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NURS 2765 A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 m$15.99
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NURS 2765 A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 m
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Course
NURS 2765
Institution
NURS 2765
A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?
a. Assess the client's lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassuranc...
,A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood
pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?
a. Assess the client's lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital
signs. b
This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid
Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the
priority.
A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk
factors for PE. What action by the nurse is most appropriate?
a. Encourage the client to walk 5 minutes each hour.
b. Refer the client to smoking cessation classes.
c. Teach the client about factor V Leiden testing.
d. Tell the client that sometimes no cause for disease
is found. c
Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with
no known risk factors for this disorder should be referred for testing. Encouraging the client to walk is healthy, but
is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no
cause is ever found, this assumption is premature.
A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen
saturation has not significantly improved. What response by the nurse is best?
a. "Breathing so rapidly interferes with oxygenation."
b. "Maybe the client has respiratory distress syndrome."
c. "The blood clot interferes with perfusion in the lungs."
d. "The client needs immediate intubation and mechanical
ventilation." c
A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved,
this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but
there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer.
Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically
ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.
A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin
time (PTT) was 25 seconds. What order should the nurse anticipate?
a. Decrease the heparin rate.
b. Increase the heparin rate.
c. No change to the heparin rate.
d. Stop heparin; start warfarin
(Coumadin). b
For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working.
A normal PTT is 25 to 35 seconds, so this client's PTT value is too low. The heparin rate needs to be increased.
Warfarin is not indicated in this situation.
A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client
has an alteration in the gene CYP2C19. What action by the nurse is best?
a. Instruct the client to eliminate all vitamin K from the diet.
b. Prepare preoperative teaching for an inferior vena cava (IVC) filter.
c. Refer the client to a chronic illness support group.
d. Teach the client to use a soft-bristled
toothbrush. b
Often clients are discharged from the hospital on warfarin (Coumadin) after a PE. However, clients with a variation
in the CYP2C19 gene do not metabolize warfarin well and have higher blood levels and more side effects. This
client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be
implanted. The nurse should prepare to do preoperative teaching on this procedure. It would be impossible to
eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best
intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for
clients on anticoagulation therapy.
A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a
serious side effect has occurred?
a. Hemoglobin: 14.2 g/dL
b. Platelet count: 82,000/L
c. Red blood cell count: 4.8/mm3
d. White blood cell count:
8.7/mm3 b
This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal
for either gender. A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is
best?
a. Assess for other manifestations of hypoxia.
b. Change the sensor on the pulse oximeter.
c. Obtain a new oximeter from central supply.
d. Tell the client to take slow, deep
breaths. a
Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing
normal or
,near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other
actions are not appropriate for a hypoxic client.
A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to
intubate for 40 seconds. What action by the nurse takes priority?
a. Ensure the client has adequate sedation.
b. Find another provider to intubate.
c. Interrupt the procedure to give oxygen.
d. Monitor the client's oxygen
saturation. c
Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should
interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation during
the procedure and monitor the client's oxygen saturation, but these do not take priority. Finding another provider
is not appropriate at this time.
An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority?
a. Determine if the tube is kinked.
b. Ensure all connections are patent.
c. Listen to the client's lung sounds.
d. Suction the endotracheal
tube. c
When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause),
obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral
breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the
nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.
A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel
(UAP)?
a. Assess the client for sedation needs.
b. Get family permission for restraints.
c. Provide frequent oral care per protocol.
d. Use nonverbal pain assessment
tools. c
The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other
actions fall within the scope of practice of the nurse.
A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the
respiratory therapist, what should the nurse ensure as a priority?
a. The client is able to initiate spontaneous breaths.
b. The inspired oxygen has adequate humidification.
c. The upper peak airway pressure limit alarm is off.
d. The upper peak airway pressure limit
alarm is on. d
The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This
is critical to prevent damage to the lungs. Alarms should never be turned off. Initiating spontaneous breathing is
important for some modes of ventilation but not others. Adequate humidification is important but does not take
priority over preventing injury.
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. a
The nurse needs to determine the cause of the agitation.
A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by
the nurse takes priority?
a. Assessing that the ventilator settings are correct
b. Ensuring 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 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 should know and check the
settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or
may not need suctioning on arrival.
A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) 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." d
Stress ulcers occur in many clients who are receiving mechanical ventilation, and often prophylactic medications
are used to prevent them. Frequently used medications include antacids, histamine blockers, and proton pump
inhibitors. Zantac is a histamine blocking agent.
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. c
The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a
patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs.
A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs
more education regarding this medication?
a. Hamburger and French fries
b. Large chef's salad and muffin
c. No selection; spouse brings pizza
d. Tuna salad sandwich and
chips b
Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high in vitamin K thus
interfere with its action and need to be eaten in moderate, consistent amounts. The chef's salad most likely has
too many leafy green vegetables, which contain high amounts of vitamin K. The other selections, while not
particularly healthy, will not interfere with the medication's mechanism of action.
A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible
barrier to self- management?
a. Poor visual acuity
b. Strict vegetarian
c. Refusal to stop smoking
d. Wants weight loss
surgery b
Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high in vitamin K thus
interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have trouble
maintaining this diet. The nurse should explore this possibility with the client. The other options are not related.
A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires
immediate intervention by the supervising nurse?
a. Assessing the client's platelet count
b. Choosing an 18-gauge, 2-inch needle
c. Not aspirating prior to injection
d. Swabbing the injection site with
alcohol b
Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions
are appropriate A client in the emergency department has several broken ribs. What care measure
will best promote comfort?
a. Allowing the client to choose the position in bed
b. Humidifying the supplemental oxygen
c. Offering frequent, small drinks of water
d. Providing warmed
blankets a
Allow the client with respiratory problems to assume a position of comfort if it does not interfere with care. Often
the client will choose a more upright position, which also improves oxygenation. The other options are less
effective comfort measures.
A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What
medication should the nurse anticipate the client will need as the priority?
a. Alteplase (Activase)
b. Enoxaparin (Lovenox)
c. Unfractionated heparin
d. Warfarin sodium
(Coumadin) a
Activase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows
this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this
setting.
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. Administer oxygen and reassess.
b. Auscultate the client's lung sounds.
c. Facilitate a portable chest x-ray.
d. Prepare to assist with
intubation. d
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.
A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best?
a. "It is chronic hypoxemia that accompanies restrictive airway disease."
b. "It is hypoxemia from lung damage due to mechanical ventilation."
c. "It is hypoxemia that continues even after the client is weaned from oxygen."
d. "It is hypoxemia that persists even with 100% oxygen
administration." d
Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign
of acute
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