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

Question 1

Which assessment finding alerts the nurse to the possibility that the intrathoracic pressure in a mechanically ventilated patient is too high?
1)Hypotension
2)Bradycardia
3)SpO₂ 88%
4)Decreased respiratory effort

Answer 1

4

Question 2

The nurse provides care to a patient who is prescribed thrombolytic therapy to treat a deep vein thrombosis (DVT). Which patient information is an absolute contraindication to this therapy necessitating the nurse to question the medication current prescription?
1)Surgery in the past 10 days
2)History of non-hemorrhagic stroke
3)Platelet count of 90,000/mm³
4)Motor vehicle crash 1 month ago

Answer 2

4

Question 3

In triaging patients in the emergency department, the nurse prioritizes the patient with which clinical manifestations?
1)Dyspnea and anxiety
2)Cyanosis and decreased level of consciousness
3)Confusion and pink skin color
4)Restlessness and tachycardia

Answer 3

2

Question 4

A patient's blood pressure drops from 120/76 to 90/60 as soon as positive end-expiratory pressure (PEEP) is initiated for the treatment of hypoxemia. What is the most likely cause of this decrease in blood pressure?
1)Decreased cardiac output
2)Decreased cardiac contractility
3)Increased pulmonary vascular resistance
4)Increased heart rate

Question 5

A patient admitted with smoke inhalation injuries develops clinical manifestations of acute respiratory distress syndrome (ARDS). The nurse prepares to implement which healthcare provider prescription?
1)Intubation and mechanical ventilation
2)Oxygen via a nasal cannula
3)Face mask oxygen administration
4)Continuous positive airway pressure via face mark

Question 6

Which prescription is the most important to decrease the risk of deep vein thrombus in a patient after surgery?
1)1,000-calorie regular diet
2)Incentive spirometry every 2 to 4 hours
3)Increase fluid intake to 1,500 to 2,000 mL/day
4)Ambulate every 2 to 4 hours

Question 7

The nurse monitors for which clinical manifestations in the patient experiencing intermediate respiratory failure?
1)Dyspnea
2)Lethargy
3)Tachycardia
4)Restlessness

Question 8

What should the nurse conclude if constant bubbling is noted in the water-seal chamber of a closed chest drainage system?
1)The system has an air leak.
2)The chest tube is obstructed.
3)The system is functioning normally.
4)The patient's lung has reexpanded.

Question 9

In the patient admitted with acute respiratory distress syndrome (ARDS), the nurse identifies the nursing diagnosis Impaired Gas Exchange related to which physiological change?
1)Increased lung compliance
2)Increased capillary permeability
3)Increased left ventricular pressure
4)Increased airway resistance

Question 10

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
2)Removing the patient from the ventilator and hyperoxygenating the patient
3)Assessing the patient for airway obstruction
4)Checking ventilator settings

Question 11

The nurse is planning care for a newly admitted patient diagnosed with pulmonary embolism. In preparing to implement prescribed anticoagulant therapy, it is important that the nurse recognize which information regarding this therapy?
1)Anticoagulation is considered second-line treatment.
2)Major hemorrhage is common with anticoagulation.
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.

Question 12

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 because this is normal."

Question 13

In the patient with acute respiratory failure, the nurse interprets which set of arterial blood gases as respiratory acidosis with hypoxemia?
1)pH 7.30, PaCO₂ 55 mm Hg, HCO₃^- 22 mEq/L, PaO₂ 66 mm Hg
2)pH 7.32, PaCO₂ 48 mm Hg, HCO₃^- 22 mEq/L, PaO₂ 88 mm Hg
3)pH 7.37, PaCO₂ 42 mm Hg, HCO₃^- 24 mEq/L, PaO₂ 82 mm Hg
4)pH 7.47, PaCO₂ 30 mm Hg, HCO₃^- 32 mEq/L, PaO₂ 75 mm Hg

Question 14

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 indicate the development of ARDS?
1)Intercostal retractions
2)Cyanosis
3)Tachypnea
4)Tachycardia

Question 15

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

Question 16

After insertion of a chest tube for a pneumothorax, a patient becomes hypotensive with neck vein distention, tracheal shift, absent breath sounds, and diaphoresis. The nurse suspects a tension pneumothorax has occurred. The nurse assesses for what potential cause of tension pneumothorax?
1)Continuous bubbling in the suction chamber
2)The pneumothorax has resolved
3)Insufficient chest tube suction
4)Kinked or obstructed tube

Question 17

Which patient requires immediate intervention by the nurse to decrease the risk for developing a deep vein thrombosis (DVT)?
1)The patient who is immobile because of a fractured hip
2)The patient who is admitted for an exacerbation of asthma
3)The patient who is obese and scheduled for laparoscopic day surgery
4)The patient who is admitted for an exacerbation of congestive heart failure

Question 18

Which arterial blood gas (ABG) results does the nurse recognize as most indicative of impending respiratory failure?
1)PaCO₂ 33 mm Hg; PaO₂ 66 mm Hg
2)PaCO₂ 30 mm Hg: PaO₂ 80 mmHg
3)PaCO₂ 45 mmHg; PaO₂ 70 mmHg
4)PaCO₂ 48 mm Hg; PaO₂ 60 mm Hg

Question 19

The patient is receiving heparin therapy for a deep vein thrombosis. Which activated partial thromboplastin time (aPTT) indicates to the nurse that anticoagulation is adequate?
1)The patient's aPPT is twice the control value.
2)The patient's aPPT is the same as the control value.
3)The patient's aPPT is half of the control value.
4)The patient's aPPT is five times the control value.

Question 20

The nurse correlates which mechanical ventilator setting as placing a patient at greatest risk for barotrauma?
1)CPAP 3 cm H₂O
2)FIO₂ 0.30
3)PEEP 7 cm H₂O
4)Low tidal volumes

Question 21

The nurse assumes care for a patient receiving a heparin infusion at 20 mL/hour. If 25,000 units are mixed in 500 mL of fluid, how many units of heparin is the patient receiving per hour? (Enter the number with no spaces or units of measurement.)

Question 22

In providing care to a patient who is being treated with mechanical ventilation for acute respiratory failure, the nurse understands the patient is at risk of ventilator-induced lung injury that includes which pathophysiological processes? Select all that apply.
1)Alveolar rupture
2)Increased vascular permeability
3)Increased pulmonary vascular resistance
4)Inflammatory-cell infiltrates
5)Pulmonary edema

Question 23

The patient is prescribed a heparin infusion at start at 2,000 units/hour. If 50,000 units are mixed in 250 mL, at what rate (mL/hour) does the nurse set the pump? (Enter the number with no spaces or units of measurement.)

Question 24

The nurse monitors for which clinical manifestations in the exudative phase of acute respiratory distress syndrome (ARDS)? Select all that apply.
1)PaCO₂ 55 mm Hg
2)Blood pressure 88/40
3)Hypoxemia
4)Respiratory alkalosis
5)Respiratory rate 26

Question 25

The nurse educator prepares to speak to a group of nursing students about insults to the lungs that may lead to the development of acute respiratory distress syndrome (ARDS). The nurse includes which as causes related to direct injury to the lungs? Select all that apply.
1)Aspiration
2)Chest trauma
3)Drug overdose
4)Pulmonary embolus
5)Septic shock

Question 26

The nurse correlates which assessment data to the patient experiencing early respiratory distress? Select all that apply.
1)Dyspnea
2)Restlessness
3)Tachycardia
4)Confusion
5)Cyanosis

Question 27

The nurse correlates which disorders as placing a patient at increased risk of acute respiratory failure (ARF) secondary to hypoventilation? Select all that apply.
1)Chronic obstructive pulmonary disorder
2)High spinal cord injury
3)Myasthenia gravis
4)Pulmonary edema
5)Opioid overdose

Question 28

A patient who had a segmental left lung resection for treatment of a lung carcinoma returns from surgery with a left posterolateral chest tube attached to a disposable water-seal chest drainage system. Which signs would indicate that the drainage system is working properly?
1)Air is bubbling in the water-seal chamber.
2)The fluid level in the water-seal chamber fluctuates.
3)The fluid level in the drainage chamber remains constant.
4)The bubbling in the suction chamber is intermittent.

Question 29

The nurse is providing care for a patient with acute respiratory distress syndrome (ARDS). The patient's PaO₂ is 75 and the ventilator is providing an FIO₂ of 0.50. What is the calculated PaO₂/FIO₂ ratio?

Question 30

The nurse monitors for which clinical manifestations in the patient diagnosed with a pulmonary embolism (PE)? Select all that apply.
1)Tachypnea
2)Hypotension
3)Shortness of breath
4)Bilateral lower extremity edema
5)Accessory muscle use