The nurse is caring for a client who developed GI bleeding 3 weeks after a diagnosis of pulmonary embolism (PE). The international normalized ratio (INR) is 6.9. Which one of these questions is most appropriate for the nurse to ask at this time?
- “Have you eaten a lot of green leafy vegetables?”
- “Have you experienced swelling of your legs?”
- “Were you massaging your calves?”
- “Have you taken any aspirin or salicylates?”
D. “Have you taken any aspirin or salicylates?”
The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure. Which findings would cause the nurse to suspect a left-sided tension pneumothorax?
- The left chest caves in on inspiration and “puffs out” on expiration.
- Chest asymmetry and jugular vein distention are present.
- The left lung field is dull to percussion with crackles present on auscultation.
- The client has bloody sputum and wheezes.
B. Chest asymmetry and jugular vein distention are present.
The charge nurse in the intensive care unit is overseeing care for a group of clients. The nurse is especially vigilant in collaboration with the primary nurse and interprofessional team in assessing for acute respiratory distress syndrome (ARDS) in which of these clients?
- Client with diabetic ketoacidosis (DKA)
- Client with atrial fibrillation
- Client with aspiration pneumonia
- Client with acute kidney failure
C. Client with aspiration pneumonia
A client has been admitted with a diagnosis of pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care?
- Teach the client to avoid using dental floss.
- Monitor the platelet count daily.
- Ensure adequate staffing for the unit.
- Notify radiology of an impending scan.
B. Monitor the platelet count daily.
The nurse is reviewing the medical record of a client with pulmonary embolism (PE). What priority does the nurse set after reviewing the blood gas result below? pH 7.46, PaCO2 30 mm Hg, HCO3– 26 mEq/L (26 mmol/L), PaO2 62 mm Hg
- Have the client breathe rapidly and deeply
- Apply oxygen
- Administer sodium bicarbonate
- Collaborate with the provider to increase the pH
B. Apply oxygen
The nurse is caring for a group of clients on a medical surgical unit. Which clients will the nurse monitor closely for respiratory failure? Select all that apply.
- Client with a brainstem tumor
- Client with acute pancreatitis
- Client with a C5 spinal cord injury
- Client using client-controlled analgesia
- Client experiencing cocaine intoxication
A. Client with a brainstem tumor
B. Client with acute pancreatitis
C. Client with a C5 spinal cord injury
D. Client using client-controlled analgesia
The intensive care nurse is working on a unit-based project to prevent intensive care unit (ICU) psychosis. Which intervention does the nurse recommend to best decrease the incidence of ICU psychosis?
- Providing frequent explanations and reassurance
- Keeping the lights on to promote orientation
- Administering sedation
- Providing television or radio for stimulation
A. Providing frequent explanations and reassurance
The nurse is caring for a group of clients on a Telemetry unit. When providing client education, which client will the nurse determine most needs information regarding preventing pulmonary embolism (PE)?
- A woman who frequently flies to Europe
- A man who works on a farm
- A man admitted for a myocardial infarction
- A woman with a bleeding disorder
A. A woman who frequently flies to Europe
When caring for a client with a pulmonary embolism, which priority intervention will the nurse use to reduce anxiety?
- Remain with the client and provide oxygen in a calm manner.
- Have the client breathe into a brown paper bag using pursed lips.
- Offer the client a mild sedative.
- Allow a family member to remain in the room.
A. Remain with the client and provide oxygen in a calm manner.
The nurse is overseeing a nursing student who is administering medications to a group of clients receiving treatment for pulmonary embolism. The nurse recognizes the student understands safety and administration of anticoagulant therapy when the student makes which of these statements?
- “The client will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days.”
- “Therapy with warfarin (Coumadin) is effective when the INR is between 2 and 3.”
- “Once the health care provider orders warfarin (Coumadin), the intravenous heparin can be discontinued.”
- “If bleeding develops, we will give platelets to reverse the anticoagulant.”
B. “Therapy with warfarin (Coumadin) is effective when the INR is between 2 and 3.”
The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority?
- Inadequate nutrition related to food–drug interactions with anticoagulant therapy
- Risk for infection related to leukocytosis
- Hypoxemia related to ventilation–perfusion mismatch
- Insufficient knowledge related to the cause of PE
C. Hypoxemia related to ventilation–perfusion mismatch
When receiving report on a group of clients on the step down unit, which client needs immediate attention by the nurse?
- A client who is receiving continuous positive airway pressure (CPAP) and has intermittent wheezing
- A client receiving mechanical ventilation who has tracheal deviation
- A client who was recently extubated and is reporting a sore throat
- A client who is receiving O2 by facemask and whose respiratory rate is 24 breaths/min
B. A client receiving mechanical ventilation who has tracheal deviation
The nurse is caring for a client who is receiving mechanical ventilation and hears the high-pressure alarm. Which action will the nurse take first?
- Check the ventilator alarm settings.
- Assess the set tidal volume.
- Listen to the client’s breath sounds.
- Call the respiratory therapist.
C. Listen to the client’s breath sounds.
A client was intubated 30 minutes ago for acute respiratory distress syndrome (ARDS) and possible sepsis. The following prescriptions have been given for the client. In what sequence will the nurse perform these actions? 1. Infuse levofloxacin (Levaquin) 500 mg IV. 2. Obtain baseline aerobic and anaerobic sputum cultures. 3. Teach the client and family methods of communicating. 4. Analyze post-intubation arterial blood gases (ABGs).
- 2, 1, 3, 4
- 4, 3, 1, 2
- 3, 4, 2, 1
- 4, 2, 1, 3
D. 4, 2, 1, 3
A client in the intensive care unit (ICU) who is receiving mechanical ventilation begins to pick at the bedcovers. Which action will the nurse take next?
- Increase the sedation.
- Assess for adequate oxygenation.
- Explain that the tube in the client’s throat helps with breathing.
- Request that the family leave to decrease the client’s agitation
B. Assess for adequate oxygenation.
The nurse is caring for a client who has just been extubated after receiving mechanical ventilation. Which action will the nurse delegate to unlicensed assistive personnel (UAP)?
- Keep the head of the bed elevated.
- Teach about incentive spirometer use.
- Monitor vital signs every 5 minutes.
- Adjust the nasal oxygen flow rate.
A. Keep the head of the bed elevated.
When caring for the client receiving mechanical ventilation, the nurse includes which of these interventions to prevent ventilator-associated pneumonia (VAP)? Select all that apply.
- Administering antibiotic prophylaxis
- Continuous removal of subglottic secretions
- Elevating the head of the bed at least 30 degrees whenever possible
- Handwashing before and after contact with the client
- Placing a nasogastric tube
- Placing the client in a negative-airflow room
B. Continuous removal of subglottic secretions
C. Elevating the head of the bed at least 30 degrees whenever possible
D. Handwashing before and after contact with the client
The nurse coming on shift prepares to perform an initial assessment of a client receiving sedation and mechanical ventilation through a tracheostomy. Which are priorities for the nurse to carry out? Select all that apply.
- Ask visitors to leave the room.
- Assess the client’s color and respirations.
- Confirm alarms and ventilator settings.
- Ensure that the tube is in proper position.
- Auscultate for bilateral breath sounds.
- Provide routine tracheostomy and mouth care.
B. Assess the client’s color and respirations.
C. Confirm alarms and ventilator settings.
D. Ensure that the tube is in proper position.
E. Auscultate for bilateral breath sounds.
The nurse is providing education about the management of respiratory failure to the family of a client who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse will communicate?
- “Sedation is needed so your loved one does not rip the breathing tube out.”
- “Suctioning is important to remove organisms from the lower airway.”
- “Paralytics and sedatives help decrease the demand for oxygen.”
- “We are encouraging oral and IV fluids to keep your loved one hydrated.”
- “Paralytics and sedatives help decrease the demand for oxygen.”
The nurse is caring for a group of clients on a medical surgical unit. For which of these individuals does the nurse provide immediate interventions to reduce the risk for pulmonary embolism (PE)?
- A client with diabetes and cellulitis of the leg
- A client receiving IV fluids through a peripheral line
- A client returning from an open reduction and internal fixation of the tibia
- A client with fluid volume deficit and hypokalemia receiving potassium supplements
C. A client returning from an open reduction and internal fixation of the tibia
When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse calls the Rapid Response Team (RRT) for intervention for which client?
- Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia
- Client with deep vein thrombosis who is receiving low–molecular-weight heparin and has ongoing calf pain
- Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry reading of 94%
- Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs
A. Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia
The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms consistent with PE will the nurse assess? Select all that apply.
- Dizziness and syncope
- Shortness of breath (SOB) worsening over the last 2 weeks
- Inspiratory chest pain
- Productive cough
- Pink, frothy sputum
A. Dizziness and syncope
C. Inspiratory chest pain
The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which respiratory modality does the nurse suggest to the interdisciplinary team as an alternative to mechanical ventilation?
- Oropharyngeal airway
- Bi-level positive airway pressure (BiPAP)
- Non-rebreather mask with 100% oxygen
- Positive end-expiratory pressure (PEEP)
B. Bi-level positive airway pressure (BiPAP)
The nurse is caring for a group of clients with respiratory disorders. For which of these clients does the nurse plan for immediate intubation?
- Client who requires suctioning of oral secretions
- Client with hypoventilation and decreased breath sounds
- Client with O2 saturation of 90%
- Client with thick, purulent secretions and crackles
B. Client with hypoventilation and decreased breath sounds