A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end- expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider?

Respiratory rate 22 breaths/min

Heart rate 106 beats/min

02 saturation of 99%

Crackles audible at lung bases

Answer and Explanation

The Correct Answer is D

D Crackles audible at the lung bases indicate the presence of pulmonary edema or fluid accumulation in the alveoli, which can compromise gas exchange and exacerbate respiratory distress. In a patient with ARDS, crackles suggest worsening pulmonary status and may indicate inadequate ventilation or oxygenation despite mechanical ventilation. Therefore, crackles at the lung bases are the most important finding to report to the healthcare provider as they may indicate a need for adjustments to the ventilator settings or additional interventions to optimize respiratory function and prevent further deterioration.

A respiratory rate of 22 breaths/min may be within an acceptable range, particularly considering that the patient is receiving mechanical ventilation. However, any significant deviation from the baseline respiratory rate or signs of respiratory distress, such as increased work of breathing or accessory muscle use, should be closely monitored and reported promptly.

B A heart rate of 106 beats/min may be within an acceptable range, although it is slightly elevated. Tachycardia can occur due to various factors, including pain, anxiety, fever, or hypoxemia. While tachycardia warrants close monitoring, it may not be the most critical finding to report unless it is associated with hemodynamic instability or other concerning symptoms.

C An oxygen saturation of 99% indicates adequate oxygenation, which is reassuring, particularly in a patient with acute respiratory distress syndrome (ARDS). However, oxygen saturation alone may not reflect the adequacy of ventilation or the severity of the underlying lung injury. Therefore, while oxygen saturation should be monitored closely, it may not be the most critical finding to report unless it declines significantly or is accompanied by other concerning symptoms.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","E"]

Explanation

A. Chronic hypertension is a significant risk factor for the development of various cardiac diseases, including coronary artery disease, left ventricular hypertrophy, heart failure, and arrhythmias. The increased workload on the heart caused by hypertension can lead to myocardial remodeling, impaired cardiac function, and ultimately heart disease.

B. Chronic hypertension can cause damage to the kidneys over time, leading to renal insufficiency or chronic kidney disease. The elevated blood pressure damages the delicate blood vessels in the kidneys, impairing their ability to filter waste products and regulate fluid and electrolyte balance. Persistent hypertension can ultimately lead to kidney dysfunction and renal failure.

C. Hypertension is a major risk factor for the development of stroke, particularly ischemic stroke (caused by a blockage in a blood vessel supplying the brain) and hemorrhagic stroke (caused by bleeding into the brain). Chronic hypertension can damage blood vessels in the brain, leading to the formation of blood clots or weakening of vessel walls, increasing the risk of stroke.

E. Chronic hypertension is a significant risk factor for the development of atrial fibrillation, a type of irregular heart rhythm characterized by rapid and chaotic electrical activity in the upper chambers of the heart (atria). The structural changes in the heart caused by hypertension, such as left atrial enlargement and fibrosis, can predispose individuals to atrial fibrillation.

D. Familial hypercholesterolemia is a genetic disorder characterized by high levels of LDL cholesterol in the blood. While chronic hypertension itself does not directly cause familial hypercholesterolemia, hypertension and hypercholesterolemia are often comorbid conditions that contribute to cardiovascular risk. Both conditions can lead to atherosclerosis, increasing the risk of heart disease and stroke.

F. Isolated systolic hypertension refers to elevated systolic blood pressure with normal diastolic blood pressure. While isolated systolic hypertension itself is a manifestation of hypertension, it is not a direct result of end-organ damage. However, if left untreated, isolated systolic hypertension can lead to complications such as stroke, heart failure, and kidney disease, which are consequences of end-organ damage from chronic hypertension.

A. Prepare to administer epinephrine B. Monitor vital signs and ECG C. Reassure the patient that the Transcutaneous Pacemaker is temporary D. Prepare to administer atropine E. Place both transcutaneous pacemaker pads on the chest over the heart F. Provide analgesia as needed after the transcutaneous pacemaker is placed

Correct Answer is ["B","C","D","E","F"]

Explanation

B. Continuous monitoring of vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is essential for assessing the patient's hemodynamic status and response to treatment.

Additionally, continuous electrocardiographic (ECG) monitoring allows for real-time assessment of cardiac rhythm and conduction abnormalities.

C. This is an important nursing action to provide comfort and reduce anxiety for the patient. Transcutaneous pacing is often used as a temporary measure to stabilize heart rate and cardiac output until more definitive treatment, such as insertion of a permanent pacemaker, can be performed.

D. Atropine is another medication commonly used in ACLS protocols for symptomatic bradycardia and heart block. It acts to increase heart rate by blocking vagal tone. However, its effectiveness in third- degree heart block may be limited, and transcutaneous pacing is often the preferred intervention in this situation.

E. Correct placement of transcutaneous pacemaker pads is crucial for effective pacing. The pads should be placed on the chest over the heart to deliver electrical impulses and stimulate myocardial contraction. Proper placement ensures optimal pacing effectiveness and patient safety.

F. This nursing action addresses the patient's comfort and pain management following the placement of the transcutaneous pacemaker. The procedure may cause discomfort or pain, and appropriate analgesia should be provided to alleviate any discomfort and promote patient comfort.

A. Epinephrine is a medication commonly used in advanced cardiac life support (ACLS) protocols for bradycardia and heart block. In this scenario, the patient's heart rate has decreased to 40 beats/minute, indicating symptomatic bradycardia and potential hemodynamic instability. Epinephrine may be administered to increase heart rate and improve cardiac output.

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Naxlex Comprehensive Predictor Exams

Which is(are) potential result(s) of end-organ damage from chronic hypertension? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

Correct Answer is ["B","C","D","E","F"]

Explanation

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially?

A nurse is caring for a client who was admitted for atrial fibrillation rapid ventricular rate of 130 beat/min with confusion. The client's blood pressure is 87/50. What order should the nurse expect to receive from the provider?

Which of the following is a common cause of cardiogenic shock?

The nurse is caring for a client who has heart failure with an EF of 40%. The client has a BP of 170/67 with an HR of 60. He currently is in normal sinus rhythm and has an amber urine output of 45ml in the last 3 hours. Which medication would the nurse expect to give first?

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

A patient with septic shock has a BP of 70/46 mm Hg. pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104" F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?