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NUR 265 Exam 2 – Accurate Solutions For Every
Question
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Practice questions for this set
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Initiate humidified O2 therapy.
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Priority patient on 100% oxygen
1 Pulmonary embolism (PE) 2
therapy
Priority action for ER patient with
3 Priority patient with heparin 4
paradoxical chest movement
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Terms in this set (58)
Pulmonary embolism (PE) Pleural friction rub
Shortness of breath and chest pain Place the patient on a cardiac monitor and pulse
response oximetry.
, Warfarin discharge comment for PE My INR is to be monitored frequently.
ABG for newly developed PE pH 7.60, PaO2 85, PaCO2 32, HCO3 23, SaO2 88
(Respiratory alkalosis)
Priority patient with heparin A patient on day 10 of heparin with blood oozing
from their Foley catheter.
Chest tube bubbling in suction control No. This is normal in the suction control chamber.
chamber
Asymmetrical chest expansion with Absolutely! YES!!
chest tube
Chest tube drainage in one hour Yes! It is >70 ml/hr.
Visible eyelets of the chest tube Yes! The tube is coming out of the pleural space.
Continuous bubbling in water seal Call the doctor to report a leak in the system.
chamber after 4 days
Patient with dyspnea and ABG values Acute respiratory failure.
Greatest risk for ARDS A burn victim receiving IV fluid boluses.
Priority patient on 100% oxygen A patient receiving 100% oxygen therapy and their
therapy PAO2 is 55.
Post-intubation priority for ARDS Evaluate post-intubation ABG from respiratory
patient therapy (RT, 30-60 minute window), and portable
chest X-ray.
Interdisciplinary care team need A 19 y/o MVA victim intubated & vented x 14 days ago
for ARDS.
Most indicative finding of tension Distended neck veins.
pneumothorax