Deck 34: Care of Critically Ill Patients With Respiratory Problems

Question 1

The nurse is caring for a client with a ventilation/perfusion mismatch who is receiving mechanical ventilation.Which intervention is a priority for this client?

A) Administering antibiotics every 6 hours
B) Positioning the client with the "good lung dependent"
C) Making sure that the pilot balloon line on the endotracheal tube is deflated
D) Ensuring that the client is able to speak clearly

Answer 1

Positioning the client with the "good lung dependent"

Question 2

The nurse is caring for a client with a pulmonary embolus who also has right-sided heart failure.Which symptom will the nurse need to intervene for immediately?

A) Respiratory rate of 28 breaths/min
B) Urinary output of 10 mL/hr
C) Heart rate of 100 beats/min
D) Dry cough

Answer 2

Urinary output of 10 mL/hr

Question 3

A client is admitted to the emergency department several hours after a motor vehicle crash.The car's driver-side airbag was activated during the accident.Which assessment requires the nurse's immediate intervention?

A) Disorientation
B) Hemoptysis
C) Pulse oximetry reading of 94%
D) Chest pain with movement

Answer 3

Hemoptysis

Question 4

The nurse is caring for a client who is receiving mechanical ventilation accompanied by positive end-expiratory pressure (PEEP).What assessment findings require immediate intervention?

A) Blood pressure drop from 110/90 mm Hg to 80/50 mm/Hg
B) Pulse oximetry value of 96%
C) Arterial blood gas (ABG): pH, 7.40; PaO₂, 80 mm Hg; PaCO₂, 45 mm Hg; HCO₃-, 26 mEq/L
D) Urinary output of 30 mL/hr

Question 5

Which assessment finding of a client requires the nurse's immediate action?

A) Being intubated for 4 days
B) Uneven breath sounds
C) Wheezing on auscultation
D) Having the endotracheal (ET) tube taped to the lower jaw

Question 6

The nurse is caring for several clients on the respiratory floor.Which client does the nurse assess most carefully for the development of acute respiratory distress syndrome (ARDS)?

A) Older adult with COPD
B) Middle-aged client receiving a blood transfusion
C) Older adult who has aspirated his tube feeding
D) Young adult with a broken leg from a motorcycle accident

Question 7

A client with dyspnea is becoming very anxious.An arterial blood gas (ABG)shows a PaO₂ of 93 mm Hg.How does the nurse best intervene?

A) Increase the oxygen.
B) Administer an antianxiety medication.
C) Administer a bronchodilator.
D) Assist with relaxation techniques.

Question 8

A client states,"At night,I usually need to sleep propped up on two pillows in the chair,but now it seems I need three pillows." What is the nurse's best response?

A) "You should try to rest more during the day."
B) "You should try to lie flat for short periods of time."
C) "You need to stay in the hospital for further evaluation."
D) "You can take medication at night so you can sleep."

Question 9

The nurse is caring for a client who has been intubated and placed on a ventilator for treatment of acute respiratory distress syndrome (ARDS).Aside from assessing oxygenation,what is the nurse's priority action?

A) Assess hemoglobin.
B) Administer ferrous sulfate.
C) Assess muscle strength.
D) Consult with the registered dietitian.

Question 10

The client receiving mechanical ventilation has become more restless over the course of the shift.Which is the nurse's first action?

A) Sedate the client.
B) Call the health care provider.
C) Assess the client for pain.
D) Assess the client's oxygenation.

Question 11

The pilot balloon on the endotracheal tube of a client being mechanically ventilated is deflated.What is the nurse's priority action?

A) Nothing; this is required during ventilation.
B) Inflate the cuff using minimal leak technique.
C) Call the Rapid Response Team.
D) Increase the tidal volume.

Question 12

A client with a large pulmonary embolism is receiving alteplase (Activase).The nurse notes frank red blood in the Foley catheter drainage bag.What is the nurse's first action?

A) Irrigate the Foley.
B) Administer an antibiotic.
C) Clamp the Foley.
D) Notify the health care provider.

Question 13

The pressure reading during inspiration on the ventilator of a client receiving mechanical ventilation is fluctuating widely.What is the nurse's first action?

A) Determine whether an air leak is present in the client's endotracheal tube cuff.
B) Have the respiratory therapist check the pressure settings.
C) Assess the client's oxygenation.
D) Manually ventilate the client with a resuscitation bag.

Question 14

The nurse is caring for a client who is intubated with an endotracheal tube and on a mechanical ventilator.The client is able to make sounds.What is the nurse's first action?

A) Check cuff inflation on the endotracheal tube.
B) Listen carefully to the client.
C) Call the health care provider.
D) Auscultate the lungs.

Question 15

A client is admitted owing to difficulty breathing.The nurse assesses the client's color,lung sounds,and pulse oximetry reading.The pulse oximetry is 90%.What is the nurse's next action?

A) Give an intermittent positive-pressure breathing treatment.
B) Administer a rescue inhaler.
C) Call for a chest x-ray.
D) Assess an arterial blood gas.

Question 16

The nurse is caring for a postoperative client who suddenly reports difficulty breathing and sharp chest pain.After notifying the Rapid Response Team,what is the nurse's priority action?

A) Elevate the head of the bed and apply oxygen.
B) Listen to the client's lung sounds.
C) Pull the call bell out of the wall socket.
D) Assess the client's pulse oximetry.

Question 17

The nurse notes that each time the mechanical ventilator delivers a breath to a client with acute respiratory distress syndrome (ARDS),the peak inspiratory pressure alarm sounds.What is the nurse's best intervention?

A) Suction the client.
B) Perform chest physiotherapy.
C) Administer an inhaler.
D) Assess the airway.

Question 18

It is determined that a client has a large pulmonary embolism (PE).Fibrinolytic therapy is initiated.What is the nurse's priority action?

A) Monitor the client's oxygenation.
B) Teach the client about potential side effects.
C) Monitor the IV insertion site.
D) Monitor for bleeding.

Question 19

The nurse is caring for a client with acute respiratory distress syndrome (ARDS)who is receiving mechanical ventilation and positive end-expiratory pressure (PEEP).The alarm sounds,indicating decreased pressure in the system.What is the nurse's best action?

A) Change the client's position.
B) Suction the client.
C) Assess lung sounds.
D) Turn off the pressure alarm.

Question 20

The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus.The client's international normalized ratio (INR)is 2.0.What is the nurse's best action?

A) Increase the heparin dose.
B) Increase the warfarin dose.
C) Continue the current therapy.
D) Discontinue the heparin.

Question 21

A client admitted for difficulty breathing becomes worse.Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)?

A) Oxygen administered at 100%, PaO₂ 60
B) Increased dyspnea
C) Anxiety
D) Chest pain
E) Pitting pedal edema
F) Clubbing of fingertips

Question 22

Which clients are at highest risk for pulmonary embolism (PE)? (Select all that apply)

A) Middle-aged client awaiting surgery
B) Older adult with a 20-pack-year history of smoking
C) Client who has been on bedrest for 3 weeks
D) Obese client who has elevated platelets
E) Middle-aged client with diabetes mellitus type 1
F) Older adult who has just had abdominal surgery

Question 23

The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation.The client's oxygen saturation has dropped from 94% to 86%.What is the priority action by the nurse?

A) Encourage the client to take deep, controlled breaths.
B) Document findings and continue to monitor the client.
C) Notify the health care provider and prepare for intubation.
D) Stabilize the chest wall with rib binders.

Question 24

The nurse assesses a client admitted for chest trauma who reports dyspnea.The nurse finds tracheal deviation and a pulse oximetry reading of 86%.What is the nurse's priority intervention?

A) Notify the health care provider and document the symptoms.
B) Intubate the client and prepare for mechanical ventilation.
C) Administer oxygen and prepare for chest tube insertion.
D) Administer an intermittent positive-pressure breathing treatment.

Question 25

The nurse is caring for a client on a ventilator when the high-pressure alarm sounds.What actions are most appropriate?

A) Assess the tubing for kinks.
B) Assess whether the tubing has become disconnected.
C) Determine the need for suctioning.
D) Call the health care provider.
E) Call the Rapid Response Team.
F) Auscultate the client's lungs.

Question 26

A client with severe respiratory insufficiency becomes short of breath during activities of daily living.Which nursing intervention is best?

A) Call the Rapid Response Team.
B) Decrease involvement in care until the episode is past.
C) Cluster morning activities to provide long rest periods.
D) Space out interventions to provide for periods of rest.

Question 27

The nurse is caring for a client who is taken off a ventilator and placed on continuous positive airway pressure (CPAP).What intervention is most appropriate for this client?

A) Administering antianxiety medications PRN
B) Administering a medication to help the client sleep
C) Telling the client to relax and let the ventilator do the work
D) Making sure the client is breathing spontaneously

Question 28

The nurse auscultates the lungs of a client on mechanical ventilation and hears vesicular breath sounds throughout the right side but decreased sounds on the left side of the chest.What is the nurse's best action?

A) Turn the client to the right side.
B) Elevate the head of the bed.
C) Assess placement of the endotracheal (ET) tube.
D) Suction the client.

Question 29

A nurse is making initial rounds on assigned clients at the beginning of the shift.One client is receiving a heparin infusion at 5 mL/hr.The nurse notes that 25,000 units of heparin are mixed in 250 mL of solution.How many units per hour is the client receiving? __________ units/hr

Question 30

The nurse is assessing arterial blood gases (ABGs).The client with which ABG reading requires the nurse's immediate attention?

A) pH, 7.32; PaCO₂, 55 mm Hg; PaO₂, 70 mm Hg
B) pH, 7.45; PaCO₂, 42 mm Hg; PaO₂, 70 mm Hg
C) pH, 7.48; PaCO₂, 38 mm Hg; PaO₂, 60 mm Hg
D) pH, 7.55; PaCO₂, 32 mm Hg; PaO₂, 50 mm Hg

Question 31

Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)?

A) Wheezes throughout lung fields
B) Hemoptysis
C) Sharp chest pain
D) Flattened neck veins
E) Hypotension
F) Pitting edema

Question 32

What is the best way for the nurse to communicate with a client who is intubated and is receiving mechanical ventilation?

A) Ask the client to point to words on a board.
B) Ask the client to blink for "yes" and "no."
C) Have the client mouth words slowly.
D) Teach the client some simple sign language.

Question 33

The nurse auscultates the following lung sound in a client with a respiratory disorder.What is the nurse's best action? (Click the media button to hear the audio clip.)

A) Have the client use an incentive spirometer.
B) Have the client cough and deep breathe.
C) Suction the client after auscultating the lower lobes of the lungs.
D) Call for the Rapid Response Team.

Question 34

The nurse is caring for a client with a high risk for pulmonary embolism (PE).Which prevention measures does the nurse add to the client's care plan?

A) Use antiembolism stockings.
B) Massage calf muscles per client request.
C) Maintain supine position with the legs flat.
D) Turn every 2 hours if client is in bed.
E) Refrain from active range-of-motion exercises.

Question 35

A client is ordered heparin 5000 units at 7 AM.The heparin is provided in a vial labeled 20,000 units per mL.How much does the nurse administer? ______ mL

Question 36

A client admitted with respiratory difficulty and decreased oxygen saturation keeps pulling off the oxygen mask.What action does the nurse take?

A) Stays with the client and replaces the oxygen mask
B) Asks the client's spouse to hold the oxygen mask in place
C) Restrains the client per facility policy
D) Contacts the health care provider and requests sedation

Question 37

The nurse is prioritizing care for a client on a ventilator.What are essential nursing interventions for this client?

A) Change the settings in accordance with provider orders.
B) Modify the settings for weaning the client.
C) Assess the reasons for alarms.
D) Compare the ventilator settings with ordered settings.
E) Assess the water level in the humidifier.
F) Change the ventilator tubing according to hospital policy.

Question 38

The nurse assesses a client who has a hemothorax and a chest tube inserted on the right side.What finding requires immediate attention?

A) Pain at the chest tube insertion site
B) Fluctuation in the water seal chamber with breathing
C) Puffiness of the skin around the chest tube insertion site and a crackling feeling
D) Dullness to percussion on the affected side