A client who has been on a mechanical ventilator for three days develops a fever of 101 degrees Fahrenheit green sputum, and right lower lobe crackles. The nurse contacts the physician regarding possible development of which complication?

Ventilator -associated pneumonia

Pulmonary embolism

Stress ulcer

Pneumothorax

Answer and Explanation

The Correct Answer is A

A) Ventilator-associated pneumonia (VAP):
Ventilator-associated pneumonia (VAP) is a type of pneumonia that develops in patients who have been on mechanical ventilation for more than 48 hours. It is a common and serious complication in critically ill patients on ventilators. Symptoms such as fever, green sputum, and right lower lobe crackles are indicative of a respiratory infection, which, in this case, is most likely VAP. VAP typically presents with signs of infection such as elevated temperature, purulent sputum, and new infiltrates on a chest x-ray, in addition to lung crackles.

B) Pulmonary embolism (PE):
Although pulmonary embolism (PE) can cause symptoms like tachypnea, chest pain, and dyspnea, it does not typically cause a fever, green sputum, or localized crackles in the lungs. PE is usually characterized by sudden onset of respiratory distress, often accompanied by hemoptysis or chest pain, and would not typically present with the localized findings in the lower lobe (e.g., crackles).

C) Stress ulcer:
Stress ulcers can occur in critically ill patients, especially those on mechanical ventilation, due to the stress response and reduced blood flow to the stomach. However, stress ulcers typically cause gastrointestinal symptoms, such as melena (black, tarry stools) or hematemesis (vomiting blood).

D) Pneumothorax:
A pneumothorax occurs when air accumulates in the pleural space, causing a collapse of the lung. It can lead to symptoms such as sudden chest pain, dyspnea, and diminished breath sounds on one side of the chest. However, it would not typically cause fever, green sputum, or localized crackles.

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Correct Answer is C

Explanation

A) Take this medication as needed for pain:
Baclofen is a muscle relaxant typically prescribed for managing spasticity associated with multiple sclerosis (MS), rather than for pain. It should be taken as prescribed, typically on a scheduled basis rather than on an as-needed basis for pain. Misunderstanding this could lead to improper use of the medication and ineffective symptom management.

B) Stop the medication if I experience dry mouth:
Dry mouth is a potential side effect of baclofen, but it should not be the reason to stop the medication abruptly. Stopping baclofen suddenly can result in withdrawal symptoms and could potentially worsen spasticity. If dry mouth or other side effects are bothersome, the client should consult the healthcare provider for management options rather than discontinuing the medication abruptly.

C) Taper this medication off over 1-2 weeks:
This statement demonstrates a correct understanding of the proper way to discontinue baclofen. Baclofen should not be stopped suddenly due to the risk of withdrawal symptoms, which can include increased spasticity, hallucinations, or seizures. A gradual tapering of the dose over a period of 1 to 2 weeks is recommended to avoid withdrawal. This is the most appropriate and safe response.

D) Feel an increase in energy with this medication:
Baclofen is not a medication designed to increase energy. Its primary purpose is to reduce muscle spasticity, not to provide a stimulant effect. If the client expects an increase in energy, this could indicate a misunderstanding of the medication's effects. Baclofen's focus is on reducing spasticity and muscle tightness, not improving energy levels.

A. Heart rate of 130 beats per minute B. PH of 7.21 (normal 7.35-7.45) C. Serum potassium 5.7 mEq/L (normal 3,5-5.3) D. Platelet count 200,000 (normal 150,000-450,000)

Correct Answer is B

Explanation

A) Heart rate of 130 beats per minute
A heart rate of 130 beats per minute is tachycardia, which is often a compensatory response to injury, particularly in cases of trauma, blood loss, or shock. It is common in the initial phase after trauma as the body attempts to compensate for decreased blood volume or oxygen delivery. However, tachycardia alone is not typically fatal in the immediate post-injury period and can often be managed.

B) pH of 7.21 (normal 7.35–7.45)
A pH of 7.21 indicates acidosis, which is life-threatening and typically arises from shock, blood loss, or severe trauma. Acidosis occurs when the body is unable to compensate for lactic acid or other metabolic byproducts that accumulate due to insufficient oxygen delivery to tissues. In the case of a gunshot wound to the abdomen, there is a high risk of internal bleeding, hypoperfusion, and hypoxia, all of which can lead to metabolic acidosis. Severe acidosis can cause organ failure, particularly affecting the heart, kidneys, and brain.

C) Serum potassium 5.7 mEq/L (normal 3.5–5.3)
A serum potassium of 5.7 mEq/L is elevated, but it is moderately high and not typically life-threatening unless it reaches much higher levels (e.g., >6.0 mEq/L), which can cause cardiac arrhythmias. Elevated potassium can occur due to cellular injury (e.g., muscle trauma or rhabdomyolysis), but it would need to be corrected to prevent complications like arrhythmias.

D) Platelet count 200,000 (normal 150,000–450,000)
A platelet count of 200,000 is within the normal range (150,000–450,000) and does not indicate a problem with coagulation. The blood loss and the NG tube hemorrhage mentioned in the scenario suggest that the patient may be at risk for bleeding, but a platelet count in the normal range suggests that the body’s ability to form clots is likely intact.

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A client who has been on a mechanical ventilator for three days develops a fever of 101 degrees Fahrenheit green sputum, and right lower lobe crackles. The nurse contacts the physician regarding possible development of which complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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