A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?
Hypoxemia
Tension pneumothorax.
Malignant hypertension
Atelectasis
The Correct Answer is B
A. Hypoxemia is a condition of low oxygen levels in the blood. PEEP can actually improve oxygenation by preventing alveolar collapse and increasing functional residual capacity.
B. Tension pneumothorax is a life-threatening condition of air accumulation in the pleural space that causes increased intrathoracic pressure and compresses the lungs, heart, and great vessels. PEEP can increase the risk of tension pneumothorax by creating excessive positive pressure in the airways and alveoli.
C. Malignant hypertension is a severe form of high blood pressure that can cause organ damage and stroke. PEEP can cause a transient increase in blood pressure due to increased intrathoracic pressure, but it does not cause malignant hypertension.
D. Atelectasis is a condition of partial or complete lung collapse due to alveolar collapse or obstruction. PEEP can prevent or treat atelectasis by maintaining positive pressure in the airways and alveoli.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Limit each of the client's visitors to 2 hr per day."
This is incorrect. While visitors should have their exposure limited, the recommended duration is typically much shorter (around 30 minutes to 1 hour), not 2 hours. This is to reduce radiation exposure.
B. "Instruct visitors to stay 1 m (3.3 feet) away from the client."
This is correct. For clients undergoing brachytherapy with a low-dose radiation implant, visitors should maintain a safe distance, usually at least 6 feet (1.8 meters), but some guidelines may state a minimum of 3.3 feet (1 meter) for safety, depending on the specific radiation dose and facility protocols.
C. "Attach a dosimeter to the client's gown."
This is incorrect. Dosimeters are generally worn by healthcare providers, not the patient. The primary purpose is to measure the radiation exposure of healthcare workers, not the patient.
D. "Strain the client's urine."
This is incorrect. Straining urine is not necessary for a patient undergoing brachytherapy. However, it may be important to monitor the urine for signs of radiation leakage, but straining is not a routine part of care.
Correct Answer is B
Explanation
- A is incorrect because massaging bony prominences on the client's left side can increase the risk of skin breakdown and pressure ulcers. The nurse should avoid applying pressure to areas with impaired circulation or sensation.
- B is correct because supporting the client's left arm on a pillow while sitting can prevent edema, contractures, and nerve damage. The nurse should also encourage the client to perform active and passive range of motion exercises on their left arm.
- C is incorrect because positioning the bedside table on the client's left side can discourage the client from using their right side, which can lead to neglect and learned nonuse. The nurse should position the bedside table on the client's right side and encourage them to reach for items with their right hand.
- D is incorrect because placing the client's cane on their left side while ambulating can cause instability and falls. The nurse should place the cane on the client's right side and instruct them to move their left leg and cane together, followed by their right leg.
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