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The nurse is caring for a client on a ventilator and the alarm goes off. Which action should the nurse implement first?
- A. Notify the respiratory therapist immediately.
- B. Check the ventilator to determine the cause.
- C. Elevate the head of the client's bed.
- D. Assess the client's oxygen saturation.
Correct Answer: B
Rationale: Checking the ventilator (B) is the first action to identify the alarm’s cause (e.g., disconnection, obstruction), per the ABCs. Notifying the therapist (A) delays intervention. Elevating the bed (C) is irrelevant. Assessing oxygen saturation (D) is secondary to addressing the ventilator issue.
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The client in the intensive care unit diagnosed with end-stage chronic obstructive pulmonary disease has a Swan-Ganz mean pulmonary artery pressure of 35 mm Hg. Which health-care provider order would the nurse question?
- A. Administer intravenous fluids of normal saline at 125 mL/hr.
- B. Provide supplemental oxygen per nasal cannula at 2 L/min.
- C. Continuous telemetry monitoring with strips every four (4) hours.
- D. Administer a loop diuretic intravenously every six (6) hours.
Correct Answer: A
Rationale: A mean pulmonary artery pressure of 35 mm Hg indicates pulmonary hypertension, common in end-stage COPD. IV fluids at 125 mL/hr (A) risk fluid overload and worsening right heart strain, so this order should be questioned. Oxygen (B), telemetry (C), and diuretics (D) are appropriate to manage hypoxia, monitor cardiac status, and reduce fluid overload.
Which arterial blood gas (ABG) results support the diagnosis of acute respiratory distress syndrome (ARDS) after the client has received O2 at 10 LPM?
- A. pH 7.38, Pao2 94, Paco2 44, Hco3 24.
- B. pH 7.46, Pao2 82, Paco2 34, Hco3 22.
- C. pH 7.48, Pao2 59, Paco2 30, Hco3 26.
- D. pH 7.33, Pao2 94, Paco2 44, Hco3 20.
Correct Answer: C
Rationale: ARDS is characterized by severe hypoxemia despite high oxygen delivery. Pao2 59 (C) despite 10 LPM oxygen indicates refractory hypoxia, a hallmark of ARDS. Normal Pao2 (94 in A and D) contradicts ARDS. Pao2 82 (B) is low but not as severe as 59, making C the best indicator of ARDS.
If the client identifies that lunches often include the following foods, which meal is the most nutritious?
- A. Tossed salad, rice, and iced tea
- B. Apple sandwich on whole wheat bread and coffee
- C. Meatless chili with beans, corn bread, and milk
- D. Chicken soup, gelatin, and sweetened lemonade
Correct Answer: C
Rationale: Meatless chili with beans, corn bread, and milk provides protein, carbohydrates, and calcium, making it the most balanced and nutritious option.
The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, Pao2 92, Paco2 38, Hco3 24. Which action should the nurse implement?
- A. Continue to monitor the client without taking any action.
- B. Encourage the client to take deep breaths and cough.
- C. Administer one (1) ampule of sodium bicarbonate IVP.
- D. Notify the respiratory therapist of the ABG results.
Correct Answer: A
Rationale: Normal ABGs (A) in ARDS indicate stability, requiring monitoring. Deep breathing (B), bicarbonate (C), and notification (D) are unnecessary.
Aside from the characteristics of the client's cough, which other pertinent assessment finding should the nurse document?
- A. Family history of respiratory disease
- B. Current vital signs
- C. Appearance of respiratory secretions
- D. Any self-treatment measures used by the client
Correct Answer: C
Rationale: The appearance of respiratory secretions (color, consistency) provides critical information about the infection's severity and type.