Question 1

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

Accepted Answer

For clients on heparin,a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working.A normal PTT is 25 to 35 seconds,so this client's PTT value is too low.The heparin rate needs to be increased.Warfarin is not indicated in this situation.

Question 2

A client appears dyspneic,but the oxygen saturation is 97%.What action by the nurse is best?

Accepted Answer

Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere,producing normal or near-normal readings in the setting of hypoxia.The nurse should conduct a more thorough assessment.The other actions are not appropriate for a hypoxic client.

Question 3

A nurse is assisting the health care provider who is intubating a client.The provider has been attempting to intubate for 40 seconds.What action by the nurse takes priority?

Accepted Answer

Each intubation attempt should not exceed 30 seconds (15 is preferable)as it causes hypoxia.The nurse should interrupt the intubation attempt and give the client oxygen.The nurse should also have adequate sedation during the procedure and monitor the client's oxygen saturation,but these do not take priority.Finding another provider is not appropriate at this time.

Question 4

A client is admitted with a pulmonary embolism (PE).The client is young,healthy,and active and has no known risk factors for PE.What action by the nurse is most appropriate?

Accepted Answer

Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events,including PE.A client with no known risk factors for this disorder should be referred for testing.Encouraging the client to walk is healthy,but is not related to the development of a PE in this case,nor is smoking.Although there are cases of disease where no cause is ever found,this assumption is premature.

Question 5

A student nurse is preparing to administer enoxaparin (Lovenox)to a client.What action by the student requires immediate intervention by the supervising nurse?

Accepted Answer

Enoxaparin is given subcutaneously,so the 18-gauge,2-inch needle is too big.The other actions are appropriate.

Question 6

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about.What action by the nurse is most appropriate?

Accepted Answer

The nurse needs to determine the cause of the agitation.The inability to communicate often makes clients anxious,even to the point of panic.Pain and confusion can also cause agitation.Once the nurse determines the cause of the agitation,he or she can implement measures to relieve the underlying cause.Reassurance is also important but may not address the etiology of the agitation.Restraints and more sedation may be necessary,but not as a first step.

Question 7

A client is being discharged soon on warfarin (Coumadin).What menu selection for dinner indicates the client needs more education regarding this medication?

Accepted Answer

Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors.Foods high in vitamin K thus interfere with its action and need to be eaten in moderate,consistent amounts.The chef's salad most likely has too many leafy green vegetables,which contain high amounts of vitamin K.The other selections,while not particularly healthy,will not interfere with the medication's mechanism of action.

Question 8

A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac)is needed since the client "only has lung problems." What response by the nurse is best?

Accepted Answer

Stress ulcers occur in many clients who are receiving mechanical ventilation,and often prophylactic medications are used to prevent them.Frequently used medications include antacids,histamine blockers,and proton pump inhibitors.Zantac is a histamine blocking agent.

Question 9

An intubated client's oxygen saturation has dropped to 88%.What action by the nurse takes priority?

Accepted Answer

When an intubated client shows signs of hypoxia,check for DOPE: displaced tube (most common cause),obstruction (often by secretions),pneumothorax,and equipment problems.The nurse listens for equal,bilateral breath sounds first to determine if the endotracheal tube is still correctly placed.If this assessment is normal,the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.

Question 10

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?

Accepted Answer

A large blood clot in the lungs will significantly impair gas exchange and oxygenation.Unless the clot is dissolved,this process will continue unabated.Hyperventilation can interfere with oxygenation by shallow breathing,but there is no evidence that the client is hyperventilating,and this is also not the most precise physiologic answer.Respiratory distress syndrome can occur,but this is not as likely.The client may need to be mechanically ventilated,but without concrete data on FiO₂ and SaO₂,the nurse cannot make that judgment.

Question 11

A client is hospitalized with a second episode of pulmonary embolism (PE).Recent genetic testing reveals the client has an alteration in the gene CYP2C19.What action by the nurse is best?

Accepted Answer

Often clients are discharged from the hospital on warfarin (Coumadin)after a PE.However,clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have higher blood levels and more side effects.This client is a poor candidate for warfarin therapy,and the prescriber will most likely order an IVC filter device to be implanted.The nurse should prepare to do preoperative teaching on this procedure.It would be impossible to eliminate all vitamin K from the diet.A chronic illness support group may be needed,but this is not the best intervention as it is not as specific to the client as the IVC filter.A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy.

Question 12

A client has been diagnosed with a very large pulmonary embolism (PE)and has a dropping blood pressure.What medication should the nurse anticipate the client will need as the priority?

Accepted Answer

Activase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability.The nurse knows this drug is the priority,although heparin may be started initially.Enoxaparin and warfarin are not indicated in this setting.

Question 13

A client has been brought to the emergency department with a life-threatening chest injury.What action by the nurse takes priority?

Accepted Answer

The priority for any chest trauma client is airway,breathing,circulation.The nurse first ensures the client has a patent airway.Assessing respiratory rate and applying oxygen are next,followed by inserting IVs.

Question 14

A nurse is preparing to admit a client on mechanical ventilation from the emergency department.What action by the nurse takes priority?

Accepted Answer

Having a bag-valve-mask device is critical in case the client needs manual breathing.The respiratory therapist is usually primarily responsible for setting up the ventilator,although the nurse should know and check the settings.Personal protective equipment is important,but ensuring client safety takes priority.The client may or may not need suctioning on arrival.

Question 15

A client is on a ventilator and is sedated.What care may the nurse delegate to the unlicensed assistive personnel (UAP)?

Accepted Answer

The client on mechanical ventilation needs frequent oral care,which can be delegated to the UAP.The other actions fall within the scope of practice of the nurse.

Question 16

A client in the emergency department has several broken ribs.What care measure will best promote comfort?

Accepted Answer

Allow the client with respiratory problems to assume a position of comfort if it does not interfere with care.Often the client will choose a more upright position,which also improves oxygenation.The other options are less effective comfort measures.

Question 17

A nurse is caring for a client on mechanical ventilation.When double-checking the ventilator settings with the respiratory therapist,what should the nurse ensure as a priority?

Accepted Answer

The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum.This is critical to prevent damage to the lungs.Alarms should never be turned off.Initiating spontaneous breathing is important for some modes of ventilation but not others.Adequate humidification is important but does not take priority over preventing injury.

Question 18

A nurse is teaching a client about warfarin (Coumadin).What assessment finding by the nurse indicates a possible barrier to self-management?

Accepted Answer

Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors.Foods high in vitamin K thus interfere with its action and need to be eaten in moderate,consistent amounts.A vegetarian may have trouble maintaining this diet.The nurse should explore this possibility with the client.The other options are not related.

Question 19

A nurse is caring for four clients on intravenous heparin therapy.Which laboratory value possibly indicates that a serious side effect has occurred?

Accepted Answer

This platelet count is low and could indicate heparin-induced thrombocytopenia.The other values are normal for either gender.

Question 20

A nurse answers a call light and finds a client anxious,short of breath,reporting chest pain,and having a blood pressure of 88/52 mm Hg on the cardiac monitor.What action by the nurse takes priority?

Accepted Answer

This client has manifestations of a pulmonary embolism,and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment.The other actions are appropriate also but are not the priority.

Quiz 32: Care of Critically Ill Patients with Respiratory Problems

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

A client appears dyspneic,but the oxygen saturation is 97%.What action by the nurse is best?

A nurse is assisting the health care provider who is intubating a client.The provider has been attempting to intubate for 40 seconds.What action by the nurse takes priority?

A client is admitted with a pulmonary embolism (PE) .The client is young,healthy,and active and has no known risk factors for PE.What action by the nurse is most appropriate?

A student nurse is preparing to administer enoxaparin (Lovenox) to a client.What action by the student requires immediate intervention by the supervising nurse?

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about.What action by the nurse is most appropriate?

A client is being discharged soon on warfarin (Coumadin) .What menu selection for dinner indicates the client needs more education regarding this medication?

A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best?

An intubated client's oxygen saturation has dropped to 88%.What action by the nurse takes priority?

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?

A client is hospitalized with a second episode of pulmonary embolism (PE) .Recent genetic testing reveals the client has an alteration in the gene CYP2C19.What action by the nurse is best?

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure.What medication should the nurse anticipate the client will need as the priority?