well answered
The nurse is caring for a client with infection. Which condition should the nurse consider as a
precursor to septic shock? - ANS ✔✔SIRS
In assessing a patient's arterial blood gases, who is diagnosed with early stage acute respiratory
failure, the nurse would expect to see which of the following results? - ANS ✔✔pH 7.48, PaCO2
30mm Hg, HCO3 26mm Hg, PaO2 52 mm Hg, SaO2 90%
Which of the following is a common complication due to decreased lung compliance and
mechanical ventilation? - ANS ✔✔pneumothoraces
A client has been admitted to the CCU in severe distress with acute respiratory failure. Initial
arterial blood gases are pH 7.33, PaCO2 65, HCO3 30, PaO2 65, SaO2 90. What is the most
important nursing action? - ANS ✔✔prepare for intubation
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a
client who has a tracheostomy tube and is receiving mechanical ventilation. What action should
the critical care nurse recommend when caring for the cuff? - ANS ✔✔monitor cuff at least
every 8 hours
A client in the intensive care unit with congestive heart failure is demonstrating shortness of
breath and complains of pleuritic chest pain. Which conditions associated with heart failure,
should the nurse most suspect in this client? - ANS ✔✔transudative pleural effusion
The nurse is evaluating the chest radiograph of a critically ill client and notices that the client's
trachea has shifted to the left of midline. What additional finding would confirm the presence of
a pneumothorax? - ANS ✔✔absent or diminished breath sounds on the right
, The client is being monitored with an end-tidal CO2 monitor and has values trending upward.
For which acid-base abnormally should the nurse assess? - ANS ✔✔respiratory acidosis
A client with ARDS requires mechanical ventilation but is at risk for barotrauma. The nurse
should anticipate which ventilator mode in the care for this client? - ANS ✔✔pressure-
controlled ventilation mode
A client in the critical care unit is orally intubated. The nurse notices that a pressure sore is
forming on the client's lip where it comes into contact with the endotracheal tube. Which
nursing action is most appropriate? - ANS ✔✔repositioning the endotracheal tube from one
side to the other
The nurse is assisting with endotracheal intubation. In what circumstances should the nurse
question the use of nasotracheal intubation? - ANS ✔✔acute sinusitis
A client is being supported with endotracheal intubation and mechanical ventilation is
becoming increasingly agitated? What is the most appropriate nursing intervention? - ANS
✔✔obtain arterial blood gas measurement
A client in severe congestive heart failure is at risk for the development of acute respiratory
failure and is receiving supplemental oxygen therapy. What nursing assessment parameter is
most indicative of acute respiratory failure? - ANS ✔✔arterial PaO2 45mm Hg
The client is being supported with mechanical ventilation and requires high levels of inspired
oxygen to maintain his arterial blood gases at acceptable levels. In an attempt to reduce the
amount of oxygen required, positive end expiratory pressure (PEEP). - ANS ✔✔increases
number of open alveoli
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a
water seal chest tube drainage system. There is fluid in the water seal column is fluctuating with