Q#1 A blood pressure of 121/93 The nurse is caring for a client who...

Question Answered step-by-step Q#1 A blood pressure of 121/93 The nurse is caring for a client who… Q#1A blood pressure of 121/93 The 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 o 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 ventilation Health Science Science Nursing NR 341 Share QuestionEmailCopy link Comments (0)