A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?
C. Notify the Rapid Response Team.
This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority
A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate?
C. Teach the client about factor V Leiden testing.
Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder should be referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature
.A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygen
saturation has not significantly improved. What response by the nurse is best?
C. The blood clot interferes with perfusion in the lungs.
A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to
be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.
A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
D. Increase the heparin rate.
For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working. A normal PTT is 25 to 35 seconds, so this clients PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.
A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best?
A. Prepare preoperative teaching for an inferior vena cava (IVC)filter.
Often clients are discharged from the hospital on warfarin (Coumadin) after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be implanted. The nurse should prepare to do preoperative teaching on this procedure. It would
be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy.
A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?
D. Platelet count: 82,000/L
This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
C. Assess for other manifestations of hypoxia.
Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.
A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?
A. Interrupt the procedure to give oxygen.
Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation during the procedure and monitor the clients oxygen saturation, but these do not take priority. Finding another provider is not appropriate at this time
An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority?
B. Listen to the clients lung sounds.
intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.
A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?
C. Provide frequent oral care per protocol.
The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse.
A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority?
on.
d. The upper peak airway pressure limit alarm is off.
C. The upper peak airway pressure limit alarm is
on.
The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but
does not take priority over preventing injury
The nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?
D. Assess the cause of the agitation.
The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain and confusion can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary, but not as a first step.
A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?
room
C. Ensuring there is a bag-valve-mask in the room
Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse should know and check the settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or
may not need suctioning on arrival.
.A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best?
C. It will prevent ulcers from the stress of mechanical ventilation.
Stress ulcers occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Zantac is a histamine blocking agent.
A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?
lines.
B. Ensure a patent airway.
The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs.
A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?
A. Large chefs salad and muffin
Warfarin works by inhibiting the synthesis of vitamin Kdependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. The chefs salad most likely has too many leafy green vegetables, which contain high amounts of vitamin K. The other selections, while not particularly healthy, will not interfere with the medications mechanism of action.
A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?
B. Strict vegetarian
Warfarin works by inhibiting the synthesis of vitamin Kdependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have trouble maintaining this diet. The nurse should explore this possibility with the client. The other options are not related.
A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse?
B. Choosing an 18-gauge, 2-inch needle
Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions are appropriate.
A client in the emergency department has several broken ribs. What care measure will best promote
comfort?
A. Allowing the client to choose the position in bed
w the client with respiratory problems to assume a position of comfort if it does not interfere with care. Often the client will choose a more upright position, which also improves oxygenation. The other options are less effective comfort measures
A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?
D. Alteplase (Activase)
Activase is a clot-busting agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.
A client is brought to the emergency department after sustaining injuries in a severe car crash. The clients chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority?
D. Prepare to assist with intubation.
This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.
A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best?
B. It is hypoxemia that persists even with 100% oxygen administration.
Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen
A nurse is caring for a client on the medical stepdown unit. The following data are related to this client:
Shortness of breath for 20 minutes, Feels frightened, Can't catch my breath
pH:7.12, PaCO2:28mmHg, PaO2:58mmHg,SaO2: 88%, Pulse: 120 RR: 34
BP 158/92 mm Hg, Lungs have crackles
What action by the nurse is most appropriate?
C. Facilitate a STAT pulmonary angiography.
This client has manifestations of pulmonary embolism (PE); however, many conditions can cause the clients
presentation. The gold standard for diagnosing a PE is pulmonary angiography. The nurse should facilitate this test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of PE.
A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)
a. Client who had a reaction to contrast dye yesterday
b. Client with a new spinal cord injury on a rotating bed
c. Middle-aged man with an exacerbation of asthma
d. Older client who is 1-day post hip replacement surgery
e. Young obese client with a fractured femur
(B)Client with a new spinal cord injury on a rotating bed
d. Older client who is 1-day post hip replacement surgery
e. Young obese client with a fractured femur
Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.
When working with women who are taking hormonal birth control, what health promotion measures should
the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)
a. Avoid drinking alcohol.
b. Eat more omega-3 fatty acids.
c. Exercise on a regular basis.
d. Maintain a healthy weight.
e. Stop smoking cigarettes.
c. Exercise on a regular basis.
d. Maintain a healthy weight.
e. Stop smoking cigarettes.
Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE
A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate?
(Select all that apply.)
a. Acknowledge the frightening nature of the illness.
b. Delegate a back rub to the unlicensed assistive personnel (UAP).
c. Give simple explanations of what is happening.
d. Request a prescription for antianxiety medication.
e. Stay with the client and speak in a quiet, calm voice.
a. Acknowledge the frightening nature of the illness.
b. Delegate a back rub to the unlicensed assistive personnel (UAP).
c. Give simple explanations of what is happening.
e. Stay with the client and speak in a quiet, calm voice.
Clients with PEs are often anxious. The nurse can acknowledge the clients fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also
reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to
hypoxia. If the clients anxiety is interfering with diagnostic testing or treatment, they can be used, but there isno evidence that this is the case.
The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)
a. Adherence to proper hand hygiene
b. Administering anti-ulcer medication
c. Elevating the head of the bed
d. Providing oral care per protocol
e. Suctioning the client on a regular
schedule
a. Adherence to proper hand hygiene
b. Administering anti-ulcer medication
c. Elevating the head of the bed
d. Providing oral care per protocol
The ventilator bundle is a group of care measures to prevent ventilator-associated pneumonia. Actions in the
bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.
A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)
a. Allow visitors at the clients bedside. b. Ensure the client can communicate if awake.
c. Keep the television tuned to a favorite channel.
d. Provide back and hand massages when turning.
e. Turn the client every 2 hours or more.
(A) allow visitors at the clients bedside.
b. Ensure the client can communicate if awake.
d. Provide back and hand massages when turning.
e. Turn the client every 2 hours or more.
There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the clients skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.
The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning
failure. What age-related changes contribute to this? (Select all that apply.)
a. Chest wall stiffness
b. Decreased muscle strength
c. Inability to cooperate
d. Less lung elasticity
e. Poor vision and hearing
a. Chest wall stiffness
b. Decreased muscle strength
d. Less lung elasticity
Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include
increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older
adults have an inability to cooperate or poor sensory acuity.
242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse
anticipate for tidal volume? (Record your answer using a whole number.) ___ mL
660 mL
A low tidal volume of 6 mL/kg is used to prevent lung injury.
242 pounds = 110 kg.
110 kg 6 mL/kg = 660 mL.
A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform
first?
C. Airway patency
A patent airway is the priority. The nurse first should make sure that the airway is patent and then should
determine whether the client is in pain and whether bone displacement or blood loss has occurred.
the nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?
C. Collect the nasal drainage on a piece of filter paper.
the client with nasal drainage after facial trauma could have a skull fracture that has resulted in leakage of
cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the fact that it forms a halo when dripped on filter paper. The other actions would be appropriate but are not as high a priority as assessing
for CSF. A CSF leak would increase the clients risk for infection.
A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first?
B. Ask the client if he or she has ever been evaluated for sleep apnea.
Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the
client is offered suggestions for treatment.
A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration?
a. tilt the head back as far as possible when swallowing.
b. Tuck the chin down when swallowing
c. Breathe slowly and deeply while swallowing.
d. Keep the head very still and straight while swallowing.
A) b. Tuck the chin down when swallowing
B) a. tilt the head back as far as possible when swallowing.
C) c. Breathe slowly and deeply while swallowing.
D) d. Keep the head very still and straight while swallowing.
A) b. Tuck the chin down when swallowing
The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration. Tilting the head back would increase the chance of aspiration. Breathing slowly would not decrease the risk of aspiration, but holding the breath would. Keeping the head still and straight would not decrease the risk for aspiration.
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?
D. A 55-year-old woman who is 50 pounds overweight
The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea.
While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first?
C. Contact the provider and prepare for intubation.
facial and neck tissue edema can occur in clients with facial trauma. Airway patency is the highest priority. Clients who experience stridor and hypoxia, manifested by anxiety and restlessness, should be immediately intubated to ensure airway patency. Albuterol decreases bronchi and bronchiole inflammation, not facial and neck edema. Although putting the client in high-Fowlers position and asking the client to perform breathing exercises may temporarily improve the clients comfort, these actions will not decrease the underlying problem or improve airway patency.
