Unit 1: Iggy 10th Ed Practice Questions Flashcards
25-1. Which statements about oxygen and oxygen therapy are true? SATA
A. An oxygen concentrator reduces the amount of carbon dioxide in atmospheric air.
B. Clients must provide informed consent to receive oxygen therapy.
C. Excessive oxygen use is a contributing cause of chronic obstructive pulmonary disease.
D. In non-emergency situations, a health care provider’s prescription is needed for oxygen therapy.
E. Oxygen can explode when handled improperly.
F. Oxygen is a beneficial element but can harm lung tissue.
G. The liquid form of oxygen is a drug to manage hypoxia, whereas the gaseous form is only an atmospheric element.
H. Unless humidity is added, therapy with oxygen dries the upper and lower mucous membranes.
C. Excessive oxygen use is a contributing cause of chronic obstructive pulmonary disease.
D. In non-emergency situations, a health care provider’s prescription is needed for oxygen therapy.
F. Oxygen is a beneficial element but can harm lung tissue.
H. Unless humidity is added, therapy with oxygen dries the upper and lower mucous membranes.
An oxygen concentrator reduces the amount of nitrogen in atmospheric air, which has the highest concentration of all gases in the atmosphere.
Oxygen is a drug that requires a prescription but not informed consent.
Excessive oxygen can form reactive oxygen species that injures lung tissue but does not cause COPD.
Oxygen is a gas that promotes combustion but does not explode.
Only oxygen gas is directly inhaled to improve gas exchange. Liquid oxygen must first be converted to a gas before it can be used.
When oxygen is delivered without humidification, especially at higher flow rates, respiratory mucous membranes can become dry and irritated.
25-2. The SpO2 of a client receiving oxygen therapy by nasal cannula at 6L/minute has dropped from 94% an hour ago to 90%. Which action does the nurse perform first to promote gas exchange before reporting the change to the primary health care provider?
A. Tighten the straps on the nasal cannula
B. Increase the oxygen flow rate to 8L/minute
C. Check the tubing for kinks, leaks, or obstructions
D. Check to determine whether the oxygen delivery system is adequately humidified
C. Check the tubing for kinks, leaks, or obstructions
Oxygen tubing is flexible and has a narrow lumen. Tubing that is kinked or obstructed or has a leak can interfere with oxygen delivery to the client and result in desaturation. The maximum flow rate is 6 L/minute for a nasal cannula and increasing the rate above this value does not result in an increase in oxygen delivery to the client. Tightening the straps on the nasal cannula can make the client uncomfortable and does not increase oxygenation. Humidifying the oxygen prevents drying of mucous membranes but does not increase the actual amount of oxygen delivered.
25-3. Which action does the nurse use to prevent harm by loss of tracheal tissue integrity in a client with a tracheostomy?
A. Providing meticulous oral care every 8 hours
B. Deflating the cuff for 15 minutes every 2 hours
C. Feeding the client liquids rather than solid foods
D. Maintaining cuff inflation pressure less than 25 cm H2O
D. Maintaining cuff inflation pressure less than 25 cm H2O
An overinflated cuff can cause tissue injury and necrosis of the tracheal tissue. Although cuff pressure must be adequate to prevent leaks, it is critical to keep the pressure lower than 25 cm H2O. Meticulous oral care can help maintain tissue integrity of oral muscous membranes but does not help tracheal tissue integrity. Neither liquids nor solid foods should enter the trachea. Deflating the cuff reduces the effectiveness of the tracheostomy for adequate ventilation.
25-4. Which conditions or changes indicate to the nurse that a client with a tracheostomy requires suctioning? Select all that apply.
A. The client has a fever.
B. Crackles and wheezes are heard on auscultation.
C. The client requests that suctioning be performed.
D. Suctioning was last performed more than 3 hours ago.
E. The tracheostomy dressing has a moderate amount of serosanguious drainage.
F. The skin around the tracheostomy is puffy and makes a crunching sound when touched.
B. Crackles and wheezes are heard on auscultation.
C. The client requests that suctioning be performed.
To avoid tissue injury, tracheostomy suctioning is performed only when indication are present that it is needed. Such indications include when crackles and/or wheezes are heard on auscultation, secretions in the airways that the client cannot clear are audible, restlessness is increased along with elevations of heart rate or respiratory rate, the client requests to be suctioned, and when the ventilator peak airway pressure is increased. Suctioning is not performed on a scheduled basis. Subcutaneous emphysema and drainage on the dressing are not indications of suctioning need. In addition, suctioning is not an appropriate response to the presence of a fever.
25-1. Which assessment finding for a client receiving oxygen therapy with a nonrebreather mask requires the nurse to intervene immediately?
A. The oxygen flow rate is set at 12 L/minute.
B. The exhalation ports are open during exhalation.
C. The exhalation ports are closed during inhalation.
D. The reservoir bag is not inflated during inhalation.
D. The reservoir bag is not inflated during inhalation.
The nonrebreather mask has a one-way valve between the mask and the reservoir and has two flaps over the exhalation ports. The flaps should be closed during inhalation to prevent room air from entering and diluting the oxygen concentration. During exhalation, air leaves through these exhalation ports. The client can only draw needed air with oxygen from the reservoir bag, which must be inflated during inhalation. The flow rate of 12 L/min is sufficient to keep the bag inflated during inhalation.
25-2. Which statement made by a client prescribed oxygen therapy at home indicates to the nurse that more instruction is needed?
A. “When I want to smoke, I will use the liquid oxygen reservoir instead of the compressed oxygen tank.”
B. “Using oxygen should help me have more breath and stamina when I eat, bathe, and take care of myself.”
C. “Even though they contain alcohol, I can still drink a glass of wine or can of beer while using oxygen.”
D. “If my shortness of breath becomes worse or if I have chest pain, I will contact my primary health care provider immediately.”
A. “When I want to smoke, I will use the liquid oxygen reservoir instead of the compressed oxygen tank.”
Oxygen, whether from a liquid reservoir or compressed oxygen tank, enhances combustion and is not to be used around open flames. Thus, the statement that switching to a liquid oxygen reservoir is safer to use while smoking rather than a oxygen from a compressed tank is completely erroneous and dangerous. Clients should contact their health care providers if breathing becomes more difficult or if chest pain occurs. Neither wine nor beer contain enough alcohol to be combustible in the presence of oxygen. Oxygen therapy can improve a client’s activity tolerance and stamina.
25-3. Which action does the nurse take care to avoid while suctioning a client’s tracheostomy tube?
A. Twirling the catheter while applying suction
B. Applying suction only when withdrawing the catheter
C. Performing oral suctioning before suctioning the artificial airway
D. Lubricating the suction catheter with sterile saline before insertion
C. Performing oral suctioning before suctioning the artificial airway
Infection is possible during tracheal suctioning because each catheter pass introduces bacteria into the trachea. Sterile technique is used for suctioning and the mouth or nose is suctioned only after suctioning the artificial airway. Tissue injury is prevented by lubricating the catheter with sterile water or saline before insertion, applying continuous suction only during catheter withdrawal, and using a twirling motion during withdrawal to prevent grabbing of the mucosa.
The client, who is 24 hours postoperative after a right lower lobectomy for stage II lung cancer and has two chest tubes in place, reports intense burning pain in his lower chest. On assessment, the nurse notes there is no bubbling on exhalation in the water seal chamber. What action will the nurse perform first?
A. Immediately notify either the Rapid Response Team or the thoracic surgical resident.
B. Assist the client to a side-lying position and re-assess the water seal chamber for bubbling.
C. Administer the prescribed opioid analgesic immediately, and then assess the chest tube system.
D. No action is needed because these responses are normal for the first post-op day after lobectomy.
B. Assist the client to a side-lying position and re-assess the water seal chamber for bubbling.
The tip of the chest tube could be lying against tissue, becoming occluded and causing the burning pain. Repositioning the client can change the position of the chest tube tip, relieving the pain and allowing drainage to continue.
A is incorrect because although no bubbling means no drainage and could lead to a tension pneumothorax, troubleshoot quickly before call the rapid response team. If repositioning does not solve the problem, then call the rapid response team.
A client who is 3 days postoperative from extensive abdominal surgery for cancer reports having difficulty “catching her breath” and having a reddish-purple, non-itchy rash on her chest. After assessing the client, what is the nurse’s best action or response to prevent harm?
A. Ask the client about possible drug allergies
B. Apply oxygen and call the rapid response team
C. Determine when she last received an opioid dose
D. Check the oxygen saturation and encourage her to cough
B. Apply oxygen and call the rapid response team
This client is at high risk for developing a pulmonary embolism from a venous thromboembolism (has cancer and recently underwent extensive abdominal surgery). She has two major symptoms of PE, sudden onset shortness of breath and petechiae on her chest. These are significant enough to call the rapid response team because and without assessing oxygen saturation or most recent opioid dose (she has no symptoms of respiratory depression) because time is of the essence in starting appropriate therapy to prevent permanent lung damage or death. Applying oxygen can help improve her gas exchange and should be done immediately. Rash caused by a drug allergy are usually red, raised, itchy, and do not look like petechiae.
Which condition, sign, or symptom does the nurse consider most relevant in assessing a client suspected to have ARDS? Select all that apply.
A. Dyspnea
B. Electrocardiograph shows ST elevation
C. Intercostal retractions
D. PaO2 84% on oxygen at 6 L/minute
E. Substernal pain or rubbing
F. Wheezing on exhalation
A. Dyspnea
C. Intercostal retractions
D. PaO2 84% on oxygen at 6 L/minute
The defining feature of ARDS is continued hypoxemia despite vigorous oxygen therapy. The hypoxia and hypoxemia triggers dyspnea and an increased breathing effort seen as intercostal retractions. Substernal pain or rubbing are not associated with ARDS. The pathophysiological problems of ARDS are in the lung tissue and not in the airways. Thus, wheezing is not a manifestation of the disorder. Although the hypoxia stimulates a variety of dysrhythmias, there are no specific ECG changes. ST elevation is associated with an evolving myocardial infarction.
The client is a 5 foot 11 inches tall, 176 lb (80 kg) woman who has been mechanically ventilated at a tidal volume of 400 mL and a respiratory rate of 12 breaths per minute for the past 24 hours. The most recent arterial blood gas (ABG) results for this client are:
pH= 7.32;
PaO2 = 84 mm Hg;
PaCO2 = 56 mm Hg.
What is the nurse’s interpretation of these results?
A. Ventilation adequate to maintain oxygenation.
B. Ventilation excessive; respiratory alkalosis present.
C. Ventilation inadequate; respiratory acidosis present.
D. Ventilation status cannot be determined from information presented.
C. Ventilation inadequate; respiratory acidosis present.
The average-size adult female has a normal tidal volume of 400-500 mL. However this client is larger than average and would have a greater tidal volume. Usually the tidal volume is set at 6 to 8 mL/kg of body weight, which would range between 480mL to 640 mL. At the current tidal volume setting this woman is being underventilated with inadequate gas exchange. Not enough oxygen is available and not enough carbon dioxide is being lost leading to respiratory acidosis.
Which symptom or change in assessment of a client with 4 broken ribs on the right side indicates to the nurse the possibility of a tension pneumothorax?
A. Distended neck veins
B. Mediastinal shift toward the left side
C. Right-sided pain on deep inhalation
D. Right side of the chest more prominent than the left
A. Distended neck veins
Any type of pneumothorax can shift the mediastinum to the unaffected side and cause the affected side to be more prominent. Pain on deep inhalation is related to the broken ribs and not a pneumothorax. The distended neck veins are a strong indicator of the life-threatening tension pneumothorax and immediate action is needed.
29-1 An attempt by a primary health care provider to intubate a client for mechanical ventilation is unsuccessful after 45 seconds. What is the nurse’s priority action?
A. Placing a nasotracheal tube
B. Assessing for bilateral breath sounds
C. Assessing oxygen saturation by pulse oximetry
D. Applying oxygen with a bag-valve-mask device
D. Applying oxygen with a bag-valve-mask device
During the intubation procedure the client is not breathing. The intubation attempt should last not longer than 15 to 30 seconds. After 45 seconds the client is very hypoxic and assessing oxygen saturation is not necessary. The client needs oxygen as quickly as possible. Assessment for bilateral breath sounds is performed after intubation to determine ensure that the tube is not in one bronchus. Placing a naso-tracheal tube is not a bedside nursing function.
29-2. Which actions does the nurse ensure are performed for a client being mechanically ventilated to prevent ventilator-associated pneumonia (VAP)? Select all that apply.
A. Assessing temperature every 4 hours
B. Checking ventilator settings every 4 hours
C. Getting the patient out of bed as soon as prescribed
D. Keeping the head of the bed elevated to 30 degrees or above
E. Maintaining the client in the prone position
F. Providing adequate humidification
G. Providing meticulous mouth care every 12 hours
H. Suggesting that the pneumonia vaccine be prescribed
C. Getting the patient out of bed as soon as prescribed
D. Keeping the head of the bed elevated to 30 degrees or above
G. Providing meticulous mouth care every 12 hours
Getting the client out of bed as quickly as possible helps prevent VAP by reducing the risk of fluid stasis in the lungs and aspiration, a common cause of VAP. Keeping the head of the bed elevated when the client is in bed also reduces the risk for aspiration. Meticulous oral care prevents colonization of bacteria that can move into the respiratory tract. Assessing temperature can help identify VAP early but does not prevent its occurrence. Checking the ventilator settings is crucial to ensure adequate gas exchange and prevent injury but does not prevent pneumonia. The prone position during mechanical ventilation is recommended only for clients with ARDS and does not prevent VAP. Humidifying the oxygen and air received by the client helps prevent drying of the respiratory tract but not VAP. VAP is not caused by the same organisms that cause infectious pneumonia and vaccination against these organisms does not prevent VAP.
29-3 A client being mechanically ventilated has all of the following changes. Which changes are most relevant in helping the nurse determine whether suctioning is needed at this time? Select all that apply.
A. Decreased SpO2
B. Elevated temperature
C. Crackles auscultated over the trachea
D. Crackles auscultated in the lung periphery
E. High-pressure ventilator alarm sounds
F. Presence of fluid within the endotracheal tube
G. Presence of fluid within the ventilator tubing
A. Decreased SpO2
C. Crackles auscultated over the trachea
E. High-pressure ventilator alarm sounds
F. Presence of fluid within the ET tube
Decreased SpO2 is often caused by excessive airway secretions and is a major indicator of the nees for suctioning. Crackles over the trachea are caused by fluid in the trachea and suctioning is needed to remove this fluid. Pressure is increased when resistance is present in the airway such as that caused by secretions. Fluid in the endotracheal tube indicates a need for immediate suctioning regardless of how recently it was last performed. Elevated temperature is not related to the need for suction. Crackles in the lung periphery would not be reduced by endotracheal suctioning. Fluid in the ventilator tubing is caused by condensation, not increased secretions in the airway.
With which client will the nurse take immediate actions to reduce the risk for developing a pulmonary embolism (PE)?
A 50 year old with type 2 diabetes mellitus and cellulitis of the leg
A 36 year old who had open reduction and internal fixation of the tibia
A 25 year old receiving IV antibiotics through a peripheral line
A 72 year old with dehydration and hypokalemia taking oral potassium supplements
A 36 year old who had open reduction and internal fixation of the tibia
To reduce the risk for developing PE, the nurse provides immediate interventions for the client who had an open reduction and internal fixation of the tibia. Lower limb surgery and perioperative immobility are high risks for deep vein thrombosis (DVT) formation and PE. Peripheral infusion of antibiotics in a younger client is not a significant risk for PE. Although dehydration is a mild risk for thrombosis, this is not as common as thromboembolic complications after orthopedic surgery.
What is the basis for the decreased oxygen saturation the nurse assesses in a client with a pulmonary embolism (PE)?
Partial bronchial airway obstruction
Thickened alveolar membranes and poor gas exchange
Increased oxygen need resulting from a septic clot PE
Shunting of deoxygenated blood to the left side of the heart
Shunting of deoxygenated blood to the left side of the heart
A PE lodges in the blood vessels decreasing perfusion to a lung area, which wastes ventilation. When this blood that has not been oxygenated is returned to the left side of the heart, it dilutes the oxygen concentration of the arterial blood entering systemic circulation.
PE does not block bronchial airways or thicken alveolar membranes. A septic clot is not the same as general sepsis, which when widespread, does increase tissue metabolism and the need for more oxygen.
Drugs from which class will the nurse prepare to administer as first-line therapy for a client just diagnosed with pulmonary embolism (PE)?
Anticoagulants
Antihypertensives
Antidysrhythmics
Antibiotics
Anticoagulants
A PE is collection of particulate matter (solids, liquids, or air) that enters venous circulation and lodges in the pulmonary vessels. Anticoagulants are the first-line therapy drugs for this problem, even if the actual particulate matter is not a clot. Anything lodged in the blood vessels will cause clot formation around it. Anticoagulants help prevent new clots from forming in the area and extension of existing clots.
Depending on other problems cause by a PE, antibiotics, or antidysrhythmics may also be used but not always. Clients with PE are hypotensive, not hypertensive.
Which new assessment finding in a client being managed for a pulmonary embolism (PE) indicates to the nurse that the client’s condition is worsening?
Increasing temperature
Abdominal cramping
Hand tremors
Distended neck veins in the high-Fowler position
Distended neck veins in the high-Fowler position
Distension of neck veins in the upright (high-Fowler) position occurs with right-sided heart failure, which is a complication of PE. None of the other changes in assessment findings are directly associated with worsening PE.
Which assessment findings in a postoperative client suggest to the nurse the possibility of a pulmonary embolism (PE) and pulmonary infarction?
Hemoptysis and shortness of breath
Fever and tracheal deviation
Audible wheezing on inhalation and exhalation
Paradoxical chest movements
Hemoptysis and shortness of breath
Symptoms of a PE with infarction include profound shortness of breath and bloody sputum (hemoptysis) from poor gas exchange and hypoxic damage to lung tissues. Paradoxical chest movements are associated with a flail chest, not PE. Tracheal deviation is associated with a pneumothorax. Audible wheezing on inhalation and exhalation is a partial obstruction of the tracheobronchial tree.
In addition to notifying the pulmonary health care provider, what is the most important action for the nurse to take first for a client with a pulmonary embolism (PE) whose arterial blood gas (ABG) values are pH 7.28, PaCO2 50 mm Hg, PaO2 62 mm Hg, and HCO3− 24 mEq/L (24 mmol/L)?
Administering sodium bicarbonate
Having the client breathe rapidly and deeply into a paper bag
Assessing for the presence of adventitious lung sounds
Increasing the oxygen flow rate
Increasing the oxygen flow rate
These ABG values indicate respiratory acidosis (low pH and high PaCO2) and severe hypoxemia (low PaO2) from greatly reduced gas exchange.
This client needs more oxygen now.
by a low partial pressure of arterial carbon dioxide (PaCO2 of 30 mm Hg) and a high pH (7.46). Breathing more rapidly and deeply into a paper bag would decrease oxygen levels and increase CO2 further, making hypoxemia and acidosis worse. The bicarbonate level is normal and requires no intervention. Adventitious sounds are expected and identifying them is not the first priority.
Which action is a priority for the nurse to prevent harm for a client with a pulmonary embolism who is receiving a continuous heparin infusion?
Assessing gums daily for indications of bleeding
Monitoring the platelet count daily
Assessing breath sounds
Comparing pedal pulses bilaterally
Monitoring the platelet count daily
Daily platelet counts are a safety priority in assessing for heparin-induced thrombocytopenia (HIT), a potential side effect of heparin.
Assessing breath sounds each shift is an important action, as is examining for indications of bleeding. However, identifying HIT early is a greater priority so that appropriate interventions can be initiated. Assessing bilateral pedal pulses is important if the source of the embolism is a venous thromboembolism (VTE) in the legs; however, this is not an important general action for a client with PE.
Which client will the nurse consider to be at the greatest risk for developing acute respiratory distress syndrome (ARDS)?
A 22 year old with a fractured clavicle
A 39 year old with uncontrolled diabetes
A 56 year old with chronic kidney disease
A 74 year old who aspirates a tube feeding
A 74 year old who aspirates a tube feeding
ARDS is a type of acute respiratory failure with hypoxemia that persists even when 100% oxygen is given, decreased pulmonary compliance, dyspnea, bilateral pulmonary edema, and dense pulmonary infiltrates on x-ray (ground-glass appearance). It often occurs after an acute lung injury such as could result from aspiration of acidic gastric contents. Clients who are receiving tube feedings are at particular risk for lung damage by aspiration.
Fractured clavicle, diabetes, and chronic kidney disease is associated with an increased risk for lung injury or ARDS.
What is the primary emphasis for the nurse who is providing care to a client with acute respiratory distress syndrome (ARDS) currently in the exudative management stage of the disorder?
Assessing the client at least hourly for tachypnea and dyspnea
Performing meticulous mouth during mechanical ventilation
Assessing for abnormal lung sounds
Monitoring urine output to identify multiple organ dysfunction syndrome early
Assessing the client at least hourly for tachypnea and dyspnea
The exudative phase includes early changes of dyspnea and tachypnea resulting from the alveoli becoming fluid filled and from pulmonary shunting and atelectasis. Early interventions focus on frequent assessment of respiratory status, supporting the client, and providing oxygen.
Abnormal lung sounds are not present at this stage because the edema is present in the interstitial tissues and not in the airways. At this stage, clients are neither intubated nor being mechanically ventilated. Multiple organ dysfunction syndrome is not a feature of this stage.
What is the best first action when the nurse assesses that the respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures but the ventilator tubing is clear?
Suctioning the tracheostomy tube
Remove the inner cannula of the tracheostomy
Humidifying the oxygen source
Increasing the percentage of oxygen
Suctioning the tracheostomy tube
The best first action by the nurse is to suction the tracheostomy tube. This will likely result in clear lung sounds and lower peak pressure.
Humidifying the oxygen source may help mobilize secretions but is not an immediate helpful action. Increasing oxygenation does nothing to clear the airway of whatever is making it noisy and is elevating peak pressures. Removing the inner cannula of a ventilated client is contraindicated.
Which action will the nurse take first for a client being mechanically ventilated who begins to pick at the bedcovers?
Administering the prescribed sedating drug
Explaining to the client that the tube helps with breathing
Requesting that the family leave to decrease the client’s agitation
Assessing for adequate oxygenation
Assessing for adequate oxygenation
The best first action by the nurse would be to assess for adequate oxygenation. Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia.
Increasing sedation is not indicated for this client and may mask symptoms such as hypoxemia or worsening respiratory failure. Although the nurse may explain to the client that he or she is intubated, it does not take priority over assessing for hypoxemia. The presence of family members may decrease, not increase, the client’s anxiety.
Which action has the highest priority for the nurse to take to prevent harm for a client being mechanically ventilated with 100% oxygen for the past 24 hours who now has new-onset crackles, decreased breath sounds, and a PaO2 level of 95 mm Hg?
Collaborating with the pulmonary health care provider to lower the FiO2 level
Assessing cognition
Placing the client in the prone position
Preparing to suction the client
Collaborating with the pulmonary health care provider to lower the FiO2 level
Prompt identification and correction of the underlying disease process and potential oxygen toxicity may require delivery of a lower FiO2. The pulmonary health care provider needs to be notified when PaO2 levels are greater than 90 mm Hg. Preventing harm from oxygen toxicity and absorptive atelectasis (new onset of crackles and decreased breath sounds) are essential. Oxygen toxicity is related to the concentration of oxygen delivered, duration of oxygen therapy, and degree of lung tissue present. The need for 100% oxygen delivery indicates that the client continues to require intubation and mechanical ventilation.
Suction is performed when rhonchi or noisy breath sounds on the anterior chest below the sternal notch (upper airway) are present. Crackles and diminished breath sounds reflect fluid or poor exchange in the lower airway, not the need for suctioning. Although prone-positioning has been used for clients with acute respiratory distress syndrome (ARDS), is not the priority action and this client has not been diagnosed with ARDS.
Which action will the nurse take first while caring for a client being mechanically ventilated when the high-pressure alarm sounds?
Comparing the ventilator settings with the prescribed settings
Turning off the alarm then assess the need for suctioning
Notifying the respiratory therapist
Auscultating the client’s breath sounds
Auscultating the client’s breath sounds
The nurse will first listen to the client’s breath sounds. Assessment always begins with the client. A typical reason for the high-pressure alarm to sound is obstruction of airflow through the ventilator circuit, usually indicating the need for suctioning. Other reasons for the high-pressure alarm to be triggered included biting the endotracheal tube or tension pneumothorax.
The nurse is concerned with the assessment of the client first, not with the ventilator or ventilator settings and does not turn off the alarms before assessing the client. Although an excessively high tidal volume could contribute to the high-pressure alarm sounding, this is not the nurse’s first concern. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention.
Which ventilator mode does the nurse expect will be set for a client with a tracheostomy who is beginning to take spontaneous breaths at his own rate and tidal volume between set ventilator breaths?
Assist-control (AC) ventilation
Continuous positive airway pressure (CPAP)
Synchronized intermittent ventilation (SIMV)
Bi-level positive airway pressure (BiPAP)
Synchronized intermittent ventilation (SIMV)
Synchronized intermittent mandatory ventilation (SIMV) is a ventilation mode in which volume and ventilatory rate are preset. It allows spontaneous breathing at the patient’s own rate and tidal volume between the ventilator breaths to coordinate breathing between the ventilator and the client.
BiPAP and CPAP are not used for clients who have an endotracheal tube. With assist-control ventilation, the preset tidal volume continues even when the client’s own respiratory rate increases, which could lead to over-ventilation.
What is the nurse’s best first action when assessing a client who was intubated a few minutes ago and finds the end-tidal carbon dioxide level is 0 and the SpO2 is 38%?
Documenting the finding in the electronic health record as the only action
Initiating the Rapid Response Team
Removing the endotracheal tube and ventilating the client with a bag-valve-mask
Obtaining a different monitor and rechecking the end-tidal carbon dioxide level
Removing the endotracheal tube and ventilating the client with a bag-valve-mask
A reading of 0 for the end-tidal carbon dioxide and the very low SpO2 level indicate that the endotracheal tube is not in the airway. Immediate action is needed. While it is present in the client’s throat, its presence is preventing air from reaching the airways. Removing the tube and ventilating the client with a bag-valve-mask device is critical to saving the client’s life. The nurse will perform these actions while having another health care worker call the Rapid Response Team.
If the client’s SpO2 was in the normal range, obtaining a different monitor and rechecking end-tidal carbon dioxide level would be a good action. However, the low oxygen saturation level indicates there is no time for rechecking the carbon dioxide level.
What type of acid–base problem will the nurse expect in a client who is being insufficiently mechanically ventilated for the past 4 hours and whose most recent arterial blood gas results include a pH of 7.29?
Respiratory acidosis with an acid excess
Metabolic acidosis with an acid excess
Respiratory acidosis with a base deficit
Metabolic acidosis with a base deficit
Respiratory acidosis with an acid excess
When a person being mechanically ventilated is insufficiently ventilated respiratory acidosis occurs with retention of carbon dioxide. The retained carbon dioxide is converted to hydrogen ions resulting in an acid excess. Bases have neither been lost nor retained in an acute respiratory acidosis. Insufficient ventilation does not cause any form of metabolic acidosis.
Which action will the nurse instruct a client with an endotracheal tube to perform when the tube is being removed?
Hold his or her breath
Inhale
Cough
Exhale
Exhale
The nurse instructs the client to inhale deeply right before extubation while the nurse deflates the tube cuff. The tube is removed while the client exhales. The nurse instructs the client to cough immediately after extubation.
What type of percussion note or sound will the nurse expect on the affected chest side of a client who has a hemothorax?
Dull
Hyperresonant
Crackling
Hypertympanic
Dull
With a hemothorax, percussion on the involved side produces a dull sound because the blood in the lung area prevents air from filling the area. Lung crackling sounds cannot be percussed, although skin crackling with subcutaneous emphysema can. Tympanic sounds on percussion are associated with abdominal assessment, not pulmonary. Any degree of resonance is associated with air-filled lung areas, not blood-filled areas.
Which assessment finding on a client who is being mechanically ventilated with positive end-expiratory pressure indicates to the nurse a possible left-sided tension pneumothorax?
Left chest caves in on inspiration and “puffs out” on expiration.
The left lung field is dull to percussion and crackles are present on auscultation.
The client has bloody sputum and wheezes.
Chest is asymmetrical and trachea deviates toward the right side.
Chest is asymmetrical and trachea deviates toward the right side.
Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention, cyanosis, and hyperresonance to percussion over the affected area. If not promptly detected and treated, tension pneumothorax is quickly fatal.
Flail chest has paradoxical chest movement with a “sucking inward” of the loose chest area during inspiration and “puffing out” of the same area during expiration. Open pneumothorax presents with decreased breath sounds, hyperresonance, and poor respiratory excursion on the affected side. Pulmonary contusion presents with hemoptysis, dullness to percussion, and crackles or wheezes.
The nurse has just received report on a group of clients. Which client is the nurse’s first priority?
A 60 year old who was recently extubated and reports a sore throat.
A 50 year old being mechanically ventilated who has tracheal deviation.
A 30 year old receiving continuous positive airway pressure (CPAP) and has intermittent wheezing.
A 40 year old receiving oxygen facemask and whose respiratory rate is 24 breaths/min.
A 50 year old being mechanically ventilated who has tracheal deviation.
The nurse needs to immediately attend to the mechanically ventilated client with a tracheal deviation. This client is showing signs of a tension pneumothorax that could lead to hypoxemia, decreased cardiac output, and shock.
The client receiving CPAP has intermittent wheezing, but is not in immediate danger or distress. The client recently extubated has sore throat which is anticipated after intubation. There is no indication this client is in need of immediate intervention. The client wearing oxygen has mild tachypnea, but is not in immediate distress or danger.
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 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.
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 treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia.
The RRT needs to quickly assess the client with a diagnosed pulmonary embolism who is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin. Tachycardia, along with bloody sputum (hemoptysis), may be a symptom of hypoxemia or hemorrhagic shock, which requires immediate intervention.
The client with deep vein thrombosis requires ongoing monitoring and is receiving appropriate treatment. Calf pain is expected in this situation. The client with a right pneumothorax requires ongoing monitoring but demonstrates adequate pulse oximetry of 94%. The client who was extubated 3 days ago requires ongoing nursing assessment, but does not have evidence of acute deterioration or severe complications.
Which assessment findings in a client at high risk for pulmonary embolism (PE) indicates to the nurse the probable presence of a PE?
Select all that apply.
Inspiratory chest pain
Dizziness and syncope
Pink, frothy sputum
Worsening dyspnea for 3 days
Tachycardia
Productive cough
Inspiratory chest pain
Dizziness and syncope
Tachycardia
Symptoms consistent with PE include: dizziness, syncope, hypotension, and fainting. Sharp, pleuritic, inspiratory chest pain, hemoptysis, and tachycardia are also characteristic of PE.
Typically SOB and dyspnea associated with PE develops abruptly rather than gradually over 2 weeks. Productive cough is associated with infection. PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema.
Which clients will the nurse monitor most closely for respiratory failure?
Select all that apply.
A 30 year old with a C-5 spinal cord injury
A 55 year old with a brainstem tumor
A 50 year old experiencing cocaine intoxication
A 65 year old with COVID-19 pneumonia
A 35 year old using client-controlled analgesia
A 40 year old with acute pancreatitis
A 30 year old with a C-5 spinal cord injury
A 55 year old with a brainstem tumor
A 65 year old with COVID-19 pneumonia
A 40 year old with acute pancreatitis
Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome; abdominal distention also ensues, which can limit respiratory excursion. Clients with cervical and high thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect the diaphragm and inter-costal muscles are affected. Opioids used in client-controlled analgesia are respiratory depressants and can depress the breathing center in the brainstem causing respiratory failure. Pneumonia, whether bacterial or viral, can result in oxygenation respiratory failure, especially in an older client who often has respiratory muscle weakness.
Cocaine is a stimulant, which would not cause respiratory failure unless a stroke ensued.
For which problems will the nurse specifically assess when the low-pressure alarm of a client’s mechanical ventilator sounds?
Select all that apply.
Mucous plugs are in the endotracheal tube.
Leak in the ventilator tubing circuit.
Client is not breathing.
Cuff leak in the endotracheal or tracheostomy tube.
Ventilator tubing is under the client.
Client is attempting to breathe against the ventilator.
Leak in the ventilator tubing circuit.
Client is not breathing.
Cuff leak in the endotracheal or tracheostomy tube.
Common causes of alarms indicating low-pressure include: cuff leaks in the endotracheal or tracheostomy tube, client stops breathing when a ventilator is in the “support” mode, and when a leak is present in the ventilator tubing circuit.
Presence of increased airway secretions or mucous plugs, client coughing or gaging, client fighting or “bucking” the ventilators, anything that decreases airway size (i.e., bronchospasms), presence of a pneumothorax, displacement of the endotracheal tube further into the tracheal bronchial tree, and external obstruction of the tubing result in high-pressure, not low-pressure.
Which blood gas value indicates to the nurse that a client is experiencing hypercarbia?
Bicarbonate = 20 mEq/L
pH = 7.33
PaO2 = 80 mm Hg
PaCO2 = 60 mm Hg
PaCO2 = 60 mm Hg
The low pH, the elevated carbon dioxide level, and the low oxygen concentration all indicate that the client is experiencing poor gas exchange and has acidosis. The low pH and the low oxygen concentration could occur without hypercarbia. Only the elevated carbon dioxide concentration confirms hypercarbia.
Which nursing action will the nurse take to prevent harm from disruption of oxygen therapy for the client receiving low-flow oxygen by simple facemask?
Keeping a small cylinder of oxygen at client’s bedside stand for emergency use in case the central oxygen delivery system fails
Changing to a nasal cannula during meals
Sealing the edges of the mask to the client’s skin with a water-soluble lubricant.
Ensuring that the flaps are closed over the exhalation ports
Changing to a nasal cannula during meals
The facemask covers the client’s mouth and must be removed during meals. Use of the nasal cannula when the client eats prevents hypoventilation or hypoxemia from the facemask being of during mealtimes.
Sealing the mask does not ensure disruption of oxygen therapy. A simple facemask does not have flaps over the exhalation ports. Central oxygen delivery system failure is a unit or facility problem that could happen anywhere; however, tank oxygen is not kept at clients’ bedsides for this potential emergency.
What is the nurse’s best first action when a client receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused?
Increasing the oxygen flow rate
Documenting the observation as the only action
Notifying the primary health care provider immediately
Repositioning the client from a high-Fowler to a low-Fowler position
Increasing the oxygen flow rate
Cerebral hypoxia is a cause of confusion and a sensitive indicator that the client needs more oxygen and action is needed. Untreated or inadequately treated hypoxemia is life threatening. Although you would want to notify the health care provider of the change in the client’s condition, the best action is to first increase the oxygen flow rate and then notify the physician.
Changing the client’s position to less upright, would not improve gas exchange.
Which changes in a client receiving oxygen therapy at 60% for more than 24 hours alert the nurse to the possibility of oxygen toxicity?
Decreased PaCO2
Client report of increased dyspnea
Production of thick, white, frothy sputum
Client demand to remove the mask
Client report of increased dyspnea
Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane, and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic.
The PaCO2 would increase, not decrease. The production of thick, frothy, white sputum is unrelated to oxygen toxicity. The client’s demand to remove the mask is not specific to oxygen toxicity.
The nurse has just received report on a group of clients. Which client is the nurse’s first priority?
A 50 year old who is 1 day postoperative from abdominal surgery and is receiving 2 L oxygen by nasal cannula.
A 55 year old was admitted yesterday with pneumonia and is receiving antibiotics and oxygen through a nasal cannula.
A 45 year old who is being discharged with a new prescription for home oxygen therapy by nasal cannula.
A 60 year old admitted 2 hours ago who has a 90–pack-year smoking history and is receiving 50% oxygen by Venturi mask.
A 60 year old admitted 2 hours ago who has a 90–pack-year smoking history and is receiving 50% oxygen by Venturi mask.
There is insufficient data to determine if this client is stable. The client is at risk for oxygen toxicity and must be assessed frequently.
The postoperative client is receiving the low oxygen therapy typical for anyone having postoperative therapy who has no other respiratory problems. The client who meets discharge criteria does not require frequent assessment. Although the client with pneumonia will require more frequent assessment than a client who does not require oxygen therapy, the client wearing the Venturi mask must be assessed first.
Which problem does the nurse suspect when a client receiving 50% oxygen by Venturi mask for 2 days now has crackles and decreased breath sounds on auscultation?
New-onset asthma
Absorptive atelectasis
Bronchiolar infection
Stasis pneumonia
Absorptive atelectasis
Absorptive atelectasis occurs when high oxygen levels are delivered that causes nitrogen dilution when oxygen diffuses from the alveoli into the blood. The alveoli collapse, which is detected as crackles and decreased breath sounds on auscultation. The problem is in the alveoli, not the airways. Although decreased breath sounds accompany pneumonia, crackles are not present with the increased density.
Which best practice technique will the nurse use when suctioning a client’s tracheostomy tube place earlier today?
Applying suction only during insertion of the catheter
Hyperoxygenating the client before and after suctioning
Ensuring each suction pass lasts no longer 30 seconds
Suctioning repeatedly until the secretions are is clear
Hyperoxygenating the client before and after suctioning
The client needs to be preoxygenated/hyperoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client needs to be hyperoxygenated for 1 to 5 minutes, or until the client’s baseline heart rate and oxygen saturation are within normal limits.
Repeat suctioning can be performed as needed for up to three total suction passes. Any additional suctioning will cause or worsen hypoxemia. Applying suction during insertion is inappropriate because suction makes advancement of the suction tube difficult and is traumatic to the airway. Suction is applied only when the suction tube is removed. Suctioning for 30 seconds is too long and can cause or worsen hypoxemia; a suction pass should last 10 to 15 seconds.
Which action will the nurse take to prevent harm from tracheal stenosis in a client after a tracheostomy?
Using commercial tube holders instead of standard tracheostomy ties
Securing the tube in a midline position
Assessing bilateral breath sound every 2 hours
Ensuring maximum cuff pressure
Securing the tube in a midline position
Tracheal stenosis, a narrowed tracheal lumen, is caused to scar tissue formation from irritation. Two methods of preventing this complication is to keep the tube from moving in the trachea and to maintain proper cuff pressure. Securing the tube in the midline position is critical regardless of whether the tube is secured with commercial tube holders or standard tape ties. Although assessing breath sounds bilateral is an important action whenever a client has a tracheostomy, but does not prevent harm from tracheal stenosis.
For which problem in a client with a tracheostomy will the nurse collaborate with the speech–language pathologist (SLP) member of the interprofessional team?
Ensuring effective communication
Determining the proper cuff pressure
Identifying early indications of infection
Assessing for vocal cord damage
Ensuring effective communication
One of the many roles of the SLP is helping health care professionals work with clients who have communication problems to find the most effective means of maintaining communication. They also may be involved in assessing clients for aspiration risk. They are not involved in vocal cord assessment (primary health care provider responsibility), infection assessment, or determining correct cuff pressure (respiratory therapist responsibility).
Which action will the nurse take first when a client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure? Which nursing action must be taken first?
Cleaning the tracheostomy inner cannula and stoma
Observing for indications that suctioning is needed
Auscultating lung sounds
Changing the tracheostomy dressing immediately
Auscultating lung sounds
The first step of the nursing process and nursing action for a client following an airway procedure is to assess for a patent airway by auscultating the client’s lungs and assessing the client’s respiratory status.
Suction is not needed if the lungs and airways are clear to auscultation. Although cleanliness is important, the PACU nurse will not typically perform this procedure immediately after the tracheotomy is created, unless copious secretions are blocking the tube.
Performing a dressing change is done every 8 hours or per hospital policy. The PACU nurse will perform this if the dressing is soiled or bloody, but assessment of airway must be performed first.
What action does the nurse take first when a client who has a “do not resuscitate” (DNR) order and a nonrebreather oxygen mask, has labored breathing?
Only provide comfort to the client.
Notify the chaplain and the family member of record.
Ensure that the tubing is patent and that oxygen flow is high.
Initiate the Rapid Response Team (RRT).
Ensure that the tubing is patent and that oxygen flow is high.
The nurse needs to first ensure that the tubing is patent and that the O2 flow is high. Labored breathing and ultimately suffocation can occur if the reservoir bag on a nonrebreather mask kinks, or if the oxygen source disconnects or is not set to high-flow levels.
The chaplain and the family member of record would not be notified until assessment confirms that death is imminent at this time. The RRT team can be called but the client may not want to be intubated, as indicated in the DNR orders. The RRT needs to know the client’s wishes when they arrive. Comforting the client must be done but is not the first action by the action.
For which situation will the nurse take immediate action to prevent harm for a client with pneumonia who is receiving 100% oxygen via a nonrebreather mask?
Sputum is now rust-colored.
Oxygen reservoir deflates during inspiration.
Crackles are present in the lung bases.
Skin is pink and flushed.
Oxygen reservoir deflates during inspiration.
The nurse takes action immediately if the reservoir bag is deflated. Suffocation can occur if the reservoir bag deflates, kinks, or if the oxygen source disconnects. The nurse needs to remove the device, refill the reservoir, and then reapply the mask.
It is anticipated that the client’s color is now pink. The client’s color is expected to improve (from ashen or gray to pink) because of an increase in PaO2 level. Crackles in lung bases are an expected finding in a client with pneumonia, as is expectorating rust-colored sputum.
Which assessment has the highest priority for the nurse to make when caring for a client who had a tracheostomy placed yesterday? Which of these assessments is essential for the nurse to make?
Examining the color and consistency of secretions
Measuring the cuff pressure
Observing for tachypnea
Checking arterial blood gas values
Observing for tachypnea
It is essential for the nurse to assess the client for tachypnea. Tachypnea can indicate hypoxia.
Assessing secretions, checking arterial blood gas values, and measuring cuff pressure are all appropriate interventions, after assessing airway and breathing.
Which actions will the nurse take to reduce risk for aspiration for a client with a tracheostomy? Select all that apply.
Inflating the tracheostomy cuff during meals
Encouraging water with meals
Teaching the client to “tuck” the chin down in the forward position to swallow
Maintaining the client upright for 30 minutes after eating
Encouraging frequent sipping from a cup
Providing small, frequent meals
Teaching the client to “tuck” the chin down in the forward position to swallow
Maintaining the client upright for 30 minutes after eating
Providing small, frequent meals
Interventions that must be noted in the client’s plan of care include having the client remain upright for at least 30 minutes after eating to reduce the chance of aspiration. Also, making sure that small frequent meals are available for the client. Shorter and more frequent intervals of eating tire the client less and also reduce the chance for aspiration. Teaching the client how to tuck the chin down in the forward position helps to open the upper esophageal sphincter and again reduces the risk of aspiration.
Sipping from a cup is contraindicated. Liquids are consumed using a spoon to ensure that the client is attempting to swallow only small volumes of liquid. Controlled small amounts of thickened liquids are given. Thin liquids such as water should be avoided because they are easily aspirated. The tracheostomy cuff needs to be deflated because an inflated tube narrows the upper esophageal sphincter opening, which increases the risk for aspiration.
Which statements regarding noninvasive positive-pressure ventilation (NPPV) are true? Select all that apply.
Can only be used safely by alert clients.
Risk for ventilator-associated pneumonia is reduced but still present.
An endotracheal tube is required for oxygen therapy.
Masks must have a tight seal for effective ventilation.
The system operates with either room air or oxygen.
Vomiting with potential aspiration can occur.
Can only be used safely by alert clients.
Masks must have a tight seal for effective ventilation.
The system operates with either room air or oxygen.
Vomiting with potential aspiration can occur.
Which statements made by a client going home with a tracheostomy indicate to the nurse the need for further teaching about correct tracheostomy care? (Select all that apply.)
Select all that apply.
“I can only take baths, but no showers.”
“I will be unable to wear a necklace.”
“I should put cotton or foam over the tracheostomy hole.”
“I will have to learn to suction myself.”
“I will notify my primary health care provider if my secretions develop a foul odor.”
“I can put normal saline in my tracheostomy to keep the secretions from getting thick.”
“I can only take baths, but no showers.”
“I will be unable to wear a necklace.”
“I should put cotton or foam over the tracheostomy hole.”
“I can put normal saline in my tracheostomy to keep the secretions from getting thick.”
Need for teaching is indicated when the client says that only baths and no showers can be taken. The client is permitted to shower with the use of a shower shield over the tracheostomy, which prevents water from entering the airway. Also, the client does not instill anything into the artificial airway unless prescribed. The client would not put cotton or foam over the tracheostomy hole; this action may cause airway obstruction. The stoma may be covered loosely with a small cotton cloth or light scarf to protect it during the day. This filters the air entering the stoma, keeps humidity in the airway, and enhances appearance.
The client is correct when commenting about learning to suction self, and will be taught clean suction technique to use at home. Also, foul-smelling secretions or drainage indicates possible infection and needs to be reported to the primary health care provider.
24.1 How will the nurse expect a client’s age-related decreased skeletal muscle strength to affect gas exchange?
Reduced gas exchange as a result of decreased alveolar surface
Reduced gas exchange as a result of longer relaxation of bronchiolar smooth muscles
Reduced gas exchange as a result of decreased changes in pressures of the chest cavity
Reduced gas exchange as a result of failure of pulmonary circulation to fully perfuse lung tissue
Reduced gas exchange as a result of decreased changes in pressures of the chest cavity
Breathing occurs through changes in the size of and pressure within the chest cavity. Contraction and relaxation of chest muscles (and the diaphragm) cause changes in the size and pressure of the chest cavity. When skeletal muscle strength is decreased in these muscles, pressure changes are decreased and less air moves in and out of the lungs. This reduced airflow limits gas exchange at the alveolar-capillary membrane. The alveolar surface itself is not decreased by weaker skeletal muscles, nor does this cause any relaxation of bronchiolar smooth muscle. Weaker skeletal muscles do not directly affect pulmonary circulation.
How will the nurse document the client’s respiratory assessment findings on auscultation that are heard as popping, discontinuous, high-pitched sounds at the end of exhalation?
Coarse crackles
Rhonchi
Wheezes
Fine crackles
Fine crackles
Fine crackles are heard as popping, discontinuous sounds that are high-pitched heard at the end of inhalation. Squeaky, musical continuous sounds heard when the client inhales and exhales are abnormal (adventitious) and described as wheezes. Coarse crackles are a rattling sound. Rhonchi are heard as low-pitched continuous snoring sounds.
What is the most relevant technique for the nurse to use when assessing a client for dyspnea?
Checking oxygen saturation by pulse oximetry
Observing the client’s rate, depth, and ease of inhalation and exhalation
Comparing previous respiratory assessment information with current data
Asking the client about whether any breathlessness is present
Asking the client about whether any breathlessness is present
Dyspnea, difficulty in breathing or breathlessness, is a subjective perception and varies among clients. Thus, only the client can rate his or her level of dyspnea.
The other measures listed for assessment of respiratory status and adequacy of ventilation and oxygenation are objective measures.
What is the nurse’s interpretation of a 50-year-old client’s respiratory assessment findings when hearing bronchial breath sounds over the left lower lobe and noting decreased fremitus and dullness to percussion in the same area?
Obstruction of the larger airways
Normal physical exam for a 50-year-old
An area of increased density
Subcutaneous emphysema
An area of increased density
Peripheral bronchial breath sounds are abnormal and can indicate atelectasis, tumor, or pneumonia. Decreased fremitus and dullness to percussion may indicate pleural effusion, which is more dense than air.
Bronchial breath sounds are normally heard only over the large airways in patients of any age, not in the periphery. An obstructed airway would have reduced bronchial breath sounds, and they would not be present in the periphery. Subcutaneous emphysema is a condition in which air is trapped within or beneath the skin. It is felt and heard as a “crackling” in the skin and subcutaneous tissues, not within any part of the respiratory tract.
What is the nurse’s best first action on finding the client’s oxygen saturation by pulse oximetry on the finger is 84%?
Apply supplemental oxygen by mask or nasal cannula.
Notify the Rapid Response Team immediately.
Assess the client’s cognitive function.
Recheck the value on the forehead.
Recheck the value on the forehead.
Although a true low oxygen saturation is an emergency, there are many causes of a low reading using pulse oximetry. The value should be verified immediately before any interventions are implemented.
For which symptoms would a nurse assess a client who worries a thoracentesis earlier today may have caused a pneumothorax? (Select all that apply.)
Select all that apply.
A) Slowing heart rate
B) Sensation of air hunger
C) Pain at the insertion site
D) Cyanosis of oral mucous membranes
E) Wheezing on inhalation and exhalation
F) Tracheal deviation
B) Sensation of air hunger
D) Cyanosis of oral mucous membranes
F) Tracheal deviation
Signs and symptoms of a pneumothorax include sensation of air hunger, tracheal deviation, and cyanosis. Other symptoms include pain on the affected side (not at the needle insertion site), rapid heart rate, rapid, shallow respirations, prominence of the affected side that does not move in and out with respiratory effort, and new onset of “nagging” cough. Wheezing is a bronchial and bronchiolar problem. It is not produced as a result of a pneumothorax.
When performing an assessment on an older client, which finding is most important for the nurse to assess further?
Soft speaking voice.
Slight kyphoscholiosis.
Inability to state name and date of birth.
Need for rest after activity.
Inability to state name and date of birth.
The nurse would further assess the client who is unable to state name and date of birth. The older client has a higher risk for hypoxemia than a younger client, and often becomes confused during acute respiratory conditions. The other assessment findings are considered normal age-related conditions in an older client and do not warrant additional investigation.
30.4. The nurse is assessing a client with mitral stenosis who is to undergo a transesophageal echocardiogram (TEE) today. Which nursing action is essential?
Reassure the client that they will not feel pain.
Teach the client about the reason for the TEE.
Auscultate the client’s precordium for murmurs.
Validate that the client has remained NPO.
Validate that the client has remained NPO.
The essential nursing action the nurse must take is to validate that the client scheduled for a TEE has remained NPO. Owing to the risk for aspiration, the client must be NPO before the procedure.
It is anticipated that the client with mitral stenosis may have an audible murmur, so auscultation is not essential at this time. Although teaching is important, the client could undergo the procedure without understanding the reason for the test. The client will have sedation during the test as it is uncomfortable. However, with sedation, the goal is to maintain client comfort during the procedure.
A client who is to undergo cardiac catheterization must be taught which essential information by the nurse?
“Take your oral hypoglycemic with a sip of water on the morning of the procedure.”
“Keep your affected leg straight for 2 to 6 hours.”
“Do not take your blood pressure medications on the day of the procedure.”
“Monitor the pulses in your feet when you get home.”
“Keep your affected leg straight for 2 to 6 hours.”
The client undergoing cardiac catheterization must be taught to keep the affected leg straight for 2 to 6 hours after the test. The client will remain in bed and the affected leg kept straight for 2 to 6 hours after the procedure, depending on the type of vascular closure device used, to allow the arterial puncture to heal well and prevent bleeding.
The nurse monitors the pulses in the affected extremity until discharge, then teaches the client to contact the primary health care provider immediately if pallor, pain, paresthesia, or coolness of the extremity develops. The client may take regular medications except oral hypoglycemics. Blood pressure may be elevated due to anxiety before the procedure, so antihypertensive medications are taken. Oral hypoglycemics are taken with or before meals based on an anticipated rise in glucose after eating. They are not taken when the client is NPO for procedures or surgery.
Which client assessment data is most consistent with cardiac pain requiring the nurse to notify the primary health care provider?
Reports of abdominal pain and belching
Reports of pressure in the upper abdomen and sternum and diaphoresis
Apparent dyspnea on exertion (DOE) and an inability to sleep flat
Reports claudication with ambulation and fatigue
Reports of pressure in the upper abdomen and sternum and diaphoresis
The client with pain most consistent with an MI is the client with pressure in the mid-abdomen and diaphoresis. Typical symptoms of MI include chest pain or pressure, ashen skin color, diaphoresis, and anxiety.
Although atypical cardiac pain can be perceived in the abdomen, abdominal pain and belching are more typical of peptic ulcer. DOE and orthopnea are typical problems for clients with heart failure. Claudication (pain in the legs with exercise or at rest) is symptomatic of peripheral arterial occlusive disease.
Which laboratory finding is consistent with acute coronary syndrome (ACS)?
Triglycerides 400 mg/dL (4.52 mmol/L)
C-reactive protein 13 mg/dL (130 mg/L)
Troponin 3.2 ng/mL (3.2 mcg/L)
Lipoprotein-a 18 mg/dL (0.64 mcmol/L)
Troponin 3.2 ng/mL (3.2 mcg/L)
Normal troponin would be less than 0.03 ng/mL (0.03 mcg/L).
Normal C-reactive protein would be less than 1 mg/dL (10 mg/L). This tests for risk for coronary artery disease (CAD), not ACS. Normal triglycerides would be 35 to 135 mg/dL (0.40 to 1.50 mmol/L) for females and 40 to 160 mg/dL (0.45 to 1.81 mmol/L) for males. This tests for risk for CAD, not ACS. Normal lipoprotein-a is less than 30 mg/dL (1.07 mcmol/L). This also tests for risk for CAD, not ACS.
A client recovering from cardiac angiography develops slurred speech. What will the nurse do first?
Assess the site of the procedure for bleeding.
Call in another nurse for a second opinion.
Maintain NPO status until the slurred speech resolves.
Perform a neurologic assessment and notify the primary care provider.
Perform a neurologic assessment and notify the primary care provider.
The first action the nurse must do when a client recovering from a cardiac angiography develops slurred speech is to perform a complete neurologic assessment and notify the primary health care provider. Based on the assessment finding, the client probably is suffering a neurologic event, possibly a stroke. Neurologic changes such as visual disturbances, slurred speech, swallowing difficulties, and extremity weakness must be reported immediately for prompt intervention.
Keeping the client NPO and waiting for symptoms to resolve are not appropriate. While the nurse can call for help from another nurse, this assessment does not warrant a second opinion and action is required immediately. While it is appropriate to assess the site of the procedure for bleeding, the slurred speech is not from bleeding at the site, rather it is likely a neurologic event so the priority is neurologic assessment.
The nurse is caring for a client immediately following a cardiac catheterization. Which nursing assessment data requires immediate nursing intervention?
A. Blood pressure 146/70
B. Hematoma developing at insertion site
C. Client reports of headache pain
D. Client reports of extreme thirst
B. Hematoma developing at insertion site
Following cardiac catheterization the client is at risk for bleeding at the insertion site. Hematoma formation is an indication that the artery is bleeding internally, and the priority nursing action is to apply manual pressure to the insertion site immediately. While the client’s blood pressure is slightly elevated the priority of care remains responding to the development of the hematoma at the insertion site. After the client is stable, the nurse can then address the client’s headache and thirst.
- The nurse is assessing the client’s heart sounds. Which instruction will the nurse provide if there is difficulty hearing heart sounds?
A. “Please roll onto your left side.”
B. “Lay all the way down on your back.”
C. “Please hold your breath while I use my stethoscope.”
D. “I will just take your pulse instead.”
A. “Please roll onto your left side.”
If the nurse is having difficulty hearing the heart sounds while auscultating, the nurse can ask the client to roll to the left side or lean forward. This positions the heart closer to the chest wall and can make the heart sounds more audible. Taking the pulse instead of auscultating is not an appropriate nursing action, nor is asking the client to hold their breath for an undetermined time period. Asking the client to lay on their back will make it more difficult to hear sounds versus easier.
The nurse is assessing the client’s cardiac rhythm and notes the following: HR 64, regular rhythm, PR interval 0.20; QRS 0.10. How will the nurse document this rhythm interpretation in the electronic health record?
A. Sinus Tachycardia
B. Sinus Bradycardia
C. Normal Sinus Rhythm
D. Sinus arrhythmia
C. Normal Sinus Rhythm
The nurse will document this rhythm interpretation as normal sinus rhythm. The heart rate does not reflect tachycardia or bradycardia and the rhythm is not irregular. All other assessment parameters are within normal sinus rhythm interpretation.
The nurse is caring for client who is experiencing occasional premature ventricular contractions. What is assessment data is most concerning to the nurse?
A. Potassium 4.8 mEq/L
B. Magnesium 2 mEq/L
C. Heart rate 90
D. History of smoking
D. History of smoking
The client’s potassium, magnesium, and heart rate are within normal limits. Nicotine can be a cause of premature ventricular contractions (PVSs) and should be discussed with this provider and the client.
Upon entering a client’s room, the nurse finds the client unresponsive. In what order will the nurse provide care?
A. Begin chest compressions
B. Check carotid pulse
C. Notify the Rapid Response Team
D. Get the crash cart/AED
E. Provide rescue breaths
C. Notify the Rapid Response Team
D. Get the crash cart/AED
B. Check carotid pulse (for 5-10 seconds)
A. Begin chest compressions
E. Provide rescue breaths
- While suctioning a client with a tracheostomy, the client becomes diaphoretic and nauseous, and the heart rate decreases to 37 beats/min. What is the priority nursing action?
A. Continue to clear the airway.
B. Stop suctioning the patient.
C. Administer atropine.
D. Call the health care provider immediately.
B. Stop suctioning the patient.
Removing the noxious stimuli causing the vagal response would be the first action. If this does not resolve the bradycardia, second action would be to administer atropine and call provider. Continuing to suction is not appropriate as this is the cause of the vagal episode.
- A client in the telemetry unit is on a cardiac monitor. The monitor technician alerts the nurse that there are no ECG complexes, and the alarm is sounding. What is the first action by the nurse?
A. Suspend the alarm.
B. Call the emergency response team.
C. Press the record button to get an ECG strip.
D. Assess the client and check lead placement.
D. Assess the client and check lead placement.
ALWAYS check the client first. Cardiac monitors are a tool for assessment, but they do not replace hands on nursing assessment.
- The nurse is caring for a patient with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol. Which data is essential for the nurse to assess prior to administration?
Troponin
Heart rate
ST segment
Myoglobin
Heart rate
The monitoring of the patient’s heart rate is essential. The effects of metoprolol are to decrease heart rate, blood pressure, and myocardial oxygen demand.
ST segment elevation is consistent with MI; it does not address monitoring of metoprolol. Elevation in troponin is consistent with a diagnosis of MI, but does not address needed monitoring for metoprolol. Elevation in myoglobin is consistent with myocardial injury in ACS, but does not address needed monitoring related to metoprolol.
- The nurse is caring for a patient with atrial fibrillation (AF). In addition to an antidysrhythmic, what medication does the nurse anticipate administering?
Magnesium sulfate
Atropine
Dobutamine
Heparin
Heparin
The nurse plans to administer heparin in addition to the antidysrhythmic. AF is the loss of coordinated atrial contractions that can lead to pooling of blood, resulting in thrombus formation. The patient is at high risk for pulmonary and systemic embolism. Heparin and other anticoagulants (e.g., enoxaparin, warfarin, and novel oral anticoagulants, when nonvalvular, such as dabigatran, rivaroxaban, apixaban, or edoxaban) are used to prevent thrombus development in the atrium, leading to the risk of embolization (i.e., stroke).
Atropine is used to treat bradycardia and not rapid heart rate associated with AF. Dobutamine is an inotropic agent used to improve cardiac output; it may cause tachycardia, thereby worsening atrial fibrillation. Although electrolyte levels are monitored in clients with dysrhythmia, magnesium sulfate is not used unless depletion is noted.
- The nurse is caring for a patient on a telemetry unit who has a regular heart rhythm and rate of 60 beats/min; a P wave precedes each QRS complex, and the PR interval is 0.20 second. Additional vital signs are: blood pressure 118/68 mm Hg, respiratory rate 16 breaths/min, and temperature 98.8° F (37° C). All of these medications are available on the medication record. What action will the nurse take?
Administer clonidine.
Administer atropine.
Administer digoxin.
Continue to monitor.
Continue to monitor.
The nurse needs to take no action other than to continue monitoring because the patient is displaying a normal sinus rhythm and normal vital signs.
Atropine is used in emergency treatment of symptomatic bradycardia. This patient has a normal sinus rhythm. Digoxin is used in the treatment of atrial fibrillation, which is, by definition, an irregular rhythm. Clonidine is used in the treatment of hypertension; a side effect is bradycardia.
- The cardiac care unit charge nurse is assigning clients to the oncoming shift. Which patient is appropriate to assign to a float RN from the medical-surgical unit?
A 92-year-old client admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min.
An 88-year-old client admitted with elevated troponin level who is hypotensive with a heart rate of 96 beats/min.
A 71-year-old client admitted for heart failure who is shortness of breath and has a heart rate of 120 to 130 beats/min.
A 64-year-old client admitted for weakness with sinus bradycardia and heart rate 58 beats/min.
A 64-year-old client admitted for weakness with sinus bradycardia and heart rate 58 beats/min.
The 64-year-old client has a stable, asymptomatic bradycardia, which usually requires monitoring but no treatment unless the patient develops symptoms and/or the slow heart rate causes a decrease in cardiac output. This patient can be managed by a nurse with less cardiac dysrhythmia training.
The 71-year-old client is unstable and requires immediate intervention for dyspnea and tachycardia. The 88-year-old client is displaying symptoms of myocardial injury (elevated troponin) and unstable blood pressure and needs immediate attention and medications. The 92-year-old client is experiencing a dysrhythmia that could deteriorate into ventricular tachycardia and requires immediate intervention by a telemetry nurse.
- A client admitted after using cocaine develops ventricular fibrillation. After determining unresponsiveness, which action will the nurse take next?
Place an oral airway and ventilate.
Start cardiopulmonary resuscitation (CPR).
Establish IV access.
Prepare for defibrillation.
Prepare for defibrillation.
Defibrillating is the priority next action before any other resuscitative measures, according to advanced cardiac life support protocols.
After immediate defibrillation, establish IV access, place an oral airway, and ventilate. CPR will be started after unsuccessful defibrillation.
- The nurse is teaching a client about the risk for bradydysrhythmias. What teaching will the nurse include?
“Use a stool softener.”
“Stop smoking and avoid caffeine.”
“Avoid potassium-containing foods.”
“Take nitroglycerin for a slow heartbeat.”
“Use a stool softener.”
The nurse will advise the client to use a stool softener. Patients at risk for bradydysrhythmias would avoid bearing down or straining during a bowel movement. The Valsalva maneuver associated with bearing down can cause bradycardia.
Patients with renal failure and hyperkalemia are instructed to avoid potassium-containing foods; if risk for hypokalemia exists, such as with diuretic therapy, the patient is instructed to eat foods high in potassium. Smoking and caffeine increase heart rate; although all people would stop smoking, patients at risk for tachycardia, premature beats, and ectopic rhythms are instructed to stop smoking and avoid caffeine. Nitroglycerin is used to reduce oxygen demand in cardiac ischemia, not for bradycardia.
- Which assessment data indicates proper function of the sinoatrial (SA) node?
The QRS complex is present.
The ST segment is elevated.
The PR interval is 0.24 second.
A P wave precedes every QRS complex.
A P wave precedes every QRS complex.
A P wave is generated by the SA node and represents atrial depolarization and needs to be followed by a QRS complex. When the electrical impulse is consistently generated from the SA node, the P waves have a consistent shape in a given lead.
The QRS complex represents ventricular depolarization. The PR interval represents time required for atrial depolarization and for the impulse delay in the atrioventricular node and travel time to the Purkinje fibers. Normal PR level is up to 0.20 seconds. Elevation of the ST segment indicates myocardial injury.
- The nurse receives a report that a client with a pacemaker has experienced loss of capture. What assessment data would the nurse anticipate?
The heart rate is 42 beats/min, and no pacemaker spikes are seen on the rhythm strip.
The patient demonstrates hiccups.
Pacemaker spikes are noted, but no P wave or QRS complex follows.
The pacemaker spike falls on the T wave.
Pacemaker spikes are noted, but no P wave or QRS complex follows.
Loss of capture occurs when the pacing stimulus (spike) is not followed by the appropriate response, either P wave or QRS complex, depending on placement of the pacing electrode.
Pacemaker spikes falling on the T wave indicate improper sensing. A heart rate of 42 beats/min with no pacemaker spikes seen on the rhythm strip indicates failure to pace or sense properly. Demand pacing would cause the pacemaker to intervene with electrical output when the heart rate falls below the set rate. Although the set rate is not given, this heart rate indicates profound bradycardia. Hiccups may indicate stimulation of the chest wall or diaphragm from wire perforation.
- Which intervention provides safety during cardioversion?
Setting the defibrillator at 220 joules
Setting the defibrillator to the synchronized mode
Applying oxygen
Obtaining informed consent
Setting the defibrillator to the synchronized mode
Safety during cardioversion depends upon setting the defibrillator to the synchronized mode to avoid discharging the shock during the vulnerable period on the T wave. Unsynchronized cardioversion may cause ventricular fibrillation.
Cardioversion is usually performed starting at a lower rate of 120 to 200 joules for biphasic machines. Although it is imperative to obtain informed consent, this does not improve the safety of the procedure. Oxygen would be turned off because it presents a safety issue; fire could result.
- A client’s rhythm strip shows a heart rate of 116 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.16 seconds, and a QRS complex measuring 0.08 seconds. How does the nurse interpret this rhythm strip?
Sinus rhythm with premature ventricular contractions
Normal sinus rhythm
Sinus bradycardia
Sinus tachycardia
Sinus tachycardia
These are the characteristics of sinus tachycardia.
A normal sinus rhythm would have a heart rate of 60 to 100 beats/min. A heart rate of less than 60 beats/min would indicate sinus bradycardia. Early QRS intervals would indicate sinus rhythm with premature ventricular contractions.
- The nurse administers amiodarone to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? (Select all that apply.)
Select all that apply.
Urine output
Respiratory rate
Heart rate
Heart rhythm
QT interval
Heart rate
Heart rhythm
QT interval
Amiodarone causes prolongation of the QT interval, which can precipitate dysrhythmia. Antidysrhythmic medications cause changes in cardiac rhythm and rate; therefore, monitoring of heart rate and rhythm is needed.
Although it is always important to monitor respiratory rate and urine output, these assessments are not specific to amiodarone.
- The nurse is caring for a client with heart rate of 143 beats/min. Which assessment data will the nurse anticipate? (Select all that apply.)
Select all that apply.
Chest discomfort
Hypotension
Flushing of the skin
Increased energy
Palpitations
Chest discomfort
Hypotension
Palpitations
Tachycardia is a heart rate greater than 100 beats/min; the patient with a tachydysrhythmia may have palpitations, chest discomfort (pressure or pain from myocardial ischemia or infarction), restlessness and anxiety, pale cool skin, and syncope (“blackout”) from hypotension. Chest discomfort and palpitations may occur because decreased time for diastole results in lower perfusion through the coronary arteries to the myocardium. Hypotension results from decreased time for ventricular filling, secondary to shortened diastole, and therefore reduced cardiac output and blood pressure. Reduced cardiac output and possible development of heart failure will cause fatigue.
In this situation, the patient will have pale, cool skin and not flushing of the skin. Also, reduced cardiac output and possible development of heart failure will cause fatigue and not increased energy.
- Which risk factors are known to contribute to atrial fibrillation? (Select all that apply.)
Select all that apply.
Advancing age
Palpitations
High blood pressure
Excessive alcohol use
Use of beta blockers
Advancing age
High blood pressure
Excessive alcohol use
Risk factors contributing to atrial fibrillation include excessive alcohol use, advancing age, and hypertension. Other risk factors involve previous ischemic stroke, transient ischemic attack or other thromboembolic event, coronary heart disease, diabetes mellitus, heart failure, mitral valve disease, obesity, and chronic kidney disease. The incidence of atrial fibrillation also occurs more often in those of European ancestry and African Americans.
Beta-adrenergic blocking agents, which reduce heart rate, are used to treat atrial fibrillation. Palpitations are a symptom of atrial fibrillation, rather than a risk or a cause.
- The nurse is teaching a client with a new pacemaker. What teaching will the nurse include? (Select all that apply.) Select all that apply.
Do not lean over electrical or gasoline motors.
Take your pulse for 20 seconds each day and record the rate.
You may bathe, taking only showers.
Be sure that you remember the rate at which your pacemaker is set.
Avoid the use of microwave ovens.
Avoid sudden, jerky movements for 8 weeks.
Do not lean over electrical or gasoline motors.
Be sure that you remember the rate at which your pacemaker is set.
Avoid sudden, jerky movements for 8 weeks.
Clients with a new pacemaker should be taught to take their pulse daily for 1 full minute each day. It is important to be aware of the rate the pacemaker is set to know which rate changes that are important to report to your health care provider. Clients with pacemakers can use microwave ovens and may bathe normally, in either the shower or bath. Sudden, jerky movements should be avoided for 8 weeks to allow the pacemaker to settle in place. Leaning over electrical or gasoline motors should be avoided and it is important to make sure electrical devices are properly grounded.
- The nurse is caring for a client immediately following a cardioversion. What nursing actions are appropriate? (Select all that apply.) Select all that apply.
Allow the client to eat a meal.
Ensure electrodes are in place for continued monitoring.
Assess the chest for burns.
Document results of procedure.
Remove crash cart from the room.
Provide continued sedation.
Administer oxygen.
Ensure electrodes are in place for continued monitoring.
Assess the chest for burns.
Document results of procedure.
Administer oxygen.
The nurse would not allow the client to eat a meal immediately following a cardioversion. The nurse will assess level of consciousness and overall client status and start with sips of liquid once the client is fully awake. The nurse will continue to carefully monitor the client, ensuring that electrodes are in place and assessing for chest burns from the electrodes used during the cardioversion. The nurse will administer oxygen until the client is fully awake. The nurse will not provide continued sedation. The nurse will document the procedure and the crash cart should remain in the room until the client is stable as lethal arrhythmias can occur during and after cardioversion.
A client is diagnosed with left-sided heart failure. Which assessment findings will the nurse expect the client to have? Select all that apply.
A. Peripheral edema
B. Crackles in both lungs
C. Tachycardia
D. Ascites
E. Tachypnea
F. S3 gallop
B. Crackles in both lungs
C. Tachycardia
E. Tachypnea
F. S3 gallop
For a client with left sided heart failure the nurse will anticipate assessment findings of crackles in both lungs, tachypnea, tachycardia, and a third heart sound, usually an S3 gallop.
Peripheral edema and ascites are associated with right sided heart failure.
A client who recently had a heart valve replacement is preparing for discharge. What statement by the client indicates that the nurse will need to do additional health teaching?
A. “I need to brush my teeth at least twice daily and rinse with water.”
B. “I will eat foods that are low in vitamin K, such as potatoes and iceberg lettuce.”
C. “I need to take a full course of antibiotics prior to my colonoscopy.”
D. “I will take my blood pressure every day and call if it is too high or low.”
C. “I need to take a full course of antibiotics prior to my colonoscopy.”
Antibiotics are only required prior to dental procedures. Good oral hygiene is the best prevention for endocarditis. The statement in option A is correct and shows the patient understands the need for oral hygiene. The patient with a mechanical valve will be on warfarin thus, foods high in Vitamin K should be avoided. This statement in option B is correct and shows the patient understands foods that are LOW in Vitamin K. This statement in option D is also correct and shows that the patient understands the importance of regular BP assessment as well as when to call the provider based on the assessment.
The nurse is caring for a hospitalized client with infective endocarditis who has been receiving antibiotics for 2 days. The client is now experiencing flank pain with hematuria. What condition will the nursing suspect?
A. Pulmonary embolus
B. Renal infarction
C. Transient ischemic attack
D. Splenic infarction
B. Renal infarction
The classic clinical signs of renal infarction, associated with embolization from infective endocarditis, are flank pain, hematuria, and pyuria.
- The nurse is caring for a client with heart failure who is on oxygen at 2L per nasal cannula with an oxygen saturation of 90%. The client states, “I feel short of breath.” Which action will the nurse take first?
A. Contact respiratory therapy.
B. Increase the oxygen to 4L.
C. Place the client in a high Fowler’s position.
D. Draw arterial blood for arterial blood gas analysis.
C. Place the client in a high Fowler’s position.
The first action of the nurse is to place the client in high Fowler’s position. This position allows for maximal lung expansion. The nurse can also place pillows under each arm to maximize chest expansion. Repositioning the client with heart failure can improve overall gas exchange. If dyspnea continues the nurse may contact respiratory therapy for a breathing treatment, assess arterial blood gases (as prescribed) or increase oxygen if warranted by ABG results.
- Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea?
Place the client in high-Fowler position with the legs down.
Reassure the client that distress can be relieved with proper intervention.
Ask a family member to remain with the client.
Monitor pulse oximetry and cardiac rate and rhythm.
Place the client in high-Fowler position with the legs down.
The best intervention to help the client with acute pulmonary edema to reduce anxiety and dyspnea is to place the client in high-Fowler position with the legs down. High-Fowler position and placing the legs in a dependent position will decrease venous return to the heart, thus decreasing pulmonary venous congestion.
Monitoring of vital signs will detect abnormalities, but will not prevent them. Reassuring the client and a family member’s presence may help alleviate anxiety, but dyspnea and anxiety resulting from hypoxemia secondary to intra-alveolar edema must be relieved.
- The nurse is caring for a client with heart failure in the coronary care unit. The client is exhibiting signs of air hunger and anxiety. Which nursing intervention will the nurse perform first for this client?
Monitor and document heart rate, rhythm, and pulses.
Encourage alternate rest and activity periods.
Position the client to alleviate dyspnea.
Determine the client’s physical limitations.
Position the client to alleviate dyspnea.
- The nurse is assessing a client with a cardiac infection. Which nursing assessment data causes the nurse to suspect infective endocarditis instead of pericarditis or rheumatic carditis?
Thickening of the endocardium
Pain aggravated by breathing, coughing, and swallowing
Splinter hemorrhages
Friction rub auscultated at the left lower sternal border
Splinter hemorrhages
Splinter hemorrhages are indicative of infective endocarditis. Petechiae (pinpoint red spots) occur in many clients with endocarditis. Splinter hemorrhages appear as black longitudinal lines or small red streaks along the distal third of the nail bed.
Friction rub in the left lower sternal border and pain aggravated by breathing, coughing, and swallowing are signs and symptoms indicative of chronic constrictive pericarditis. Thickening of the endocardium is indicative of rheumatic carditis.
- After receiving change-of-shift report about these four clients, which client would the nurse assess first?
A 79 year old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min.
A 55 year old admitted with pulmonary edema who received furosemide and whose current O2 saturation is 94%.
A 46 year old with aortic stenosis who takes digoxin and has new-onset frequent premature ventricular contractions.
A 68 year old with pericarditis who is reporting sharp chest pain with inspiration.
A 46 year old with aortic stenosis who takes digoxin and has new-onset frequent premature ventricular contractions.
The nurse would first assess the 46 year old with aortic stenosis on digoxin and now has new-onset frequent PVCs. The PVCs may be indicative of digoxin toxicity. Further assessment for clinical signs and symptoms of digoxin toxicity must be done and the primary health care provider notified about the dysrhythmia.
The 55 year old is stable and can be assessed after the client with aortic stenosis. The 68 year old may be assessed after the client with aortic stenosis. This type of pain is expected in pericarditis. Tachycardia is expected in the 79 year old because rejection will cause signs of decreased cardiac output, including tachycardia. This client may be seen after the client with aortic stenosis.
- For a client with an 8-cm abdominal aortic aneurysm, which assessment data must be addressed immediately?
Blood pressure (BP) 192/102 mm Hg
Report of constipation
Anxiety
Heart rate 52 beats/min
Blood pressure (BP) 192/102 mm Hg
The problem that must be addressed immediately in a client with an 8-cm abdominal aneurysm is a BP of 192/102 mm Hg. Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture.
The nurse must consider the client’s usual pulse. However, bradycardia does not pose a risk for aneurysm rupture. Straining at stool can elevate blood pressure and pose a risk for dissection. However, a potential problem would not be addressed before an actual problem. Anxiety may be benign or may be a symptom of something serious. However, the elevated blood pressure is an immediate risk.
- When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement?
“I have a headache. May I have some acetaminophen?”
“I have had hoarseness for a few weeks.”
“I feel my heart beating in my abdominal area.”
“I just started to feel a pain in my belly and low back.”
“I just started to feel a pain in my belly and low back.”
The nurse suspects dissection of an AAA when the client says that “I just started to feel a tearing pain in my belly.” Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA.
The sensation of feeling the heartbeat in the abdomen is a symptom of AAA but not of dissection or rupture. Headache may be benign or indicative of cerebral aneurysm or increased intracranial pressure. Hoarseness, shortness of breath, and difficulty swallowing may be symptoms of thoracic aortic aneurysm.
- The nurse is caring for a client who had abdominal aortic aneurysm (AAA) repair. Which assessment data is most concerning to the nurse?
Urine output of 20 mL over 2 hours
Blood pressure of 106/58 mm Hg
+3 pedal pulses
Absent bowel sounds
Urine output of 20 mL over 2 hours
The nurse caring for a client who had an AAA repair would be most alarmed with the client’s urine output of 20 mL over 2 hours. Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria.
Reduction of systolic blood pressure to 100 to 120 mm Hg is appropriate. Paralytic ileus may be a complication of AAA repair, but is not a priority over decreased urine output. +3 pedal pulses is a normal physical assessment finding.
Which client who has just arrived in the emergency department does the nurse assess as emergent and in need of immediate medical evaluation?
A 64 year old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C).
A 60 year old with venous insufficiency who has new-onset right calf pain and tenderness.
A 69 year old with a 40–pack-year cigarette history who is reporting foot numbness.
A 70 year old with a history of diabetes who has “tearing” back pain and is diaphoretic.
A 70 year old with a history of diabetes who has “tearing” back pain and is diaphoretic.
The client who just arrived in the ED and needs immediate medical evaluation is the 70 year old with a history of diabetes who has “tearing” back pain and is diaphoretic. This client’s history and clinical signs and symptoms suggest possible aortic dissection. The nurse will immediately assess the client’s blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery.
The 64 year old is most stable and can be seen last. The 60 year old and the 69 year old would both be seen soon, but the 70-year-old client must be seen first.
- A client is admitted to the hospital with an abdominal aortic aneurysm. Which assessment data would cause the nurse to suspect that the aneurysm has ruptured?
A. Shortness of breath and hemoptysis
B. Sudden, severe low back pain and bruising along the flank
C. Gradually increasing substernal chest pain and diaphoresis
D. Rapid development of patchy blue mottling on feet and toes
B. Sudden, severe low back pain and bruising along the flank
A sudden onset of low back pain with flank bruising is a classic sign of aneurysm rupture. This is a medical emergency requiring immediate nursing intervention.
The nurse is caring for a client with chest pain. What assessment data would cause the nurse to suspect unstable angina? Select all that apply.
A. ST changes
B. Troponin T 0.6 ng/mL
C. Pain lasts 15-25 minutes
D. Increased number of angina attacks
E. The intensity of the chest pain has increased.
A. ST changes
C. Pain lasts 15-25 minutes
D. Increased number of angina attacks
E. The intensity of the chest pain has increased.
A normal troponin value is anticipated with unstable angina. A troponin value of 0.6ng/mL is elevated and would be indicative of a myocardial infarction. All other assessment data can accompany unstable angina.
The nurse is assessing a client who had a coronary artery bypass graft yesterday. Which assessment data indicates the client is at risk for decreased perfusion?
A. Heart rate of 50 beats/min
B. Potassium level of 4.2 mEq/L
C. Systolic blood pressure of 120 mm/Hg
D. 50 ml of bloody drainage in chest tube over 4 hours
A. Heart rate of 50 beats/min
A heart rate of 50 beats per minute is a risk for decreased perfusion. All other choices are not risks for decreased perfusion or normal parameters.
- The nurse is providing community education regarding myocardial infarction. What teaching will the nurse include? Select all that apply.
A. Denial is a common reaction to chest pain.
B. A myocardial infarction can occur in minutes.
C. Exercise at least 20 minutes 3 to 4 times per week.
D. Age is a significant risk factor in the development of CAD.
E. Women are more likely to experience atypical chest pain.
F. Atherosclerosis is a primary factor in the development of CAD.
A. Denial is a common reaction to chest pain.
D. Age is a significant risk factor in the development of CAD.
E. Women are more likely to experience atypical chest pain.
F. Atherosclerosis is a primary factor in the development of CAD.
Denial is a common reaction to chest pain that often causes a delay in seeking treatment. Age is a significant risk factor in the development of CAD, with risk increasing with age. Women are more likely to experience atypical symptoms of chest pain such as indigestion. Atherosclerosis is the primary factor in development of CAD. A myocardial infarction evolves over hours, not minutes. Exercise for 20 minutes 3 to 4 times a week is not often enough or long enough.
- A client who is 9 days post coronary artery bypass graft presents to a follow up appointment. Which client statement requires nursing action?
A. “My chest hurts when I sneeze or cough.”
B. “If I get tired when I walk, then I stop and rest for a bit.”
C. “I have a bandage on my sternum to collect the drainage.”
D. “I haven’t had my normal appetite since the surgery.”
C. “I have a bandage on my sternum to collect the drainage.”
Sternal wound infections can develop between 5 days and several weeks following CABG surgery. The client should not be experiencing any drainage from sternum at this time, and the need for a bandage to collect the drainage is indicative of sternal infection. This requires immediate notification of the healthcare provider. It is expected that the client will have chest discomfort when sneezing or coughing because of the sternotomy incision. Resting after walking or walking until tired is also an appropriate method to build stamina following surgery. It is not uncommon to have a decreased appetite for 5 -6 weeks following CABG surgery.
- The nurse assesses a client who had a coronary artery bypass graft yesterday. Which assessment finding will cause the nurse to suspect cardiac tamponade?
A. Incisional pain with decreased urine output
B. Muffled heart sounds with the presence of JVD
C. Sternal wound drainage with nausea
D. Increased blood pressure and decreased heart rate
B. Muffled heart sounds with the presence of JVD
Symptoms are part of Beck’s Triad, which are indicative of tamponade. Incisional pain is expected. While sternal wound drainage is a problem, it is not an indicator of cardiac tamponade. With tamponade, blood pressure will decrease and the heart rate will increase.
- A client with angina has received education about acute coronary syndrome. Which client statement indicates understanding?
“Because this is temporary, I don’t need medications for my heart.”
“I need to tell my wife I’ve had a heart attack.”
“This is a warning sign and I need to change my lifestyle to prevent a heart attack.”
“Angina is a temporary blood flow problem that will resolve.”
“This is a warning sign and I need to change my lifestyle to prevent a heart attack.”
The statement by the client that angina is a warning sign and needing to alter lifestyle shows that the client understands the teaching. Health promotion efforts are directed toward controlling or altering modifiable risk factors for CAD, which will then lower the risk of progression in unstable angina and/or MI.
Although anginal pain is temporary, it reflects underlying coronary artery disease (CAD), which requires attention, including lifestyle modifications. Angina reflects tissue ischemia, but infarction represents tissue necrosis. Clients with underlying CAD may need medications such as aspirin, lipid-lowering agents, antianginals, or antihypertensives.
- The nurse is caring for a client in phase 1 cardiac rehabilitation. Which activity does the nurse suggest?
Planning and participating in a walking program
Placing a chair in the shower for independent hygiene
Consultation with social worker for disability planning
The need to increase activities slowly at home
Placing a chair in the shower for independent hygiene
Placing a chair in the shower is an activity performed in phase 1 cardiac rehabilitation. It begins with the acute illness and ends with discharge from the hospital. Phase 1 focuses on promoting rest and allowing clients to improve their activities of daily living based on their abilities.
Phase 2 begins after discharge and continues through convalescence at home, including consultation with a social worker for long-term planning. It consists of achieving and maintaining a vital and productive life while remaining within the limits of the heart’s ability to respond to increases in activity and stress. Phase 3 refers to long-term conditioning, such as a walking program.
- The nurse is caring for a client 36 hours after coronary artery bypass grafting. Which assessment causes the nurse to terminate an activity and return the client to bed?
Incisional discomfort
HR 72 beats/min and regular
Respiratory rate 28 breaths/min
Urinary frequency
Respiratory rate 28 breaths/min
The activity should be terminated when the nurse assesses the client’s respiration rate of 28 breaths/min. This indicates activity intolerance.
Pulse 72 beats/min and regular is a normal finding. Urinary frequency may indicate infection or diuretic use, but not activity intolerance. Incisional pain with activity after surgery is anticipated. Pain medication would be available.
- The nurse in the coronary care unit is caring for a group of clients who have had a myocardial infarction. Which client will the nurse see first?
Client with third-degree heart block on the monitor
Client with dyspnea on exertion when ambulating to the bathroom
Client who refuses to take heparin or nitroglycerin
Client with normal sinus rhythm and PR interval of 0.28 second
Client with third-degree heart block on the monitor
The client with the third-degree heart block needs to be seen first. Third-degree heart block is a serious complication that indicates that a large portion of the left ventricle and conduction system are involved. This type of block usually requires pacemaker insertion.
A normal rhythm with prolonged PR interval indicates first-degree heart block, which usually does not require treatment. The client with dyspnea on exertion when ambulating to the bathroom is not at immediate risk. The client’s uncooperative behavior when refusing to take heparin or nitroglycerin may indicate fear or denial; he should be seen after emergency situations have been handled.
- The client in the cardiac care unit has had a large myocardial infarction. What assessment data indicates to the nurse the onset of left ventricular failure?
Expectoration of yellow sputum
Crackles in the lung fields
Pedal edema
Urine output of 1500 mL on the preceding day
Crackles in the lung fields
Signs and symptoms of left ventricular failure and pulmonary edema are noted by listening for crackles and identifying their locations in the lung fields.
A urine output of 1500 mL is normal. Edema is a sign of right ventricular heart failure. Yellow sputum indicates the presence of white blood cells and possible infection.
- A client undergoing coronary artery bypass grafting asks why the surgeon has chosen to use the internal mammary artery for the surgery. Which nursing response is appropriate?
“This way you will not need to have a leg incision.”
“These arteries remain open longer.”
“The surgeon has chosen this approach because of your age.”
“The surgeon prefers this approach because it is easier.”
“These arteries remain open longer.”
The correct response by the nurse is that mammary arteries remain open and patent much longer than other grafts.
Although no leg incision will be made with this approach, veins from the legs do not remain patent as long as the mammary artery graft does. Long-term patency, not ease of the procedure, is the primary concern. Age is not a determining factor in selection of these grafts.
- A client has just returned from coronary artery bypass graft surgery. Which assessment data requires immediate nursing action?
Chest tube drainage 175 mL last hour
Temperature 98.2° F (36.8° C)
Incisional pain 6 on a scale of 0-10
Serum potassium 3.9 mEq/L (3.9 mmol/L)
Chest tube drainage 175 mL last hour
The nurse needs to report chest drainage over 150 mL/hr to the surgeon. Although some bleeding is expected after surgery, 175 mL/hr is excessive. This requires immediate nursing action to notify the health care provider.
Although hypothermia is a common problem after surgery, a temperature of 98.2° F (36.8° C) is a normal finding. Serum potassium of 3.9 mEq/L (3.9 mmol/L) is a normal finding. Incisional pain of 6 on a scale of 0-10 is expected immediately after major surgery; the nurse would administer prescribed analgesics.
- The nurse is assessing a client with chest pain to evaluate whether the client is experiencing angina or myocardial infarction (MI). Which assessment is indicative of an MI?
Chest pain brought on by exertion or stress.
Substernal chest discomfort relieved by nitroglycerin or rest
Substernal chest pressure relieved only by opioids
Substernal chest discomfort occurring at rest.
Substernal chest pressure relieved only by opioids
Substernal chest pressure relieved only by opioids is typically indicative of MI.
Substernal chest discomfort that occurs at rest is not necessarily indicative of MI, and it could be a sign of unstable angina. Both chest pain brought on by exertion or stress and substernal chest discomfort relieved by nitroglycerin or rest are indicative of angina.
- A client comes to the emergency department with chest discomfort. Which action does the nurse perform first?
Administers oxygen therapy.
Provides pain relief medication.
Remains calm and stays with the client.
Obtains the client’s description of the chest discomfort.
Obtains the client’s description of the chest discomfort.
A description of the chest discomfort must be obtained first, before further action can be taken.
Neither oxygen therapy nor pain medication is the first priority in this situation. An assessment is needed first. Remaining calm and staying with the client are important but are not matters of highest priority.
- The nurse is caring for a client who is scheduled for a percutaneous transluminal angioplasty (PTCA). Which client statement indicates a need for further teaching?
“I will be awake during this procedure.”
“I must lie still after the procedure.”
“My angina will be gone for good.”
“I will have a balloon in my artery to widen it.”
“My angina will be gone for good.”
In this situation, further teaching is needed when the client states that angina will be gone after the PTCA. The client’s angina may not be eliminated. Reocclusion is possible after PTCA.
The client is typically awake, but drowsy, during this procedure. PTCA uses a balloon to widen the artery, and the client will have to lie still after the procedure because of the large-bore venous access.
- After receiving change-of-shift report in the coronary care unit, which client will the nurse assess first?
The client who had a percutaneous coronary angioplasty who has a dose of heparin scheduled.
A client who has first-degree heart block, rate 68 beats/min, after having an inferior myocardial infarction.
The client who had bradycardia after a myocardial infarction and now has a paced heart rate of 64 beats/min.
The client with acute coronary syndrome who has a 3-lb (1.4-kg) weight gain and dyspnea.
The client with acute coronary syndrome who has a 3-lb (1.4-kg) weight gain and dyspnea.
The nurse needs to first assess the client with acute coronary syndrome with dyspnea and weight gain. These are symptoms of left ventricular failure and pulmonary edema. This client needs prompt intervention.
A scheduled heparin dose does not take priority over dyspnea; it can be administered after the client with dyspnea is taken care of. The client with a pacemaker and a normal heart rate is not in danger. First-degree heart block is rarely symptomatic, and the client has a normal heart rate.
- Which atypical symptoms may be present in a female client experiencing myocardial infarction (MI)? (Select all that apply.) Select all that apply.
Sharp, inspiratory chest pain
Dyspnea
Extreme fatigue
Dizziness
Anorexia
Dyspnea
Extreme fatigue
Dizziness
Many women who experience an MI present with dyspnea, light-headedness and dizziness, and fatigue.
Sharp, pleuritic pain is more consistent with pericarditis or pulmonary embolism. Anorexia is neither a typical nor an atypical sign of MI.
- Which assessment data cause the nurse to suspect that a client who had a myocardial infarction (MI) is developing cardiogenic shock?
Select all that apply.
Cool, diaphoretic skin
Crackles in the lung fields
Anxiety and restlessness
Respiratory rate of 12 breaths/min
Temperature of 100.4° F (38.0° C)
Bradycardia
Cool, diaphoretic skin
Crackles in the lung fields
Anxiety and restlessness
The client with shock has cool, moist skin. Because of extensive tissue necrosis, the left ventricle cannot forward blood adequately, resulting in pulmonary congestion and crackles in the lung fields due to poor tissue perfusion. A change in mental status, anxiety, and restlessness are also expected.
All types of shock (except neurogenic) present with tachycardia, not bradycardia. Due to pulmonary congestion, a client with cardiogenic shock typically has tachypnea. A respiratory rate of 12 breaths/min is within normal limits. Cardiogenic shock does not present with low-grade fever. Fever would be more likely to occur in pericarditis.
The nurse is teaching a class on the management of sepsis. What teaching will the nurse include regarding the Hour-1 sepsis management bundle? Select all that apply.
Measure fibrinogen levels.
Measure lactate levels.
Initiate insulin therapy according to blood glucose levels.
Administer broad-spectrum antibiotics.
Begin rapid administration of crystalloids for hypotension.
A bundle is a group of two or more interventions that has been shown to be effective when applied in a sequence.
A care bundle is a group of two or more interventions that have been shown to be effective when applied in a timely sequence. The following are included in the Hour-1 Sepsis bundle:
1. Measure lactate level.
2. Obtain blood cultures before administering antibiotics.
3. Administer broad-spectrum antibiotics.
4. Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.
5. Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure ≥65 mm Hg.
Which acid–base problem does the nurse expect when the ventilator of a client being mechanically ventilated is set at too high a rate of breaths per minute for 6 hours?
Acid-deficit alkalosis
Acid excess acidosis
Base excess alkalosis
Base-deficit acidosis
Acid-deficit alkalosis
A ventilator set at either too high a ventilation rate and/or at too great a tidal volume will cause the client to lose too much carbon dioxide, leading to an acid-deficit respiratory alkalosis.
- Which body system will the nurse assess first to prevent harm for a client who has severe metabolic acidosis?
Gastrointestinal system
Respiratory system
Cardiovascular system
Autonomic nervous system
Cardiovascular system
During acidosis, the body attempts to bring the pH closer to normal by moving free hydrogen ions into cells in exchange for potassium ions. This exchange can cause hyperkalemia, which alters all excitable membranes. In the heart, hyperkalemia can block electrical conduction through the heart and cause severe bradycardia and even cardiac arrest. Although all body systems are affected to some degree, the cardiovascular system must be assessed first to institute actions to prevent death.
- For which client does the nurse remain alert for the possibility of respiratory acidosis?
Client with increased urinary output
Client who is anxious and breathing rapidly
Client receiving IV normal saline bolus
Client with multiple rib fractures
Client with multiple rib fractures
A client with multiple rib fractures may have poor gas exchange from shallow breathing because of pain and because the rib fractures may inhibit adequate chest expansion. A client who is anxious and breathing rapidly is at risk for respiratory alkalosis, not acidosis. A normal saline bolus does not result in respiratory acidosis. An increased urinary output would not be a stimulus for a respiratory acid–base imbalance.
Which mechanism will the nurse consider the most likely cause of pure acute respiratory acidosis in a client who has bilateral pneumonia?
A) Underelimination of bicarbonate ions
B) Underproduction of hydrogen ions
C) Overelimination of bicarbonate ions
D) Overelimination of hydrogen ions
E) Overproduction of hydrogen ions
F) Underelimination of hydrogen ions
G) Underproduction of bicarbonate ions
H) Overproduction of bicarbonate ions
E) Overproduction of hydrogen ions
Unlike metabolic acidosis, respiratory acidosis results from only one cause—retention of CO2, causing overproduction of free hydrogen ions. Bicarbonate is not involved as a cause or as a compensatory mechanism. Recall that carbon dioxide and hydrogen ions are directly related in human physiology. An increase in one always causes an increase in the other. Retention of CO2 is the problem, not failure of the body to directly eliminate hydrogen ions.
Which conditions could cause a client to develop acidosis?
Select all that apply.
A) Ventilator at too low a tidal volume
B) Sepsis
C) Severe diarrhea
D) Hypovolemic shock
E) Prolonged nasogastric suctioning
F) Hyperventilation
A) Ventilator at too low a tidal volume
B) Sepsis
C) Severe diarrhea
D) Hypovolemic shock
Sepsis and hypovolemic shock result in anaerobic metabolism and increased production of carbon dioxide, lactic acid, and free hydrogen ions. When a ventilator is set at too low of a tidal volume for the client’s size, hypoventilation occurs with poor gas exchange and retained carbon dioxide. Severe diarrhea causes excess loss of bicarbonate ions in the stool, resulting in a base-deficit metabolic acidosis. Hyperventilation can result in respiratory alkalosis, not acidosis. Prolonged nasogastric suctioning results in a loss of hydrochloric acid and leads to an acid-deficit metabolic alkalosis.
For which signs and symptoms will the nurse assess in a client who has acute respiratory acidosis with a PaCO2 level of 88 mm Hg? (Select all that apply.)
Select all that apply.
A) Hyperactive deep tendon reflexes
B) Acute confusion
C) Lethargy
D) Hypotension
E) pH 7.49
F) Tall T-waves
B) Acute confusion
C) Lethargy
D) Hypotension
F) Tall T-waves
When caring for a client with acute respiratory failure and respiratory acidosis, the nurse would assess for lethargy, hypotension, and fatigue. Clients with acidosis have problems associated with decreased excitable tissues, including hypotension and decreased perfusion, impaired memory and cognition, increased risk for falls, and reduced neuromuscular responses (not hyperactive deep tendon reflexes). The pH will be below 7.35, which is a characteristic of acidosis. Acute confusion occurs because of reduced gas exchange and reduced cognition.
- The nurse is caring for a postoperative client at risk for hypovolemic shock. Which assessment indicates an early sign of shock?
First-degree heart block
Blood pressure 100/48 mm Hg
Respiratory rate 12 breaths/min
Heart rate 120 beats/min
Heart rate 120 beats/min
Tachycardia is an early symptom of shock. Heart and respiratory rates increased from the client’s baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal (not hypotensive). Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart.
Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal and not abnormally low. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock and are related to lack of oxygen to the heart.
- Which client demonstrates the highest risk for hypovolemic shock?
Client receiving a blood transfusion
Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion
Client with myocardial infarction
Client with severe ascites
Client with severe ascites
A client with severe ascites best demonstrates the problem with the highest risk for hypovolemic shock. Fluid shifts from vascular to intra-abdominal may cause decreased circulating blood volume and poor tissue perfusion.
The client receiving a blood transfusion does not have as high a risk as the client with severe ascites. Myocardial infarction results in tissue necrosis in the heart muscle, but no blood or fluid losses occur. Owing to excess antidiuretic hormone secretion, the client with SIADH will retain fluid and therefore is not at risk for hypovolemic shock.
- The nurse is caring for a client in the refractory stage shock. Which intervention does the nurse consider?
Enrollment in a cardiac transplantation program
Admission to rehabilitation hospital for ambulatory retraining
Collaboration with home care agency for return to home
Discussion with family and provider regarding palliative care
Discussion with family and provider regarding palliative care
When caring for a client in the refractory stage of shock, the nurse considers discussing palliative care with the family and provider. In this irreversible phase, therapy is not effective in saving the client’s life, even if the cause of shock is corrected and mean arterial pressure temporarily returns to normal. A discussion on palliative care would be considered.
Rehabilitation or returning home is unlikely. The client with sustained tissue hypoxia is not a candidate for organ transplantation.
- Which client has a risk for hypovolemic shock?
A client with esophageal varices
A client with kidney failure
A client with arthritis taking daily acetaminophen
A client with pain from a kidney stone
A client with esophageal varices
The client with esophageal varices is at risk for hypovolemic shock. Esophageal varices are caused by portal hypertension where the portal vessels are under high pressure. With this high pressure, the portal vessels are prone to rupture, causing massive upper gastrointestinal tract bleeding and hypovolemic shock.
As the kidneys fail, fluid is typically retained, causing fluid volume excess, not hypovolemia. Arthritis and daily acetaminophen use do not cause GI bleeding and hypovolemia. Nonsteroidal anti-inflammatory drugs such as naproxen and ibuprofen may predispose the client to gastrointestinal (GI) bleeding and hypovolemia. Although a kidney stone may cause hematuria, massive blood loss or hypovolemia generally does not occur.
- Which problem places a client at highest risk for sepsis?
Client owns an iguana
Pericarditis
Post kidney transplant
Pernicious anemia
Post kidney transplant
A client with post kidney transplant is the highest risk for sepsis. This client will need to take lifelong immune suppressant therapy and is at risk for infection from internal and external organisms.
Pernicious anemia is related to lack of vitamin B12, not to bone marrow failure (aplastic anemia), which would place the client at risk for infection. Inflammation of the pericardial sac is an inflammatory condition that does not pose a risk for septic shock. Although owning pets, especially cats and reptiles, poses a risk for infection, the immune-suppressed kidney transplant client has a greater risk for infection, sepsis, and death.
- How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present?
Lactate 81 mg/dL (9.0 mmol/L)
Partial thromboplastin time 64 seconds
Potassium 2.8 mEq/L (2.8 mmol/L)
PaCO2 58 mm Hg
Lactate 81 mg/dL (9.0 mmol/L)
The client with septic shock and a lactate level of 81 mg/dL (0.9 mmoL/L) indicates that severe tissue hypoxia is present. Poor tissue oxygenation at the cellular level causes anaerobic metabolism, with the by-product of lactic acid.
Elevated partial pressure of carbon dioxide occurs with hypoventilation, which may be related to respiratory muscle fatigue, secretions, and causes other than hypoxia. Coagulation times reflect the ability of the blood to clot, not oxygenation at the cellular level. Elevation in potassium appears in septic shock due to acidosis, but this value is decreased and is not consistent with septic shock.
- The assistive personnel (AP) is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22 breaths/min. What is the appropriate nursing action?
Compare these vital signs with the last several readings.
Increase the rate of intravenous fluids.
Request that the surgeon see the client.
Reassess vital signs using different equipment.
Compare these vital signs with the last several readings.
The nurse will take the vital sign trends into consideration. A BP of 90/60 mm Hg may be normal for this client.
Calling the surgeon is not necessary at this point, and increasing IV fluids is not indicated. The same equipment must be used when vital signs are taken postoperatively.
- The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action will the nurse take first?
Take the client’s vital signs.
Ensure that blood cultures were drawn.
Insert an intravenous line.
Administer the antibiotic.
Ensure that blood cultures were drawn.
The nurse’s first action when planning to administer an antibiotic to a newly admitted patent in septic shock is to ensure that blood cultures were drawn. Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered. Antibiotics are not administered until after all cultures are taken.
An intravenous line will be needed, but the nurse must ensure that blood cultures have been drawn. Monitoring the client’s vital signs is important, but the antibiotic must be administered within 1 hour of shock recognition.
- Which nurse would be assigned to care for a client who is intubated with septic shock due to a methicillin-resistant Staphylococcus aureus (MRSA) infection?
The RN who will also be caring for a client who had coronary artery bypass graft (CABG) surgery 12 hours ago.
The RN with 2 years of experience in intensive care unit (ICU).
The LPN/LVN who has 20 years of experience.
The new RN who recently finished orienting and is working independently with moderately complex clients.
The RN with 2 years of experience in intensive care unit (ICU).
The RN with 2 years ICU experience would be assigned to care for an intubated client with septic shock due to a MRSA infection. This RN with current intensive care experience who is not caring for a postoperative client is an appropriate nurse to care for this client.
Care of the unstable client with intubation and mechanical ventilation is not within the scope of practice for the LPN/LVN. A client who is experiencing septic shock is too complex for the new RN. Although the RN who is also caring for the post-CABG client is experienced, this assignment will put the post-CABG client at risk for MRSA infection.
- A postoperative client is admitted to the intensive care unit (ICU) with hypovolemic shock. Which nursing action will the nurse delegate to an experienced assistive personnel (AP)?
Assess level of alertness.
Obtain vital signs every 15 minutes.
Measure hourly urine output.
Check oxygen saturation.
Measure hourly urine output.
The nurse delegates to an experienced ICU AP the measurement of hourly urine output for a client with hypovolemic shock. Monitoring hourly urine output is included in nursing assistant education and does not require special clinical judgment. The nurse will evaluate the results.
Obtaining vital signs, monitoring oxygen saturation, and assessing mental status in critically ill clients requires the clinical judgment of the critical care nurse because immediate intervention may be needed.
- When caring for a client who is obtunded and admitted with shock of unknown origin, which action will the nurse take first?
Obtain IV access and hang prescribed fluid infusions.
Assess level of consciousness and pupil reaction to light.
Apply the automatic blood pressure cuff.
Check the airway and respiratory status.
Check the airway and respiratory status.
The nurse’s first action when caring for an obtunded client admitted with shock is to check the client’s airway and respiratory status. When caring for any client, determining airway and respiratory status is the priority.
The airway takes priority over obtaining IV access, applying the blood pressure cuff, and assessing for changes in the client’s mental status.
- Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated?
Reduced urinary output and increased respiratory rate
Low-grade fever and mild hypotension
Low oxygen saturation rate and decreased cognition
Localized erythema and edema
Low-grade fever and mild hypotension
Low-grade fever and mild hypotension in a postoperative client can indicate very early sepsis. With treatment, the probability of recovery is high.
Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate severe sepsis. Reduced urinary output and increased respiratory rate indicate active (not early) sepsis.
- A client is exhibiting signs and symptoms of early shock. Which nursing actions support the psychosocial integrity of the client?
Select all that apply.
A) Ask family members to stay with the client.
B) Increase IV and oxygen rates.
C) Call the health care provider.
D) Remain with the client.
E) Reassure the client that everything is being done for him or her.
A) Ask family members to stay with the client.
D) Remain with the client.
E) Reassure the client that everything is being done for him or her.
To support the psychosocial integrity of a client in early shock, the nurse would have a familiar person nearby to comfort the client. The nurse would also remain with the client and offer genuine support to reassure the client that everything is being done for her.
The health care provider would be notified, and increasing IV and oxygen rates may be needed, but these actions do not support the client’s psychosocial integrity.
- The nurse is teaching a class on the management of sepsis. What teaching will the nurse include regarding the Hour-1 sepsis management bundle?
Select all that apply.
A) Measure fibrinogen levels.
B) Measure lactate levels.
C) Initiate insulin therapy according to blood glucose levels.
D) Administer broad-spectrum antibiotics.
E) Begin rapid administration of crystalloids for hypotension.
F) A bundle is a group of two or more interventions that has been shown to be effective when applied in a sequence.
B) Measure lactate levels.
D) Administer broad-spectrum antibiotics.
E) Begin rapid administration of crystalloids for hypotension.
F) A bundle is a group of two or more interventions that has been shown to be effective when applied in a sequence.
A care bundle is a group of two or more interventions that have been shown to be effective when applied in a timely sequence. The following are included in the Hour-1 Sepsis bundle:
1. Measure lactate level.
2. Obtain blood cultures before administering antibiotics.
3. Administer broad-spectrum antibiotics.
4. Begin rapid administration of 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.
5. Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure ≥65 mm Hg.
- Based on the assessment data, which client will the nurse identify as having a higher risk for developing sepsis and septic shock? Select all that apply.
A) A 40-year-old female with a history of a double lung transplant 4 years ago.
B) A 41-year-old male client with a closed fracture of the femur.
C) A 44-year-old female client with a history of anxiety and infertility.
D) A 38-year-old male with HIV who has a low viral load.
E) A 54-year-old female with breast cancer who is receiving chemotherapy.
F) A 44-year-old male client who has a history of alcoholism and diabetes mellitus.
G) An 86-year-old male with acute onset confusion.
A) A 40-year-old female with a history of a double lung transplant 4 years ago.
D) A 38-year-old male with HIV who has a low viral load.
E) A 54-year-old female with breast cancer who is receiving chemotherapy.
F) A 44-year-old male client who has a history of alcoholism and diabetes mellitus.
G) An 86-year-old male with acute onset confusion.
While any person can develop sepsis, there are certain conditions that predispose clients to sepsis and septic shock. The 54-year-old female is at higher risk due to cancer and chemotherapy. The 86-year-old male is higher risk due to an age above 80 years. The 44 year old has a higher risk due to alcoholism and diabetes. The 38 year old has an increased risk due to immunosuppression and HIV. The 40 year old is at higher risk due to immunosuppression and transplant status. A closed fracture does not increase risk, nor does anxiety and infertility.
- A client in the progressive stage of hypovolemic shock has all of the following signs, symptoms, or changes. Which signs will the nurse attribute to ongoing compensatory mechanisms? Select all that apply.
A. Increasing pallor
B. Increasing thirst
C. Increasing confusion
D. Increasing heart rate
E. Increasing respiratory rate
F. Decreasing systolic blood pressure
G. Decreasing blood pH
H. Decreasing urine output
A. Increasing pallor
B. Increasing thirst
D. Increasing heart rate
E. Increasing respiratory rate
H. Decreasing urine output
Compensatory mechanisms attempt to maintain perfusion and gas exchange to vital organs. Thus these mechanisms shunt blood away from less vital organs and try to prevent further volume losses. The increasing pallor occurs because blood is shunted away from skin and mucous membranes to the heart, brain, liver, and lungs. Increasing thirst and decreasing urine output help to increase blood volume by stimulating the patient to drink and by preventing fluid loss through the urine. Increasing heart rate and respiratory rate work to maintain gas exchange to those selected organs that continue to be perfused. Increasing confusion indicates the compensatory mechanisms are failing and that the brain is not being adequately perfused. Decreasing systolic blood pressure also is an indication of worsening shock. Decreasing blood pH is not a compensatory action; it is an indication of inadequate gas exchange.
- The nurse is reviewing the laboratory profile of a client with hypovolemic shock. What lab values will the nurse anticipate?
A. pH 7.51
B. PaO2 106 mmHg
C. PaCO2 49 mmHg
D. Lactate 0.4 mmol/L
C. PaCO2 49 mmHg
The client with hypovolemic shock is most likely experiencing anerobic cellular metabolism. As such, the nurse will anticipate decreased pH, decreased PaO2, increased PaCO2, and increased lactate levels.
The nurse is caring for a client with hypovolemic shock that is bleeding from a traumatic injury to the upper chest wall. What is the priority nursing action?
A. Insert a large bore IV catheter.
B. Administer supplemental oxygen.
C. Elevate the client’s feet, keeping the head flat.
D. Apply direct pressure to the area of overt bleeding.
D. Apply direct pressure to the area of overt bleeding.
The priority nursing action is to apply direct pressure to the area of overt bleeding. The nurse will first apply pressure then elevate the client’s feet, administer supplemental oxygen if oxygen saturations are below 92% and insert a large bore IV catheter.
The nurse is teaching a client’s family regarding the diagnosis of septic shock. Which teaching will the nurse include? Select all that apply.
A. “The blood cultures will tell us for sure if your loved one has septic shock.”
B. “The client’s change in behavior and lethargy may be associated with septic shock.”
C. “Antibiotics, as prescribed, will be started within the hour to treat the sepsis.”
D. “An insulin drip has been started to keep the client’s glucose as low as possible.”
E. “Septic shock is easily treated with multiple antibiotics.”
B. “The client’s change in behavior and lethargy may be associated with septic shock.”
C. “Antibiotics, as prescribed, will be started within the hour to treat the sepsis.”
A recent change in behavior or altered level of consciousness are often indicators of sepsis and septic shock. Part of the sepsis bundle of care is the administration of antibiotics within one hour of recognizing sepsis. The blood cultures may or may not confirm he diagnosis of septic shock. Bacteremia may not be present. Insulin therapy is used to maintain blood glucose levels between 140 mg/dL (7.7 mmol/L) and 180 mg/dL (10 mmol/L) (Stapleton & Heyland, 2018). Keeping the blood glucose level below 110 mg/dL (6.1 mmol/L) is associated with increased mortality. Septic shock is not easily treated.
- Which new assessment finding in a client being treated for hypovolemic shock indicates to the nurse that interventions are currently effective?
A. Oxygen saturation remains unchanged.
B. Core body temperature has increased to 99° F (37.2° C).
C. The client correctly states the month and year.
D. Serum lactate and serum potassium levels are declining.
D. Serum lactate and serum potassium levels are declining.
Serum lactate levels and serum potassium levels both rise when shock progresses and more tissues are metabolizing under anaerobic conditions. A decline in both values indicates that the client is responding to the current interventions for hypovolemic shock. Oxygen saturation staying the same suggests that the shock is not progressing at this time but does not indicate the interventions are correcting shock. The increase in body temperature is not great enough to indicate improvement or worsening of shock. The fact that the client can correctly state the month and the year by itself does not indicate improvement because information is not provided about his or her earlier cognition or level of consciousness.
- The nurse is caring for a patient in the initial stage of hypovolemic shock. What assessment data will the nurse anticipate?
A. Heart rate 118
B. 2+ pedal pulses
C. Bilateral fine crackles in lung bases
D. BP change from 100/60 to 100/40
A. Heart rate 118
With the initial stage of shock, an increase is heart rate is often the first indicator. Because stroke volume is decreased the pedal pulses are often difficult to palpate and easily blocked. A normal pedal pulse (2+) would not be anticipate. The nurse would not anticipate bilateral fine crackles in the lungs with hypovolemic shock. The nurse would anticipate a narrow pulse pressure change (versus a widened pulse pressure). With vasoconstriction, diastolic pressure increases, but systolic pressure remains the same. This creates a narrow pulse pressure.
- The nurse is assessing a client with septic shock. What assessment data indicates a progression of shock? Select all that apply.
A. BP change from 86/50 to 100/64
B. HR change from 98 to 76
C. Cool and clammy skin
D. Petechiae along the gum line
E. Urine output 45 ml/hr
A. BP change from 86/50 to 100/64
C. Cool and clammy skin
D. Petechiae along the gum line
As sepsis progresses, cardiac output is higher as are heart rate and blood pressure. The nurse would interpret the increasing blood pressure as an indication of worsening condition versus improvement. As sepsis progresses, circulation is compromised and presents as cool, clammy skin, with pallor and cyanosis. DIC can occur with sepsis progression causing petechiae and ecchymoses, occurring anywhere on the body. The decrease in heart rate is not associated with progression of shock (the heart rate, like the BP would increase). The urine output is within normal limits and would not indicate progression of shock.
