Chapter 29: Critical Care of Patients with
Respiratory Emergencies
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. 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. Assess the cause of the agitation.
b. Reassure the client that he or she is safe.
c. Restrain the client’s hands.
d. Sedate the client immediately.
ANS: A
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, confusion, and hypoxia
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. Ensuring the client is adequately
oxygenated is the priority.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Mechanical ventilation, Anxiety MSC: Client Needs
Category: Physiological Integrity: Reduction of Risk Potential
2. A nurse is preparing to admit a client on mechanical ventilation for acute respiratory
failure from the emergency department. What action does the nurse take first?
, a. Assessing that the ventilator settings are correct
b. Ensuring that there is a bag-valve-mask in the room
c. Obtaining personal protective equipment
d. Planning to suction the client upon arrival to the room
ANS: B
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 would know and check the settings. Personal protective equipment
is important, but ensuring client safety is the most important action. The client may or
may not need suctioning on arrival.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Mechanical ventilation, Client safety MSC: Client Needs
Category: Safe and Effective Care Environment: Management of Care
3. A client is on mechanical ventilation and the client’s spouse wonders why ranitidine is
needed since the client “only has lung problems.” What response by the nurse is best?
a. “It will increase the motility of the gastrointestinal tract.”
b. “It will keep the gastrointestinal tract functioning normally.”
c. “It will prepare the gastrointestinal tract for enteral feedings.”
d. “It will prevent ulcers from the stress of mechanical ventilation.”
ANS: D
Stress ulcers can occur in many clients who are receiving mechanical ventilation, and
often prophylactic medications are used to prevent them and possible subsequent
aspiration. Frequently used medications include antacids, histamine blockers, and
proton pump inhibitors. Ranitidine is a histamine-blocking agent.
DIF: Understanding TOP: Integrated Process: Teaching/Learning
KEY: Mechanical ventilation, Histamine blocker MSC: Client
, Needs Category: Physiological Integrity: Pharmacological and Parenteral
Therapies
4. A client has been brought to the emergency department with a life-threatening chest
injury. What action by the nurse takes priority?
a. Apply oxygen at 100%.
b. Assess the respiratory rate.
c. Ensure a patent airway.
d. Start two large-bore IV lines.
ANS: C
The priority for any chest trauma client is airway, breathing, and circulation. The
nurse first ensures that the client has a patent airway. Assessing respiratory rate and
applying oxygen are next, followed by inserting IVs.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Emergency nursing, Primary survey, Trauma MSC:
Client Needs Category: Safe and Effective Care Environment: Management of
Care
5. A client with ARDS is receiving minimal amounts of IV fluids. The new nurse notes
the client is scheduled to receive a diuretic at this time. The nurse consults the Staff
Development Nurse to determine the best course of action. What will the new nurse
do?
a. Contact the primary health care provider.
b. Give the ordered diuretic as scheduled.
c. Request an increase in the IV rate.
d. Calculate the client’s 24-hour fluid balance.
ANS: B
Respiratory Emergencies
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. 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. Assess the cause of the agitation.
b. Reassure the client that he or she is safe.
c. Restrain the client’s hands.
d. Sedate the client immediately.
ANS: A
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, confusion, and hypoxia
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. Ensuring the client is adequately
oxygenated is the priority.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Mechanical ventilation, Anxiety MSC: Client Needs
Category: Physiological Integrity: Reduction of Risk Potential
2. A nurse is preparing to admit a client on mechanical ventilation for acute respiratory
failure from the emergency department. What action does the nurse take first?
, a. Assessing that the ventilator settings are correct
b. Ensuring that there is a bag-valve-mask in the room
c. Obtaining personal protective equipment
d. Planning to suction the client upon arrival to the room
ANS: B
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 would know and check the settings. Personal protective equipment
is important, but ensuring client safety is the most important action. The client may or
may not need suctioning on arrival.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Mechanical ventilation, Client safety MSC: Client Needs
Category: Safe and Effective Care Environment: Management of Care
3. A client is on mechanical ventilation and the client’s spouse wonders why ranitidine is
needed since the client “only has lung problems.” What response by the nurse is best?
a. “It will increase the motility of the gastrointestinal tract.”
b. “It will keep the gastrointestinal tract functioning normally.”
c. “It will prepare the gastrointestinal tract for enteral feedings.”
d. “It will prevent ulcers from the stress of mechanical ventilation.”
ANS: D
Stress ulcers can occur in many clients who are receiving mechanical ventilation, and
often prophylactic medications are used to prevent them and possible subsequent
aspiration. Frequently used medications include antacids, histamine blockers, and
proton pump inhibitors. Ranitidine is a histamine-blocking agent.
DIF: Understanding TOP: Integrated Process: Teaching/Learning
KEY: Mechanical ventilation, Histamine blocker MSC: Client
, Needs Category: Physiological Integrity: Pharmacological and Parenteral
Therapies
4. A client has been brought to the emergency department with a life-threatening chest
injury. What action by the nurse takes priority?
a. Apply oxygen at 100%.
b. Assess the respiratory rate.
c. Ensure a patent airway.
d. Start two large-bore IV lines.
ANS: C
The priority for any chest trauma client is airway, breathing, and circulation. The
nurse first ensures that the client has a patent airway. Assessing respiratory rate and
applying oxygen are next, followed by inserting IVs.
DIF: Remembering TOP: Integrated Process: Nursing Process: Assessment
KEY: Emergency nursing, Primary survey, Trauma MSC:
Client Needs Category: Safe and Effective Care Environment: Management of
Care
5. A client with ARDS is receiving minimal amounts of IV fluids. The new nurse notes
the client is scheduled to receive a diuretic at this time. The nurse consults the Staff
Development Nurse to determine the best course of action. What will the new nurse
do?
a. Contact the primary health care provider.
b. Give the ordered diuretic as scheduled.
c. Request an increase in the IV rate.
d. Calculate the client’s 24-hour fluid balance.
ANS: B
