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 B

Explanation

A) Determine when the patient last ate and call for spiritual advisor:
While it is important to gather a comprehensive history, including when the patient last ate, and to provide emotional support such as calling a spiritual advisor, these actions are not the priority in this situation. The immediate concern is the patient's physical condition and addressing the potential trauma to the chest and abdominal organs. Bowel sounds in the chest suggest a serious injury, such as a diaphragmatic rupture, which requires immediate surgical intervention.

B) Assess vital signs and immediately notify the trauma surgeon:
Hearing bowel sounds in the chest is a strong indication of a diaphragmatic injury, possibly a rupture, which can lead to the bowel being displaced into the chest cavity. This is a life-threatening emergency that can result in respiratory distress, impaired organ function, and infection. The nurse should assess vital signs to determine if the patient is stable or in shock and then immediately notify the trauma surgeon to facilitate urgent surgical intervention. Immediate surgical repair is necessary to prevent further complications such as respiratory compromise or sepsis.

C) Request an order for a chest x-ray and stop IV fluids:
A chest x-ray may be ordered later to confirm the presence of diaphragmatic injury or other chest trauma, but the priority action is to notify the trauma surgeon immediately. Stopping IV fluids is not appropriate in this situation; the patient likely needs continued fluid resuscitation, especially if they are in shock or have significant blood loss from their traumatic injuries.

D) Medicate the patient's pain and obtain consent for surgery:
Pain management is important for the patient’s comfort, but surgical intervention should not be delayed while obtaining consent. The trauma surgeon should be notified immediately, and surgery should be expedited without waiting for consent. In trauma cases, consent for life-saving procedures may be implied if the patient is unconscious or unable to provide consent due to the urgency of the situation.

Correct Answer is ["13.7"]

Explanation

Given:

Ordered dose of Furosemide: 1 mg/kg

Patient weight: 121 lbs

Concentration of Furosemide: 40 mg/10 mL (4 mg/mL)

Step 1: Convert patient weight from pounds to kilograms:

1 pound (lb) = 0.453592 kilograms (kg)

Patient weight in kg = 121 lbs x 0.453592 kg/lb = 54.877832 kg

Step 2: Calculate the total dose of Furosemide:

Total dose (mg) = Ordered dose (mg/kg) x Patient weight (kg)

Total dose (mg) = 1 mg/kg x 54.877832 kg

Total dose (mg) = 54.877832 mg

Step 3: Calculate the volume to be administered:

Volume (mL) = Total dose (mg) / Concentration (mg/mL)

Volume (mL) = 54.877832 mg / 4 mg/mL

Volume (mL) = 13.719458 mL

Step 4: Round to the nearest tenth:

Volume (mL) ≈ 13.7 mL

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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

The nurse is caring for a patient with multiple traumatic injuries following an occupational accident where the patient fell from a 30ft high ladder. Upon assessment, the-nurse hears bowel sounds in the chest. What should the nurse do next?

Correct Answer is B

Explanation

A patient is ordered 1 mg/kg of furosemide IV push. The patient weights 121 lbs. The medication is supplied 40 mg/10 mL. How many mL should the nurse administer? (round to the nearest tenth)

Correct Answer is ["13.7"]

Explanation

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