Flashcard 1

Front

The nurse is caring for a patient with a new tracheostomy. What assessment finding requires immediate action? Options: O2 sat of 96%, Patient coughing up thin, clear secretions through tracheostomy, Crackling and popping sensation around the neck, Bleeding around the tracheostomy

Back

Crackling and popping sensation around the neck

Front

The nurse is to administer vancomycin to the client diagnosed with sepsis, ARDS and is receiving mechanical ventilation. The client is to have a peak and trough level completed on this dose of vancomycin. Which action should the nurse initiate first?

Back

Determine if the trough level has already been drawn on the client.

Front

What ABG finding should the nurse most correlate to the change in assessment for a patient with COPD who is disoriented, anxious, and combative? Options: An oxygen saturation of 91%, A carbon dioxide of 32, A carbon dioxide of 62, A bicarb level of 24

Back

A carbon dioxide of 62

Front

In the nursing care of a patient recently intubated and placed on mechanical ventilation with PEEP, what nursing action would take the highest priority? Options: assessing for presence of pulses, monitoring blood pressure, obtaining temperature every 4 hours, monitoring urinary output

Back

monitoring blood pressure

Front

What action is the most appropriate to include in the plan of care for ventilator acquired pneumonia prevention in a patient with respiratory failure receiving mechanical ventilation through an ETT? Options: Administer ordered antibiotics as scheduled, Hyperoxygenate the patient before suctioning, Maintain the head of bed at a 45 degree angle & oral care, Suction the airway only when coarse crackles are audible

Back

Maintain the head of bed at a 45 degree angle & oral care

Front

You are caring for a 75-year-old patient who sustained a fall from a ladder. What assessment finding should give you the most immediate concern in this patient? Change in orientation, Hypotension, Peripheral edema, Regular heart rate and rhythm

Back

Change in orientation

Front

The patient had a right-sided chest tube inserted two hours ago for a pneumothorax. The nurse observes no tidaling. Which action should be implemented next?

Back

Check the tubing for kinks or clots

Front

The patient just received emergency intubation for respiratory distress. What should the nurse perform next?

Back

Assess for bilateral breath sounds

Front

The nurse is caring for a patient experiencing pulmonary edema. The pulmonary artery wedge pressure reading is 12 mmHg. The nurse would correctly identify the cause of pulmonary edema as:

Back

ARDS

Front

What is the priority nursing intervention for the following arterial blood gas results?
pH: 7.49
CO2: 28
PO2: 80
SpO2: 95%
HCO3: 23

Back

Encourage patient to take slow, deep breaths