Nursing NUR408 Exam 2 – Practice Questions and Answers Study Guide
What are some risk factors for a PE?( - ANS ✔✔- prolonged immobilization
- central lines
- surgery (long bone surgeries)
- pregnancy
- obesity
- advancing age
- conditions that increase clotting
- hx of thromboembolism (have developed a clot and it moved)
What are some teaching points to help prevent PEs? - ANS ✔✔*prevention
- smoking cessation
- reducing weight
- staying active
- if traveling drinks lots of water, change positions while on long flights, avoid crossing legs, get
up and walk
What do thrombolytics do? - ANS ✔✔Break up clots
(end in -ase)
Why might someone who has a PE be on anticoags? - ANS ✔✔it will prevent the clot from
getting bigger
What are some labs you might see in someone who is in acute respiratory failure? - ANS
✔✔Pao2 > 60 OR
Paco2 > 45 w/ pH < 7.35 w/ SaO2 <90%
,Examples of intervention for acute respiratory failure - ANS ✔✔- O2: NC @ 2L up to intubation
- Drug therapy: furosemide, fluids, Bicarb
- position of comfort: vent changes, sit them where they can breath
What is ARDS? - ANS ✔✔Acute respiratory distress syndrome/ "stiff lung" : hypoxemia that
persists even when 100% of o2 is given, decreased pulmonary compliance/lungs won't expand,
co2 exchange can't happen
What might you see during a physical assessment in a pt who has ARDS? - ANS ✔✔- hyperpnea
- noisy respiration
- cyanosis
- pallor
- intercostal or substernal retraction
- see "broken glass"/gray and white on xray
Intervention for ARDS? - ANS ✔✔- ET intubation & mechanical ventilation w/ PEEP or CPAP
- Drug therapy: antibiotics
- Nutrition therapy via NG tube
ET tube placement steps - ANS ✔✔1- ET tube placed/intubated
2- give 6 breaths
3- co2 detector, yellow is good (purple is bad)
4- listen for breath sounds, see rise
Examples of chest trauma - ANS ✔✔- pulmonary contusion
- rib fracture
, - flail chest: more than one part of the rib has been fractured, "balloons out"
- pneumonothorax
- hemothorax
(- tension pneumonothorax)
Difference between dry and wet chest tube placement - ANS ✔✔- Dry: can DIAL suction up to
40
- Wet: can only go up to 20
The nurse is caring for four clients. Which client does the nurse identify at greatest risk of
developing acute respiratory distress syndrome (ARDS)?
A.24-year-old male admitted with blunt chest trauma and aspiration
B.39-year-old male with a history of alcohol abuse and chronic pancreatitis
C.70-year-old male post heart valve surgery receiving 1 unit of packed red blood cells
D.84-year-old female on antibiotics for pneumonia - ANS ✔✔A
A client is being discharged to home on warfarin therapy after an acute pulmonary embolism
(PE). Which client response indicates a need for further teaching by the nurse?
A."I should limit my alcohol consumption."
B."I should drink more green tea and cranberry juice."
C."I should take the medication at the same time every day."
D."I should make an appointment for weekly blood draws." - ANS ✔✔B - pt likely going home
on anticoags, foods to avoid - (leafy green vegetables, green tea, alcohol, cranberry juice)
A client in acute respiratory failure is classified as having ventilatory failure. The nurse
understands that which finding is a potential extrapulmonary cause of ventilatory failure?
What are some risk factors for a PE?( - ANS ✔✔- prolonged immobilization
- central lines
- surgery (long bone surgeries)
- pregnancy
- obesity
- advancing age
- conditions that increase clotting
- hx of thromboembolism (have developed a clot and it moved)
What are some teaching points to help prevent PEs? - ANS ✔✔*prevention
- smoking cessation
- reducing weight
- staying active
- if traveling drinks lots of water, change positions while on long flights, avoid crossing legs, get
up and walk
What do thrombolytics do? - ANS ✔✔Break up clots
(end in -ase)
Why might someone who has a PE be on anticoags? - ANS ✔✔it will prevent the clot from
getting bigger
What are some labs you might see in someone who is in acute respiratory failure? - ANS
✔✔Pao2 > 60 OR
Paco2 > 45 w/ pH < 7.35 w/ SaO2 <90%
,Examples of intervention for acute respiratory failure - ANS ✔✔- O2: NC @ 2L up to intubation
- Drug therapy: furosemide, fluids, Bicarb
- position of comfort: vent changes, sit them where they can breath
What is ARDS? - ANS ✔✔Acute respiratory distress syndrome/ "stiff lung" : hypoxemia that
persists even when 100% of o2 is given, decreased pulmonary compliance/lungs won't expand,
co2 exchange can't happen
What might you see during a physical assessment in a pt who has ARDS? - ANS ✔✔- hyperpnea
- noisy respiration
- cyanosis
- pallor
- intercostal or substernal retraction
- see "broken glass"/gray and white on xray
Intervention for ARDS? - ANS ✔✔- ET intubation & mechanical ventilation w/ PEEP or CPAP
- Drug therapy: antibiotics
- Nutrition therapy via NG tube
ET tube placement steps - ANS ✔✔1- ET tube placed/intubated
2- give 6 breaths
3- co2 detector, yellow is good (purple is bad)
4- listen for breath sounds, see rise
Examples of chest trauma - ANS ✔✔- pulmonary contusion
- rib fracture
, - flail chest: more than one part of the rib has been fractured, "balloons out"
- pneumonothorax
- hemothorax
(- tension pneumonothorax)
Difference between dry and wet chest tube placement - ANS ✔✔- Dry: can DIAL suction up to
40
- Wet: can only go up to 20
The nurse is caring for four clients. Which client does the nurse identify at greatest risk of
developing acute respiratory distress syndrome (ARDS)?
A.24-year-old male admitted with blunt chest trauma and aspiration
B.39-year-old male with a history of alcohol abuse and chronic pancreatitis
C.70-year-old male post heart valve surgery receiving 1 unit of packed red blood cells
D.84-year-old female on antibiotics for pneumonia - ANS ✔✔A
A client is being discharged to home on warfarin therapy after an acute pulmonary embolism
(PE). Which client response indicates a need for further teaching by the nurse?
A."I should limit my alcohol consumption."
B."I should drink more green tea and cranberry juice."
C."I should take the medication at the same time every day."
D."I should make an appointment for weekly blood draws." - ANS ✔✔B - pt likely going home
on anticoags, foods to avoid - (leafy green vegetables, green tea, alcohol, cranberry juice)
A client in acute respiratory failure is classified as having ventilatory failure. The nurse
understands that which finding is a potential extrapulmonary cause of ventilatory failure?
