MS Exam 1 Flashcards
After assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?
a. Weak cough effort
b. Profuse green sputum
c. Respiratory rate of 28 breaths/minute
d. Resting pulse oximetry (SpO2) of 85%
ANS: A
The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.
The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?
a. Increased tactile fremitus c. Hyperresonance to percussion
b. Dry, nonproductive cough d. A grating sound on auscultation
ANS: A
Increased tactile fremitus over the area of pulmonary consolidation is expected with bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal pneumonia typically presents with a loose, productive cough. Adventitious breath sounds such as crackles and wheezes are typical. A grating sound is more representative of a pleural friction rub rather than pneumonia.
A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance?
a. Restrict oral fluids during the day.
b. Teach pursed-lip breathing technique.
c. Assist the patient to splint the chest when coughing.
d. Encourage the patient to wear the nasal O2 cannula.
ANS: C
Coughing is less painful and more likely to be effective when the patient splints the chest during coughing. Fluids should be encouraged to help liquefy secretions. Nasal O2 will improve gas exchange, but will not improve airway clearance. Pursed-lip breathing is used to improve gas exchange in patients with chronic obstructive pulmonary disease but will not improve airway clearance.
The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions?
a. “I will call my health care provider if I still feel tired after a week.”
b. “I will continue to do deep breathing and coughing exercises at home.”
c. “I will schedule two appointments for the pneumonia and influenza vaccines.”
d. “I will cancel my follow-up chest x-ray appointment if I feel better next week.”
ANS: B
Patients should continue to cough and deep breathe after discharge. Fatigue is expected for several weeks. The pneumococcal and influenza vaccines can be given at the same time in different arms. A follow-up chest x-ray needs to be done in 6 to 8 weeks to evaluate resolution of pneumonia.
Which action should the nurse plan to prevent aspiration in a high-risk patient?
a. Turn and reposition an immobile patient at least every 2 hours.
b. Place a patient with altered consciousness in a side-lying position.
c. Insert a nasogastric tube for feeding a patient with high calorie needs.
d. Monitor respiratory symptoms in a patient who is immunosuppressed.
ANS: B
With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and O2 saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Conditions that increase the risk of aspiration include decreased level of consciousness (e.g., seizure, anesthesia, head injury, stroke, alcohol intake), difficulty swallowing, and nasogastric intubation with or without tube feeding.
A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective?
a. Bronchial breath sounds are heard at the right base.
b. The patient coughs up small amounts of green mucus.
c. The patient’s white blood cell (WBC) count is 9000/µL.
d. Increased tactile fremitus is palpable over the right chest.
ANS: C
The normal WBC count indicates that the antibiotics have been effective. All the other data suggest that a change in treatment is needed.
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?
a. Teach about the reason for the blood tests.
b. Schedule an appointment for a chest x-ray.
c. Teach the patient about providing specimens for 3 consecutive days.
d. Instruct the patient to collect several separate sputum specimens today.
ANS: C
Sputum specimens are obtained on 2 to 3 consecutive days for bacteriologic testing for Mycobacterium tuberculosis. The patient should not provide all the specimens at once. Blood cultures are not used for tuberculosis testing. A chest x-ray is not bacteriologic testing. Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely based on chest x-ray findings because other diseases can mimic the appearance of TB.
A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider’s order to discontinue airborne precautions unless which assessment finding is documented?
a. Chest x-ray shows no upper lobe infiltrates.
b. TB medications have been taken for 6 months.
c. Mantoux testing shows an induration of 10 mm.
d. Sputum smears for acid-fast bacilli are negative.
ANS: D
Repeated negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. Chest x-rays are not used to determine whether treatment has been successful. Taking medications for 6 months is necessary, but the multidrug-resistant forms of the disease might not be eradicated after 6 months of therapy. Repeat Mantoux testing would not be done because the result will not change even with effective treatment.
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?
a. “I will take the bus instead of driving.”
b. “I will stay indoors whenever possible.”
c. “My spouse will sleep in another room.”
d. “I will keep the windows closed at home.”
ANS: C
Teach the patient how to minimize exposure to close contacts and household members. Homes should be well ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or on public transportation.
A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient’s illness?
a. Ask the patient about any visual changes in red-green color discrimination.
b. Question the patient about experiencing shortness of breath, hives, or itching.
c. Explain that orange discolored urine and tears are normal while taking this medication.
d. Advise the patient to stop the drug and report the symptoms to the health care provider.
ANS: C
Orange-colored body secretions are a side effect of rifampin. The patient does not have to stop taking the medication. The findings are not indicative of an allergic reaction. Alterations in red-green color discrimination commonly occurs when taking ethambutol, which is a different tuberculosis medication.
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?
a. Yellow-tinged sclera
b. Orange-colored sputum
c. Thickening of the fingernails
d. Difficulty hearing high-pitched voices
ANS: A
Noninfectious hepatitis is a toxic effect of isoniazid, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy. Presbycusis is an expected finding in the older adult patient. Orange discoloration of body fluids is an expected side effect of rifampin and not an indication to call the health care provider.
A patient diagnosed with active tuberculosis (TB) is homeless and has a history of alcohol abuse. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
a. Repeat warnings about the high risk for infecting others several times.
b. Give the patient written instructions about how to take the medications.
c. Arrange for a daily meal and drug administration at a community center.
d. Arrange for the patient’s friend to administer the medication on schedule.
ANS: C
Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen, and arranging a daily meal will help ensure that the patient is available to receive the medication. The other nursing interventions may be appropriate for some patients but are not likely to be as helpful for this patient’s situation.
After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?
a. Teach about drug-resistant TB.
b. Schedule directly observed therapy.
c. Ask the patient whether medications have been taken as directed.
d. Discuss the need for an injectable antibiotic with the health care provider.
ANS: C
The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed.
Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse?
a. Use and side effects of isoniazid
b. Standard four-drug therapy for TB
c. Need for annual repeat TB skin testing
d. Bacille Calmette-Guérin (BCG) vaccine
ANS: A
The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test result. BCG vaccine is not used in the United States for TB and would not be helpful for this individual, who already has a TB infection.
The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse?
a. The patient is offered a tissue from the box at the bedside.
b. A surgical face mask is applied before visiting the patient.
c. A snack is brought to the patient from the unit refrigerator.
d. Hand washing is performed before entering the patient’s room.
ANS: B
A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the patient’s room because the HEPA mask can filter out 100% of small airborne particles. Hand washing before entering the patient’s room is appropriate. Because anorexia and weight loss are frequent problems in patients with TB, bringing food to the patient is appropriate. The student nurse should perform hand washing after handling a tissue that the patient has used, but no precautions are necessary when giving the patient an unused tissue.
An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease?
a. Treat workers with pulmonary fibrosis.
b. Teach about symptoms of lung disease.
c. Require the use of protective equipment.
d. Monitor workers for coughing and wheezing.
ANS: C
Prevention of lung disease requires the use of appropriate protective equipment such as masks. The other actions will help in recognition or early treatment of lung disease but will not be effective in prevention of lung damage. Repeated exposure eventually results in diffuse pulmonary fibrosis. Fibrosis is the result of tissue repair after inflammation.
Which information about prevention of lung disease should the nurse include for a patient with a 42 pack-year history of cigarette smoking?
a. Resources for support in smoking cessation
b. Reasons for annual sputum cytology testing
c. Erlotinib (Tarceva) therapy to prevent tumor risk
d. Computed tomography (CT) screening for cancer
ANS: A
Because smoking is the major cause of lung cancer, the most important role for the nurse is teaching patients about the benefits of and means of smoking cessation. CT scanning is currently being investigated as a screening test for high-risk patients. However, if there is a positive finding, the person already has lung cancer. Sputum cytology is a diagnostic test, but does not prevent cancer or disease. Erlotinib may be used in patients who have lung cancer, but it is not used to reduce the risk of developing cancer.
A lobectomy is scheduled for a patient with stage I non–small cell lung cancer. The patient tells the nurse, “I would rather have chemotherapy than surgery.” Which response by the nurse is most appropriate?
a. “Are you afraid that the surgery will be very painful?”
b. “Did you have bad experiences with previous surgeries?”
c. “Tell me what you know about the treatments available.”
d. “Surgery is the treatment of choice for stage I lung cancer.”
ANS: C
More assessment of the patient’s concerns about surgery is indicated. An open-ended response will elicit the most information from the patient. The answer beginning, “Surgery is the treatment of choice” is accurate, but it discourages the patient from sharing concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the patient’s reasons for not wanting surgery. Chemotherapy is the primary treatment for small cell lung cancer. In non–small cell lung cancer, chemotherapy may be used in the treatment of nonresectable tumors or as adjuvant therapy to surgery.
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take?
a. Clamp the chest tube in two places.
b. Administer the prescribed morphine.
c. Milk the chest tube to remove any clots.
d. Assist the patient with incentive spirometry.
ANS: B
Treat the pain. The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy. Milking or stripping chest tubes is no longer recommended because these practices can dangerously increase intrapleural pressures and damage lung tissues. Position tubing so that drainage flows freely to negate need for milking or stripping. An air leak is expected in the initial postoperative period after thoracotomy. Clamping the chest tube is not indicated and may lead to dangerous development of a tension pneumothorax.
A patient with newly diagnosed lung cancer tells the nurse, “I don’t think I’m going to live to see my next birthday.” Which is the best initial response by the nurse?
a. “Are you ready to talk with your family members about dying now?”
b. “Would you like to talk to the hospital chaplain about your feelings?”
c. “Can you tell me what it is that makes you think you will die so soon?”
d. “Do you think that taking an antidepressant medication would be helpful?”
ANS: C
The nurse’s initial response should be to collect more assessment data about the patient’s statement. The answer beginning “Can you tell me what it is” is the most open-ended question and will offer the best opportunity for obtaining more data. The remaining answers offer interventions that may be helpful to the patient, but more assessment is needed to determine whether these interventions are appropriate.
The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?
a. A large air leak in the water-seal chamber
b. 400 mL of blood in the collection chamber
c. Complaint of pain with each deep inspiration
d. Subcutaneous emphysema at the insertion site
ANS: B
The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?
a. Paradoxical chest movement c. Heart rate of 110 beats/minute
b. Complaint of chest wall pain d. Large bruised area on the chest
ANS: A
Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?
a. Emergency pericardiocentesis c. Bronchodilator administration
b. Stabilization of the chest wall d. Chest tube connected to suction
ANS: D
The patient’s history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage to suction. The other therapies would be appropriate for an acute asthma attack, flail chest, or cardiac tamponade, but the patient’s clinical manifestations are not consistent with these problems.
A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate?
a. Adjust the dial on the wall regulator.
b. Continue to monitor the collection device.
c. Document the presence of a large air leak.
d. Notify the surgeon of a possible pneumothorax.
ANS: B
Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system.
The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient’s postoperative care?
a. Bed rest for the first 24 hours
b. Positioning only on the right side
c. Frequent use of an incentive spirometer
d. Chest tube placement to continuous suction
ANS: C
Frequent deep breathing and coughing are needed after chest surgery to prevent atelectasis. To promote gas exchange, patients after pneumonectomy are positioned on the surgical side. Early mobilization decreases the risk for postoperative complications such as pneumonia and deep vein thrombosis. In a pneumonectomy, chest tubes may or may not be placed in the space from which the lung was removed. If a chest tube is used, it is clamped and only released by the surgeon to adjust the volume of serosanguineous fluid that will fill the space vacated by the lung. If the cavity overfills, it could compress the remaining lung and compromise the cardiovascular and pulmonary function. Daily chest x-rays can be used to assess the volume and space.
The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies?
a. Observe for distended neck veins.
b. Auscultate for crackles in the lungs.
c. Palpate for heaves or thrills over the heart.
d. Monitor for elevated white blood cell count.
ANS: A
Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical manifestations of right ventricular failure such as peripheral edema, jugular venous distention, and right upper-quadrant abdominal tenderness would be expected. Crackles in the lungs are likely to be heard with left-sided heart failure. Findings in cor pulmonale include evidence of right ventricular hypertrophy on electrocardiography and an increase in intensity of the second heart sound. Heaves or thrills are not common with cor pulmonale. White blood count elevation might indicate infection but is not expected with cor pulmonale.
A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient’s condition is improving?
a. Patient’s chest x-ray indicates clear lung fields.
b. Heart rate is between 60 and 100 beats/minute.
c. Patient reports a decrease in exertional dyspnea.
d. Blood pressure (BP) is less than 140/90 mm Hg.
ANS: C
Because a major symptom of IPAH is exertional dyspnea, an improvement in this symptom would indicate that the medication was effective. Nifedipine will affect BP and heart rate, but these parameters would not be used to monitor the effectiveness of therapy for a patient with IPAH. The chest x-ray will show clear lung fields even if the therapy is not effective.
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?
a. Start a peripheral IV line to administer sedatives.
b. Position the patient sitting up on the side of the bed.
c. Obtain a collection device to hold 3 liters of pleural fluid.
d. Remind the patient not to eat or drink anything for 6 hours.
ANS: B
When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema.
The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates to the nurse that the teaching has been effective?
a. “I will make an appointment to see the doctor every year.”
b. “I will stop taking the prednisone if I experience a dry cough.”
c. “I will not worry if I feel a little short of breath with exercise.”
d. “I will call the health care provider right away if I develop a fever.”
ANS: D
Low-grade fever may indicate infection or acute rejection so the patient should notify the health care provider immediately if the temperature is elevated. Patients require frequent follow-up visits with the transplant team. Annual health care provider visits would not be sufficient. Home O2 use is not an expectation after lung transplant. Shortness of breath should be reported. Low-grade fever, fatigue, dyspnea, dry cough, and O2 desaturation are signs of rejection. Immunosuppressive therapy, including prednisone, needs to be continued to prevent rejection.
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
a. Chest x-ray via stretcher
b. Blood cultures from two sites
c. Ciprofloxacin (Cipro) 400 mg IV
d. Acetaminophen (Tylenol) rectal suppository
ANS: B
Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest x-ray and acetaminophen administration can be done last.
The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
a. O2 saturation is 88%.
b. Blood pressure is 155/90 mm Hg.
c. Pain level is 5 (on 0 to 10 scale) with a deep breath.
d. Respiratory rate is 24 breaths/minute when lying flat.
ANS: A
O2 saturation would be expected to improve after a thoracentesis. A saturation of 88% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low O2 saturation is the priority.
A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first?
a. Codeine c. Acetaminophen (Tylenol)
b. Guaifenesin d. Piperacillin/tazobactam (Zosyn)
ANS: D
Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications are also appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.
A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider?
a. The Mantoux test had an induration of 7 mm.
b. The chest-x-ray showed infiltrates in the lower lobes.
c. The patient has a cough that is productive of blood-tinged mucus.
d. The patient is being treated with antiretrovirals for HIV infection.
ANS: D
Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat TB. The other data are expected in a patient with HIV and TB.
A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the priority?
a. Hyperthermia related to infectious illness
b. Impaired transfer ability related to weakness
c. Ineffective airway clearance related to thick secretions
d. Impaired gas exchange related to respiratory congestion
ANS: D
All of these nursing diagnoses are appropriate for the patient, but the patient’s O2 saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.
The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?
a. UAP assist the patient to ambulate to the bathroom.
b. UAP help splint the patient’s chest during coughing.
c. UAP transfer the patient to a bedside chair for meals.
d. UAP lower the head of the patient’s bed to 15 degrees.
ANS: D
Positioning the patient with the head of the bed lowered will decrease ventilation. The other actions are appropriate for a patient with pneumonia.
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first?
a. Administer anticoagulant drug therapy.
b. Notify the patient’s health care provider.
c. Prepare patient for a spiral computed tomography (CT).
d. Elevate the head of the bed to a semi-Fowler’s position.
ANS: D
The patient has symptoms consistent with a pulmonary embolism (PE). Elevating the head of the bed will improve ventilation and gas exchange. The other actions can be accomplished after the head is elevated (and O2 is started). A spiral CT may be ordered by the health care provider to identify PE. Anticoagulants may be ordered after confirmation of the diagnosis of PE.
The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?
a. A 23-yr-old patient with cystic fibrosis who has pulmonary function testing scheduled
b. A 46-yr-old patient on bed rest who is complaining of sudden onset of shortness of breath
c. A 77-yr-old patient with tuberculosis (TB) who has four medications due in 15 minutes
d. A 35-yr-old patient who was admitted with pneumonia and has a temperature of 100.2° F (37.8° C)
ANS: B
Patients on bed rest who are immobile are at high risk for deep vein thrombosis (DVT). Sudden onset of shortness of breath in a patient with a DVT suggests a pulmonary embolism and requires immediate assessment and action such as O2 administration. The other patients should also be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?
a. “Do you take any over-the-counter (OTC) medications?”
b. “Do you have any family members with a history of TB?”
c. “How long has it been since you moved to the United States?”
d. “Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB?”
ANS: D
Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (e.g., chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.
A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take?
a. Keep the head of the patient’s bed positioned flat.
b. Cover the wound tightly with an occlusive dressing.
c. Position the patient so that the left chest is dependent.
d. Tape a nonporous dressing on three sides over the wound.
ANS: D
The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.
The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first?
a. Assist the patient to sit upright in a chair.
b. Splint the patient’s chest during coughing.
c. Medicate the patient with prescribed morphine.
d. Observe the patient use the incentive spirometer.
ANS: C
A major reason for atelectasis and poor airway clearance in patients after chest surgery is incisional pain (which increases with deep breathing and coughing). The first action by the nurse should be to medicate the patient to minimize incisional pain. The other actions are all appropriate ways to improve airway clearance, but should be done after the morphine is given.
The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse?
a. The O2 saturation is 90%.
b. The blood pressure is 98/56 mm Hg.
c. The epoprostenol (Flolan) infusion is disconnected.
d. The international normalized ratio (INR) is prolonged.
ANS: C
The half-life of this drug is 6 minutes, so the nurse will need to restart the infusion as soon as possible to prevent rapid clinical deterioration. The other data also indicate a need for ongoing monitoring or intervention, but the priority action is to reconnect the infusion.
A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (on 0 to 10 scale) “whenever I take a deep breath.” Which action will the nurse take next?
a. Auscultate for breath sounds.
b. Administer the PRN morphine.
c. Have the patient cough forcefully.
d. Notify the patient’s health care provider.
ANS: A
The patient’s statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.
A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?
a. Purpose of antibiotic therapy
b. Ways to limit oral fluid intake
c. Appropriate use of cough suppressants
d. Safety concerns with home O2 therapy
ANS: C
Cough suppressants are frequently prescribed for acute bronchitis. Because most acute bronchitis is viral in origin, antibiotics are not prescribed unless there are systemic symptoms. Fluid intake is encouraged. Home O2 is not prescribed for acute bronchitis, although it may be used for chronic bronchitis.
Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting?
a. Providing supportive care to patients diagnosed with pertussis
b. Teaching family members about the need for careful hand washing
c. Teaching patients about the need for adult pertussis immunizations
d. Encouraging patients to complete the prescribed course of antibiotics
ANS: C
The increased rate of pertussis in adults is thought to be caused by decreasing immunity after childhood immunization. Immunization is the most effective method of protecting communities from infectious diseases. Hand washing should be taught, but pertussis is spread by droplets and contact with secretions. Supportive care does not shorten the course of the disease or the risk for transmission. Taking antibiotics as prescribed does assist with decreased transmission, but patients are likely to have already transmitted the disease by the time the diagnosis is made.
An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching?
a. Listening to the patient’s lung sounds several times during the shift
b. Placing the patient on droplet precautions in a private hospital room
c. Monitoring patient serology results to identify the infecting organism
d. Increasing the O2 flow rate to keep the O2 saturation over 90%
ANS: B
Fungal infections are not transmitted from person to person. Therefore no isolation procedures are necessary. The other actions by the new nurse are appropriate.
Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess?
a. Teach the patient to avoid the use of over-the-counter expectorants.
b. Assist the patient with chest physiotherapy and postural drainage.
c. Notify the health care provider immediately about any bloody or foul-smelling sputum.
d. Teach about the need for prolonged antibiotic therapy after discharge from the hospital.
ANS: D
Long-term antibiotic therapy is needed for effective eradication of the infecting organisms in lung abscess. Chest physiotherapy and postural drainage are not recommended for lung abscess because they may lead to spread of the infection. Foul-smelling and bloody sputum are common clinical manifestations in lung abscess. Expectorants may be used because the patient is encouraged to cough.
The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?
a. “I am going to buy a rib binder to wear during the day.”
b. “I can take shallow breaths to prevent my chest from hurting.”
c. “I should plan on taking the pain pills only at bedtime so I can sleep.”
d. “I will use the incentive spirometer every hour or two during the day.”
ANS: D
Prevention of the complications of atelectasis and pneumonia is a priority after rib fracture. This can be ensured by deep breathing and coughing. Use of a rib binder, shallow breathing, and taking pain medications only at night are likely to result in atelectasis.
The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?
a. Document the amount of drainage every 8 hours.
b. Obtain samples of drainage for culture from the system.
c. Assess patient pain level associated with the chest tube.
d. Check the water-seal chamber for the correct fluid level.
ANS: A
UAP education includes documentation of intake and output. The other actions are within the scope of practice and education of licensed nursing personnel.
After change-of-shift report, which patient should the nurse assess first?
a. A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his legs and feet
b. A 28-yr-old with a history of a lung transplant and a temperature of 101° F (38.3° C)
c. A 40-yr-old with a pleural effusion who is complaining of severe stabbing chest pain
d. A 64-yr-old with lung cancer and tracheal deviation after subclavian catheter insertion
ANS: D
The patient’s history and symptoms suggest possible tension pneumothorax, a medical emergency. The other patients also require assessment as soon as possible, but tension pneumothorax will require immediate treatment to avoid death from inadequate cardiac output or hypoxemia.
Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)?
a. Age d. O2 saturation
b. Blood pressure e. Presence of confusion
c. Respiratory rate f. Blood urea nitrogen (BUN) level
ANS: A, B, C, E, F
Data collected for the CURB-65 are mental status (confusion), BUN (elevated), blood pressure (decreased), respiratory rate (increased), and age (65 years and older). The other information is also essential to assess, but are not used for CURB-65 scoring.
The nurse notes new onset confusion in an older patient who is normally alert and oriented. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].)
a. Obtain the O2 saturation.
b. Check the patient’s pulse rate.
c. Document the change in status.
d. Notify the health care provider.
ANS:
A, B, D, C
Assessment for physiologic causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done
A 74-yr-old patient has just arrived in the emergency department. After assessment reveals a pulse deficit of 46 beats, the nurse will anticipate that the patient may require
a. emergent cardioversion.
b. a cardiac catheterization.
c. hourly blood pressure (BP) checks.
d. electrocardiographic (ECG) monitoring.
ANS: D
Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It indicates that there may be a cardiac dysrhythmia that would best be detected with ECG monitoring. Frequent BP monitoring, cardiac catheterization, and emergent cardioversion are used for diagnosis and/or treatment of cardiovascular disorders but would not be as helpful in determining the immediate reason for the pulse deficit.
The nurse is reviewing the 12-lead electrocardiograph (ECG) for a healthy 74-yr-old patient who is having an annual physical examination. What finding is of most concern to the nurse?
a. A right bundle-branch block. c. The QRS duration is 0.13 seconds.
b. The PR interval is 0.21 seconds. d. The heart rate (HR) is 41 beats/min.
ANS: D
The resting HR does not change with aging, so the decrease in HR requires further investigation. Bundle-branch block and slight increases in PR interval or QRS duration are common in older individuals because of increases in conduction time through the AV node, bundle of His, and bundle branches.
During a physical examination of an older patient, the nurse palpates the point of maximal impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. The best follow-up action for the nurse to take will be to
a. ask about risk factors for atherosclerosis.
b. determine family history of heart disease.
c. assess for symptoms of left ventricular hypertrophy.
d. auscultate carotid arteries for the presence of a bruit.
ANS: C
The PMI should be felt at the intersection of the fifth intercostal space and left midclavicular line. A PMI located outside these landmarks indicates possible cardiac enlargement, such as with left ventricular hypertrophy (LVH). The other assessments are part of a general cardiac assessment but do not represent follow-up for LVH. Cardiac enlargement is not necessarily associated with atherosclerosis or carotid artery disease.
To auscultate for S3 or S4 gallops in the mitral area, the nurse listens with the
a. diaphragm of the stethoscope with the patient lying flat.
b. bell of the stethoscope with the patient in the left lateral position.
c. diaphragm of the stethoscope with the patient in a supine position.
d. bell of the stethoscope with the patient sitting and leaning forward.
ANS: B
Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope is best to use for the higher pitched sounds such as S1 and S2.
To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory test result will the nurse plan to review?
a. Troponin c. Low-density lipoprotein (LDL)
b. Homocysteine (Hcy) d. B-type natriuretic peptide (BNP)
ANS: D
Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (troponin) or risk for coronary artery disease (Hcy and LDL).
While doing the hospital admission assessment for a thin older adult, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take next?
a. Teach the patient about aneurysms.
b. Notify the hospital rapid response team.
c. Instruct the patient to remain on bed rest.
d. Document the finding in the patient chart.
ANS: D
Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals. The nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary.
A patient is scheduled for a cardiac catheterization with coronary angiography. Before the test, the nurse informs the patient that
a. it will be important not to move at all during the procedure.
b. monitored anesthesia care will be provided during the procedure.
c. a flushed feeling may be noticed when the contrast dye is injected.
d. arterial pressure monitoring will be required for 24 hours after the test.
ANS: C
A sensation of warmth or flushing is common when the contrast material is injected, which can be anxiety producing unless it has been discussed with the patient. The patient may receive a sedative drug before the procedure, but monitored anesthesia care is not used. Arterial pressure monitoring is not routinely used after the procedure to monitor blood pressure. The patient is not immobile during cardiac catheterization and may be asked to cough or take deep breaths.
The nurse notes that a patient who was admitted with heart failure has jugular venous distention (JVD) when lying flat in bed. Which follow-up action should the nurse take next?
a. Obtain vital signs, including oxygen saturation.
b. Have the patient perform the Valsalva maneuver.
c. Document this JVD finding in the patient’s record.
d. Observe for JVD with the patient elevated 45 degrees.
ANS: D
When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a common (but not a clinically significant) finding. Obtaining vital signs and oxygen saturation is not warranted at this point. JVD is an expected finding when a patient performs the Valsalva maneuver because right atrial pressure increases. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is significant. The nurse will document the JVD in the medical record if it persists when the head is elevated.
The nurse teaches the patient being evaluated for rhythm disturbances with a Holter monitor to
a. connect the recorder to a computer once daily.
b. exercise more than usual while the monitor is in place.
c. remove the electrodes when taking a shower or tub bath.
d. keep a diary of daily activities while the monitor is worn.
ANS: D
The patient is instructed to keep a diary describing daily activities while Holter monitoring is being accomplished to help correlate any rhythm disturbances with patient activities. Patients are taught that they should not take a shower or bath during Holter monitoring and that they should continue with their usual daily activities. The recorder stores the information about the patient’s rhythm until the end of the testing, when it is removed and the data are analyzed.
When auscultating over the patient’s abdominal aorta, the nurse hears a loud humming sound. The nurse documents this finding as a
a. thrill. c. murmur.
b. bruit. d. normal finding.
ANS: B
A bruit is the sound created by turbulent blood flow in an artery. Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel. A murmur is the sound caused by turbulent blood flow through the heart. Auscultating a bruit in an artery is not normal and indicates pathology.
The nurse has received the laboratory results for a patient who developed chest pain 4 hours ago and may be having a myocardial infarction. The laboratory test result most helpful in indicating myocardial damage will be
a. myoglobin. c. homocysteine (Hcy)
b. troponins T and I. d. creatine kinase-MB (CK-MB).
ANS: B
Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly specific to myocardium. They are the preferred diagnostic marker for myocardial infarction. Myoglobin rises in response to myocardial injury within 30 to 60 minutes. It is rapidly cleared from the body, thus limiting its use in the diagnosis of myocardial infarction. Low-density lipoprotein cholesterol is useful in assessing cardiovascular risk but is not helpful in determining whether a patient is having an acute myocardial infarction. Creatine kinase (CK-MB) is specific to myocardial injury and infarction and increases 4 to 6 hours after the infarction occurs. It is often trended with troponin levels. Homocysteine (Hcy) is an amino acid that is produced during protein catabolism. Elevated Hcy levels can be either hereditary or acquired from dietary deficiencies of vitamin B6, cobalamin (vitamin B12), or folate. Elevated levels of Hcy have been linked to a higher risk of CVD, peripheral vascular disease, and stroke.
When assessing a newly admitted patient, the nurse notes a murmur along the left sternal border. To acquire more information about the murmur, which action will the nurse take?
a. Palpate the peripheral pulses.
b. Determine the timing of the sound.
c. Find the point of maximal impulse.
d. Compare apical and radial pulse rates.
ANS: B
Murmurs are caused by turbulent blood flow, such as occurs when blood flows through a damaged valve. Relevant information includes the position in which the murmur is heard best (e.g., sitting and leaning forward), the timing of the murmur in relation to the cardiac cycle (e.g., systole, diastole), and where on the thorax the murmur is heard best. The other information is important in the cardiac assessment but will not provide information that is relevant to the murmur.
The nurse hears a murmur between the S1 and S2 heart sounds at the patient’s left fifth intercostal space and midclavicular line. How will the nurse record this information?
a. Systolic murmur heard at mitral area
b. Systolic murmur heard at Erb’s point
c. Diastolic murmur heard at aortic area
d. Diastolic murmur heard at the point of maximal impulse
ANS: A
The S1 signifies the onset of ventricular systole. S2 signifies the onset of diastole. A murmur occurring between these two sounds is a systolic murmur. The mitral area is the intersection of the left fifth intercostal space and the midclavicular line. The other responses describe murmurs heard at different landmarks on the chest and/or during the diastolic phase of the cardiac cycle.
A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a patient. The RN will need to intervene immediately if the student nurse
a. presses on the skin over the tibia for 10 seconds to check for edema.
b. palpates both carotid arteries simultaneously to compare pulse quality.
c. documents a murmur heard along the right sternal border as a pulmonic murmur.
d. places the patient in the left lateral position to check for the point of maximal impulse.
ANS: B
The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected. However, they are not dangerous to the patient.
Which action will the nurse implement for a patient who arrives for a calcium-scoring CT scan?
a. Insert an IV catheter.
b. Administer oral sedative medications.
c. Teach the patient about the procedure.
d. Confirm that the patient has been fasting.
ANS: C
The nurse will need to teach the patient that the procedure is rapid and involves little risk. None of the other actions are necessary.
Which information obtained by the nurse who is admitting the patient for magnetic resonance imaging (MRI) will be important to report to the health care provider before the MRI?
a. The patient has an allergy to shellfish.
b. The patient has a history of atherosclerosis.
c. The patient has a permanent cardiac pacemaker.
d. The patient took the prescribed heart medications today.
ANS: C
MRI is contraindicated for patients with implanted metallic devices such as pacemakers. The other information does not affect whether or not the patient can have an MRI.
When the nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill, which assessment finding requires the most rapid action by the nurse?
a. Patient complaint of feeling tired
b. Sinus tachycardia at a rate of 110 beats/min
c. Inversion of T waves on the electrocardiogram
d. Blood pressure (BP) increase from 134/68 to 150/80 mm Hg
ANS: C
ECG changes associated with coronary ischemia (such as T-wave inversions and ST segment depression) indicate that the myocardium is not getting adequate O2 delivery and that the exercise test should be terminated immediately. Increases in BP and heart rate are normal responses to aerobic exercise. Feeling tired is also normal as the intensity of exercise increases during the stress testing.
The standard policy on the cardiac unit states, “Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.” The nurse will need to call the health care provider about the
a. postoperative patient with a BP of 116/42 mm Hg.
b. newly admitted patient with a BP of 150/87 mm Hg.
c. patient with left ventricular failure who has a BP of 110/70 mm Hg.
d. patient with a myocardial infarction who has a BP of 140/86 mm Hg.
ANS: A
The mean arterial pressure (MAP) is calculated using the formula MAP = (systolic BP + 2 diastolic BP)/3. The MAP for the postoperative patient in answer 3 is 67. The MAP in the other three patients is higher than 70 mm Hg.
When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is most important for the nurse to communicate to the health care provider?
a. The patient’s pedal pulses are +1.
b. The patient is allergic to shellfish.
c. The patient had a heart attack 1 year ago.
d. The patient has not eaten anything today.
ANS: B
The contrast dye used for the procedure is iodine based, so patients who have shellfish allergies will require treatment with medications such as corticosteroids and antihistamines before the angiogram. The other information is also communicated to the health care provider but will not require a change in the usual precardiac catheterization orders or medications.
A transesophageal echocardiogram (TEE) is ordered for a patient with possible endocarditis. Which action included in the standard TEE orders will the nurse need to accomplish first?
a. Start an IV line. c. Place the patient on NPO status.
b. Start O2 per nasal cannula. d. Give lorazepam (Ativan) 1 mg IV.
ANS: C
The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the patient on NPO status as soon as the order is received. The other actions also will need to be accomplished but not until just before or during the procedure.
The nurse and unlicensed assistive personnel (UAP) on the telemetry unit are caring for four patients. Which nursing action can be delegated to the UAP?
a. Teaching a patient about exercise electrocardiography
b. Attaching ECG monitoring electrodes after a patient bathes
c. Checking the catheter insertion site for a patient who is recovering from a coronary angiogram
d. Monitoring a patient who has just returned to the unit after a transesophageal echocardiogram
ANS: B
UAP can be educated in standardized lead placement for ECG monitoring. Assessment of patients who have had procedures where airway maintenance (transesophageal echocardiography) or bleeding (coronary angiogram) is a concern must be done by the registered nurse (RN). Patient teaching requires RN level education and scope of practice.
The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular unit. Which laboratory result is most important to communicate as soon as possible to the health care provider?
a. High troponin I level
b. Increased triglyceride level
c. Very low homocysteine level
d. Elevated high-sensitivity C-reactive protein level
ANS: A
The elevation in troponin I indicates that the patient has had an acute myocardial infarction. Further assessment and interventions are indicated. The other laboratory results are indicative of increased risk for coronary artery disease but are not associated with acute cardiac problems that need immediate intervention.
A patient who has been in the intensive care unit for 4 days has disturbed sensory perception from sleep deprivation. Which action should the nurse include in the plan of care?
a. Administer prescribed sedatives or opioids at bedtime to promote sleep.
b. Cluster nursing activities so that the patient has uninterrupted rest periods.
c. Silence the alarms on the cardiac monitors to allow 30- to 40-minute naps.
d. Eliminate assessments between 2200 and 0600 to allow uninterrupted sleep.
ANS: B
Clustering nursing activities and providing uninterrupted rest periods will minimize sleep-cycle disruption. Sedative and opioid medications tend to decrease the amount of rapid eye movement (REM) sleep and can contribute to sleep disturbance and disturbed sensory perception. Silencing the alarms on the cardiac monitors would be unsafe in a critically ill patient, as would discontinuing all assessments during the night.
Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse gives to reduce a patient’s left ventricular afterload?
a. Mean arterial pressure (MAP)
b. Systemic vascular resistance (SVR)
c. Pulmonary vascular resistance (PVR)
d. Pulmonary artery wedge pressure (PAWP)
ANS: B
SVR reflects the resistance to ventricular ejection, or afterload. The other parameters may be monitored but do not reflect afterload as directly.
While close family members are visiting, a patient has a respiratory arrest, and resuscitation is started. Which action by the nurse is best?
a. Tell the family members that watching the resuscitation will be very stressful.
b. Ask family members if they wish to remain in the room during the resuscitation.
c. Take the family members quickly out of the patient room and remain with them.
d. Assign a staff member to wait with family members just outside the patient room.
ANS: B
Evidence indicates that many family members want the option of remaining in the room during procedures such as cardiopulmonary resuscitation (CPR) and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient.
After surgery for an abdominal aortic aneurysm, a patient’s central venous pressure (CVP) monitor indicates low pressures. Which action should the nurse take?
a. Administer IV diuretic medications.
b. Increase the IV fluid infusion per protocol.
c. Increase the infusion rate of IV vasodilators.
d. Elevate the head of the patient’s bed to 45 degrees.
ANS: B
A low CVP indicates hypovolemia and a need for an increase in the infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head or increasing vasodilators may decrease cerebral perfusion.
When caring for a patient with pulmonary hypertension, which parameter will the nurse use to directly evaluate the effectiveness of the treatment?
a. Central venous pressure (CVP)
b. Systemic vascular resistance (SVR)
c. Pulmonary vascular resistance (PVR)
d. Pulmonary artery wedge pressure (PAWP)
ANS: C
PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters may also be monitored but do not directly assess for pulmonary hypertension.
The intensive care unit (ICU) nurse educator determines that teaching a new staff nurse about arterial pressure monitoring has been effective when the nurse
a. balances and calibrates the monitoring equipment every 2 hours.
b. positions the zero-reference stopcock line level with the phlebostatic axis.
c. ensures that the patient is supine with the head of the bed flat for all readings.
d. rechecks the location of the phlebostatic axis with changes in the patient’s position.
ANS: B
For accurate measurement of pressures, the zero-reference level should be at the phlebostatic axis. There is no need to rebalance and recalibrate monitoring equipment every 2 hours. Accurate hemodynamic readings are possible with the patient’s head raised to 45 degrees or in the prone position. The anatomic position of the phlebostatic axis does not change when patients are repositioned.
When monitoring the effectiveness of treatment for a patient with a large anterior wall myocardial infarction, the most pertinent measurement for the nurse to obtain is
a. central venous pressure (CVP).
b. systemic vascular resistance (SVR).
c. pulmonary vascular resistance (PVR).
d. pulmonary artery wedge pressure (PAWP).
ANS: D
PAWP reflects left ventricular end diastolic pressure (or left ventricular preload) and is a sensitive indicator of cardiac function. Because the patient is high risk for left ventricular failure, the PAWP must be monitored. An increase will indicate left ventricular failure. The other values would also provide useful information, but the most definitive measurement of changes in cardiac function is the PAWP.
Which action should the nurse take when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery?
a. Fast flush the arterial line.
b. Check the left hand for pallor.
c. Assess for cardiac dysrhythmias.
d. Re-zero the monitoring equipment.
ANS: C
The low pressure alarm indicates a drop in the patient’s blood pressure, which may be caused by cardiac dysrhythmias. There is no indication to re-zero the equipment. Pallor of the left hand would be caused by occlusion of the radial artery by the arterial catheter, not by low pressure. There is no indication of a need for flushing the line.
Which nursing action is needed when preparing to assist with the insertion of a pulmonary artery catheter?
a. Determine if the cardiac troponin level is elevated.
b. Auscultate heart sounds before and during insertion.
c. Place the patient on NPO status before the procedure.
d. Attach cardiac monitoring leads before the procedure.
ANS: D
Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it is important for the nurse to monitor for these during insertion. Pulmonary artery catheter insertion does not require anesthesia, and the patient will not need to be NPO. Changes in cardiac troponin or heart and breath sounds are not expected during pulmonary artery catheter insertion.
While assisting with the placement of a pulmonary artery (PA) catheter, the nurse notes that the catheter is correctly placed when the balloon is inflated and the monitor shows a
a. typical PA pressure waveform.
b. tracing of the systemic arterial pressure.
c. tracing of the systemic vascular resistance.
d. typical PA wedge pressure (PAWP) tracing.
ANS: D
The purpose of a PA line is to measure PAWP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAWP readings are available. After insertion, the balloon is deflated and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line, and the systemic vascular resistance is a calculated value, not a waveform.
Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take action?
a. The right hand feels cooler than the left hand.
b. The mean arterial pressure (MAP) is 77 mm Hg.
c. The system is delivering 3 mL of flush solution per hour.
d. The flush bag and tubing were last changed 2 days previously.
ANS: A
The change in temperature of the right hand suggests that blood flow to the right hand is impaired. The flush system needs to be changed every 96 hours. A mean arterial pressure (MAP) of 75 mm Hg is normal. Flush systems for hemodynamic monitoring are set up to deliver 3 to 6 mL/hr of flush solution.
The central venous oxygen saturation (ScvO2) is decreasing in a patient who has severe pancreatitis. To determine the possible cause of the decreased ScvO2, the nurse assesses the patient’s
a. lipase level. c. urinary output.
b. temperature. d. body mass index.
ANS: B
Elevated temperature increases metabolic demands and O2 use by tissues, resulting in a drop in O2 saturation of central venous blood. Information about the patient’s body mass index, urinary output, and lipase will not help in determining the cause of the patient’s drop in ScvO2.
An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic shock. Which assessment data indicate to the nurse that the goals of treatment with the IABP are being met?
a. Urine output of 25 mL/hr
b. Heart rate of 110 beats/minute
c. Cardiac output (CO) of 5 L/min
d. Stroke volume (SV) of 40 mL/beat
ANS: C
A CO of 5 L/min is normal and indicates that the IABP has been successful in treating the shock. The low SV signifies continued cardiogenic shock. The tachycardia and low urine output also suggest continued cardiogenic shock.
The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care?
a. Avoid the use of anticoagulant medications.
b. Measure the patient’s urinary output every hour.
c. Provide passive range of motion for all extremities.
d. Position the patient supine with head flat at all times.
ANS: B
Monitoring urine output will help determine whether the patient’s cardiac output has improved and also help monitor for balloon displacement blocking the renal arteries. The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon.
While waiting for heart transplantation, a patient with severe cardiomyopathy has a ventricular assist device (VAD) implanted. When planning care for this patient, the nurse should anticipate
a. preparing the patient for a permanent VAD.
b. administering immunosuppressive medications.
c. teaching the patient the reason for complete bed rest.
d. monitoring the surgical incision for signs of infection.
ANS: D
The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immunosuppression is not necessary for nonbiologic devices such as the VAD.
To verify the correct placement of an oral endotracheal tube (ET) after insertion, the best initial action by the nurse is to
a. obtain a portable chest x-ray.
b. use an end-tidal CO2 monitor.
c. auscultate for bilateral breath sounds.
d. observe for symmetrical chest movement.
ANS: B
End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion are also used, but they are not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured.
To maintain proper cuff pressure of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse should
a. inflate the cuff with a minimum of 10 mL of air.
b. inflate the cuff until the pilot balloon is firm on palpation.
c. inject air into the cuff until a manometer shows 15 mm Hg pressure.
d. inject air into the cuff until a slight leak is heard only at peak inflation.
ANS: D
The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patient’s size. Cuff pressure should be maintained at 20 to 25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon.
The nurse notes premature ventricular contractions (PVCs) while suctioning a patient’s endotracheal tube. Which next action by the nurse is indicated?
a. Plan to suction the patient more frequently.
b. Decrease the suction pressure to 80 mm Hg.
c. Give antidysrhythmic medications per protocol.
d. Stop and ventilate the patient with 100% oxygen.
ANS: D
Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation. The nurse should stop suctioning and ventilate the patient with 100% O2. There is no indication that more frequent suctioning is needed. Lowering the suction pressure will decrease the effectiveness of suctioning without improving the hypoxemia. Because the PVCs occurred during suctioning, there is no need for antidysrhythmic medications (which may have adverse effects) unless they recur when the suctioning is stopped and patient is well oxygenated.
Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning?
a. The patient was last suctioned 6 hours ago.
b. The patient’s oxygen saturation drops to 93%.
c. The patient’s respiratory rate is 32 breaths/min.
d. The patient has occasional audible expiratory wheezes.
ANS: C
The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed and not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning the patient may induce bronchospasm and increase wheezing. An O2 saturation of 93% is acceptable and does not suggest that immediate suctioning is needed.
The nurse notes thick, white secretions in the endotracheal tube (ET) of a patient who is receiving mechanical ventilation. Which intervention will most directly treat this finding?
a. Reposition the patient every 1 to 2 hours.
b. Increase suctioning frequency to every hour.
c. Add additional water to the patient’s enteral feedings.
d. Instill 5 mL of sterile saline into the ET before suctioning.
ANS: C
Because the patient’s secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions.
Four hours after mechanical ventilation is initiated, a patient’s arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3– of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to
a. increase the FIO2. c. increase the respiratory rate.
b. increase the tidal volume. d. decrease the respiratory rate.
ANS: D
The patient’s PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal volume would further lower the PaCO2.
A patient with respiratory failure has arterial pressure–based cardiac output (APCO) monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 12 cm H2O. Which information indicates that a change in the ventilator settings may be required?
a. The arterial pressure is 90/46.
b. The stroke volume is increased.
c. The heart rate is 58 beats/minute.
d. The stroke volume variation is 12%.
ANS: A
The hypotension suggests that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and (potentially) cardiac output. The other assessment data would not be a direct result of PEEP and mechanical ventilation.
A nurse is weaning a 68-kg patient who has chronic obstructive pulmonary disease (COPD) from mechanical ventilation. Which patient assessment finding indicates that the weaning protocol should be stopped?
a. The patient’s heart rate is 97 beats/min.
b. The patient’s oxygen saturation is 93%.
c. The patient respiratory rate is 32 breaths/min.
d. The patient’s spontaneous tidal volume is 450 mL.
ANS: C
Tachypnea is a sign that the patient’s work of breathing is too high to allow weaning to proceed. The patient’s heart rate is within normal limits, but the nurse should continue to monitor it. An O2 saturation of 93% is acceptable for a patient with COPD. A spontaneous tidal volume of 450 mL is within the acceptable range.
The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted?
a. Heart rate is slow at 58 beats/min.
b. Mean arterial pressure (MAP) is 56 mm Hg.
c. Systemic vascular resistance (SVR) is elevated.
d. Pulmonary artery wedge pressure (PAWP) is low.
ANS: C
Vasoconstrictors such as norepinephrine will increase SVR, and this will increase the work of the heart and decrease peripheral perfusion. The infusion rate may need to be decreased. Bradycardia, hypotension (MAP of 56 mm Hg), and low PAWP are not associated with norepinephrine infusion.
When evaluating a patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient’s temperature is 101.8° F. What should the nurse plan to do?
a. Discontinue the catheter and culture the tip.
b. Use the catheter only for fluid administration.
c. Change the flush system and monitor the site.
d. Check the site more frequently for any swelling.
ANS: A
The information indicates that the patient has a local and systemic infection caused by the catheter, and the catheter should be discontinued to avoid further complications such as endocarditis. Changing the flush system, continued monitoring, or using the line for fluids will not help prevent or treat the infection.
An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to
a. give PRN lorazepam (Ativan) and cancel the transfer.
b. inform the receiving nurse and then transfer the patient.
c. notify the health care provider and postpone the transfer.
d. obtain an order for restraints as needed and transfer the patient.
ANS: B
The patient’s history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the ICU environment. Informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation.
The family members of a patient who has been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take first?
a. Explain ICU visitation policies and encourage family visits.
b. Escort the family from the waiting room to the patient’s bedside.
c. Describe the patient’s injuries and the care that is being provided.
d. Invite the family to participate in an interprofessional care conference.
ANS: C
Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the patient’s appearance and the ICU environment before visiting the patient for the first time. ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse.
The nurse is caring for a patient who has an arterial catheter in the left radial artery for arterial pressure–based cardiac output (APCO) monitoring. Which information obtained by the nurse requires a report to the health care provider?
a. The patient has a positive Allen test result.
b. There is redness at the catheter insertion site.
c. The mean arterial pressure (MAP) is 86 mm Hg.
d. The dicrotic notch is visible in the arterial waveform.
ANS: B
Redness at the catheter insertion site indicates possible infection. The Allen test is performed before arterial line insertion, and a positive test result indicates normal ulnar artery perfusion. A MAP of 86 mm Hg is normal, and the dicrotic notch is normally present on the arterial waveform.
The nurse responds to a ventilator alarm and finds the patient lying in bed gasping and holding the endotracheal tube (ET) in her hand. Which action should the nurse take next?
a. Activate the rapid response team.
b. Provide reassurance to the patient.
c. Call the health care provider to reinsert the tube.
d. Manually ventilate the patient with 100% oxygen.
ANS: D
The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team are also appropriate after the nurse has stabilized the patient’s oxygenation.
The nurse notes that a patient’s endotracheal tube (ET), which was at the 22-cm mark, is now at the 25-cm mark, and the patient is anxious and restless. Which action should the nurse take next?
a. Check the O2 saturation.
b. Offer reassurance to the patient.
c. Listen to the patient’s breath sounds.
d. Notify the patient’s health care provider.
ANS: C
The nurse should first determine whether the ET tube has been displaced into the right mainstem bronchus by listening for unilateral breath sounds. If so, assistance will be needed to reposition the tube immediately. The other actions are also appropriate, but detection and correction of tube malposition are the most critical actions.
The nurse educator is evaluating the care that a new registered nurse (RN) provides to a patient receiving mechanical ventilation. Which action by the new RN indicates the need for more education?
a. The RN increases the FIO2 to 100% before suctioning.
b. The RN secures a bite block in place using adhesive tape.
c. The RN asks for assistance to resecure the endotracheal tube.
d. The RN positions the patient with the head of bed at 10 degrees.
ANS: D
The head of the patient’s bed should be positioned at 30 to 45 degrees to prevent ventilator-associated pneumonia. The other actions by the new RN are appropriate.
A patient who is orally intubated and receiving mechanical ventilation is anxious and is “fighting” the ventilator. Which action should the nurse take next?
a. Verbally coach the patient to breathe with the ventilator.
b. Sedate the patient with the ordered PRN lorazepam (Ativan).
c. Manually ventilate the patient with a bag-valve-mask device.
d. Increase the rate for the ordered propofol (Diprivan) infusion.
ANS: A
The initial response by the nurse should be to try to decrease the patient’s anxiety by coaching the patient about how to coordinate respirations with the ventilator. The other actions may also be helpful if the verbal coaching is ineffective in reducing the patient’s anxiety.
The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action indicates that the new RN is safe?
a. The RN plans to suction the patient every 1 to 2 hours.
b. The RN uses a closed-suction technique to suction the patient.
c. The RN tapes the connection between the ventilator tubing and the ET.
d. The RN changes the ventilator circuit tubing routinely every 48 hours.
ANS: B
The closed-suction technique is used when patients require high levels of PEEP (>10 cm H2O) to prevent the loss of PEEP that occurs when disconnecting the patient from the ventilator. Suctioning should not be scheduled routinely, but it should be done only when patient assessment data indicate the need for suctioning. Taping connections between the ET and ventilator tubing would restrict the ability of the tubing to swivel in response to patient repositioning. Ventilator tubing changes increase the risk for ventilator-associated pneumonia and are not indicated routinely.
The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm H2O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops
a. O2 saturation of 93%.
b. green nasogastric tube drainage.
c. respirations of 20 breaths/minute.
d. increased jugular venous distention.
ANS: D
Increases in jugular venous distention in a patient with a subarachnoid hemorrhage may indicate an increase in intracranial pressure (ICP) and that the PEEP setting is too high for this patient. A respiratory rate of 20, O2 saturation of 93%, and green nasogastric tube drainage are within normal limits.
A patient who is receiving positive pressure ventilation is scheduled for a spontaneous breathing trial (SBT). Which finding by the nurse is most likely to result in postponing the SBT?
a. New ST segment elevation is noted on the cardiac monitor.
b. Enteral feedings are being given through an orogastric tube.
c. Scattered rhonchi are heard when auscultating breath sounds.
d. hydromorphone (Dilaudid) is being used to treat postoperative pain.
ANS: A
Myocardial ischemia is a contraindication for ventilator weaning. The ST segment elevation is an indication that weaning should be postponed until further investigation and/or treatment for myocardial ischemia can be done. Ventilator weaning can proceed when opioids are used for pain management, abnormal lung sounds are present, or enteral feedings are being used.
After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first?
a. Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilator
b. Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoring
c. Patient who was successfully weaned and extubated 4 hours ago and has no urine output for the last 6 hours
d. Patient with a central venous O2 saturation (ScvO2) of 69% while on bilevel positive airway pressure (BiPAP)
ANS: C
The decreased urine output may indicate acute kidney injury or that the patient’s cardiac output and perfusion of vital organs have decreased. Any of these causes would require rapid action. The data about the other patients indicate that their conditions are stable and do not require immediate assessment or changes in their care. Continuous PETCO2 monitoring is frequently used when patients are intubated. The rest mode should be used to allow patient recovery after a failed SBT, and an ScvO2 of 69% is within normal limits.
After change-of-shift report, which patient should the progressive care nurse assess first?
a. Patient who was extubated this morning and has a temperature of 101.4°F (38.6°C)
b. Patient with bilevel positive airway pressure (BiPAP) for obstructive sleep apnea and a respiratory rate of 16
c. Patient with arterial pressure monitoring who is 2 hours post–percutaneous coronary intervention and needs to void
d. Patient who is receiving IV heparin for a venous thromboembolism and has a partial thromboplastin time (PTT) of 101 sec
ANS: D
The findings for this patient indicate high risk for bleeding from an elevated (nontherapeutic) PTT. The nurse needs to adjust the rate of the infusion (dose) per the health care provider’s parameters. The patient with BiPAP for sleep apnea has a normal respiratory rate. The patient recovering from the percutaneous coronary intervention will need to be assisted with voiding and this task could be delegated to unlicensed assistive personnel. The patient with a fever may be developing ventilator-associated pneumonia, but addressing the bleeding risk is a higher priority.
A patient’s vital signs are pulse 90, respirations 24, and BP 128/64 mm Hg, and cardiac output is 4.7 L/min. The patient’s stroke volume is _____ mL. (Round to the nearest whole number.)
ANS:
52
Stroke volume = Cardiac output/heart rate
52 mL = (4.7 L x 1000 mL/L)/90
When assisting with oral intubation of a patient who is having respiratory distress, in which order will the nurse take these actions? (Put a comma and a space between each answer choice [A, B, C, D, E].)
a. Obtain a portable chest-x-ray.
b. Position the patient in the supine position.
c. Inflate the cuff of the endotracheal tube after insertion.
d. Attach an end-tidal CO2 detector to the endotracheal tube.
e. Oxygenate the patient with a bag-valve-mask device for several minutes.
ANS:
E, B, C, D, A
The patient is pre-oxygenated with a bag-valve-mask system for 3 to 5 minutes before intubation and then placed in a supine position. After the intubation, the cuff on the endotracheal tube is inflated to occlude and protect the airway. Tube placement is assessed first with an end-tidal CO2 sensor and then with chest x-ray examination.
The nurse is caring for a patient who has an intraaortic balloon pump (IABP) after a massive heart attack. When assessing the patient, the nurse notices blood backing up into the IABP catheter. In which order should the nurse take the following actions? (Put a comma and a space between each answer choice [A, B, C, D].)
a. Confirm that the IABP console has turned off.
b. Assess the patient’s vital signs and orientation.
c. Obtain supplies for insertion of a new IABP catheter.
d. Notify the health care provider of the IABP malfunction.
ANS:
A, B, D, C
Blood in the IABP catheter indicates a possible tear in the balloon. The console should shut off automatically to prevent complications such as air embolism. Next, the nurse will assess the patient and communicate with the health care provider about the patient’s assessment and the IABP problem. Finally, supplies for insertion of a new IABP catheter may be needed based on the patient assessment and the decision of the health care provider.
Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure?
a. Chest x-ray
b. O2 saturation
c. Arterial blood gas analysis
d. Central venous pressure monitoring
ANS: C
Arterial blood gas (ABG) analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs provide information about the PaCO2 and pH. The other tests may also be done to help in assessing oxygenation or determining the cause of the patient’s ventilatory failure.
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.
ANS: B
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)
ANS: B
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.
ANS: B
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 c. In the tripod position
b. On the right side d. In the high-Fowler’s position
ANS: A
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%.
ANS: A
Increasing somnolence 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.
A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following drugs ordered. Which drug should the nurse discuss with the health care provider before giving?
a. gentamicin 60 mg IV
b. pantoprazole (Protonix) 40 mg IV
c. sucralfate (Carafate) 1 g per nasogastric tube
d. methylprednisolone (Solu-Medrol) 60 mg IV
ANS: A
Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other drugs are appropriate for the patient with ARDS.
A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with
a. obtaining a ventilation-perfusion scan.
b. drawing blood for arterial blood gases.
c. positioning the patient for a chest x-ray.
d. insertion of a pulmonary artery catheter.
ANS: D
Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema.
A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced?
a. The patient’s PaO2 is 50 mm Hg and the SaO2 is 88%.
b. The patient has subcutaneous emphysema on the upper thorax.
c. The patient has bronchial breath sounds in both the lung fields.
d. The patient has a first-degree atrioventricular heart block with a rate of 58 beats/min.
ANS: B
The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not specific indications that PEEP should be reduced
Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient’s caregiver is accurate?
a. “PEEP will push more air into the lungs during inhalation.”
b. “PEEP prevents the lung air sacs from collapsing during exhalation.”
c. “PEEP will prevent lung damage while the patient is on the ventilator.”
d. “PEEP allows the breathing machine to deliver 100% O2 to the lungs.”
ANS: B
By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage (e.g., fibrotic changes that occur with ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.
When prone positioning is used for a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective?
a. The patient’s PaO2 is 89 mm Hg, and the SaO2 is 91%.
b. Endotracheal suctioning results in clear mucous return.
c. Sputum and blood cultures show no growth after 48 hours.
d. The skin on the patient’s back is intact and without redness.
ANS: A
The purpose of prone positioning is to improve the patient’s oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective.
The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2° F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action should the nurse take next?
a. Give the scheduled IV antibiotic.
b. Give the PRN acetaminophen (Tylenol).
c. Obtain oxygen saturation using pulse oximetry.
d. Notify the health care provider of the patient’s vital signs.
ANS: C
The patient’s increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Giving the scheduled antibiotic and the PRN acetaminophen will also be done, but they are not the highest priority for a patient who may be developing ARDS.
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.
ANS: A
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.
A patient admitted with acute respiratory failure has ineffective airway clearance related to thick secretions. Which nursing intervention would specifically address this patient problem?
a. Encourage use of the incentive spirometer.
b. Offer the patient fluids at frequent intervals.
c. Teach the patient the importance of ambulation.
d. Titrate oxygen level to keep O2 saturation above 93%.
ANS: B
Because the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. Patients should be instructed to use the incentive spirometer on a regular basis (e.g., every hour) to facilitate the clearance of the secretions. The other actions may also be helpful in improving the patient’s gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.
A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next?
a. Increase the tidal volume and respiratory rate.
b. Decrease the fraction of inspired oxygen (FIO2).
c. Perform endotracheal suctioning more frequently.
d. Lower the positive end-expiratory pressure (PEEP).
ANS: D
Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for another pneumothorax.
After receiving change-of-shift report on a medical unit, which patient should the nurse assess first?
a. A patient with cystic fibrosis who has thick, green-colored sputum
b. A patient with pneumonia who has crackles bilaterally in the lung bases
c. A patient with emphysema who has an oxygen saturation of 90% to 92%
d. A patient with septicemia who has intercostal and suprasternal retractions
ANS: D
This patient’s history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of O2 and use of positive-pressure ventilation. The other patients should also be assessed, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.
A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding by the nurse is most important to report to the health care provider?
a. The patient has bibasilar lung crackles.
b. The patient is sitting in the tripod position.
c. The patient’s pulse oximetry indicates a 91% O2 saturation.
d. The patient’s respirations have dropped to 10 breaths/minute.
ANS: D
A drop in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore immediate action such as positive-pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An O2 saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.
When assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse finds a new onset of agitation and confusion. Which action should the nurse take first?
a. Observe for facial symmetry.
b. Notify the health care provider.
c. Attempt to calm and reorient the patient.
d. Assess oxygenation using pulse oximetry.
ANS: D
Because agitation and confusion are frequently the initial indicators of hypoxemia, the nurse’s initial action should be to assess O2 saturation. The other actions are also appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider.
The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action?
a. The patient’s PaO2 is 45 mm Hg.
b. The patient’s PaCO2 is 33 mm Hg.
c. The patient’s respirations are shallow.
d. The patient’s respiratory rate is 32 breaths/min.
ANS: A
The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient’s poor oxygenation.
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.
ANS: C
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.
ANS: D
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% c. Crackles audible at lung bases
b. Heart rate 106 beats/minute d. Respiratory rate 22 breaths/minute
ANS: A
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%.
ANS: A
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
ANS: A
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.
During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first?
a. Give the prescribed PRN sedative drug.
b. Offer reassurance and reorient the patient.
c. Use pulse oximetry to check the oxygen saturation.
d. Notify the health care provider about the patient’s status.
ANS: C
Agitation may be an early indicator of hypoxemia. The other actions may also be appropriate, depending on the findings about O2 saturation.
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?
a. Older age and anemia c. Recent arthroscopic procedure
b. Albumin level and weight loss d. Confusion and disorientation to time
ANS: B
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
All of these interventions are part of the ventilator bundle that is recommended to prevent VAP. Arterial blood gases may be done daily but are not always necessary and do not help prevent VAP.
A registered nurse (RN) is the group leader of practical nurses and nursing assistive personnel. Which nursing care model is the RN using?
a. Case management
b. Total patient care
c. Primary nursing
d. Team nursing
ANS: D
In team nursing, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs. Total patient care involves an RN being responsible for all aspects of care for one or more patients. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members.
A nurse is overseeing the care of patients with severe diabetes and patients with heart failure to improve cost-effectiveness and quality of care. Which nursing care delivery model is the nurse using?
a. Team nursing
b. Total patient care
c. Primary nursing
d. Case management
ANS: D
Case management is unique because clinicians, either as individuals or as part of a collaborative group, oversee the management of patients with specific, complex health problems or are held accountable for some standard of cost management and quality. Case management is a care approach that coordinates and links health care services to patients and families while streamlining costs. In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. Total patient care involves an RN being responsible for all aspects of care for one or more patients. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members.
