base balance. Restlessness, confusion, agitation, and combative behavior suggest inadequate oxygen delivery to the brain
A 72-yr-old woman with aspiration pneumonia develops severe respiratory distress. Her PaO2 is 42 mmHg and FIO2 is 80%. Which intervention should the nurse complete first?
A Stat portable chest radiography
B Administer lorazepam (Ativan) 1 mg IV push
C Place the patient in a prone position on a rotational bed
D Position the patient with arms supported away from the chest
The nurse will first position the patient to facilitate ventilation. Additional oxygen support may be necessary. Refractory hypoxemia indicates the patient is not demonstrating acute lung injury but has now developed acute respiratory distress syndrome (ARDS). If the PaO2 is 42 mm Hg on 80% FIO2 (fraction of inspired oxygen; room air is 21% FIO2), then the PaO2/FIO2 ratio is 52.5, indicating ARDS (PaO2/FIO2 ratio < 200). Stat portable chest radiography may show worsening infiltrates or "white lung." A rotational bed placing the patient in prone position would be a strategy to use for select patients with ARDS. This patient's age, diagnosis, and comorbidities may indicate appropriateness for this treatment. Administration of lorazepam (Ativan) 1 mg may be harmful to this patient's oxygenation status. Further assessment would be needed to determine safety
The nurse is caring for a 37-yr-old female patient with multiple musculoskeletal injuries who has developed acute respiratory distress syndrome (ARDS). Which intervention should the nurse initiate to prevent stress ulcers?
A Observe stools for frank bleeding and occult blood.
B Maintain head of the bed elevation at 30 to 45 degrees.
C Begin enteral feedings as soon as bowel sounds are present.
D Administer prescribed lorazepam (Ativan) to reduce anxiety.
Stress ulcers prevention includes early initiation of enteral nutrition to protect the gastrointestinal (GI) tract from mucosal damage. Antiulcer agents such as histamine (H2)-receptor antagonists, proton pump inhibitors, and mucosal protecting agents are also indicated to prevent stress ulcers. Monitoring for GI bleeding does not prevent stress ulcers. Ventilator-associated pneumonia related to aspiration is prevented by elevation of the head of bed to 30 to 45 degrees Stress ulcers are not caused by anxiety. Stress ulcers are related to GI ischemia from hypotension, shock, and acidosis
A 56-yr-old man with acute respiratory distress syndrome (ARDS) is on positive pressure ventilation (PPV). The patient's cardiac index is 1.4 L/min and pulmonary artery wedge pressure is 8 mm Hg. What order by the physician is important for the nurse to question?
A Initiate a dobutamine infusion at 3 mcg/kg/min.
B Administer 1 unit of packed red blood cells over the next 2 hours.
C Change the maintenance intravenous (IV) rate from 75 to 125 mL/hr.
D Increase positive end-expiratory pressure (PEEP) from 10 to 15 cm H2O.
Patients on PPV and PEEP frequently experience decreased cardiac output (CO) and cardiac index (CI). High levels of PEEP increase intrathoracic pressure and cause decreased venous return which results in decreased CO. Interventions to improve CO include lowering the PEEP, administering crystalloid fluids or colloid solutions, and use of inotropic drugs (e.g., dobutamine, dopamine). Packed red blood cells may also be administered to improve CO and oxygenation if the hemoglobin is less than 9 or 10 mg/dL
A patient is in acute respiratory distress syndrome (ARDS) as a result of sepsis. Which measure would be implemented to maintain cardiac output?
A Administer crystalloid fluids.
B Position the patient in the Trendelenburg position.
C Place the patient on fluid restriction and administer diuretics.
D Perform chest physiotherapy and assist with staged coughing.
Low cardiac output may necessitate crystalloid fluids in addition to lowering positive end-expiratory pressure (PEEP) or administering inotropes. The Trendelenburg position (not recommended to treat hypotension) and chest physiotherapy are unlikely to relieve decreased cardiac output, and fluid restriction and diuresis would be inappropriate interventions
Which patient would most benefit from noninvasive positive pressure ventilation (NIPPV) to promote oxygenation?
A A patient whose cardiac output and blood pressure are unstable
B A patient whose respiratory failure is due to a head injury with loss of consciousness
C A patient with a diagnosis of cystic fibrosis and who is currently producing copious secretions
D A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis
NIPPV such as continuous positive airway pressure (CPAP) is most effective in treating patients with respiratory failure resulting from chest wall and neuromuscular disease. It is not recommended in patients who are experiencing hemodynamic instability, decreased level of consciousness, or excessive secretions
The nurse in the cardiac care unit is caring for a patient who has developed acute respiratory failure. Which medication is used to decrease patient pulmonary congestion and agitation?
For a patient with acute respiratory failure related to the heart, morphine is used to decrease pulmonary congestion as well as anxiety, agitation, and pain. Albuterol is used to reduce bronchospasm. Azithromycin is used for pulmonary infections. Methylprednisolone is used to reduce airway inflammation and edema
Maintenance of fluid balance in the patient with ARDS involves
a. hydration using colloids.
b. administration of surfactant.
c. fluid restriction and diuretics as necessary.
d. keeping the hemoglobin at levels above 9 g/dL (90 g/L).
In a patient with ARDS, management of fluid balance includes limiting pulmonary edema by monitoring stroke volume variation or maintaining the pulmonary artery wedge pressure as low as possible without impairing cardiac output. Patients are often placed on fluid restriction, and diuretics are used as necessary
When explaining respiratory failure to the patient's family, what should the nurse use as an accurate description?
a. The absence of ventilation
b. Any episode in which part of the airway is obstructed
c. Inadequate gas exchange to meet the metabolic needs of the body
d. An episode of acute hypoxemia caused by a pulmonary dysfunction
Respiratory failure results when the transfer of oxygenor carbon dioxide function of the respiratory system isimpaired and, although the definition is determined by PaO2and PaCO2 levels, the major factor in respiratory failure isinadequate gas exchange to meet tissue oxygen (O2) needs. Absence of ventilation is respiratory arrest and partial airway obstruction may not necessarily cause respiratory failure. Acute hypoxemia may be caused by factors other than pulmonary dysfunction
When the V/Q lung scan result returns with a mismatch ratio that is greater than 1, which condition should be suspected?
c. Pulmonary embolus
d. Ventricular septal defect
There will be more ventilation than perfusion (V/Qratio greater than 1) with a pulmonary embolus. Pain andatelectasis will cause a V/Q ratio less than 1. A ventricularseptal defect causes an anatomic shunt as the bloodbypasses the lungs
What are the primary pathophysiologic changes that occur in the injury or exudative phase of ARDS (SATA)?
b. Shortness of breath
c. Interstitial and alveolar edema
d. Hyaline membranes line the alveoli
e. Influx of neutrophils, monocytes, and lymphocytes
ANS: A, C, D
The injury or exudative phase is the early phase of ARDS when atelectasis and interstitial and alveoli edemaoccur and hyaline membranes composed of necrotic cells,protein, and fibrin line the alveoli. Together, these decreasegas exchange capability and lung compliance. Shortnessof breath occurs but it is not a physiologic change. Theincreased inflammation and proliferation of fibroblastsoccurs in the reparative or proliferative phase of ARDS,which occurs 1 to 2 weeks after the initial lung injury
The nurse suspects that a patient with PEEP is experiencing negative effects of this ventilatory maneuver when which of the following is assessed?
a. Increasing PaO2
b. Decreasing blood pressure
c. Decreasing heart rate (HR)
d. Increasing central venous pressure (CVP)
PEEP increases intrathoracic and intrapulmonicpressures, compresses the pulmonary capillary bed, andreduces blood return to both the right and left sides ofthe heart. Increased PaO2 is an expected effect of PEEP.Preload (CVP) and cardiac output (CO) are decreased,often with a dramatic decrease in BP
Prone positioning is considered for a patient with ARDS who has not responded to other measures to increase PaO2. The nurse knows that this strategy will
a. increase the mobilization of pulmonary secretions.
b. decrease the workload of the diaphragm and intercostal muscles.
c. promote opening of atelectatic alveoli in the upper portion of the lung.
d. promote perfusion of nonatelectatic alveoli in the anterior portion of the lung.
When a patient with ARDS is supine, alveoli in theposterior areas of the lung are dependent & fluid-filledand the heart and mediastinal contents place more pressure on the lungs, predisposing to atelectasis. If the patient is turned prone, air-filled nonatelectatic alveoli in the anterior portion of the lung receive more blood and perfusion may be better matched to ventilation, causing less V/Q mismatch. Lateral rotation therapy is used to stimulate postural drainage and help mobilize pulmonary secretions
Norepinephrine (Levophed) has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine?
a. The patient's central venous pressure is 3 mm Hg.
b. The patient is in sinus tachycardia at 120 beats/min.
c. The patient is receiving low dose dopamine (Intropin).
d. The patient has had no urine output since being admitted.
Adequate fluid administration is essential before administration of vasopressors to patients with hypovolemic shock. The patient's low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.
Which assessment information is most important for the nurse to obtain to evaluate whether treatment of a patient with anaphylactic shock has been effective?
a. Heart rate
c. Blood pressure
d. Oxygen saturation
Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.
The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a right forearm IV. Which assessment finding obtained by the nurse indicates a need for immediate action?
a. The patient's heart rate is 58 beats/minute.
b. The patient's extremities are warm and dry.
c. The patient's IV infusion site is cool and pale.
d. The patient's urine output is 28 mL over the last hour.
The coldness and pallor at the infusion site suggest extravasation of the phenylephrine. The nurse should discontinue the IV and, if possible, infuse the medication into a central line. An apical pulse of 58 is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-mL urinary output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it does not indicate a need for a change in therapy or immediate action.
A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)?
a. Prepare to administer atropine IV.
b. Obtain baseline body temperature.
c. Infuse large volumes of lactated Ringer's solution.
d. Provide high-flow oxygen (100%) by non-rebreather mask.
e. Prepare for emergent intubation and mechanical ventilation.
ANS: A, B, D, E
All of the actions are appropriate except to give large volumes of lactated Ringer's solution. The patient with neurogenic shock usually has a normal blood volume, and it is important not to volume overload the patient. In addition, lactated Ringer's solution is used cautiously in all shock situations because the failing liver cannot convert lactate to bicarbonate.
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.
ANS: 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.
The client with which laboratory result is at risk for hemorrhagic shock?
A. International normalized ratio (INR) 7.9
B. Partial thromboplastin time (PTT) 12.5 seconds
C. Platelets 170,000/mm3
D. Hemoglobin 8.2 g/dL
Prolonged INR indicates that blood takes longer than normal to clot; this client is at risk for bleeding. PTT of 12.5 seconds and a platelet value of 170,000/mm3 are both normal and pose no risk for bleeding. Although a hemoglobin of 8.2 g/dL is low, the client could have severe iron deficiency or could have received medication affecting the bone marrow.
The nurse reviews the medical record of a client with hemorrhagic shock, which contains the following information: Pulse 140 beats/min and thready, ABG respiratory acidosis, Blood pressure 60/40 mm Hg, Lactate level 7 mOsm/L, Respirations 40/min and shallow. All of these provider prescriptions are given for the client. Which does the nurse carry out first?
A. Notify anesthesia for endotracheal intubation.
B. Give Plasmanate 1 unit now.
C. Give normal saline solution 250 mL/hr.
D. Type and crossmatch for 4 units of packed red blood cells (PRBCs).
Establishing an airway is the priority in all emergency situations. Although administering Plasmanate and normal saline, and typing and crossmatching for 4 units of PRBCs are important actions, airway always takes priority.
A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? (Select all that apply.)
A. Ask family members to stay with the client.
B. Call the health care provider.
C. Increase IV and oxygen rates.
D. Remain with the client.
E. Reassure the client that everything is being done for him or her.
ANS: A, D, E
Having a familiar person nearby may provide comfort to the client. The nurse should remain with the client who is demonstrating physiologic deterioration. Offering genuine reassurance supports the client who is anxious. The health care provider should be notified, and increasing IV and oxygen rates may be needed, but these actions do not support the client's psychosocial integrity.
Which clients are at immediate risk for hypovolemic shock? (Select all that apply.)
A. Unrestrained client in motor vehicle accident
B. Construction worker
D. Surgical intensive care client
E. 85-year-old with gastrointestinal virus
ANS: A, D, E
The client who is unrestrained in a motor vehicle accident is prone to multiple trauma and bleeding. Surgical clients are at high risk for hypovolemic shock owing to fluid loss and hemorrhage. Older adult clients are prone to shock; a gastrointestinal virus results in fluid losses. Unless injured or working in excessive heat, the construction worker and the athlete are not at risk for hypovolemic shock; they may be at risk for dehydration.
A massive gastrointestinal bleed has resulted in hypovolemic shock in an older patient. What is a priority nursing diagnosis?
a. Acute pain
b. Impaired skin integrity
c. Decreased cardiac output
d. Ineffective tissue perfusion
The many deleterious effects of shock are all related to inadequate perfusion and oxygenation of every body system. This nursing diagnosis supersedes the other diagnoses
The nurse would recognize which clinical manifestation as suggestive of sepsis?
a. Sudden diuresis unrelated to drug therapy
b. Hyperglycemia in the absence of diabetes
c. Respiratory rate of seven breaths per minute
d. Bradycardia with sudden increase in blood pressure
Hyperglycemia in patients with no history of diabetes is a diagnostic criterion for sepsis. Oliguria, not diuresis, typically accompanies sepsis along with tachypnea and tachycardia
After coronary artery bypass graft surgery a patient has postoperative bleeding that requires returning to surgery for repair. During surgery, the patient has a myocardial infarction (MI). After restoring the patient's body temperature to normal, which patient parameter is the most important for planning nursing care?
a. Cardiac index (CI) of 5 L/min/m2
b. Central venous pressure of 8 mm Hg
c. Mean arterial pressure (MAP) of 86 mm Hg
d. Pulmonary artery pressure (PAP) of 28/14 mm Hg
Pulmonary hypertension as indicated by an elevated PAP indicates impaired forward flow of blood because of left ventricular dysfunction or hypoxemia. Both can be a result of the MI. The CI, CVP, and MAP readings are normal
Appropriate treatment modalities for the management of cardiogenic shock include (select all that apply)
a. dobutamine to increase myocardial contractility.
b. vasopressors to increase systemic vascular resistance.
c. circulatory assist devices such as an intraaortic balloon pump.
d. corticosteroids to stabilize the cell wall in the infarcted myocardium.
e. Trendelenburg positioning to facilitate venous return and increase preload.
ANS: A, C
Dobutamine (Dobutrex) is used in patients in cardiogenic shock with severe systolic dysfunction. Dobutamine increases myocardial contractility, decreases ventricular filling pressures, decreases systemic vascular resistance and pulmonary artery wedge pressure, and increases cardiac output, stroke volume, and central venous pressure. Dobutamine may increase or decrease the heart rate. The workload of the heart in cardiogenic shock may be reduced with the use of circulatory assist devices such as an intraaortic balloon pump or ventricular assist device
As the body continues to try to compensate for hypovolemic shock, there is increased angiotensin II from the activation of the renin-angiotensin-aldosterone system. What physiologic change occurs r/t the increased angiotensin II?
b. decreased BP and CO
c. aldosterone release results in sodium and water excretion
d. ADH release increases water reabsorption
The pt is in compensatory stage of shock, what manifestations indicate this to the nurse (select all)
a. pale and cool
c. lower BP than baseline
d. moist crackles in the lungs
e. hyperactive bowel sounds
f. tachypnea and tachycardia
ANS :A, C, F
The nurse suspects sepsis as a cause of shock when the laboratory test results indicate
c. decreased hemoglobin
d. increased blood urea nitrogen (BUN)
A pt w/ acute pancreatitis is experiencing hypovolemic shock. which initial orders for the pt will the nurse implement first?
a. start 1000 mL of NS at 500 ml/hr
b. obtain blood cultures before starting IV antibiotics
c. draw blood for hematology and coagulation factors
d. administer high-flow oxygen w/ a non-rebreather mask
A pt w/ hypovolemic shock is receiving LR solution for fluid replacement therapy. During this therapy, which laboratory result is the most important for the nurse to monitor?
a. serum pH
b. serum sodium
c. serum potassium
d. Hgb and Hct
During administration of IV norepinephrine (Levophed), what should the nurse assess the patient for?
b. marked diuresis
c. metabolic alkalosis
d. decreased tissue perfusion
When administering any vasoactive drug during the treatment of shock, the nurse should know that what is the goal of therapy?
a. increasing urine output to 50 mL/day
b. constriction of vessels to maintain BP
c. maintaining a MAP of at least 65 mm Hg
d. dilating vessels to improve tissue perfusion
A pt in the progressive stage of shock has rapid, deep respirations. The nurse documents that the patient's hyperventilation is compensating for metabolic acidosis when the patient's ABG results include what?
a. pH 7.42, PaO2 80 mm Hg
b. pH 7.48, PaO2 69 mmHg
c. pH 7.38, PaO2 30 mmHg
d. pH 7.32, PaO2 48 mm Hg
what statements describing systemic inflammatory response syndrome (SIRS) and/or multiple organ dysfunction syndrome (MODS) is accurate?
a. MODS may occur independently from SIRS
b. all pts w/ septic shock develop MODS
c. the GI system is often the first to show evidence of dysfunction in SIRS and MODS
d. a common initial mediator that causes endothelial damage leading to SIRS and MODS is endotoxin
A patient w/ a gunshot wound to the abdomen is being treated for hypovolemic and septic shock. To monitor the pt for early organ damage associated w/ MODS, what is the most important for the nurse to assess?
a. urine output
b. breath sounds
c. peripheral circulation
d. central venous pressure
increase SVR, BP, and improve tissue perfusion
Septic Assessment Findings can include
- Respiratory rate above 20
- A heart rate above 90
- WBC less than 4000 or over 12000
- hypo/hyperthermia (<96.8 or >100.4)
Sepsis is most common cause of SIRS, therefore
- infective sources should be removed asap
- strict/proper hand washing
- pts should be ambulated asap
T or F: Enteral nurtition is perfered to parenteral who are unable to take PO b/c enteral helps maintain integrity of intestine
Treatment for VAP
- Assess readiness for extubation daily
- Keep HOB elevated > than 30
- Sedation holiday
- Protonix (also known as Pantoprazole, PPI)
If decreased perfusion to the gut, what are assessment findings?
- absent bowel sounds
- hypoactive bowel sounds
- GI bleeding
- paralyitc ileus
Risk factors for ARDS
- gastropulmonary aspiration/reflux
- Massive blood product transfusion
- used to temporary IV inotropic support that should be given to those in cardiogenic shock
- short-term use for pts with decreased contractility due to heart failure or cardiac surgery
- used to treat cardiac decompensation (weakened heart muscles)
Clinical Manifestation of DIC
- Confusion/speech changes/trouble speeking/dizziness
- blood in urine or no urine
- bleeding at site of wounds from surgical cuts/placement of needles
Tx for Anaphylactic shock
epinephrine, oxygen, antihistamine/steriods, and beta-agonist (like albuterol)
Medication examples of nephrotoxic drugs
- aminoglucoside antibiotics (-mycin) like gentamicin and tobramycin
- amphotericin B & Cyclosporine
- Chemotherapeutic drugs like carboplatin or cisplatin
- NSAIDS & Radiocontrast dye
First line vasopressor in septic shock
- epinephrine and vasopressin are 2nd line for refactory shock
- used to control frequent urination, increased thirst, and DM
- one of the strongest vasopressor agents for septic shock
- more time needed to reach a steady state and achieve an adequate increased BP
- depending on dose can cause coronary vasoconstriction or vasodilation
T or F: Nurse should teach pt good forceful coughing techniques using abdominal muscles
Best indicator for fluid resusictation has been successful
DIC can be characterized by
- include a low platelet count
- elevated D-dimer concentration
- prolonged clotting times such as PT
- presense of petechiae
T or F: Ventilation-perfusion mismatch occurs with PE therefore O2 flow rates should be increased in these patients
ARDS characteristics include
- increased RR
- Diagnosis of gram negative sepsis
Findings in pt who is having difficulty breathing
- intercostal & suprasternal retractions
- decreased SpO2
- labored breathing
What value are you concerned regarding a PaO2 in the ICU
60 and below
PaO2 can indicate
hypoxemia and respiratory failure
Ventilator alarm trouble shooting should include (list order)
- Assess pt
- check for leads/disconnections starting from pt following tube back to vent
- assess vent to make sure its power cord is plugged into an electric outlet
- begin manual ventilation w/ ambubag if problem cannot be identified and pt is symptomatic
What is the intial treatment for hypotension in pts with septic shock
T of F: a nonrebreathing mask can deliver a concentration of up to 95% oxygen with an oxygen flow rate of 10 to 15 L/min
Normal PaO2 level
80-100 mm Hg
When All values are abnormal
- if one is high while others low, is respiratory
- if all values go in same direction, is metabolic
pH brought back within normal range
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.
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 caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?
a. Elevate head of bed to 30 to 45 degrees.
b. Give enteral feedings at no more than 10 mL/hr.
c. Suction the endotracheal tube every 2 to 4 hours.
d. Limit the use of positive end-expiratory pressure.
Elevation of the head decreases the risk for aspiration. Positive end-expiratory pressure is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient's high energy needs.
In caring for the patient with ARDS, what is the most characteristic sign the nurse would expect the patient to exhibit?
a. Refractory hypoxemia
b. Bronchial breath sounds
c. Progressive hypercapnia
d. Increased pulmonary artery wedge pressure (PAWP)
(Refractory hypoxemia, hypoxemia that does not respondto increasing concentrations of oxygenation by any route,is a hallmark of ARDS and is always present. Bronchialbreath sounds may be associated with the progression ofARDS. PaCO2 levels may be normal until the patient is nolonger able to compensate in response to the hypoxemia.Pulmonary artery wedge pressure (PAWP) that is normallyelevated in cardiogenic pulmonary edema is normal in thepulmonary edema of ARDS.)
After endotracheal intubation and mechanical ventilation have been started, a patient in respiratory failure becomes very agitated and is breathing asynchronously with the ventilator. What is it most important for the nurse to do first?
a. Evaluate the patient's pain level, ABGs, and electrolyte values
b. Sedate the patient to unconsciousness to eliminate patient awareness
c. Administer the PRN vecuronium (Norcuron) to promote synchronous ventilations
d. Slow the rate of ventilations provided by the ventilator to allow for spontaneous breathing by the patient
(It is most important to assess the patient for the causeof the restlessness and agitation (e.g., pain, hypoxemia,electrolyte imbalances) and treat the underlying causebefore sedating the patient. Although sedation, analgesia,and neuromuscular blockade are often used to controlagitation and pain, these treatments may contribute toprolonged ventilator support and hospital days.)
Which changes of aging contribute to the increased risk for respiratory failure in older adults (select all that apply)?
a. Alveolar dilation
b. Increased delirium muscle strength
c. Changes in vital signs
d. Increased infection risk
e. Decreased respiratory
f. Diminished elastic recoil within the airways
ANS: A, D, E, F
(Changes from aging that increase the olderadult's risk for respiratory failure include alveolar dilation,increased risk for infection, decreased respiratory musclestrength, and diminished elastic recoil in the airways.Although delirium can complicate ventilator management,it does not increase the older patient's risk for respiratoryfailure. The older adult's blood pressure (BP) and heart rate(HR) increase but this does not affect the risk for respiratoryfailure. The ventilatory capacity is decreased and the largerair spaces decrease the surface area for gas exchange, which increases the risk.)
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