Question 1

Which assessment finding alerts the nurse to the possibility that the intrathoracic pressure in a mechanically ventilated patient is too high?

Accepted Answer

D

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?

Accepted Answer

D

Question 3

In triaging patients in the emergency department, the nurse prioritizes the patient with which clinical manifestations?

Accepted Answer

Cyanosis and decreased level of consciousness indicate severe hypoxia and potential life-threatening conditions, requiring immediate medical attention.

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?

Accepted Answer

Decreased cardiac output is the most likely cause of the decrease in blood pressure when PEEP is initiated. PEEP can increase intrathoracic pressure, which in turn can decrease venous return to the heart, leading to a decrease in cardiac output and subsequently a drop in blood pressure.

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?

Accepted Answer

Intubation and mechanical ventilation are often necessary for patients with ARDS to ensure adequate oxygenation and ventilation, as ARDS can severely impair gas exchange. Oxygen via a nasal cannula or face mask, and continuous positive airway pressure (CPAP) via face mask, may not provide sufficient support for the severe respiratory failure seen in ARDS.

Question 6

Which prescription is the most important to decrease the risk of deep vein thrombus in a patient after surgery?

Accepted Answer

Ambulation every 2 to 4 hours is the most effective method listed for decreasing the risk of deep vein thrombosis (DVT) after surgery. It promotes blood circulation and prevents blood from pooling and clotting in the veins.

Question 7

The nurse monitors for which clinical manifestations in the patient experiencing intermediate respiratory failure?

Accepted Answer

The answer of The nurse monitors for which clinical manifestations...

Question 8

What should the nurse conclude if constant bubbling is noted in the water-seal chamber of a closed chest drainage system?

Accepted Answer

Constant bubbling in the water-seal chamber of a closed chest drainage system indicates an air leak. This could be from the patient's pleural space or the drainage system itself, suggesting that air is continuously escaping from the lung or the system, which is not normal functioning.

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?

Accepted Answer

Increased capillary permeability is a key physiological change in ARDS that leads to fluid leakage into the alveolar spaces, impairing gas exchange.

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?

Accepted Answer

DAssessing the patient for airway obstruction (C) is a priority to ensure the patient's airway is clear and that they are receiving adequate ventilation. Checking the ventilator settings (D) is also crucial to ensure the machine is properly set to meet the patient's current respiratory needs. Both actions are immediate priorities to address the low oxygen saturation.

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?

Accepted Answer

Heparin and warfarin are often started simultaneously in the treatment of conditions like pulmonary embolism. Heparin acts quickly and is used while waiting for warfarin, which takes several days to reach effective levels in the blood, to exert its anticoagulant effects. This approach ensures continuous anticoagulation during the initial treatment phase.

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?

Accepted Answer

Using a soft toothbrush and an electric razor and avoiding injuries are measures to prevent bleeding, which is a risk associated with anticoagulant therapy.

Question 13

In the patient with acute respiratory failure, the nurse interprets which set of arterial blood gases as respiratory acidosis with hypoxemia?

Accepted Answer

Respiratory acidosis is characterized by a low pH (less than 7.35) and an elevated PaCO2 (greater than 45 mm Hg), indicating hypoventilation. Hypoxemia is indicated by a low PaO2 (less than 80 mm Hg). Choice A shows both of these conditions: pH 7.30, PaCO2 55 mm Hg, and PaO2 66 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?

Accepted Answer

Tachypnea is an early clinical manifestation of ARDS, indicating the patient's effort to increase oxygenation and eliminate carbon dioxide due to impaired gas exchange.

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?

Accepted Answer

Impaired Gas Exchange is the priority nursing diagnosis because a pulmonary embolism directly affects the lungs' ability to exchange oxygen and carbon dioxide, leading to reduced arterial oxygen saturation and dyspnea.

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?

Accepted Answer

A tension pneumothorax can occur if the chest tube becomes kinked or obstructed, preventing air from escaping the pleural space, leading to increased pressure and subsequent cardiovascular compromise.

Question 17

Which patient requires immediate intervention by the nurse to decrease the risk for developing a deep vein thrombosis (DVT)?

Accepted Answer

The patient who is immobile because of a fractured hip is at the highest risk for developing a deep vein thrombosis (DVT) due to prolonged immobility, which can lead to blood pooling and clot formation in the deep veins of the legs. Immediate intervention is necessary to prevent this complication.

Question 18

Which arterial blood gas (ABG) results does the nurse recognize as most indicative of impending respiratory failure?

Accepted Answer

The ABG result with a PaCO2 of 48 mm Hg and a PaO2 of 60 mm Hg (D) is most indicative of impending respiratory failure due to the elevated carbon dioxide (hypercapnia) and decreased oxygen levels (hypoxemia), suggesting both ventilation and oxygenation issues.

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?

Accepted Answer

For patients receiving heparin therapy, an aPTT of about 1.5 to 2.5 times the control value is generally considered therapeutic, indicating adequate anticoagulation.

Question 20

The nurse correlates which mechanical ventilator setting as placing a patient at greatest risk for barotrauma?

Accepted Answer

PEEP (Positive End-Expiratory Pressure) at higher levels can increase the risk for barotrauma by causing overdistension of the alveoli.

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