Chapter 29: Critical Care of Patients with Respiratory Emergencies

Which client will the nurse assess most frequently for a venous thromboembolism (VTE) to prevent harm from a pulmonary embolism (PE)?

A. 75-year old with left heart failure

B. 65-year-old with breast cancer

C. 55-year-old after a total knee replacement

D. 44-year-old with type 2 diabetes mellitus

C. 55-year-old after a total knee replacement

Which additional assessment findings support the nurse's suspicion that the client who reports a sudden onset of shortness of breath may have a pulmonary embolism (PE)? Select all that apply?

A. Sp0, 85%

B. Hoarseness

C. Diaphoresis

D. Hypertension

E.Crushing chest pain radiating to the jaw

F. Crackles in a lower lung lobe

A. Sp0, 85%

C. Diaphoresis

F. Crackles in a lower lung lobe

In addition to arterial blood gas levels, for which diagnostic test will the nurse prepare a client who is suspected to have a pulmonary embolism (PE)?

A. Computed tomography pulmonary angiography

B. Carbon monoxide diffusion capacity

C. Pneumoencephalogram

D. 12-lead ECG

AA. Computed tomography pulmonary angiography

Which action will the nurse instruct an assistive personnel (AP) to avoid performing on a client after abdominal surgery to prevent harm from a pulmonary embolism?

A. Encouraging fluid intake

B. Massaging the clients calves

C. Ambulating the client in the hall

D. Changing the clients position every 2 hours

B. Massaging the clients calves

Which actions are most appropriate for the nurse to take immediately when a client has indications of a pulmonary embolism (PE)?

Select all that apply.

A. Apply oxygen.

B. Reassure the client.

C. Increase the IV flow rate.

D. Elevate the head of the bed.

E. Initiate the Rapid Response Team.

F. Instruct the client to not cross his or her legs.

A. Apply oxygen.

B. Reassure the client.

D. Elevate the head of the bed.

E. Initiate the Rapid Response Team.

What changes in care orders does the nurse anticipate in response to reporting to the primary health care provider that a client who has been receiving heparin IV for the past 3 days may have received twice the prescribed dose?

Select all that apply.

A. Activated partial thromboplastin time (aPTT)

B. International normalized ratio (INR)

C. Arterial blood gas (ABG) values

D. Protamine sulfate

E. Prothrombin time

F. Vitamin K

A. Activated partial thromboplastin time (aPTT)

D. Protamine sulfate

Which change in a client's laboratory values does the nurse interpret as being consistent with the presence of a pulmonary embolism (PE)?

A. pH 7.36

B. Elevated D-dimer

C. Low levels of factor V Leiden

D. Decreased leukocyte count

B. Elevated D-dimer

Which symptoms indicate to the nurse that the management of a client with a pulmonary embolism (PE) is not effective? Select all that apply.

A. Partial thromboplastin time (PTT) is 2.0 times normal

B. ECG shows increasing dysthythmias

C. Client has stopped sweating

D. Neck veins are distended

E. Sacral edema is present

F. Pulse oximetry is 88%

B. ECG shows increasing dysthythmias

D. Neck veins are distended

E. Sacral edema is present

F. Pulse oximetry is 88%

The nurse anticipates a prescription for which drug when the client with a pulmonary embolism being managed with IV crystalloids remains hypotensive with a low cardiac output?

A. Alteplase

B. Warfarin

C. Morphine

D. Dobutamine

D. Dobutamine

Which client information indicates to the nurse that management of a pulmonary embolism

(PE) is effective? Select all that apply.

A. Pulse oximetry of 95%

B. Arterial blood gas, pH of 7.28

C. Clients desire to go home

D. Absence of pallor or cyanosis

E. Mental status at client's baseline

F. Palpable peripheral pulses

A. Pulse oximetry of 95%

D. Absence of pallor or cyanosis

E. Mental status at client's baseline

F. Palpable peripheral pulses

Which precaution is a priority for the nurse to teach a client as part of discharge instructions af ter a pulmonary embolism (PE) to prevent harm?

A. Report excessive bleeding immediately.

B. Take your pulse and temperature twice daily.

C. Drink at least 3 L of water or other fluids daily.

D. Avoid crowds, small children, and people who are ill.

A. Report excessive bleeding immediately.

By which critical arterial blood gas (ABG)

values will the nurse interpret as meeting the classification for acute respiratory failure?

Select all that apply.

A. Paco, 39 mm Hg

B. Paco, 62 mm Hg

C. Pao, 78 mm Hg

D. Pao, 55 mm Ig

E. pH value of < 7.3

F. Sao2 80%

B. Paco, 62 mm Hg

D. Pao, 55 mm Ig

E. pH value of < 7.3

F. Sao2 80%

Which action is most important for the nurse

to perform first for a client suspected of having acute respiratory failure?

A. Initiating an IV

B. Applying oxygen

C. Calling the Rapid Response Team

D. Asking the client about a history of respiratory disorders

B. Applying oxygen

Which client will the nurse consider to be at

greatest risk for acute respiratory distress syndrome (ARDS)?

A. 22-year-old who received 10 units of blood after a motor vehicle accident

B. 24-year-old with asthma who has not taken prescribed asthma medications for 2 weeks

C. 62-year-old with chronic obstructive pulmonary disease who has pneumonia

D. 78-year-old with chronic heart failure and pulmonary edema

A. 22-year-old who received 10 units of blood after a motor vehicle accident

Which assessment will the nurse perform first when a client at risk for acute respiratory distress syndrome (ARDS) becomes cyanotic and diaphoretic?

A. Compare current ECG tracing with baseline measurement.

B. Measure the blood pressure in both arms.

C. Auscultate breath sounds bilaterally.

D. Measure pulse oximetry.

D. Measure pulse oximetry.

Which phase of acute respiratory syndrome

(ARDS) case management does the nurse identify for a client who has been intubated for 6 days and has progressive hypoxemia that responds poorly to high levels of oxygen?

A. Resolution phase

B. Recovery phase

C. Exudative phase

D. Fibrosing alveolitis phase

D. Fibrosing alveolitis phase

Which action does the nurse take first when a

client who is intubated and being mechanically

ventilated has an oxygen saturation of 89%, a

heart rate of 120 beats/min, is increasingly agitated and restless, and has lung sounds that are finished on one side?

A. Notify the provider and prepare for re-intubation or repositioning the tube.

B. Document the findings and request a prescription for a sedative.

C. Call respiratory therapy to obtain a set of arterial blood gases

D. Reposition the tube and call radiology for a stat chest x-ray

A. Notify the provider and prepare for re-intubation or repositioning the tube.

Which assessment finding in a client with an endotracheal tube most strongly indicates to the nurse that the tube remains correctly in the trachea and is not in the esophagus?

A. Stomach contents cannot be aspirated.

B. Oxygen saturation is greater than 50%.

C. End-tidal carbon dioxide level is 38 mm Hg.

D. No air is heard in the stomach when auscultated with a stethoscope.

C. End-tidal carbon dioxide level is 38 mm Hg

For which problems will the nurse specifically assess when the high-pressure alarm of a client's mechanical ventilator sounds? Select all that apply.

A. Mucus plug

B. Bronchospasm

C. Client coughing

D. Air leak in tube cuff

E. Client fighting the ventilator

F. Ventilator tubing disconnected

A. Mucus plug

B. Bronchospasm

C. Client coughing

E. Client fighting the ventilator

Which clients will the nurse expect to most likely need to be intubated and mechanically ventilated? Select all that apply.

A. 25-year-old with burns who has severe swelling of oral mucosa

B. 38-year-old with copious secretions and ineffective cough

C. 45-year-old with SpO, of 93% on a high-flow oxygen face mask

D. 56-year-old with pneumonia, increasing fatigue, and shallow respirations

E. 62-year-old with COPD who is able to cough and has an SpO2 of 90%

F. 72-year-old with moderate heart failure and orthopnea

A. 25-year-old with burns who has severe swelling of oral mucosa

B. 38-year-old with copious secretions and ineffective cough

D. 56-year-old with pneumonia, increasing fatigue, and shallow respirations

Which action will the nurse take first to prevent harm for a client being mechanically ventilated who is biting and chewing at the endotracheal tube (ET)?

A. Request an order for soft wrist restraints.

B. Immediately suction the client's mouth.

C. Administer a paralyzing agent.

D. Insert an oral airway.

D. Insert an oral airway.

What are the characteristics of a mechanical ventilator that is pressure-cycled? Select all that apply.

A. Its main function is to provide positive pressure only during expiration to keep lungs partially inflated.

B. Air is forced into the lungs during inhalation until a preset pressure is reached

C. The client's own inspiratory efforts control the volume provided.

D. It usually requires either a tracheostomy or endotracheal tube.

E. A safety feature is that a client cannot be hyperventilated.

F. Tidal volumes and inspiratory times are

varied.

B. Air is forced into the lungs during inhalation until a preset pressure is reached

D. It usually requires either a tracheostomy or endotracheal tube.

F. Tidal volumes and inspiratory times are

varied.

Which actions are most important for the nurse to perform to prevent a mechanically ventilated client from developing ventilator-associated pneumonia (VAP)? Select all that apply.

A. Preventing aspiration

B. Performing oral care every at least 12 hours

C. Suctioning every 1-2 hours around the clock

D. Turning and repositioning client every 2 hours

E. Preventing pressure ulcers around the mouth

F. Keeping the HOB elevated at least 30 degrees

A. Preventing aspiration

B. Performing oral care every at least 12 hours

D. Turning and repositioning client every 2 hours

E. Preventing pressure ulcers around the mouth

F. Keeping the HOB elevated at least 30 degrees

Which assessment finding for a client who is receiving mechanical ventilation in synchronized intermittent mandatory ventilation

(SIM) mode indicates to the nurse probable readiness to be weaned?

A. Fever from a respiratory infection has resolved.

B. Client is alert and oriented to place and person.

C. Client receives 1-2 mechanical ventilator breaths/min.

D. Arterial blood gas values are maintained within normal limits.

CC. Client receives 1-2 mechanical ventilator breaths/min.

Which assessment finding does the nurse expect for a client who was extubated 2 hours ago?

A. Restlessness

B. Hoarseness

C. Dyspnea

D. Stridor

B hoarseness

Which conditions indicate to the nurse that a client being mechanically ventilated needs to be suctioned? Select all that apply.

A. Presence of ronchi when listening to breath sounds

B. Presence of moisture in the ventilator tubing

C. Audible secretions in the endotracheal tube

D. Low-pressure alarm sounds

E. Increased peak inspiratory pressure (PIP)

F. Tubing becomes disconnected from the ventilator

A. Presence of ronchi when listening to breath sounds

C. Audible secretions in the endotracheal tube

E. Increased peak inspiratory pressure (PIP)

Which assessment is most important for the

nurse to perform for a client with chest trauma who is at high risk for a pulmonary contusion?

A. Observing for chest movements

B. Aulscultating for breath sounds

C. Listening for hyperresonance

D. Observing for deviation

B. Aulscultating for breath sounds

Which assessment findings indicate to the nurse that a client with a flail chest may require mechanical ventilation?

A. Constant pain and anxiety

B. Hypoxemia and hypercarbia

C. Paradoxical chest movements

D. Tachycardia and hypertension

B. Hypoxemia and hypercarbia