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WorksheetsComplex 2
Total questions: 173
Worksheet time: 2hrs 30mins
The nurse is caring for a patient with acute respiratory failure and identifies “Risk for Ineffective Airway Clearance” as a nursing diagnosis. A nursing intervention relevant to this diagnosis is to
obtain an order for venous thromboembolism prophylaxis.
.
reposition the patient every 2 hours.
provide adequate sedation
elevate the head of the bed to 30 degrees.
The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms?
Decreasing PaO2 levels despite increased FiO2
administration
Elevated alveolar surfactant levels
Increased lung compliance with increased FiO2
administration
Respiratory acidosis associated with hyperventilation
The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration?
Hypoventilation and respiratory acidosis
Hyperventilation and respiratory acidosis
Hypoventilation and respiratory alkalosis
Respiratory acidosis and normal oxygen levels
Intrapulmonary shunting refers to
blood that is shunted from the left side of the heart to the
right and causes heart failure.
blood that is shunted from the right side of the heart to the
left without oxygenation.
alveoli that are not perfused.
shunting of blood supply to only one lung.
When fluid is present in the alveoli,
diffusion of oxygen and carbon dioxide is impaired.
hypoventilation occurs.
the patient is in heart failure.
alveoli collapse, and atelectasis occurs.
In assessing a patient, the nurse understands that an early sign of hypoxemia is
restlessness.
clubbing of nail beds.
hypotension.
cyanosis.
The basic underlying pathophysiology of acute respiratory distress syndrome results in
damage to the right mainstem bronchus.
a decrease in the number of white blood cells available.
damage to the type II pneumocytes, which produce surfactant.
decreased capillary permeability.
The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The provider prescribes a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the provider of this assessment and anticipates an order for
guided imagery.
continuous lateral rotation therapy.
neuromuscular blockade.
prone positioning.
A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation?
Mechanical ventilation via an endotracheal tube
Emergency tracheostomy and mechanical ventilation
Oxygen at 100% via bag-valve-mask device
Noninvasive positive-pressure ventilation (NPPV)
Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma?
Metabolic alkalosis
Respiratory acidosis
Metabolic acidosis
Respiratory alkalosis
An acute exacerbation of asthma is treated with which of the following?
Inhaled bronchodilators and intravenous corticosteroids
Corticosteroids and theophylline by mouth
Prone positioning or continuous lateral rotation
Sedation and inhaled bronchodilators
The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse instructs,
“If you get the pneumococcal vaccine, you’ll never get pneumonia
again.”
“It is important for you to get an annual influenza shot to
reduce your risk of pneumonia.”
“Stay away from cold, drafty places because that increases your
risk of pneumonia when you get home.”
“Since you have been treated for pneumonia, you now have
immunity from getting it in the future.”
The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the patient to prevent exacerbation by:
limiting activity until the patient is able to climb two flights
of stairs.
obtaining an appointment for follow-up pulmonary function
studies 1 week after discharge.
taking medications on a “prn” basis according to symptoms.
taking all asthma medications as prescribed.
The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia?
Bradycardia
Change in sputum characteristics
Pursed-lip breathing
Hypoventilation and respiratory acidosis
The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is
amniotic fluid embolus.
fat embolus from a long bone fracture.
vegetation that dislodges from an infected central venous
catheter.
deep vein thrombosis from lower extremities.
The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following?
Mobility
Antiseptic oral care
Coughing and deep breathing
Bed rest with head of bed elevated
Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)?
Bradycardia and hyperventilation are classic symptoms of PE.
Dyspnea, chest pain, and hemoptysis occur in nearly all patients
with PE.
PE should be suspected in any patient who has unexplained
cardiorespiratory complaints and risk factors for VTE.
Most critically ill patients are at low risk for VTE and PE and
do not require prophylaxis.
A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains to the patient:
“I’m going to contact the pharmacist to see if you can take this
medication by mouth.”
“This medication will dissolve any blood clots you might get.”
“This injection is being given to prevent blood clots from
forming.”
“You should not be receiving this medication. I will contact the
provider to get it stopped.”
A definitive diagnosis of pulmonary embolism can be made by
chest x-ray examination.
arterial blood gas (ABG) analysis.
ventilation-perfusion scanning.
pulmonary angiogram.
A strategy for preventing pulmonary embolism in patients at risk who cannot take anticoagulants is
administration of two aspirin tablets every 4 hours.
infusion of thrombolytics.
insertion of a vena cava filter.
subcutaneous heparin administration every 12 hours.
Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery?
Aspirin
Thrombolytics
Heparin
Embolectomy
The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)?
Increased oxygen saturation via pulse oximetry
Increased peak inspiratory pressure on the ventilator
PaO2/FiO2 ratio >300
Normal chest radiograph with enlarged cardiac structures
The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%).
130; meets criteria for ARDS
468; normal lung function
46.8; meets criteria for ARDS
Not enough data to compute the ratio
The nurse is assessing a patient with acute respiratory distress syndrome. An expected assessment is
PAOP of 10 mm Hg and PaO2 of 55.
PAOP of 20 mm Hg and cardiac output of 3 L/min.
PAOP of 5 mm Hg and high systemic vascular resistance.
cardiac output of 10 L/min and low systemic vascular resistance.
The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following?
Management and protection of the airway
Psychological support to patient and family
Prevention of skin breakdown and nerve damage
Prevention of gastric aspiration
During rounds, the provider alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is
an optional treatment to improve ventilation.
less of a risk for skin breakdown because the patient is face
down.
used to provide continuous lateral rotational turning.
possible with minimal help from coworkers.
The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the
left ventricle.
trachea.
mainstem bronchus.
alveolar-capillary membrane.
Identify diagnostic criteria for ARDS. (Select all that apply.)
Decreased cardiac output
Bilateral infiltrates on chest x-ray study
PAOP less than 18 mm Hg
Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg
PaO2/ FiO2 ratio of less than 200
Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.)
Implementing a comprehensive oral care program is an
intervention for preventing VAP.
Tooth brushing is performed every 2 hours for the greatest
effect.
Protocols that include chlorhexidine gluconate have been
effective in preventing VAP.
Oral care protocols should include oral suctioning and brushing
teeth.
Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.)
Opens collapsed alveoli
Improves arterial oxygenation
Increases functional residual capacity
Prevents collapse of unstable alveoli
Which of the following are components of the Institute for Healthcare Improvement’s (IHI’s) ventilator bundle? (Select all that apply.)
Interrupt sedation each day to assess readiness to extubate.
Provide prophylaxis for peptic ulcer disease.
Maintain head of bed at least 30 degrees of elevation.
Provide deep vein thrombosis prophylaxis.
Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.)
Graduated compression stockings
Heparin or low–molecular weight heparin for patients at risk
Sequential compression devices
Strict bed rest
The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.)
Drain condensate from the ventilator tubing away from the
patient.
Elevate the head of the bed 30 to 45 degrees.
Instill normal saline as part of the suctioning procedure.
Perform regular oral care with chlorhexidine.
The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.)
high Fowler’s.
sitting in a chair.
side lying with head of bed elevated.
supine with the bed flat.
The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.)
Airway clearance therapies
Antibiotic therapy
Lung transplant
Nutritional support
Tracheostomy
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?
Oral fluid intake is 100 mL for the past 8 hours.
Urine output is 30 mL/hr.
Blood pressure is 90/40 mm Hg.
There is prolonged skin tenting over the sternum.
A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?
Serum hematocrit of 42%
Reported weight gain of 2.2 lb (1 kg)
Serum sodium level of 120 mg/dL
Urinary output of 280 mL during past 8 hours
A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
Skin turgor
Urine output
Edema presence
Daily weight
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?
“Drink more fluids in the late evening.”
“Increase fluids if your mouth feels dry.”
“More fluids are needed if you feel thirsty.”
“If you feel confused, you need more to drink.”
A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. Which action is appropriate for the nurse to take?
Assess for facial muscle spasms.
Suggest that the health care provider order a basic metabolic
panel.
Recommend the patient avoid drinking orange juice with meals.
Ask the patient about loose stools.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?
“I will try to drink at least 8 glasses of water every day.”
“I will use a salt substitute to decrease my sodium intake.”
“I will increase my intake of potassium-containing foods.”
“I will drink apple juice instead of orange juice for
breakfast.”
A patient with new-onset confusion and hyponatremia is being admitted. When making room assignments, the charge nurse should take which action?
Assign the patient to a room near the nurse’s station.
Assign the patient to a semi-private room.
Place the patient on telemetry to monitor for peaked T waves..
Place the patient in a room nearest to the water fountain.
IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?
Administer the KCl as a rapid IV bolus.
Infuse the KCl at a rate of 10 mEq/hour.
Discontinue cardiac monitoring during the infusion.
Only give the KCl through a central venous line.
A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question?
Infuse 5% dextrose in water at 125 mL/hr.
.
Administer 3% saline at 50 mL/hr for a total of 200 mL
Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for
nausea.
Administer IV morphine sulfate 4 mg every 2 hours PRN.
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
Respiratory alkalosis
Respiratory acidosis
The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take?
Give the prescribed PRN lorazepam (Ativan).
Administer the prescribed normal saline bolus and insulin.
Start the prescribed PRN oxygen at 2 to 4 L/min.
Encourage the patient to take deep slow breaths.
An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?
Edema
Pallor
A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?
Urinary output
Lung sounds
The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient’s condition has improved?
Decreased peripheral edema
Blood pressure 110/72 mm Hg
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?
Metabolic alkalosis
Metabolic acidosis
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication?
Metoprolol (Lopressor) 12.5 mg/day
Digoxin (Lanoxin) 0.25 mg/day
Lantus insulin 24 U subcutaneously every evening
Ibuprofen (Motrin) 400 mg every 6 hours
The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
Maintain the patient on bed rest.
Auscultate lung sounds every 4 hours.
Encourage fluid intake up to 4000 mL every day.
Monitor for Trousseau’s and Chvostek’s signs.
When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient’s food tray?
Grape juice
Skim milk
A patient has a magnesium level of 1.3 mg/dL. Which assessment would help the nurse identify a likely cause of this value?
Daily alcohol intake
Multivitamin/mineral use
Dietary protein intake
Over-the-counter (OTC) laxative use
A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is accurate?
“The prescribed infusion can be given more rapidly when the
patient has a central line.”
“There is a decreased risk for infection when 25% dextrose is
infused through a central line.”
“The hypertonic solution will be more rapidly diluted when given
through a central line.”
“The required blood glucose monitoring is based on samples
obtained from a central line.”
The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?
Avoid using friction when cleaning around the CVAD insertion
site.
Use the push-pause method to flush the CVAD after giving medications.
Position the patient’s face toward the CVAD during injection cap
changes.
Obtain an order from the health care provider to change CVAD
dressing.
An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
Na+ 154 mEq/L (154 mmol/L)
PO4-3 4.8 mg/dL (1.55 mmol/L)
The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?
Oral temperature of 100.1°F
Gradually decreasing level of consciousness (LOC)
Serum sodium level of 138 mEq/L (138 mmol/L)
Weight gain of 2 pounds (1 kg) over the admission weight
A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient has peripheral edema and shortness of breath. Which assessment should the nurse complete first?
Capillary refill
Mental status
A patient with renal failure who arrives for outpatient hemodialysis is unresponsive to questions and has decreased deep tendon reflexes. Family members report that the patient has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. Which action should the nurse take first?
Notify the patient’s health care provider.
Obtain an order to draw a potassium level.
Review the last magnesium level on the patient’s chart.
Teach the patient about magnesium-containing antacids.
A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction. The patient complains of anxiety and incisional pain. The patient’s respiratory rate is 32 breaths/min, and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?
Check to make sure the nasogastric tube is patent.
Give the patient the PRN IV morphine sulfate 4 mg.
Teach the patient how to take slow, deep breaths when anxious.
Notify the health care provider about the ABG results.
Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/LVN)?
Flush a saline lock with normal saline.
Verify blood products prior to administration.
Remove the patient’s central venous catheter.
Titrate the flow rate of vasoactive IV medications.
A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?
The patient complains of generalized fatigue.
The patient is experiencing laryngeal stridor.
The patient has numbness and tingling of the lips.
The patient’s bowels have not moved for 4 days.
Following a thyroidectomy, a patient complains of “a tingling feeling around my mouth.” Which assessment should the nurse complete?
Abnormal serum potassium level
Decreased thyroid hormone level
Presence of the Chvostek’s sign
Bleeding on the patient’s dressing
A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?
Arterial blood pH is 7.32.
Serum potassium is 5.1 mEq/L.
Arterial oxygen saturation is 91%.
Serum calcium is 18 mg/dL.
When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?
The patellar and triceps reflexes are absent.
The bibasilar breath sounds are decreased.
The patient reports feeling “sick to my stomach.”
The patient has been sleeping most of the day.
A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?
There are crackles throughout both lung fields.
The patient’s radial pulse is 105 beats/min.
There is sediment and blood in the patient’s urine.
The blood pressure increases from 120/80 to 142/94 mm Hg.
The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next?
Give oral calcium citrate tablets.
Check parathyroid hormone level.
Administer vitamin D supplements.
Monitor ionized calcium level.
A patient comes to the clinic complaining of frequent, watery stools for the past 2 days. Which action should the nurse take first?
Check the patient’s blood pressure.
Obtain the baseline weight.
Draw blood for serum electrolyte levels.
Ask about extremity numbness or tingling.
Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?
Offer reassurance to the patient.
Notify the health care provider.
Auscultate the patient’s breath sounds.
Give prescribed PRN morphine sulfate IV.
After receiving change-of-shift report, which patient should the nurse assess first?
Patient with serum potassium level of 5.0 mEq/L who is
complaining of abdominal cramping
Patient with serum magnesium level of 1.1 mEq/L who has tremors
and hyperactive deep tendon reflexes
Patient with serum phosphorus level of 4.5 mg/dL who has
multiple soft tissue calcium-phosphate precipitates
Patient with serum sodium level of 145 mEq/L who has a dry mouth
and is asking for a glass of water
During the admission process, the nurse obtains information about a patient through a physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate?
Risk for impaired skin integrity
Risk for injury: seizures
The nurse teaches a patient about discharge instructions after a rhinoplasty. Which statement, if made by the patient, indicates that the teaching was successful?
“My nose will look normal after 24 to 48 hours.”
“I will elevate my head for 48 hours to minimize swelling.”
“I will remove and reapply the nasal packing every day.”
“I can take 800 mg ibuprofen every 6 hours for pain.”
The nurse plans to teach a patient how to manage allergic rhinitis. Which information should the nurse include in the teaching plan?
Using oral antihistamines for 2 weeks before the allergy season
may prevent reactions.
Identifying and avoiding environmental triggers are the best way
to prevent symptoms.
Corticosteroid nasal sprays will reduce inflammation, but
systemic effects limit their use.
Frequent hand washing is the primary way to prevent spreading
the condition to others.
The nurse discusses management of upper respiratory infections (URIs) with a patient who has acute sinusitis. Which statement by the patient indicates that additional teaching is needed?
“I will drink lots of juices and other fluids to stay well
hydrated.”
“I can use nasal decongestant spray until the congestion is
gone.”
“I will watch for changes in nasal secretions or the sputum that
I cough up.”
“I can take acetaminophen (Tylenol) to treat my sinus
discomfort.”
The nurse has just auscultated coarse crackles bilaterally on a patient with a tracheostomy tube in place. If the patient is unsuccessful in coughing up secretions, what action should the nurse take?
Encourage increased incentive spirometer use.
Put on sterile gloves and use a sterile catheter to suction.
Preoxygenate the patient for 3 minutes before suctioning.
Encourage the patient to increase oral fluid intake.
A patient with a tracheostomy has a new order for a fenestrated tracheostomy tube. Which action should the nurse include in the plan of care in collaboration with the speech therapist?
Leave the tracheostomy inner cannula inserted at all times.
Assess the ability to swallow before using the fenestrated tube.
Inflate the tracheostomy cuff during use of the fenestrated
tube.
Place the decannulation cap in the tube before cuff deflation.
The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would determine if the cuff has been properly inflated?
Use a hand-held manometer to measure cuff pressure.
Review the health record for the prescribed cuff pressure.
Insert the decannulation plug before removing the nonfenestrated
inner cannula.
Suction the patient through a fenestrated inner cannula to clear
secretions.
Which statement by the patient indicates that teaching has been effective for a patient scheduled for radiation therapy of the larynx?
“I will need to buy a water bottle to carry with me.”
“I should not use any lotions on my neck and throat.”
“Until the radiation is complete, I may have diarrhea.”
“Alcohol-based mouthwashes will help clean my mouth.”
A nurse obtains a health history from a patient who has a 35 pack-year smoking history. The patient complains of hoarseness and tightness in the throat and difficulty swallowing. Which question is important for the nurse to ask?
“Do you have a family history of head or neck cancer?”
“How much alcohol do you drink in an average week?”
“Do you use antihistamines for upper airway congestion?”
“Have you had frequent streptococcal throat infections?”
A patient scheduled for a total laryngectomy and radical neck dissection for cancer of the larynx asks the nurse, “Will I be able to talk normally after surgery?” What is the most accurate response by the nurse?
“You won’t be able to talk right after surgery, but you will be
able to speak again after the tracheostomy tube is removed.”
“You will breathe through a permanent opening in your neck, but
you will not be able to communicate orally.”
“You won’t be able to speak as you used to, but there are
artificial voice devices that will give you the ability to speak normally.”
“You will have a permanent opening into your neck, and you will
need rehabilitation for some type of voice restoration.”
A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse indicates that this identified problem is resolving?
The patient allows the nurse to suction the tracheostomy.
The patient asks how to clean the tracheostomy stoma and tube.
The patient uses a communication board to request “No Visitors.”
The patient’s spouse provides the daily tracheostomy care.
The nurse completes discharge instructions for a patient with a total laryngectomy. Which statement by the patient indicates that additional instruction is needed?
“I must keep the stoma covered with an occlusive dressing.”
“I can participate in my prior fitness activities except
swimming.”
“I need to have smoke and carbon monoxide detectors installed.”
“I should wear a Medic-Alert bracelet to identify me as a neck
breather.”
Which action should the nurse take first when a patient develops epistaxis?
Pack the affected nare tightly with an epistaxis balloon.
Obtain silver nitrate that may be needed for cauterization.
Instill a vasoconstrictor medication into the affected nare.
Apply squeezing pressure to the nostrils for 10 minutes.
A nurse is caring for a patient who has had a total laryngectomy and radical neck dissection. During the first 24 hours after surgery what is the priority nursing action?
Keep the patient in semi-Fowler’s position.
Monitor the incision for bleeding.
Teach the patient to suction the tracheostomy.
Maintain adequate IV fluid intake.
After a laryngectomy, a patient coughs violently during suctioning and dislodges the tracheostomy tube. Which action should the nurse take first?
Cover stoma with sterile gauze and ventilate through stoma.
Arrange for arterial blood gases to be drawn immediately.
Attempt to reinsert the tracheostomy tube with the obturator in
place.
Assess the patient’s oxygen saturation and notify the health
care provider.
Which patient in the ear, nose, and throat (ENT) clinic should the nurse assess first?
A patient who is complaining of a sore throat and has a muffled
voice
A patient who is receiving radiation for throat cancer and has
severe fatigue
A patient with a history of a total laryngectomy whose stoma is
red and inflamed
A patient who has a “scratchy throat” and a positive rapid strep
antigen test
The nurse obtains the following assessment data on an older patient who has influenza. Which information will be most important for the nurse to communicate to the health care provider?
Myalgia and persistent headache
Fever of 100.4° F (38° C)
Sore throat and frequent cough
Diffuse crackles in the lungs
Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy?
Suction the tracheostomy when directed.
Assess the patient’s risk for aspiration.
Teach the patient to provide tracheostomy self-care.
Determine the need for tracheostomy tube replacement.
The nurse is caring for a hospitalized older patient who has nasal packing in place after a nosebleed. Which assessment finding will require the most immediate action by the nurse?
The nose appears red and swollen.
The patient reports level 8 (0 to 10 scale) pain.
The patient’s temperature is 100.1° F (37.8° C).
The oxygen saturation is 89%.
After being hit by a baseball, a patient arrives in the emergency department with a possible nasal fracture. Which finding by the nurse is most important to report to the health care provider?
Complaint of nasal pain
Clear nasal drainage
Inability to breathe through the nose
Bilateral nose swelling and bruising
A patient arrives in the ear, nose, and throat clinic complaining of a piece of tissue being “stuck up my nose” and with foul-smelling nasal drainage from the right nare. Which action should the nurse take first?
Notify the clinic health care provider.
Ask the patient about how the cotton got into the nose.
Obtain aerobic culture specimens of the drainage.
Have the patient occlude the left nare and blow the nose.
The nurse is caring for a patient who has acute pharyngitis caused by Candida albicans. Which action is appropriate for the nurse to include in the plan of care?
Assess patient for allergies to penicillin antibiotics.
Teach patient to “swish and swallow” prescribed oral nystatin
Avoid giving the patient warm food or warm liquids to drink.
Teach the patient to sleep in a warm, dry environment.
When assessing a patient with a sore throat, the nurse notes anterior cervical lymph node swelling, a temperature of 101.6° F (38.7° C), and yellow patches on the tonsils. Which action will the nurse anticipate taking?
Use a swab to obtain a sample for a rapid strep antigen test.
Teach the patient about the use of expectorants.
Teach the patient to avoid nonsteroidal antiinflammatory drugs
(NSAIDs).
Discuss the need to rinse the mouth out after using any
inhalers.
The clinic nurse is teaching a patient with acute sinusitis. Which interventions should the nurse plan to include in the teaching session (select all that apply)?
Taking a hot shower will increase sinus drainage and decrease
pain.
Decongestants can be used to relieve swelling.
You will be more comfortable if you keep your head in an upright
position.
Saline nasal spray can be made at home and used to wash out
secretions.
Blowing the nose should be avoided to decrease the nosebleed
risk.
The nurse is reviewing the medical records for five patients who are scheduled for their yearly physical examinations in September. Which patients should receive the inactivated influenza vaccination (select all that apply)?
A 76-yr-old nursing home resident
A 36-yr-old female patient who is pregnant
A 42-yr-old patient who has a 15 pack-year smoking history
A 30-yr-old patient who takes corticosteroids for rheumatoid
arthritis
A 24-yr-old patient who has allergies to penicillin and
cephalosporins
After assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?
Respiratory rate of 28 breaths/minute
Weak cough effort
Resting pulse oximetry (SpO2) of 85%
Profuse green sputum
The nurse assesses the chest of a patient with pneumococcal pneumonia. Which finding would the nurse expect?
Dry, nonproductive cough
Increased tactile fremitus
A patient with bacterial pneumonia has coarse crackles and thick sputum. Which action should the nurse plan to promote airway clearance?
Restrict oral fluids during the day.
Assist the patient to splint the chest when coughing.
Encourage the patient to wear the nasal O2 cannula.
Teach pursed-lip breathing technique.
The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions?
“I will call my health care provider if I still feel tired after
a week.”
“I will cancel my follow-up chest x-ray appointment if I feel
better next week.”
“I will continue to do deep breathing and coughing exercises at
home.”
“I will schedule two appointments for the pneumonia and
influenza vaccines.”
Which action should the nurse plan to prevent aspiration in a high-risk patient?
Turn and reposition an immobile patient at least every 2 hours.
Place a patient with altered consciousness in a side-lying
position.
Insert a nasogastric tube for feeding a patient with high
calorie needs.
Monitor respiratory symptoms in a patient who is
immunosuppressed.
A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective?
The patient coughs up small amounts of green mucus.
Bronchial breath sounds are heard at the right base.
Increased tactile fremitus is palpable over the right chest.
The patient’s white blood cell (WBC) count is 9000/µL.
The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?
Teach about the reason for the blood tests.
Schedule an appointment for a chest x-ray.
Teach the patient about providing specimens for 3 consecutive
days.
Instruct the patient to collect several separate sputum
specimens today.
A patient is admitted with active tuberculosis (TB). The nurse should question a health care provider’s order to discontinue airborne precautions unless which assessment finding is documented?
Chest x-ray shows no upper lobe infiltrates.
TB medications have been taken for 6 months.
Mantoux testing shows an induration of 10 mm.
Sputum smears for acid-fast bacilli are negative.
The nurse teaches a patient about the transmission of pulmonary tuberculosis (TB). Which statement, if made by the patient, indicates that teaching was effective?
“I will take the bus instead of driving.”
“My spouse will sleep in another room.”
“I will keep the windows closed at home.”
“I will stay indoors whenever possible.”
A patient who is taking rifampin (Rifadin) for tuberculosis calls the clinic and reports having orange discolored urine and tears. Which response by the nurse reflects accurate knowledge about the medication and the patient’s illness?
Question the patient about experiencing shortness of breath,
hives, or itching.
Ask the patient about any visual changes in red-green color
discrimination.
Advise the patient to stop the drug and report the symptoms to
the health care provider.
Explain that orange discolored urine and tears are normal while
taking this medication.
An older patient is receiving standard multidrug therapy for tuberculosis (TB). The nurse should notify the health care provider if the patient exhibits which finding?
Orange-colored sputum
Yellow-tinged sclera
Difficulty hearing high-pitched voices
Thickening of the fingernails
A patient diagnosed with active tuberculosis (TB) is homeless and has a history of alcohol abuse. Which intervention by the nurse will be most effective in ensuring adherence with the treatment regimen?
Give the patient written instructions about how to take the
medications.
Arrange for a daily meal and drug administration at a community
center.
Repeat warnings about the high risk for infecting others several
times.
Arrange for the patient’s friend to administer the medication on
schedule.
After 2 months of tuberculosis (TB) treatment with isoniazid, rifampin (Rifadin), pyrazinamide, and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?
Schedule directly observed therapy.
Teach about drug-resistant TB.
Discuss the need for an injectable antibiotic with the health
care provider.
Ask the patient whether medications have been taken as directed.
Employee health test results reveal a tuberculosis (TB) skin test of 16-mm induration and a negative chest x-ray for a staff nurse working on the pulmonary unit. The nurse has no symptoms of TB. Which information should the occupational health nurse plan to teach the staff nurse?
Use and side effects of isoniazid
Standard four-drug therapy for TB
Need for annual repeat TB skin testing
Bacille Calmette-Guérin (BCG) vaccine
The nurse supervises a student nurse who is assigned to take care of a patient with active tuberculosis (TB). Which action, if performed by the student nurse, would require an intervention by the nurse
A surgical face mask is applied before visiting the patient.
A snack is brought to the patient from the unit refrigerator.
Hand washing is performed before entering the patient’s room.
The patient is offered a tissue from the box at the bedside.
An occupational health nurse works at a manufacturing plant where there is potential exposure to inhaled dust. Which action recommended by the nurse is intended to prevent lung disease?
Require the use of protective equipment.
Treat workers with pulmonary fibrosis.
Teach about symptoms of lung disease.
Monitor workers for coughing and wheezing.
Which information about prevention of lung disease should the nurse include for a patient with a 42 pack-year history of cigarette smoking?
Computed tomography (CT) screening for cancer
Erlotinib (Tarceva) therapy to prevent tumor risk
Reasons for annual sputum cytology testing
Resources for support in smoking cessation
A lobectomy is scheduled for a patient with stage I non–small cell lung cancer. The patient tells the nurse, “I would rather have chemotherapy than surgery.” Which response by the nurse is most appropriate?
“Did you have bad experiences with previous surgeries?”
“Tell me what you know about the treatments available.”
“Surgery is the treatment of choice for stage I lung cancer.”
“Are you afraid that the surgery will be very painful?”
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take?
Clamp the chest tube in two places.
Administer the prescribed morphine.
Assist the patient with incentive spirometry.
Milk the chest tube to remove any clots.
A patient with newly diagnosed lung cancer tells the nurse, “I don’t think I’m going to live to see my next birthday.” Which is the best initial response by the nurse?
“Are you ready to talk with your family members about dying
now?”
“Would you like to talk to the hospital chaplain about your
feelings?”
“Can you tell me what it is that makes you think you will die so
soon?”
“Do you think that taking an antidepressant medication would be
helpful?”
The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?
A large air leak in the water-seal chamber
Complaint of pain with each deep inspiration
Subcutaneous emphysema at the insertion site
400 mL of blood in the collection chamber
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment?
Complaint of chest wall pain
Paradoxical chest movement
When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?
Chest tube connected to suction
Bronchodilator administration
A patient who has a right-sided chest tube after a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is appropriate?
Continue to monitor the collection device.
Document the presence of a large air leak.
Notify the surgeon of a possible pneumothorax.
Adjust the dial on the wall regulator.
The nurse provides preoperative instruction for a patient scheduled for a left pneumonectomy. Which information should the nurse include about the patient’s postoperative care?
Positioning only on the right side
Chest tube placement to continuous suction
Frequent use of an incentive spirometer
Bed rest for the first 24 hours
The nurse administers prescribed therapies for a patient with cor pulmonale and right-sided heart failure. Which assessment could be used to evaluate the effectiveness of the therapies?
Auscultate for crackles in the lungs.
Palpate for heaves or thrills over the heart.
Monitor for elevated white blood cell count.
Observe for distended neck veins.
A patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving nifedipine (Procardia). Which assessment would best indicate to the nurse that the patient’s condition is improving?
Patient’s chest x-ray indicates clear lung fields.
Patient reports a decrease in exertional dyspnea.
Blood pressure (BP) is less than 140/90 mm Hg.
Heart rate is between 60 and 100 beats/minute.
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?
Remind the patient not to eat or drink anything for 6 hours.
Position the patient sitting up on the side of the bed.
Start a peripheral IV line to administer sedatives.
Obtain a collection device to hold 3 liters of pleural fluid.
The nurse completes discharge teaching for a patient who has had a lung transplant. Which patient statement indicates to the nurse that the teaching has been effective?
“I will stop taking the prednisone if I experience a dry cough.”
“I will not worry if I feel a little short of breath with
exercise.”
“I will call the health care provider right away if I develop a
fever.”
“I will stop taking the prednisone if I experience a dry cough.”
“I will not worry if I feel a little short of breath with
exercise.”
“I will make an appointment to see the doctor every year.”
“I will call the health care provider right away if I develop a
fever.”
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
Chest x-ray via stretcher
Blood cultures from two sites
Ciprofloxacin (Cipro) 400 mg IV
Acetaminophen (Tylenol) rectal suppository
The nurse is caring for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
Blood pressure is 155/90 mm Hg.
O2 saturation is 88%.
Pain level is 5 (on 0 to 10 scale) with a deep breath.
Respiratory rate is 24 breaths/minute when lying flat.
A patient who has just been admitted with community-acquired pneumococcal pneumonia has a temperature of 101.6° F with a frequent cough and is complaining of severe pleuritic chest pain. Which prescribed medication should the nurse give first?
Acetaminophen (Tylenol)
Piperacillin/tazobactam (Zosyn)
A patient is diagnosed with both human immunodeficiency virus (HIV) and active tuberculosis (TB) disease. Which information obtained by the nurse is most important to communicate to the health care provider?
The Mantoux test had an induration of 7 mm.
The patient is being treated with antiretrovirals for HIV
infection.
The patient has a cough that is productive of blood-tinged
mucus.
The chest-x-ray showed infiltrates in the lower lobes.
A patient with pneumonia has a fever of 101.4° F (38.6° C), a nonproductive cough, and an O2 saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the priority?
Hyperthermia related to infectious illness
Ineffective airway clearance related to thick secretions
Impaired transfer ability related to weakness
Impaired gas exchange related to respiratory congestion
The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?
UAP assist the patient to ambulate to the bathroom.
UAP lower the head of the patient’s bed to 15 degrees.
UAP help splint the patient’s chest during coughing.
UAP transfer the patient to a bedside chair for meals.
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/min, blood pressure of 100/60 mm Hg, and respirations of 42 breaths/min. Which action should the nurse take first?
Administer anticoagulant drug therapy.
Prepare patient for a spiral computed tomography (CT).
Notify the patient’s health care provider.
Elevate the head of the bed to a semi-Fowler’s position.
The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?
A 23-yr-old patient with cystic fibrosis who has pulmonary
function testing scheduled
A 46-yr-old patient on bed rest who is complaining of sudden
onset of shortness of breath
A 35-yr-old patient who was admitted with pneumonia and has a
temperature of 100.2° F (37.8° C)
A 77-yr-old patient with tuberculosis (TB) who has four
medications due in 15 minutes
The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?
“Do you take any over-the-counter (OTC) medications?”
“Did you receive the bacille Calmette-Guérin (BCG) vaccine for
TB?”
“How long has it been since you moved to the United States?”
“Do you have any family members with a history of TB?”
A patient is admitted to the emergency department with an open stab wound to the left chest. What action should the nurse take?
Keep the head of the patient’s bed positioned flat.
Tape a nonporous dressing on three sides over the wound.
Position the patient so that the left chest is dependent.
Cover the wound tightly with an occlusive dressing.
The nurse notes that a patient has incisional pain, a poor cough effort, and scattered coarse crackles after a thoracotomy. Which action should the nurse take first?
Splint the patient’s chest during coughing.
Medicate the patient with prescribed morphine.
Assist the patient to sit upright in a chair.
Observe the patient use the incentive spirometer.
The nurse is caring for a patient with idiopathic pulmonary arterial hypertension (IPAH). Which assessment information requires the most immediate action by the nurse?
The O2 saturation is 90%.
The epoprostenol (Flolan) infusion is disconnected.
The international normalized ratio (INR) is prolonged.
The blood pressure is 98/56 mm Hg.
A patient who was admitted the previous day with pneumonia complains of a sharp pain of 7 (on 0 to 10 scale) “whenever I take a deep breath.” Which action will the nurse take next?
Administer the PRN morphine.
Auscultate for breath sounds.
Notify the patient’s health care provider.
Have the patient cough forcefully.
A patient has acute bronchitis with a nonproductive cough and wheezes. Which topic should the nurse plan to include in the teaching plan?
Purpose of antibiotic therapy
Appropriate use of cough suppressants
Safety concerns with home O2 therapy
Ways to limit oral fluid intake
Which action by the nurse will be most effective in decreasing the spread of pertussis in a community setting?
Providing supportive care to patients diagnosed with pertussis
Teaching family members about the need for careful hand washing
Encouraging patients to complete the prescribed course of
antibiotics
Teaching patients about the need for adult pertussis
immunizations
An experienced nurse instructs a new nurse about how to care for a patient with dyspnea caused by a pulmonary fungal infection. Which action by the new nurse indicates a need for further teaching?
Listening to the patient’s lung sounds several times during the
shift
Monitoring patient serology results to identify the infecting
organism
Increasing the O2 flow rate to keep the O2
saturation over 90%
Placing the patient on droplet precautions in a private hospital
room
Which intervention will the nurse include in the plan of care for a patient who is diagnosed with a lung abscess?
Assist the patient with chest physiotherapy and postural
drainage.
Teach about the need for prolonged antibiotic therapy after
discharge from the hospital.
Notify the health care provider immediately about any bloody or
foul-smelling sputum.
Teach the patient to avoid the use of over-the-counter
expectorants.
The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?
“I am going to buy a rib binder to wear during the day.”
“I will use the incentive spirometer every hour or two during
the day.”
“I should plan on taking the pain pills only at bedtime so I can
sleep.”
“I can take shallow breaths to prevent my chest from hurting.”
The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?
Obtain samples of drainage for culture from the system.
Assess patient pain level associated with the chest tube.
Document the amount of drainage every 8 hours.
Check the water-seal chamber for the correct fluid level.
After change-of-shift report, which patient should the nurse assess first?
A 28-yr-old with a history of a lung transplant and a
temperature of 101° F (38.3° C)
A 72-yr-old with cor pulmonale who has 4+ bilateral edema in his
legs and feet
A 64-yr-old with lung cancer and tracheal deviation after
subclavian catheter insertion
A 40-yr-old with a pleural effusion who is complaining of severe
stabbing chest pain
Which factors will the nurse consider when calculating the CURB-65 score for a patient with pneumonia (select all that apply)?
Blood pressure
Presence of confusion
Respiratory rate
Blood urea nitrogen (BUN) level
Age
Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure?
Chest x-ray
Arterial blood gas analysis
Central venous pressure monitoring
O2 saturation
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient’s oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take?
Suction the patient’s oropharynx.
Instruct the patient to cough and deep breathe.
Help the patient to sit in a more upright position.
Increase the prescribed O2 flow rate.
A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?
Administration of 100% O2 by non-rebreather mask
Insertion of a mini-tracheostomy with frequent suctioning
Initiation of continuous positive pressure ventilation (CPAP)
Endotracheal intubation and positive pressure ventilation
The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes, a weak cough effort, and complains of fatigue. Which action should the nurse take next?
Position the patient on the left side.
.
Place a humidifier in the patient’s room.
Schedule a 4-hour rest period for the patient.
Assist the patient with staged coughing
A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to improve gas exchange?
On the right side
On the left side
When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider?
The patient is very somnolent.
The patient complains of weakness.
The patient’s oxygen saturation is 90%.
The patient’s blood pressure is 164/98.
The patient is very somnolent.
A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following drugs ordered. Which drug should the nurse discuss with the health care provider before giving?
sucralfate (Carafate) 1 g per nasogastric tube
pantoprazole (Protonix) 40 mg IV
gentamicin 60 mg IV
methylprednisolone (Solu-Medrol) 60 mg IV
A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with
obtaining a ventilation-perfusion scan.
insertion of a pulmonary artery catheter.
drawing blood for arterial blood gases.
positioning the patient for a chest x-ray.
A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced?
The patient’s PaO2 is 50 mm Hg and the SaO2
is 88%.
The patient has subcutaneous emphysema on the upper thorax.
The patient has bronchial breath sounds in both the lung fields.
The patient has a first-degree atrioventricular heart block with
a rate of 58 beats/min.
Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient’s caregiver is accurate?
“PEEP prevents the lung air sacs from collapsing during
exhalation.”
“PEEP will push more air into the lungs during inhalation.”
“PEEP will prevent lung damage while the patient is on the
ventilator.”
“PEEP allows the breathing machine to deliver 100% O2
to the lungs.”
When prone positioning is used for a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective?
Endotracheal suctioning results in clear mucous return.
Sputum and blood cultures show no growth after 48 hours.
The skin on the patient’s back is intact and without redness.
The patient’s PaO2 is 89 mm Hg, and the SaO2
is 91%.
The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2° F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action should the nurse take next?
Give the scheduled IV antibiotic.
Notify the health care provider of the patient’s vital signs.
Obtain oxygen saturation using pulse oximetry.
Give the PRN acetaminophen (Tylenol).
A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?
Give enteral feedings at no more than 10 mL/hr.
Elevate head of bed to 30 to 45 degrees.
Limit the use of positive end-expiratory pressure.
Suction the endotracheal tube every 2 to 4 hours.
A patient admitted with acute respiratory failure has ineffective airway clearance related to thick secretions. Which nursing intervention would specifically address this patient problem?
Encourage use of the incentive spirometer.
Teach the patient the importance of ambulation.
Offer the patient fluids at frequent intervals.
Titrate oxygen level to keep O2 saturation above 93%.
A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next?
Increase the tidal volume and respiratory rate.
Lower the positive end-expiratory pressure (PEEP).
Perform endotracheal suctioning more frequently.
Decrease the fraction of inspired oxygen (FIO2).
After receiving change-of-shift report on a medical unit, which patient should the nurse assess first?
A patient with pneumonia who has crackles bilaterally in the
lung bases
A patient with emphysema who has an oxygen saturation of 90% to
92%
A patient with cystic fibrosis who has thick, green-colored
sputum
A patient with septicemia who has intercostal and suprasternal
retractions
A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding by the nurse is most important to report to the health care provider?
The patient has bibasilar lung crackles.
The patient’s respirations have dropped to 10 breaths/minute.
The patient’s pulse oximetry indicates a 91% O2
saturation.
The patient is sitting in the tripod position.
When assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse finds a new onset of agitation and confusion. Which action should the nurse take first?
Observe for facial symmetry.
Notify the health care provider.
Assess oxygenation using pulse oximetry.
Attempt to calm and reorient the patient.
The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action?
The patient’s PaO2 is 45 mm Hg.
The patient’s PaCO2 is 33 mm Hg.
The patient’s respirations are shallow.
The patient’s respiratory rate is 32 breaths/min.
The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider?
Persistent cough of blood-tinged sputum.
Oxygen saturation 90% on 100% O2 by nonrebreather
mask.
Temperature 101.5° F (38.6° C) after 2 days of IV antibiotics.
Scattered crackles in the posterior lung bases.
Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/LVN) working in the intensive care unit?
Assess breath sounds every hour.
Place patient in the prone position.
Insert an indwelling urinary catheter.
Monitor central venous pressures.
A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider?
Heart rate 106 beats/minute
O2 saturation of 99%
Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?
No sedative has been ordered for the patient.
There is no cough or gag reflex when the patient is suctioned.
The patient’s oxygen saturation remains between 90% to 93%.
The patient does not respond to verbal stimulation.
The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider?
Red-brown drainage from nasogastric tube
Arterial blood gases: pH of 7.31, PaCO2 of 50, and
PaO2 of 68
Scattered coarse crackles heard throughout lungs
Blood urea nitrogen (BUN) level 32 mg/dL
During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first?
Give the prescribed PRN sedative drug.
Use pulse oximetry to check the oxygen saturation.
Notify the health care provider about the patient’s status.
Offer reassurance and reorient the patient.
The nurse reviews the electronic health record for a patient scheduled for a total hip replacement. Which assessment data shown in the accompanying figure increase the patient’s risk for respiratory complications after surgery?
Older age and anemia
Albumin level and weight loss
Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)?
Give prescribed pantoprazole (Protonix).
Provide a “sedation holiday” daily.
Elevate the head of the bed to at least 30°.
Provide oral care with chlorhexidine (0.12%) solution daily.
Obtain arterial blood gases daily.
