Question 1

A nurse is caring for a client who is on mechanical ventilation.What actions will promote comfort in this client? (Select all that apply.)

Accepted Answer

There are many basic care measures that can be employed for the client who is on a ventilator.Allowing visitation,providing a means of communication,massaging the client's skin,and routinely turning and repositioning the client are some of them.Keeping the TV on will interfere with sleep and rest.

Question 2

When working with women who are taking hormonal birth control,what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)

Accepted Answer

Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight,exercising on a regular basis,and not smoking.Avoiding alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.

Question 3

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure.What age-related changes contribute to this? (Select all that apply.)

Accepted Answer

Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall,decreased muscle strength,and less elasticity of lung tissue.Not all older adults have an inability to cooperate or poor sensory acuity.

Question 4

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia.What actions are included in this practice? (Select all that apply.)

Accepted Answer

The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia.Actions in the bundle include using proper hand hygiene,giving anti-ulcer medications,elevating the head of the bed,providing frequent oral care per policy,preventing aspiration,and providing pulmonary hygiene measures.Suctioning is done as needed.

Question 5

A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best?

Accepted Answer

Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen.It is a cardinal sign of acute respiratory distress syndrome.It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.

Question 6

A client is brought to the emergency department after sustaining injuries in a severe car crash.The client's chest wall does not appear to be moving normally with respirations,oxygen saturation is 82%,and the client is cyanotic.What action by the nurse is the priority?

Accepted Answer

This client has manifestations of flail chest and,with the other signs,needs to be intubated and mechanically ventilated immediately.The nurse does not have time to administer oxygen and wait to reassess,or to listen to lung sounds.A chest x-ray will be taken after the client is intubated.

Question 7

A nurse is caring for a client on the medical stepdown unit.The following data are related to this client:

What action by the nurse is most appropriate?

Accepted Answer

This client has manifestations of pulmonary embolism (PE); however,many conditions can cause the client's presentation.The gold standard for diagnosing a PE is pulmonary angiography.The nurse should facilitate this test as soon as possible.The client does not have wheezing,so a respiratory treatment is not needed.The client is not unstable enough to need intubation and mechanical ventilation.IV anticoagulants are not given without a diagnosis of PE.

Question 8

A client with a new pulmonary embolism (PE)is anxious.What nursing actions are most appropriate? (Select all that apply.)

Accepted Answer

Clients with PEs are often anxious.The nurse can acknowledge the client's fears,delegate comfort measures,give simple explanations the client will understand,and stay with the client.Using a calm,quiet voice is also reassuring.Sedatives and antianxiety medications are not used routinely because they can contribute to hypoxia.If the client's anxiety is interfering with diagnostic testing or treatment,they can be used,but there is no evidence that this is the case.

Question 9

A 242-pound client is being mechanically ventilated.To prevent lung injury,what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.)___ mL

Accepted Answer

The answer of A 242-pound client is being mechanically ventilated.To...

Question 10

A nurse is caring for five clients.For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)

Accepted Answer

Conditions that place clients at higher risk of developing PE include prolonged immobility,central venous catheters,surgery,obesity,advancing age,conditions that increase blood clotting,history of thromboembolism,smoking,pregnancy,estrogen therapy,heart failure,stroke,cancer (particularly lung or prostate),and trauma.A contrast dye reaction and asthma pose no risk for PE.

Quiz 32: Care of Critically Ill Patients with Respiratory Problems

A nurse is caring for a client who is on mechanical ventilation.What actions will promote comfort in this client? (Select all that apply.)

When working with women who are taking hormonal birth control,what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE) ? (Select all that apply.)

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure.What age-related changes contribute to this? (Select all that apply.)

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia.What actions are included in this practice? (Select all that apply.)

A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best?

A client is brought to the emergency department after sustaining injuries in a severe car crash.The client's chest wall does not appear to be moving normally with respirations,oxygen saturation is 82%,and the client is cyanotic.What action by the nurse is the priority?

A nurse is caring for a client on the medical stepdown unit.The following data are related to this client: What action by the nurse is most appropriate?

A client with a new pulmonary embolism (PE) is anxious.What nursing actions are most appropriate? (Select all that apply.)

A 242-pound client is being mechanically ventilated.To prevent lung injury,what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.)___ mL

A nurse is caring for five clients.For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE) ? (Select all that apply.)