NUR250 Final Group 3 - ARDS - NCLEX questions

NUR250 Final Group 3 - ARDS - NCLEX questions 4.8 (6 reviews) Students also studied Terms in this set (20) Science MedicineNursing Save Respiratory Saunders 13 terms Khurram_Shehzad5 Preview NCLEX Respiratory Nursing Teacher 10 terms milotic24Preview Respiratory - Saunders NCLEX-PN E...82 terms NURSE_FLUFFY Preview Saunde 30 terms mel

• The nurse is assessing a client with multiple trauma who

is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

• Bilateral Wheezing
• Inspiratory crackles
• Intercostal retractions
• Increased respiratory rate

Answer: D

Rationale: The earliest detectable sign of ARDS is an increased RR, which can

begin from 1-96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis.Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

• The low-pressure alarm sounds on a ventilator. The

nurse assesses and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action?

• Administer oxygen
• Check the client's vital signs
• Ventilate the client manually
• Start cardiopulmonary resuscitation

Answer: C

If at any time an alarm is sounding, and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin CPR. Checking vital signs is not the initial action. Although O2 is helpful, it will not provide ventilation to the client.

• The nurse is evaluating the client's response to

treatment of a pleural effusion with a chest tube. The nurse notes a respiratory rate of 20 breaths per minute, fluctuation of the fluid level in the water seal chamber, and a decrease in the amount of drainage by 30 mL since the previous shift. Based on this information, which interpretation should the nurse make?

• Water should be added to the water seal chamber
• The client is responding well to treatment
• Suction should be decreased to the system
• The system should be assessed for an air leak

Answer: B

Fluctuations in the water seal chamber is an expected and normal finding with a chest tube. Since the client is being treated for a pleural effusion, it can eb determined that they are responding well to treatment if the amount of drainage is gradually decreasing because drainage is being effectively removed. If drainage were to stop suddenly, the chest tube should be assessed for a kink or blockage.There is no indication to decrease suction, in fact it is unclear whether the client is hooked to suction at all. There is no data to indicate an air leak or need to add water to the water seal chamber.

• The nurse is trouble-shooting multiple ventilator alarms

sounding for a client who is intubated and being mechanically ventilated. The alarms persist despite suctioning, repositioning the client and ensuring that the ventilator tubing is unobstructed. Which actions will the nurse perform next? Select all that apply.

• Turn off all ventilator alarms until a cause is found to

prevent scaring the patient.

• Page the HCP to request additional sedation.
• Ensure that the endotracheal tube marking is at the

client's incisor

• Increase the PEEP to improve gas exchange
• Disconnect the client from the ventilator and use the

manual resuscitation bag

• Change all ventilator tubing
• STAT page the respiratory therapist.
• Determine when the client received the last dose of

the paralytic agent.

Answer: B, C, E, F

• The nurse caring for a client with an acute lung injury

understands ARDS is acute respiratory failure with these

features: Select all that apply.

• Reduced surfactant activity
• Bradycardia and decreased respiratory rate
• Hypoxemia that persists even after 100% oxygen

treatment

• Bilateral pulmonary edema
• Inflammation with formation of Aschoff bodies
• Dense pulmonary infiltrates on x-ray (ground glass

appearance)

Answer: A, C, D, F

Reduced surfactant activity causes decreased pulmonary compliance, a feature of ARDS. ARDS is associated with tachycardia and an increase in respiratory rate with intercostal retractions. Refractory hypoxemia is a cardinal feature of ARDS, along with pulmonary edema and "whited-out" appearance on x-ray. Inflammation associated with Aschoff bodies are features of Rheumatic carditis.

• A male adult patient on mechanical ventilation is

receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V.as needed. Which assessment finding indicates that the patient needs another pancuronium dose?

• Leg movement
• Finger movement
• Lip movement
• Fighting the ventilator

Answer: D

Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting encdotracheal intubation and paralyzing the patient so that the mechanical ventilator can do its work.Fighting the ventilator is a sign that the patient needs another pancuronium dose.The nurse should administer 0.01 to 0.02 mg/kg I.V. every 20 to 60 minutes.Movement of the legs, or lips has no effect on the ventilator and therefore is not used to determine the need for another dose.

• Nurse Ruth assessing a patient for tracheal

displacement should know that the trachea will deviate

toward the:

• Contralateral side in a simple pneumothorax
• Affected side in a hemothorax
• Affected side in a tension pneumothorax
• Contralateral side in hemothorax

Answer: D

The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax, accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation, the trachea will not shift. Tracheal deviation toward the contralateral side in simple pneumothorax is seen when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.

• A male patient's X-ray result reveals bilateral white-

outs, indicating adult respiratory distress syndrome

(ARDS). This syndrome results from:

• Cardiogenic pulmonary edema
• Respiratory alkalosis
• Increased pulmonary capillary permeability
• Renal failure

Answer: C

ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it does not cause ARDS. Renal failure does not cause ARDS, either.

• The nurse is caring for a client who is on a mechanical

ventilator. Blood gas results indicate a pH of 7.50 and a PaCO2 of 30mmHg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?

• Sodium level of 145 mEq/L
• Potassium level of 3.0 mEq/L
• Magnesium level of 1.3 mEq/L
• Phosphorus level of 4.3 mg/dL

Answer: B

Hypokalemia - Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids.This occurs in conditions that cause overstimulation of the respiratory system.Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.

• The nurse has a prescription to give a client

salmeterol, 2 puffs, and beclomethasone dipropionate, 2 puffs, by metered-dose inhaler. The nurse should administer the medication using which procedure?

• Beclomethasone first and then salmeterol
• Salmeterol first and then the beclomethasone
• Alternating a single puff of each, beginning with the

salmeterol

• Alternating a single puff of each, beginning with the

beclomethasone

Answer: B

Salmeterol is an adrenergic bronchodilator and beclomethasone is a glucocorticoid. Bronchodilators are always administered before glucocorticoids when both are to be given on the same time schedule. This allows for the widening of the air passages by the bronchodilator, which then makes the glucocorticoid more effective.

• Which of the following patients are MOST at risk for

developing pneumonia? Select-all-that-apply:

• A 53-year-old female recovering from abdominal

surgery.

• A 69-year-old patient who recently received the

pneumococcal conjugate vaccine.

• A 42-year-old male with COPD and is on continuous

oxygen via nasal cannula.

• A 8 month old with RSV (respiratory syncytial virus)

infection.The answers are A, C, and D.Rationale: Risks factors for pneumonia include: recent surgery, lung disorder (ex:

COPD), and viral infection (ex: RSV). Option B is a preventive measure in

preventing pneumonia.

• You're providing discharge teaching to a client who

was admitted for pneumonia. You are discussing measures the client can take to prevent pneumonia.Which of the following statements by the client indicates they did NOT understand your education material?

• "I'll use hand sanitizer regularly while I'm out in public."
• "It is important I don't receive the Pneumovax vaccine

since I'm already immune to pneumonia."

• "I will try to avoid large crowds of people during the

peak of flu season."

• "It is important I try to quit smoking."

The answer is B.Rationale: All the other options are correct statements regarding the prevention of pneumonia. However, option B is incorrect because although the patient has had pneumonia they should still receive the Pneumovax vaccine to prevent other forms of pneumonia.

• Which of the following are typical signs and symptoms

of pneumonia? Select-all-that-apply:

• Stridor
• Coarse crackles
• Oxygen saturation less than 90%
• Non-productive, nagging cough
• Elevated white blood cells
• Low PCO2 of less than 35
• Tachypnea

The answers are B, C, E, and G.Rationale: These are typical signs and symptoms of pneumonia. Stridor is not very common. A PRODUCTIVE cough that can be nagging is very typical, and there is usually a HIGH PCO2 of 45 or greater due to the lungs retaining carbon dioxide.

• A client has been hospitalized in the ICU for a near

drowning event. The client's respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS?

• infiltrates only on the upper lobes
• enlargement of the heart with bilateral lower lobe

infiltrates

• white-out infiltrates bilaterally
• normal chest x-ray

The answer is C.

Rationale: This is a finding found in ARDS....pronounce white-out infiltrates

bilaterally.

• A client is on mechanical ventilation with PEEP

(positive end-expiratory pressure). Which finding below indicates the client is developing a complication related to their therapy and requires immediate treatment?

• HCO3 26 mmHg
• Blood pressure 70/45
• PaO2 80 mmHg
• PaCO2 38 mmHg

The answer is B.

Rationale: Mechanical ventilation with PEEP can cause issues with intrathoracic

pressure and decrease the cardiac output (watch out for a low blood pressure) along with hyperinflation of the lungs (possible pneumothorax or subq emphysema which is air that escapes into the skin because the lungs are leaking air).