Question 1

The nurse is providing care to a patient who is diagnosed with acute respiratory distress syndrome (ARDS).Which clinical manifestation does the nurse anticipate for this patient who is experiencing hypoxia as a result of the ARDS diagnosis?

Accepted Answer

Dyspnea is a common clinical manifestation seen in patients with ARDS as it is caused by severe respiratory distress and hypoxia. Fluid imbalance, hypertension, and bradycardia are not commonly associated with ARDS.

Question 2

A patient with acute respiratory distress syndrome (ARDS)is being weaned from mechanical ventilation.Which nursing action is appropriate for this patient?

Accepted Answer

Placing the patient in the Fowler position can help improve oxygenation and facilitate weaning from mechanical ventilation. Increasing oxygen percentage may not be effective in improving the patient's ability to breathe on their own, and sedation with morphine may further decrease respiratory drive. Morning care may need to be postponed until after the weaning procedure to minimize patient fatigue.

Question 3

The nurse has instructed a patient recovering from a pulmonary embolism on long-term anticoagulant therapy.Which patient statement indicates that instruction has been effective?

Accepted Answer

Using a soft toothbrush and an electric razor, as well as avoiding injuries, are important precautions to take while on anticoagulant therapy to prevent bleeding. Bloody sputum and bruises are not normal and should be reported to the healthcare provider. Eating a well-balanced diet with green salads may be important for overall health but is not directly related to anticoagulant therapy.

Question 4

The nurse is preparing to discharge a patient recovering from a pulmonary embolism.Which topics are appropriate for the nurse to include in the teaching session?

Accepted Answer

Anticoagulant administration schedule is important to include in the teaching session as it is crucial for preventing another pulmonary embolism. The other options are not appropriate as the patient should not resume the use of over-the-counter medications without consulting a healthcare provider, the diet should be discussed with a dietician, and the activity level should be gradually increased under the guidance of a healthcare provider.

Question 5

A patient diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea.Which is the priority nursing diagnosis for this patient?

Accepted Answer

The reduction in arterial oxygen saturation and dyspnea are indications of impaired gas exchange, which is the priority nursing diagnosis for this patient. The other options are also appropriate for a patient with a pulmonary embolism, but they are not the priority concern.

Question 6

A patient admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS).Which health-care provider prescription does the nurse anticipate for this patient?

Accepted Answer

Patients with ARDS require mechanical ventilation to support oxygenation and ventilation. Oxygen via a nasal cannula or face mask administration may not provide enough support in severe cases of ARDS. Continuous positive airway pressure may also not be sufficient in severe cases of ARDS.

Question 7

A patient is brought into the emergency department (ED)after being in a motor vehicle accident.The patient has suffered traumatic injury that may involve multiple body systems.Which is the priority nursing assessment for this patient?

Accepted Answer

Airway maintenance with cervical spine protection is the priority nursing assessment for a patient with potential multiple traumatic injuries. This ensures that the patient can breathe adequately and avoid further cervical spine injury. Once the airway is secured, the nurse can proceed to assess breathing, circulation, and neurological status. Hemorrhage control may also be necessary during circulation assessment. However, ensuring the airway is maintained takes priority over other assessments.

Question 8

The nurse is concerned that a patient admitted for a total hip replacement is at risk for thrombus formation and pulmonary embolism.Which assessment finding supports the nurse's concern?

Accepted Answer

A BMI of 35.8 indicates obesity, which is a risk factor for thrombus formation and pulmonary embolism, especially after surgery like a total hip replacement.

Question 9

The nurse is planning care for a newly admitted patient diagnosed with pulmonary embolism.The nurse anticipates the patient will need anticoagulant therapy.What is true regarding this therapy for the treatment of this condition?

Accepted Answer

Heparin is usually initiated first, followed by warfarin, as they have different mechanisms of action. Major hemorrhage is a potential side effect of anticoagulant therapy, but it is not common. Heparin does not alter the synthesis of vitamin K-dependent clotting factors, but it does inhibit the activity of thrombin and factor Xa, thereby preventing further clots. Anticoagulant therapy is considered first-line treatment for pulmonary embolism.

Question 10

A patient scheduled for surgery is being instructed in leg exercises and the pneumatic compression device.The nurse includes these instructions to decrease which postoperative complication?

Accepted Answer

Leg exercises and pneumatic compression devices are used to decrease the risk of deep vein thrombosis (DVT) in postoperative patients. DVT is a serious complication that can occur due to reduced mobility and blood flow, causing blood clots to form in the veins of the legs, which can lead to a pulmonary embolism.

Question 11

A nurse caring for a patient with a pulmonary embolism expects to find which diagnostic result?

Accepted Answer

A pulmonary embolism can cause an increase in heart rate and may also result in nonspecific T-wave changes on an EKG. Patchy infiltrates on a chest x-ray may be seen in conditions such as pneumonia, but not specifically in a pulmonary embolism. A metabolic alkalosis on an arterial blood gas and an elevated CO2 level found on an end-tidal carbon dioxide monitor would not be expected findings in a patient with a pulmonary embolism.

Question 12

The nurse in the intensive care unit (ICU)is caring for a patient diagnosed with acute respiratory distress syndrome (ARDS).Vital signs prior to endotracheal intubation: HR 108 bpm,RR 32 bpm,BP 88/58 mm Hg,and oxygen saturation 82%.The patient is intubated and placed on mechanical ventilation with positive pressure ventilation.Which assessment finding indicates a further decrease of cardiac output secondary to positive pressure ventilation?

Accepted Answer

A decrease in urine output indicates a decrease in cardiac output, which can be a potential complication of positive pressure ventilation. Blood pressure of 90/60 mm Hg is within normal range and does not necessarily indicate a decrease in cardiac output. An increase in heart rate of only 2 bpm may not be significant, as the patient was already tachycardic prior to intubation. An oxygen saturation of 90% is also within an acceptable range and does not necessarily indicate a decrease in cardiac output.

Question 13

A patient with a respiratory rate of eight breaths per minute has an oxygen saturation of 82%.Which nursing diagnosis is a priority for this patient?

Accepted Answer

A respiratory rate of eight breaths per minute is severely low, indicating compromised ventilation. This can lead to inadequate oxygenation of the body tissues and organs, which is evidenced by the low oxygen saturation level of 82%. Therefore, the priority nursing diagnosis for this patient should be Impaired Spontaneous Ventilation.

Question 14

The nurse is providing care to several patients on a medical-surgical unit.Which patient is at highest risk for a nonthrombotic pulmonary embolism?

Accepted Answer

Patients who are postoperative from orthopedic surgeries, specifically femur fracture repairs, are at the highest risk for nonthrombotic pulmonary embolisms. This is due to the possibility of fat emboli or bone marrow emboli traveling to the lungs from the fracture site. The other options listed do not have as high of a risk for nonthrombotic pulmonary embolism.

Question 15

The nurse is planning care for a patient with a pulmonary embolism.Which intervention would assist with the patient's decrease in cardiac output?

Accepted Answer

Monitoring pulmonary arterial pressures helps assess the impact of the embolism on the heart and can guide interventions to improve cardiac output.

Question 16

The nurse caring for a patient recovering from an abdominal hysterectomy suspects the patient is experiencing a pulmonary embolism.Which clinical manifestation supports the nurse's suspicion?

Accepted Answer

Dyspnea and shortness of breath are common symptoms of pulmonary embolism, which is a blockage in one of the pulmonary arteries in the lungs. Nausea, decreased urine output, and activity intolerance are not specific to pulmonary embolism and may be present with a variety of other conditions.

Question 17

The nurse is providing discharge instructions to an older adult patient who is going home after having a total knee replacement.Which will the nurse include in the discharge teaching to decrease the patient's risk for developing a thrombosis or pulmonary embolism?

Accepted Answer

The use of compression stockings can decrease the risk of developing deep vein thrombosis (DVT) and pulmonary embolism (PE) after surgery. Placing pillows under the knees and limiting fluids may provide comfort but does not reduce the risk for DVT/PE. Limiting ambulation can increase the risk for DVT/PE.

Question 18

The nurse is providing care to a patient with an infected leg wound.The patient is exhibiting symptoms of a systemic infection and is receiving intravenous antibiotics.The patient states to the nurse,"I am having trouble breathing." Based on this data,which does the nurse suspect the patient is experiencing?

Accepted Answer

The patient's statement of trouble breathing, along with systemic infection symptoms and receiving intravenous antibiotics, indicates the possibility of acute respiratory distress syndrome (ARDS), which is a serious lung condition that can occur in patients with systemic infections. Allergic response to antibiotic therapy may cause respiratory symptoms, but it is less likely with an infected wound. Deep vein thrombosis and anemia can cause respiratory distress but are less likely in this scenario.

Question 19

The nurse caring for a patient admitted with septic shock is aware of the need to assess for the development of acute respiratory distress syndrome (ARDS).Which early clinical manifestation would indicate the development of ARDS?

Accepted Answer

Tachypnea (rapid breathing) is an early sign of ARDS as the body tries to compensate for decreased oxygen levels. Intercostal retractions and cyanosis may also occur in later stages, while tachycardia is a non-specific finding in many conditions and not specific to ARDS.

Question 20

The nurse caring for a newborn on a ventilator for acute respiratory distress syndrome (ARDS)informs the parents that the newborn is improving.Which data supports the nurse's assessment of the newborn's condition?

Accepted Answer

Oxygen saturation of 92% indicates that the newborn is receiving sufficient oxygenation and is improving from ARDS. Increased PCO2 and pulmonary vascular resistance, as well as decreased urine output, are signs of respiratory distress and worsening condition.

Quiz 27: Coordinating Care for Critically Ill Patients With Respiratory Dysfunction

The nurse is providing care to a patient who is diagnosed with acute respiratory distress syndrome (ARDS) .Which clinical manifestation does the nurse anticipate for this patient who is experiencing hypoxia as a result of the ARDS diagnosis?

A patient with acute respiratory distress syndrome (ARDS) is being weaned from mechanical ventilation.Which nursing action is appropriate for this patient?