Q#1 The nurse is caring for a client who has ‘do not resuscitate…

QuestionAnswered step-by-stepQ#1 The nurse is caring for a client who has ‘do not resuscitate…Q#1The nurse is caring for a client who has ‘do not resuscitate order on the chart’. The nurse is making hourly rounds and find the client pale and pulseless. Which is the appropriate nursing action?o  Induce basic life support.o  Call the rapid response teamo  Notify the primary healthcare providero  Give emergency medication and withhold incubation.Q#3The nurse is caring for a client receiving mechanical ventilation with the vital signs and settings depicted below. During daily rounds, the primary healthcare provider informs the nurse to increase the positive end-expiratory pressure (PEEP) on the ventilator to 100 cm H2O and obtain a sputum sample. What is the priority nursing action? Vital Signs Mechanical Ventilator Settings Heat rate: 98Pulse oximetry; 78%Blood pressure: 120/80 mm/HgRespiratory rate: 28 breaths per minute Mode: SIMWFiO2: 60%RR: 14PEEP: 5cm H2OVT: 35cm H2O  o  Obtain the sputum sampleo  Increase the PEEP as orderedo  Decrease the respiratory rate insteado  Continue to monitor the clientQ#4When planning to perform terminal wearing for a client at the end-of-life, it is important to inform the family of what aspect of care?o  The ventilator setting that will be decreased.o  Feedings will continue as the client is not hungry.o  Pain will be controlled during the weaning processo  Only 3 family members be will be permitted at the beside.Q#5The nurse is caring for a client who is mechanically ventilated. The nurse is repositioning the client when the endotracheal tube is dislodged. The client is not showing any obvious signs of distress. What is the priority nursing action?o  initiate CPR and call a codeo  Notify the primary healthcare providero  Remove the tube and reintubate the cliento  Manually ventilate the clientQ#6An intensive care nurse is receiving bedside report from members of the healthcare team for further management care. What information would require immediate action by the oncoming team?o  Client has absent breath sounds noted throughout ling fields on auscultation.o  Client has a pulse-oximetry reading of 90% on room airo  Client is on a ventilator in assist control (A/C) mode.o  Client has a prolonged exhalationQ#7To determine the effects of therapy for a client who is being treated for heart failure, which laboratory test results will the nurse plan to review?o  Troponino  B-type natriuretic peptide (BNP)o  Homocysteine (Hcy)o  Low-density lipoprotein (LDL)Q#8The nurse is caring for a client after a cardiac catheterization, which assessment finding is most concerning to the nurse?o  Palpable pedals pulseso  Slight swelling at the catheter insertion siteo  Pain at the insertion site rates as 4 on a scale of 0-10.o  Bright red blood at the catheter insertion siteQ#9Which findings by the nurse should result in postponing the spontaneous breathing trials for a client receiving mechanical ventilation?o  Enteral nutrition is being given through an orogastric tube.o  Scattered rhonchi are heard when auscultating breath soundso  New ST segment elevation is observed on the cardiac monitor.o  Hydromorphone is being used to treat postoperative pain.Q#10A client with acute respiratory distress syndrome on mechanical ventilation is becoming increasingly restless. The client blood pressure is 90/60 mm/Hg, heart rate is 128 beats/min and oxygen saturation is 88% on FiO2 of 50%. Coarse rhonchi are audible in all lung fields on auscultation. What is the best nursing action?o  Hyper-oxygenate with 100% oxygen and suction the client.o  Administer neuromuscular blockade as ordered.o  Increase PEEP to 10 and sedate the client.o  Increase FiO2 to 60% for five minutes.Q#11When assessing client for ventilator- associated pneumonia (VAP), it is most important for the nurse to report which findings to primary care provider?o  A temperature of 98 o  A blood pressure of 121/93o  A chest x-ray with localized infiltrateso  A leukocyte counts of 9000 cells/ microliterQ#12A client with chronic obstructive pulmonary disease who was hospitalized with acute respiratory syndrome is being discharged on albuterol. Which information is most important for the nurse to client regarding this medication?o  ‘Report increased nervousness or heart palpations’o  ‘Rinse mouth with water after using inhaler’o  ‘Use salmeterol prior to albuterol as needed’o  ‘Report nausea and vomiting after use.’Q#13A client comes to Emergency Department (ED) with acute respiratory failure. Which prescription would the nurse complete first?o  Order chesty x-ray.o  Obtain sputum sample.o  Obtain arterial blood gaseso  Order pulmonary function test.Q#14To evaluate the effectiveness of albuterol in a client with an acute asthma attack, which nursing assessment would be best?o  Presence of pulses paradoxeso  Client’s use of accessory muscleso  Client’s ability to speak without difficultyo  Peak expiratory flow reading compared with baseline.Q#15The nurse is caring for a client with pneumonia. To prevent complications, which nursing action(s) should be initiated? [Select all that apply]o  Administer flu vaccine prior to discharge.o  Restrict oral intake to prevent fluid overload.o  Obtain blood culture prior to starting antibiotics.o  Administer first dose of antibiotics within 24 hours of admissiono  Instruct client to take prescribed antibiotics until medication is goneQ#16A client receiving treatment for pulmonary emboli has a pulse oximetry reading of 95%. What action should the nurse take?o  Administer bronchodilatoro  Increase oxygen flow rate to 4L/mino  Document findings and continue to monitoro  Notify primary healthcare provider of need for intubation.Q#17The nurse is caring for a client admitted with adult respiratory disease syndrome (ARDS). Which assessment findings would be most concerning?o  Rapid heart rateo  Client complains of shortness of breatho  Chest x-ray results of opacityo  Crackles heard on auscultationQ#18The nurse is caring for a client on a ventilator. To prevent pneumonia, the nurse would provide which instruction(s) to the healthcare team? [Select all that apply]o  Administer omeprazoleo  Keep client in the supine positiono  Assess client for readiness to wean dailyo  Provide oral care with chlorahexidineo  Ambulate the client in the hallway two times per day.Q#19Prone positioning is being used for client with acute respiratory distress syndrome (ARDS). Which information obtained by the nurse indicates that the positioning is effective?o  The client’s PaO2 is 89 mm Hg, and the SaO2 is 91%o  Endotracheal suctioning results in clear mucous returno  Sputum and blood cultures show no growth after 48 hourso  The skin on the client’s back is intact and without rednessQ#20A client in respiratory distress on CPAP with an FiO2 of 50% has the following ABG results: pH 7.50, PaO2 52 mmHg, PaCO2 29 mmHg, HCO3 22 mEq/L. Respirations are rapid and shallow. Which action should the nurse initiate first? o  Administer sodium bicarbonate IV pusho  Administer midazolam (Versed) IV pusho  Increase FiO2 to 70% and redraw ABGs in 30 minuteso  Prepare client for intubation and mechanical ventilationQ#21A nurse caring for a client with acute respiratory failure on mechanical ventilation. To prevent complications, which assessment would be most important for the nurse to include in the plan of care?o  A 0- 10 pain assessmento  Psychosocial nursing assessmento  A complete skin assessment o  The client’s ability to communicateQ#22The nurse is assessing a client with chronic obstructive pulmonary disease whose pulse oximetry reading is 85% on room air. Which instruction would the nurse give to the licensed practical nurse (LPN)?o  ‘Apply oxygen via rebreather mask at 2L/min.’o  ‘Prepare client for intubation and mechanical ventilation’o  ‘Administer oxygen and quickly increase rate to 10 L/min.’o  ‘Apply oxygen and slowly increase to a flow rate of 4L/min.’Q#23A nurse is analysing a client’s lab values. What lab can influence the client’s oxygenation status?o  D-dimer assayo  Glomerular filtration rateo  Percentage of neutrophilso  Hemoglobin levelQ#24The primary healthcare provider ordered an IV infusion of magnesium sulfate at 7 mL/hr. The medication available is 10, 000 mg of magnesium sulfate in 500 mL NS. How many mg is the client receiving per minute? (If needed, round to the nearest tenth.) Write the number only.   Q#25The primary healthcare provider ordered an IV infusion of nitroprusside at 0.3 mcg/kg/min. The client weighs 68 lb. How many mg is the client receiving per minute? Write the number only (Do not round)   Q#26The healthcare team I conducting a spontaneous breathing trial using continuous positive airway pressure (CPAM). The nurse notes nasal flaring and retractions. The client heart rate is 130 beats/min, blood pressure 165/90 mm Hg, respiratory rate 7 breath/min. Which is t5he priority nursing action?o  Place the client in the prone positiono  Liberate the client from the ventilatoro  Obtain an order for arterial blood gaseso  Assess airway patency and manually ventilate the client.Q#27Four hours after mechanical ventilation is initiated, a client’s arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23mmol/L). What change should the nurse anticipate to the ventilator setting?o  Increase the FiO2o  Increase the tidal volume o  Increase the respiratory rateo  Decrease the respiratory rateQ#28The nurse reviews the complete blood cell (CBC) count results for a client who is scheduled for surgery. The results are white blood cell (WBC) count 10.2 * 103/uL, haemoglobin 15 g/dL; haematocrit 45%; platelets 150 * 103/uL. Which action should the nurse take?o  Notify the surgeon and anesthesiologist immediatelyo  Ask the client about any symptoms of a recent infectiono  Continue to prepare the client for the surgical procedureo  Discuss the possibility of blood transfusion with the clientQ# 29The nurse obtains a blood pressure of 176/82 mm Hg for a client. What is the client’s mean arterial pressure (MAP)? (Round to the nearest whole number) Write the number only.  Q# 30While in the holding area, a client reveals to the nurse that his father had a high fever after surgery. What action taken by the nurse is a priority?o  Place a medical alert sticker on the front of the client’s chart.o  Alert the anesthesia care provider of the family member’s reaction to surgery.o  Give 650 mg of acetaminophen per rectum as a preventive measureo  Reassure the client that his temperature will be monitored closely after surgery.Q#31 When caring for a client who has received a general anesthetic, the circulating nurse notes red, raised wheals on the client’s arms. Which is the best nursing action?o  Apply lotion to the affected areaso  Cover the arms with sterile drapeso  Recheck the client’s arms during surgeryo  Notify the anesthesia care practitioner (ACP)Q#32Which actions will the nurse include in the surgical time-out procedure before surgery?o  Have the client state name and date of birtho  Assess the client’s urine outputo  Check for patency of IV lineso  Have the surgeon identify the clientQ#33A postoperative client has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first?o  Perform a bladder scano  Insert a straight cathetero  Encourage increased oral fluid intakeo  Assist the client to ambulate to the bathroomQ#34The nurse is caring for a mechanically ventilated client and responds to a high peak respiratory pressure alarm. Which are possible causes for the alarm? [Select all that apply]o  Agonal breathingo  Secretions in the airwayo  Kinks in the ventilator tubingo  Coughing or attempting to talko  Disconnection from the ventilator Q#35The nurse is attempting to wean a client from the ventilator. The client is not tolerating the weaning process. Which assessment findings are potential causes of difficulty weaning? [Select all that apply]o  Hemoglobin 8g/dLo  Blood pressure 100/98 mmHgo  Decreasing level of consciousnesso  Cardiac output of 4 liters per minuteo  Bilateral infiltrates noted on chest x-rayQ#36The nurses is caring for an unresponsive terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be appropriate?o  Suction the patient’s moutho  Administer oxygen via face masko  Document Cheyne-Stokes respirationso  Place the patient in high Fowler’s positionQ#37The nurse is caring for a patient with lung cancer in a home hospice program. Which action by the nurse is appropriate?o  Discuss cancer risk factors and appropriate lifestyle modificationso  Teach the patient about the purpose of chemotherapy and radiationo  Encourage the patient to discuss past life events and their meaningso  Accomplish a thorough head-to-toe assessment several times a weekQ#38A hospice nurse who has become close to a terminally ill patient is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time?o  Contact a grief counsellor as soon as possibleo  Cry along with the patient’s family memberso  Leave the home quickly to allow the family to grieve privatelyo  Consider leaving the hospice work because patient losses are commonQ#39The nurse admits a terminally ill patient to the hospital. What is the first action that the nurse should complete when planning the patient’s care?o  Determine the patient’s wishes regarding end-of-life careo  Emphasize the importance of addressing any family issueso  Discuss the normal grief process with the patient and familyo  Encourage the patient to talk about the fears or unresolved issuesQ#40A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results pH 7.32, PaO2 88 mmHg, PaCO2 37mmHg, and HCO3 16 mEq/L. How should the nurse interpret these results?o  Metabolic acidosiso  Metabolic alkalosiso  Respiratory acidosiso  Respiratory alkalosisQ#41The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider?o  Oral temperature of 100.1 OFo  Serum sodium level of 138 mEq/L (138 mmol/L)o  Gradually decreasing level of consciousness (LOC)o  Weight gain of 2 pounds (1 kg) over the admission weightQ#42Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines and medications delegate to a licensed practical/vocational nurse (LPN/LVN)?o  Flush a saline lock with normal salineo  Verify blood products prior to administrationo  Remove the patient’s central venous cathetero  Titrate the flow rate of vasoactive IV medicationsQ#43During the administration of the thrombolytic agent to a client with an acute myocardial infarction, the nurse should stop the drug infusion if the client experiences which abnormal cues?o  Bleeding from the gumso  A decrease in level of consciousnesso  Increase in blood pressureo  A non-sustained episode of ventricular tachycardiaQ#44Which electrocardiographic (ECG) change is most important for the nurse to report to the healthcare provider when caring for a client with chest pain?o  Inverted P waveo  Sinus tachycardiao  ST-segment elevationo  Sinus bradycardia Q#45Dopamine 4 mcg/kg/min is ordered for a client who weighs 175lbs. The solution available is 400mg of Dopamine in 250mL D5W. To infuse by infusion pump. How many mg/min will have infused? Write the number only (Do not round)   Q#46The nurse notes during the pre-operative assessment that her patient who has not had any prior surgeries says “for some reason my arm feel very itchy when you touched them wearing those gloves and it appears red over”. Which action is most important for the nurse to take?o  Notify the dietician about the specific food allergieso  Alert the physician about the possible latex allergyo  Reassure the patient that all allergies are noted on the health recordo  Ask whether the patient uses antihistamines to reduce allergic reactionsQ#47The nurse is caring for a client with a possible myocardial infarction. Which intervention should the nurse anticipate in the initial plan of care?o  12 lead ECG within 25 minutes of arrival.o  Cardiac catheterization within 90 minutes of arrival if STEMI is notedo  Administer beta blockers within 48 hours of admissionQ#48Which action should the nurse perform when preparing a client with supraventricular tachycardia for cardioversion who is alert and has blood pressure of 110/66mmHg?o  Give a sedative before cardioversion is implementedo  Turn the synchronizer switch to the “off” position.o  Set the defibrillator/cardioverter energy to 360 jouleso  Provide assisted ventilations with a bag-valve-mask deviceQ#49A client develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mmHg, and is complaining of feeling faint. Which action should the nurse take next?o  Apply the transcutaneous pacemaker (TCP) padso  Recheck the heart rhythm and BP in 5 minuteso  Have the client perform the Valsalva maneuver o  Give the scheduled dose of diltiazem Q#50A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?o  Sinus tachycardiao  Atrial fibrillationo  Sinus bradycardiao  First degree AV blockQ#51Identify the above rhythmo  Ventricular tachycardiao  Ventricular fibrillationo  Asystoleo  Torsade de pointesQ#52A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?o  Left ventricular failureo  Fluid overloado  Intra-cardial shunto  Hypovolemia Q#53A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditionso  Intracranial pressureo  Spinal cord perfusiono  Hemodynamic statuso  Renal functionQ#54A nurse is caring for a client who just had a cardiac catheterization. Which of the following nursing interventions should the nurse include in the client’s plan of care? (Select all that apply)o  Check peripheral pulses in the affected extremityo  Place the client in high-Fowler’s positiono  Measure the client’s vital signs every 4 hourso  Keep the client’s hip and leg extendedo  Have the client remain in bed up to 6 hours.Q#55The nurse notices the following rhythm on the cardiac monitor. What is the best nursing action?o  Start dopamine infusion to stimulate heart functiono  Begin transcutaneous pacing of the patiento  Give atropine to increase heart rateo  Assess for hemodynamic instabilityQ#56The nurse notices ventricular tachycardia on the heart monitor. When the client is assessed, the client is found to be unresponsive with no pulse. What is the best nursing action?o  Treat with intravenous amiodarone or lidocaineo  Begin cardiopulmonary resuscitation and advanced life supporto  Provide electrical cardioversiono  Ignore the rhythm because it is benignQ#57The nurses is assessing a client with left-sided heart failure. Which symptoms would the nurse expect to find?o  Dependent edemao  Distended neck veinso  Dyspnea and crackleso  Nausea and vomitingQ#581.    Which therapeutic interventions may be withdrawn or withheld from the terminally ill client? (Select all that apply)o  Antibioticso  Dialysiso  Nutritiono  Pain medicationso  Simple nursing interventions such as repositioning and hygieneQ#591.    The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The physician orders a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient continues to “fight” the ventilator. What physician order does the nurse anticipate?o  Continuous lateral rotation therapyo  Guided imageryo  Neuromuscular blockadeo  Prone positioningQ#60The nurse in the ICU should recognize which ABG finding as associated with acute respiratory failure?o  PaO2 is 70mmHg and PaO2 is 48 mmHgo  PaO2 is 80mmHg and SaO2 is 96%o  PaO2 is 60mmHg and SaO2 is 90%o  PaO2 is 46mmHg and PaO2 is 67mmHgQ#61A nurse in the ICU suspects that a patient is developing hypoxia. Which assessment finding is one of the earliest findings as hypoxia develops?o  Restlessnesso  Tachycardiao  Intercostal muscle retractionso  Cyanosis Q#62A nurse in the ICU is caring for a patient who was just placed on a ventilator for treatment of acute respiratory distress syndrome (ARDS). Which strategy is the most likely to prevent ventilator-induced lung injury (VILI)?o  Tidal volume (Vt) between 4 and 8 mL/kgo  PEEP greater than 25 cm H2Oo  Intravenous fluid rate greater than 200 mL/houro  Maintain PaCO2 less than 35 mmHgQ#63A nurse is caring for a mechanically ventilated patient and notes the high pressure alarm sounding. The nurse cannot quickly identify the cause of the alarm and notes the patient’s oxygen saturation is decreasing and heart rate and respiratory rate are increasing. What is the nurse’s priority action?o  Ask respiratory therapist to get a new ventilatoro  Call the rapid response team to assess the patient.o  Manually ventilate the patiento  Continue to find the cause of the alarm and fix itQ#64A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85mmHg, and HCO3 25mEq/L. The patient’s current ventilator settings are A/C mode, Vt 500, RR 18, PEEP 10, FiO2 60%. The nurse would anticipate an order for the change in:o  An inverse ration setting of 2:1o  The respiratory rate to 20 bpmo  The FiO2 to 100%o  The respiratory rate to 14 bpmQ#65Which is positive and expiratory pressure (PEEP) used when a patient is placed on mechanical ventilation?o  Permit smaller tidal volumes with permissive hypercapniao  Prevent alveolar collapse throughout the respiratory cycleo  Promote complete emptying of the lungs during exhalationo  Provide for delivery of 100% oxygen to the lungs under pressureQ#66The ICU nurse is attempting to wean a patient from the ventilator. The nurse would stop the weaning process if assessment findings indicated: [Select all that apply]o  Oxygen saturation ? 90%o  Respiratory rate of 25bpmo  Heart rate change 10% from baselineo  Agitation Q#67After change-of-shift report on a ventilator weaning unit, which patient should the nurse assess first?o  Patient who failed a spontaneous breathing trial and has been placed in a rest mode on the ventilatoro  Patient who is intubated and has continuous partial pressure end-tidal CO2 (PETCO2) monitoringo  Patient who was successfully weaned and extubated 4 hours ago and has no urine output for the last 6 hours.o  Patient with a central nervous O2 saturation (ScvO2) of 69% while on bi-level positive airways pressure (BiPAP)Q#68The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows a potentially lethal rhythm. The patient has no pulse. The patient does not have a “do not resuscitate” order written on the chart. What is the appropriate nursing action?o  Contact the attending physician immediately to determine if CPR should be initiated.o  Contact the family immediately to determine if they want CPR to be started.o  Give emergency medications but withhold intubationo  Initiate CPR and call a code.Q#69A patient’s ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from 0.6 to 0.7 and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patient’s blood pressure drops from 120/76 mmHg to 90//60 mmHg. What is the most likely cause of this decrease in blood pressure?o  Decrease in cardiac outputo  Hypovolemiao  Increase in venous returno  Oxygen toxicityQ#70A patient’s endotracheal tube is not secured tightly. The respiratory care practitioner assists the nurse in taping the tube. After the tube is re-taped, the nurse auscultates the patient’s lungs and notes that the breath sounds over the left lungs fields are absent. The nurse suspects which of the following?o  The endotracheal tube is in the right mainstem bronchuso  The patient has a left pneumothoraxo  The patient has aspirated secretions during the procedureo  The stethoscope earpiece is clogged with wax    Health ScienceScienceNursingNR 341Share Question

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