LP 7 Acute Respiratory

When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse?

• The patient is somnolent

• The patient's SpO2 is 90%

• The patient complains of weakness

• The patient's blood pressure is 162/94

Which assessment finding by the nurse when caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates that the PEEP may need to be decreased?

• The patient has subcutaneous emphysema.

• The patient has a sinus bradycardia with a rate of 52.

• The patient's PaO2 is 50 mm Hg and the SaO2 is 88%.

• The patient has bronchial breath sounds in both the lung fields.

The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next?

• Administer the scheduled IV antibiotic.

• Give the PRN acetaminophen (Tylenol) 650 mg.

• Obtain oxygen saturation using pulse oximetry.

• Notify the health care provider of the patient's vital signs.

To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation?

• Avoid use of positive end-expiratory pressure (PEEP).

• Suction every 2 hours.

• Elevate head of bed to 30 to 45 degrees.

• Give enteral feedings at no more than 10 mL/hr.

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a pneumothorax. Which action will the nurse anticipate taking?

• Lower the positive end-expiratory pressure (PEEP).

• Increase the fraction of inspired oxygen (FIO2).

• Suction more frequently.

• Increase the tidal volume.

When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first?

• Check pupil reaction to light.

• Notify the health care provider.

• Attempt to calm and reassure the patient.

• Assess oxygenation using pulse oximetry.

The nurse is caring for a 22-year-old patient who came to the emergency department with acute respiratory distress. Which information about the patient requires the most rapid action by the nurse?

• Respiratory rate is 32 breaths/min.

• Pattern of breathing is shallow.

• The patient's PaO2 is 45 mm Hg.

• The patient's PaCO2 is 34 mm Hg.

The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider?

• Cough that is productive of blood-tinged sputum

• Scattered crackles throughout the posterior lung bases

• Temperature of 101.5° F (38.6° C) after 2 days of IV antibiotic therapy

• Oxygen saturation (SpO2) has dropped to 90% with administration of 100% O2 by non-rebreather mask.

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?

• Breathing so rapidly interferes with oxygenation.

• Maybe the client has respiratory distress syndrome.

• The blood clot interferes with perfusion in the lungs.

• The client needs immediate intubation and mechanical ventilation.

A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?

• Decrease the heparin rate.

• Increase the heparin rate.

• No change to the heparin rate.

• Stop heparin; start warfarin (Coumadin).