MDC 4 NUR 2755 Exam 2: Multidimensional Care IV Questions and Answers (Scored A)

The patient is a 54-year-old male with history of COPD, who was rushed to the emergency department with increasing shortness of breath, pyrexia, and a productive cough with yellow-green sputum. Measurement of arterial blood gas shows pH 7.3, PaCO2 68 mmHg, HCO3 28 mmol/L, and PaO2 60 mmHg. How would you interpret this? - ANSWER Respiratory acidosis, partially compensated Silver sulfadiazine (Silvadene, Thermazene) - ANSWER Watch for allergic reaction causing a drop in white blood cell count. Do not use if reaction to sulfonamide has occurred. Use on deep partial-thickness or full-thickness wounds. Monitor wounds for infection A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/min. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which of the following? - ANSWER An increased pH with an increased HCO3 A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Based on this documentation, which of the following did the nurse observe? - ANSWER Respirations that are labored and increased in depth and rate A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? - ANSWER Decreased lung compliance A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? - ANSWER Sudden onset of dyspnea A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? - ANSWER Chest tube insertion A nurse is caring for a client who is experiencing acute opioid toxicity. Which of the following actions should the nurse identify as the priority? - ANSWER Ensure an adequate airway A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is experiencing shortness of breath. Which of the following actions should the nurse perform first? - ANSWER Place the client in an upright position A nurse is assessing a client who has pharyngitis. Which of the following findings is the nurse's priority to report to the provider? - ANSWER Inspiratory stridor A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen therapy at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? - ANSWER Increase the oxygen flow and request an arterial blood gas determination A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take? - ANSWER Instruct the client to perform the Valsalva maneuver during removal A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse take first? - ANSWER Encourage deep breathing and coughing Rib fracture cause - ANSWER blunt trauma to chest wall; CPR Rib fracture pain - ANSWER defensive movements reduced depth of breathing reduced clearing of secretions Flail Chest - ANSWER At least 2 neighboring ribs in 2 or more places Paradoxical chest movement Blunt trauma, CPR can Cause Vasodilator (Nitroprusside) - ANSWER decreases pulmonary artery pressure if impeding cardiac contractility pulmonary embolism risk factors - ANSWER prolonged immobility central venous catheter surgery obesity advancing age hx. of thromboembolism smoking pregnancy estrogen therapy HF stroke