NSG 201H -Coordinating Care for Critically Ill Patients

NSG 201H -Coordinating Care for Critically Ill Patients

NSG 201H -Coordinating Care for Critically Ill Patients With Respiratory Dysfunction

Chapter 27: Coordinating Care for Critically Ill Patients With Respiratory Dysfunction

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____     1.   The nurse is providing care to a patient who is diagnosed with acute respiratory distress syndrome (ARDS). Which clinical manifestation does the nurse anticipate for this patient who is experiencing hypoxia as a result of the ARDS diagnosis?

1)	Fluid imbalance
2)	Hypertension
3)	Bradycardia
4)	Dyspnea

 

____     2.   The nurse is providing care to a patient with an infected leg wound. The patient is exhibiting symptoms of a systemic infection and is receiving intravenous antibiotics. The patient states to the nurse, “I am having trouble breathing.” Based on this data, which does the nurse suspect the patient is experiencing?

1)	Allergic response from antibiotic therapy
2)	Deep vein thrombosis
3)	Acute respiratory distress syndrome
4)	Anemia

 

____     3.   A patient with a respiratory rate of eight breaths per minute has an oxygen saturation of 82%. Which nursing diagnosis is a priority for this patient?

1)	Risk for Infection
2)	Impaired Spontaneous Ventilation
3)	Risk for Acute Confusion
4)	Decreased Cardiac Output

 

 

____     4.   A patient with acute respiratory distress syndrome (ARDS) is being weaned from mechanical ventilation. Which nursing action is appropriate for this patient?

1)	Increase percentage of oxygen being provided through the ventilator
2)	Place in the Fowler position
3)	Provide morning care during the weaning procedures
4)	Medicate with morphine for pain as needed

 

____     5.   A patient is brought into the emergency department (ED) after being in a motor vehicle accident. The patient has suffered traumatic injury that may involve multiple body systems. Which is the priority nursing assessment for this patient?

1)	Breathing and ventilation
2)	Circulation with hemorrhage control
3)	Airway maintenance with cervical spine protection
4)	Disability and neurological assessment

 

____     6.   The nurse caring for a newborn on a ventilator for acute respiratory distress syndrome (ARDS) informs the parents that the newborn is improving. Which data supports the nurse’s assessment of the newborn’s condition?

1)	Increased PCO2
2)	Oxygen saturation of 92%
3)	Pulmonary vascular resistance increases
4)	Less than 1 mL/kg/hour urine output

 

____     7.   The nurse caring for a patient admitted with septic shock is aware of the need to assess for the development of acute respiratory distress syndrome (ARDS). Which early clinical manifestation would indicate the development of ARDS?

1)	Intercostal retractions
2)	Cyanosis
3)	Tachypnea
4)	Tachycardia

 

____     8.   A patient admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS). Which health-care provider prescription does the nurse anticipate for this patient?

1)	Mechanical ventilation
2)	Oxygen via a nasal cannula
3)	Face mask oxygen administration
4)	Continuous positive airway pressure

 

NSG 201H -Coordinating Care for Critically Ill Patients

____     9.   The nurse in the intensive care unit (ICU) is caring for a patient diagnosed with acute respiratory distress syndrome (ARDS). Vital signs prior to endotracheal intubation: HR 108 bpm, RR 32 bpm, BP 88/58 mm Hg, and oxygen saturation 82%. The patient is intubated and placed on mechanical ventilation with positive pressure ventilation. Which assessment finding indicates a further decrease of cardiac output secondary to positive pressure ventilation?

1)	Blood pressure 90/60 mm Hg
2)	Urine output 25mL/hr
3)	Heart rate 110 bpm
4)	Oxygen saturation 90%

 

____   10.   The nurse caring for a patient recovering from an abdominal hysterectomy suspects the patient is experiencing a pulmonary embolism. Which clinical manifestation supports the nurse’s suspicion?

1)	Nausea
2)	Decreased urine output
3)	Dyspnea and shortness of breath
4)	Activity intolerance

 

____   11.   The nurse is concerned that a patient admitted for a total hip replacement is at risk for thrombus formation and pulmonary embolism. Which assessment finding supports the nurse’s concern?

1)	Body mass index (BMI) 35.8
2)	Former cigarette smoker
3)	Blood pressure 132/88 mm Hg
4)	Age 45 years

 

____   12.   The nurse is providing discharge instructions to an older adult patient who is going home after having a total knee replacement. Which will the nurse include in the discharge teaching to decrease the patient’s risk for developing a thrombosis or pulmonary embolism?

1)	Place pillows under the knees when in bed
2)	Use compression stockings
3)	Limit ambulation
4)	Limit fluids

 

____   13.   A patient diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. Which is the priority nursing diagnosis for this patient?

1)	Ineffective Tissue Perfusion
2)	Anxiety
3)	Impaired Gas Exchange
4)	Impaired Physical Mobility

 

____   14.   The nurse is planning care for a patient with a pulmonary embolism. Which intervention would assist with the patient’s decrease in cardiac output?

1)	Provide oxygen
2)	Keep protamine sulfate at the bedside
3)	Monitor pulmonary arterial pressures
4)	Assess for bleeding

 

NSG 201H -Coordinating Care for Critically Ill Patients

____   15.   The nurse has instructed a patient recovering from a pulmonary embolism on long-term anticoagulant therapy. Which patient statement indicates that instruction has been effective?

1)	“I will expect bloody sputum when I brush my teeth.”
2)	“I need to use a soft toothbrush and an electric razor, and avoid injuries.”
3)	“I need to eat a well-balanced diet with green salads.”
4)	“I can expect to be bruised, since this is normal.”

 

____   16.   A patient scheduled for surgery is being instructed in leg exercises and the pneumatic compression device. The nurse includes these instructions to decrease which postoperative complication?

1)	Infection
2)	Delayed wound healing
3)	Contractures
4)	Deep vein thrombosis

 

____   17.   The nurse is preparing to discharge a patient recovering from a pulmonary embolism. Which topics are appropriate for the nurse to include in the teaching session?

1)	Resume the use of any over-the-counter medications
2)	Diet to include green leafy vegetables
3)	Anticoagulant administration schedule
4)	Resume normal activity level

 

____   18.   The nurse is providing care to several patients on a medical-surgical unit. Which patient is at highest risk for a nonthrombotic pulmonary embolism?

1)	The patient who is receiving intravenous pain medication
2)	The patient who is postoperative from a femur fracture repair
3)	The patient with a primary lung tumor
4)	The patient who uses intravenous illicit drugs

 

____   19.   A nurse caring for a patient with a pulmonary embolism expects to find which diagnostic result?

1)	Patchy infiltrates on chest x-ray
2)	Metabolic alkalosis on arterial blood gas
3)	Elevated CO2 level found on end-tidal carbon dioxide monitor
4)	Tachycardia and nonspecific T-wave changes on EKG

 

____   20.   The nurse is planning care for a newly admitted patient diagnosed with pulmonary embolism. The nurse anticipates the patient will need anticoagulant therapy. What is true regarding this therapy for the treatment of this condition?

1)	It is considered second-line treatment.
2)	Major hemorrhage is common.
3)	Heparin and warfarin (Coumadin) are usually initiated at the same time.
4)	Heparin alters the synthesis of vitamin K–dependent clotting factors, preventing further clots.

 

NSG 201H -Coordinating Care for Critically Ill Patients

____   21.   The nurse working with a student nurse is providing care for a patient requiring mechanical ventilation. The student nurse asks the meaning of assist control. Which response by the nurse is the most appropriate?

1)	“Assist control is a means of delivering ventilation that delivers a preset volume and/or pressure each time the patient begins an inspiration.”
2)	“Assist control allows the patient to breathe independently, but supplies a breath if the patient does not begin an inhalation in a specified period of time.”
3)	“Assist control is used when weaning a patient from the ventilator because the patient must exercise the muscles of respiration in order to get a full breath.”
4)	“Assist control is often used when a patient is receiving a paralytic agent.”

 

____   22.   The nurse is providing care for the patient requiring mechanical ventilation. Which action by the nurse would be inappropriate when providing care to this patient?

1)	Confirming airway placement by auscultating the lungs and checking the length marking of the tube at the lip
2)	Assuring that tube cuff inflation is no greater than 15 cm H2O, and that there is no audible air leak
3)	Assuring ventilator tubing is secured and does not pull on the patient’s airway
4)	Verifying correct ventilator settings

 

____   23.   The nurse working in the intensive care unit is assigned a patient requiring mechanical ventilation. When responding to the ventilator alarm, the nurse sees a high-pressure alarm. Which nursing action is the priority?

1)	Silencing the alarm
2)	Removing the patient from the ventilator and using a bag-valve device to oxygenate the patient until the respiratory therapist can be summoned
3)	Emptying the collected water from the ventilator tubing
4)	Assessing the patient

 

 

____   24.   The nurse is providing care for a patient requiring mechanical ventilation. When the nurse enters the room at the beginning of the shift, the patient’s monitor displays a heart rate of 64 and oxygen saturation of 88%. Which nursing action is the priority?

1)	Increasing the oxygen concentration and quickly assessing the patient
2)	Removing the patient from the ventilator and hyperoxygenating and hyperventilating the patient
3)	Assessing the patient for airway obstruction
4)	Checking ventilator settings

 

NSG 201H -Coordinating Care for Critically Ill Patients

Completion

Complete each statement.

 

25. The nurse is providing care to a patient admitted to the emergency department with the diagnosis of acute respiratory distress syndrome (ARDS). When educating the patient’s family on the disease progress, in which order will the nurse present the material? (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234)

 

1) Initiation of ARDS

2) Onset of pulmonary edema

3) End-stage ARDS

4) Alveolar collapse

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____   26.   The nurse educator prepares to speak to a group of nursing students about direct and indirect insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS). Which conditions will the nurse include in the teaching session? Select all that apply.

1)	Septic shock
2)	Viral pneumonia
3)	Aspirin overdose
4)	Head injury
5)	Angioplasty

 

____   27.   A patient receiving treatment for acute respiratory distress syndrome (ARDS) is demonstrating anxiety and fear of having to stay on the ventilator indefinitely. Which interventions by the nurse are appropriate? Select all that apply.

1)	Explain about care areas specifically designed for long-term ventilatory support.
2)	Dim the lights and reduce distracting noise, such as the television.
3)	Instruct that intubation and ventilation are temporary measures.
4)	Encourage family visits and participation in care.
5)	Remain with the patient as much as possible.

 

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____   28.   Which assessment data would cause the nurse to document the patient is experiencing early respiratory distress? Select all that apply.

1)	Dyspnea
2)	Restlessness
3)	Tachycardia
4)	Confusion
5)	Cyanosis