NSG 3130 EXAM 4 TEST BANK QUESTIONS WITH SOLUTIONS MANUAL

The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which oxygen delivery device will the nurse use for this patient? a. Non-rebreather mask b. Bag-valve-mask unit c. Continuous positive airway pressure (CPAP) d. High-flow nasal cannula b. Bag-valve-mask unit The priority of the nurse is to ventilate the patient manually using a bag-valve-mask (BVM) unit. This allows air to be forced into the patient's lungs when there are no spontaneous respirations. The non-rebreather mask and nasal cannula require the patient to breathe on his or her own. CPAP is used for patients who are awake, oriented, and in respiratory failure. The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient is breathing spontaneously but is minimally responsive and having difficulty maintaining a patent airway. Which intervention is the most appropriate for the patient to improve oxygenation? a. Insert an oral airway. b. Lower the head of the bed. c. Turn the patient's head to the side. d. Monitor the patient's pulse oximetry. a. Insert an oral airway. An oral (oropharyngeal) airway will prevent the patient's tongue from falling back and occluding the airway. Lowering the head of the bed will only increase airway occlusion and risk of aspiration. Turning the patient's head to the side will not clear the back of the patient's tongue from the airway. Monitoring the patient's pulse oximetry will not improve oxygenation or clear the airway. The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient's pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of the nurse? a. Administer the ordered intravenous diuretic. b. Prepare for insertion of a chest tube. c. Suction secretions from the patient's respiratory tract. d. Have the patient use the ordered incentive spirometer. a. Administer the ordered intravenous diuretic. The patient's respiratory distress is due to pulmonary edema and fluid overload from left-sided congestive heart failure. A patient with heart failure may be on diuretics. A diuretic will pull the excess fluid out of the body through the urine and relieve the patient's distress. A chest tube is not needed as the fluid is within the alveoli rather than between the lung and chest wall. Suctioning and use of an incentive spirometer will not address fluid overload or improve the patient's symptoms. The nurse is caring for a patient who has been intubated with an oral endotracheal tube for several weeks. The physicians predict that the patient will need to remain on a ventilator for at least several more weeks before he will be able to maintain his airway and breathe on his own. What procedure does the nurse anticipate will be planned for the patient to facilitate recovery? a. Placement of a tracheostomy tube b. Diagnostic thoracentesis c. Pulmonary angiogram d. Lung transplantation surgery a. Placement of a tracheostomy tube Placement of a tracheostomy tube will secure the patient's airway directly through the trachea, eliminating the need for the endotracheal tube. This will make the patient more comfortable and may allow eating while minimizing damage to the oropharynx from the endotracheal tube. The nurse is caring for a patient with a chest tube who was transported to radiology for testing. When the patient returns to the nursing unit, the transporter shows the nurse the patient's chest tube collection device, which was badly damaged after being caught in the elevator door. What is the priority action of the nurse? a. Clamp the chest tube until the collection device is replaced. b. Cover the insertion site with a new occlusive dressing. c. Ensure that there is gentle bubbling in the water seal chamber. d. Check the patient's lung sounds and pulse oximetry. a. Clamp the chest tube until the collection device is replaced. The broken collection device may no longer be used to collect chest tube drainage. Clamping the chest tube until the collection device is replaced will prevent air from entering the lung space until the new collection device is attached. The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has the highest priority? a. Activity intolerance r/t generalized weakness and hypoxemia b. Impaired nutritional intake r/t poor appetite and increased metabolic needs c. Impaired airway clearance r/t thick secretions in trachea and bronchi d. Lack of knowledge r/t use of nebulizer and inhaled bronchodilators c. Impaired airway clearance r/t thick secretions in trachea and bronchi. Airway maintenance and patency is the highest priority for all patients, especially patients with respiratory disorders. Oxygenation is the most important human need. The other diagnoses can apply once the patient's airway is kept patent. The nurse is caring for a patient who developed a pulmonary embolism after surgery. Which goal statement is the highest priority for the nurse to include in the patient's care plan for the diagnosis impaired gas exchange r/t impaired pulmonary blood flow from embolus? a. The patient will maintain pulse oximetry values of at least 95% on room air. b. The patient will verbalize understanding of ordered anticoagulants. c. The patient will report chest pain of no greater than 3 on a 1 to 10 scale. d. The patient will ambulate 50 feet in hallway without shortness of breath. a. The patient will maintain pulse oximetry values of at least 95% on room air. Oxygenation is the most important human need, so adequate oxygenation of tissues as evidenced by pulse oximetry values of at least 95% on room air is the highest priority goal. The other goals may be addressed once the oxygenation goal has been met. The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented. What is the priority action of the nurse? a. Obtain an arterial blood gas to check for carbon dioxide retention. b. Increase the patient's oxygen until the pulse oximetry is greater than 98%. c. Lower the head of the patient's bed and insert a nasal airway. d. Administer a mild sedative and reorient the patient as needed. a. Obtain an arterial blood gas to check for carbon dioxide retention. Alteration of lung tissue may decrease delivery of oxygen to the alveoli, impede transfer of oxygen from alveoli to the bloodstream, and hinder expulsion of carbon dioxide. COPD causes impaired gas exchange, leading to decreased oxygen levels and higher circulating levels of carbon dioxide (i.e., respiratory acidosis). Confusion and disorientation in a patient with severe COPD may likely be due to carbon dioxide retention. An arterial blood gas should be drawn to determine if this is the case. COPD patients should be kept on low oxygen flow rates whenever possible to avoid impeding the drive to breathe. Lowering the head of the bed will increase the difficulty of breathing as the abdominal contents press on the diaphragm. A sedative will cause respiratory depression and should be avoided. The nurse is caring for a patient who has been prescribed warfarin (Coumadin) therapy after being diagnosed with atrial fibrillation. The patient asks the nurse what could happen if the prescription doesn't get filled. What is the nurse's best response? a. "You could have a stroke." b. "Your kidneys could fail." c. "You could develop heart failure." d. "You could go into respiratory failure." a. "You could have a stroke." A major complication of chronic atrial fibrillation is formation of blood clots within the atria due to sluggish blood flow. Anticoagulation therapy is common to prevent blood clot formation that could travel to the brain, causing a stroke. The preceptor is working with a new nurse to provide care for a patient with a chest tube to relieve a pneumothorax. Which action by the new nurse indicates need for additional teaching about chest tube care? a. The suction is discontinued when the patient is ambulated to the bathroom. b. The collection device is emptied at the end of the shift and output recorded in the chart. c. The patient's bed is placed in the semi-Fowler's position to facilitate lung reexpansion. d. The patient is encouraged to use his incentive spirometer at least 10 times every hour. b. The collection device is emptied at the end of the shift and output recorded in the chart. The chest tube collection device is not emptied at the end of the shift. Instead, the amount of drainage present at the end of the shift (or specified time) is marked on the collection device and the amount of drainage is documented in the patient's chart.