2514 Fall ox-circ review

For a male client with an endotracheal tube, which nursing action is most essential?

• Auscultating the lungs for bilateral breath sounds

• Turning the client from side to side every two hours

• Monitoring serial blood gas values every 4 hours

• Provide oral care every 2 hours

Which of the following is the most common clinical manifestation of pericarditis?

• Epigastric discomfort

• Night sweats

• Friction rub

• Weight gain

A nurse checks the arterial blood gas (ABG) results of an older adult and finds that the client's pH is 7.34, PaCO2 is 46mmHg and HCO3 is 27 mEq/L. What is the nurses interpretation?

• Metabolic alkalosis

• Respiratory alkalosis

• Metabolic acidosis

• Respiratory acidosis

While caring for a client with ventricular tachycardia (VT), the nurse determines the client has no pulse. Which treatment should the nurse provide for the client first?

• Administer an antiarrhythmic medication like amiodarone

• Provide electrolyte replacements

• Perform cardiopulmonary resuscitation (CPR)

• Perform a cardioversion

Answer explanation

The first line treatment that is given to a client with pulseless VT in an emergency situation is to provide CPR. Chest compressions an rescue breaths keep blood and oxygen circulating in the body

A nurse is carding for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator associated pneumonia?

• Position the head of the client's bed in the flat position

• Turn the client every 4 hours

• Brush the client's teeth with a suction toothbrush every 12 hours

• Provide humidity by maintaining moisture within the ventilator tubing

Answer explanation

The nurse should swab the clients mouth with chlorihexidine q2h and brush the client's teeth every 12 hours with antimicrobial rinse to reduce growth of bacteria

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?

• The patient is hypoxic from suctioning

• The patient is having a stress reaction

• The patient is having an MI

• The patient is in a hypermetabolic state

Answer explanation

hypoxia can induce dysrhythmias

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium (neuromuscular blocking agent). The nurse recognizes that this medication is for which of the following purposes?

• Decrease chest wall compliance

• Suppress respiratory effort

• Induce sedation

• Decrease respiratory secretions

Answer explanation

Neuromuscular blocking agents, induce paralysis and suppress the cleint's respiratory efforts to the point of apnea, allowing the mechanical ventilator to take over the work of breathing for the client. The therapy is especially helpful for a client who has ARDS and poor lung compliance. They relax skeletal muscles, there for improve chest wall compliance

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretation of a low CVP pressure should the nurse make?

• Fluid overload

• Left ventricular failure

• Intracardiac shunt

• Hypovolemia

Answer explanation

A low CVP indicates reduced right ventricular preload which can be seen in clients who are experiencing hypovolemia, excessive blood loss, or overdiuresis.

A nurse is caring for a client who has an acute respiratory failure. The nurse should monitor the client for which of the following manifestations of the condition (Select all that apply)

• Severe dyspnea

• Nausea

• Decreased level of consciousness

• Headache

• Hypotension

Answer explanation

Severe dyspnea is a manifestation of respiratory faiure as a result of hypxemia. Decreased LOC is a manifestation of respiratoyr failure due to hypercapnia. Headache is a manifestation due to hypercapnia. Hypotension is due to acidosis and hypercapnia. GI manifestations are not related to respiratory failure

A nurse in PACU is assessing a client who has an endotracheal tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

• Blockage of the ET tube by the client's tongue

• Passage of the ET tube into the esophagus

• Movement of the ET tube into the right main bronchus

• Infection of the vocal cords

Answer explanation

During intubation, the staff can misplace the ET tube in the right mainstem bronchus. The nurse should identify absence of chest wall movement or breath sounds on a single side as indication ET tube displacement, and should notify appropriate personnel to reposition the tube