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MDC 4.
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?
- - ANS - -Respiratory acidosis, partially compensated
Silver sulfadiazine (Silvadene, Thermazene) - - ANS - -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? - - ANS - -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? - - ANS - -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? - - ANS - -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? - - ANS - -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? - - ANS - -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? - - ANS - -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? - - ANS - -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? - - ANS - -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? - - ANS - -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? - - ANS - -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? - - ANS - -
Encourage deep breathing and coughing
Rib fracture cause - - ANS - -blunt trauma to chest wall; CPR
Rib fracture pain - - ANS - -defensive movements
reduced depth of breathing
reduced clearing of secretions
Flail Chest - - ANS - -At least 2 neighboring ribs in 2 or more places
Paradoxical chest movement
Blunt trauma, CPR can Cause
Vasodilator (Nitroprusside) - - ANS - -decreases pulmonary artery pressure if
impeding cardiac contractility
, pulmonary embolism risk factors - - ANS - -prolonged immobility
central venous catheter
surgery
obesity
advancing age
hx. of thromboembolism
smoking
pregnancy
estrogen therapy
HF
stroke
trauma
Ventilatory and Oxygenation failure - - ANS - -bronchioles and alveoli are diseased
(oxygen failure), the work of breathing increases until respiratory muscles cannot
function effectively (ventilatory failure)
HYPOVENTILATION
ventilatory and oxygenation failure: people - - ANS - -chronic bronchitis
emphysema
CF
Asthma attack