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NU335 Med Surg /adult Health Proctored Exam
Total Questions : 82
Showing 10 questions, Sign in for moreThe nurse is caring for a patient with a chest tube status-post lobectomy. To ensure the chest tube drainage system is functioning correctly, as the patient breathes, the nurse will monitor which chamber of the drainage system for tidaling?
Which nursing interventions are appropriate for managing ITP? Select all that apply.
A patient is admitted with hypercapnic respiratory failure secondary to chronic obstructive pulmonary disease (COPD). The nurse anticipates which collaborative interventions to address the patient's condition? Select all that apply.
The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic finding supports this diagnosis?
A patient is admitted with acute pericarditis and reports severe chest pain. The nurse identifies the nursing diagnosis fo Acute pain related to the inflammatory process. Which nursing action is most appropriate to relieve the patient's pain?
1330 - Client intubated and mechanically ventilated. Breath sounds diminished on the left side. Large amount of frothy secretions observed in endotracheal tube.
1530-Suctioned endotracheal tube, thick secretions noted. Patient sedated and unresponsive to verbal stimuli, but responds to painful stimuli.
|
Vital Sign |
1300 |
1700 |
|
Temperature |
38.8°C (101.8°F) |
30.1°C (102.4°F) |
|
Heart Rate |
120/min |
115/min |
|
Respiratory Rate |
30/min (ventilator-assisted) |
28/min (ventilator-assisted) |
|
Blood Pressure |
90/50 mmHg |
85/45 mmHg |
|
Oxygen Saturation |
85% on 100% FIO2 |
88% on 100% FI02 |
|
Test |
1300 |
1600 |
Reference range |
|
PaO2 |
50 mmHg |
55 mmHg |
75-100 mmHg |
|
PaCO2 |
60 mmHg |
58 mmHg |
35-45 mmHg |
|
pH |
7.25 |
7.28 |
7.35-7.45 |
|
HCO3- |
22 mmol |
23 mmol |
23-26 mmol |
- Initiate broad-spectrum antibiotics: Piperacillin-tazobactam 4.5g IV q6h
- Maintain sedation: Propofol infusion at 50mcg/kg/min, titrate to RASS-310-4
- Obtain daily ABG to monitor respiratory status.
An elderly client is admitted to the ICU with difficulty breathing and requires close monitoring.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Explanation
Rationale for correct choices
• Cardiogenic shock: The client presents with hypotension, tachycardia, low oxygen saturation despite 100% FIO2, frothy pulmonary secretions, and diminished breath sounds, all indicating fluid overload and poor cardiac output. ABG shows hypoxemia and respiratory acidosis, consistent with pulmonary edema from cardiogenic shock. These findings, together with the need for mechanical ventilation and sedative support, point toward impaired cardiac function leading to shock rather than a primary respiratory or thrombotic problem.
• Elevate the head of the bed: Elevating the head of the bed helps improve ventilation and oxygenation by reducing pulmonary venous return and promoting lung expansion. In a patient with pulmonary edema secondary to cardiogenic shock, this position decreases the work of breathing and helps mobilize secretions for more effective suctioning.
• Implement hemodynamic monitoring: Continuous hemodynamic monitoring allows the nurse to track blood pressure, cardiac output, and perfusion status, which are critical in cardiogenic shock. This monitoring enables early detection of further deterioration and guides titration of fluids, vasoactive drugs, and inotropic support. It also ensures timely response to hypotension or arrhythmias, which are common complications in shock.
• Oxygen saturation levels: Monitoring oxygen saturation provides immediate feedback on the patient’s respiratory status and effectiveness of oxygen delivery. Hypoxemia indicates worsening pulmonary edema or inadequate ventilation, guiding adjustments in ventilator settings or suctioning frequency. This is essential to evaluate progress and prevent further tissue hypoxia.
• Central venous pressure: Central venous pressure monitoring helps assess intravascular volume and right-sided heart function, providing insight into preload and fluid status. In cardiogenic shock, CVP trends help determine whether fluid resuscitation or diuresis is appropriate, guiding therapy to optimize cardiac output without worsening pulmonary congestion. Tracking CVP assists in evaluating the patient’s response to interventions.
Rationale for incorrect choices
• Pulmonary embolism: Although the patient has hypoxemia and tachycardia, there is no evidence of sudden onset pleuritic pain, unilateral leg swelling, or risk factors for thromboembolism. Pulmonary embolism typically causes acute right-sided strain rather than the frothy pulmonary secretions seen here.
• Status asthmaticus: Status asthmaticus usually presents with wheezing, prolonged expiratory phase, and bronchospasm, which are not noted in the auscultation findings. Diminished breath sounds with frothy secretions suggest fluid overload rather than airway obstruction. The patient’s ABG also shows hypoxemia with hypercapnia, consistent with alveolar flooding.
• Acute myocardial infarction (MI)
While MI can precipitate cardiogenic shock, the client’s presenting features focus on systemic hypotension, pulmonary edema, and decreased perfusion rather than acute chest pain or ECG changes typical of MI. MI may be the underlying cause but does not fully explain the immediate critical status; the priority is managing shock.
• Discontinue intravenous fluids: Fluid restriction may be indicated later, but immediate discontinuation of IV fluids is not the first-line intervention in unstable patients. The nurse must first assess hemodynamics and oxygenation before adjusting fluid therapy, as abrupt cessation could worsen hypotension and perfusion.
• Initiate oral nutrition: Oral nutrition is inappropriate in a sedated, mechanically ventilated patient due to aspiration risk. Nutritional support may be considered later via enteral or parenteral routes once hemodynamic stability is achieved. It is not an immediate action to address cardiogenic shock.
• Insert urinary catheter: A urinary catheter may help monitor urine output in shock, but it is secondary to interventions that directly support hemodynamics and oxygenation. It is not an immediate action to stabilize cardiogenic shock, though it may be implemented for ongoing fluid balance assessment.
• Calcium levels: Calcium levels are not directly relevant to assessing the patient’s cardiogenic shock or respiratory compromise. They do not provide actionable information about oxygenation or fluid status and are not priority parameters for monitoring progress in this scenario.
• Body mass index: Body mass index is irrelevant in the acute ICU setting for cardiogenic shock. It does not reflect immediate changes in cardiac output, oxygenation, or perfusion, and does not guide urgent interventions.
• Capillary refill: Capillary refill may provide a rough estimate of peripheral perfusion, but in critically ill, sedated patients on vasopressors or with hypotension, it is unreliable. Central measures like CVP and continuous oxygen saturation are more accurate for monitoring the patient’s progress.
A 37-yr-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function?
A patient with massive trauma and possible spinal cord injury is admitted to the emergency department. The nurse suspects that the patient may be experiencing neurogenic shock based on which assessment finding?
Prescribed: Begin propofol IV infusion at 9 mL/hr
Available: propofol 1000 mg/100 mL
Patient's weight: 75 kg
Calculate how many mcg/kg/min the patient is receiving? Record your answer to whole number.
Explanation
- Identify the ordered infusion rate and available concentration
Infusion Rate: 9 mL/hr
Available Concentration: 1000 mg/100 mL = 10 mg/mL
- Calculate the total mg/hr being infused
Total mg/hr = 9 × 10
= 90 mg/hr
- Convert mg/hr to mcg/min
90 mg/hr × 1000 mcg/mg = 90,000 mcg/hr
90,000 ÷ 60 min = 1,500 mcg/min
- Calculate mcg/kg/min
Patient weight: 75 kg
Rate = 1,500 ÷ 75
= 20 mcg/kg/min
Prescribed: Amiodarone hydrochloride 5 mg/kg as IV push now
Available: Amiodarone hydrochloride 150 mg/3 mL
Patient weight: 80 kg
How many mL will the nurse administer for the prescribed dose? 8 Record your answer in whole number.
Explanation
Calculation:
- Identify the ordered dose and available concentration
Ordered Dose: 5 mg/kg
Patient Weight: 80 kg
Dose in mg = 5 × 80
= 400 mg
Available Concentration: 150 mg/3 mL = 50 mg/mL
- Calculate the volume to administer
Volume to administer = Ordered Dose ÷ Concentration
= 400 ÷ 50
= 8 mL
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