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The nurse is caring for a patient in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The patient has become hypotensive. What is the cause of this complication to the ARDS treatment?
- A. Pulmonary hypotension due to decreased cardiac output
- B. Severe and progressive pulmonary hypertension
- C. Hypovolemia secondary to leakage of fluid into the interstitial spaces
- D. Increased cardiac output from high levels of PEEP therapy
Correct Answer: C
Rationale: Systemic hypotension may occur in ARDS as a result of hypovolemia secondary to leakage of fluid into the interstitial spaces and depressed cardiac output from high levels of PEEP therapy. Pulmonary hypertension, not pulmonary hypotension, sometimes is a complication of ARDS, but it is not the cause of the patient becoming hypotensive.
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The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the nurse implement to most decrease the patients risk of developing pulmonary emboli (PE)?
- A. Early ambulation
- B. Increased dietary intake of protein
- C. Maintaining the patient in a supine position
- D. Administering aspirin with warfarin
Correct Answer: A
Rationale: For patients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The patient does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The patient should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be administered with warfarin because it will increase the patients risk for bleeding.
The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition?
- A. Pneumothorax
- B. Anxiety
- C. Acute bronchitis
- D. Aspiration
Correct Answer: A
Rationale: If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The patient is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the patients recent trauma they are inconsistent with anxiety, bronchitis, or aspiration.
A new employee asks the occupational health nurse about measures to prevent inhalation exposure of the substances. Which statement by the nurse will decrease the patients exposure risk to toxic substances?
- A. Position a fan blowing on the toxic substances to prevent the substance from becoming stagnant in the air
- B. Wear protective attire and devices when working with a toxic substance
- C. Make sure that you keep your immunizations up to date to prevent respiratory diseases resulting from toxins
- D. Always wear a disposable paper face mask when you are working with inhalable toxins
Correct Answer: B
Rationale: When working with toxic substances, the employee must wear or use protective devices such as face masks, hoods, or industrial respirators. Immunizations do not confer protection from toxins and a paper mask is normally insufficient protection. Never position a fan directly blowing on the toxic substance as it will disperse the fumes throughout the area.
A patient has been brought to the ED by the paramedics. The patient is suspected of having ARDS. What intervention should the nurse first anticipate?
- A. Preparing to assist with intubating the patient
- B. Setting up oxygen at 5 L/minute by nasal cannula
- C. Performing deep suctioning
- D. Setting up a nebulizer to administer corticosteroids
Correct Answer: A
Rationale: A patient who has ARDS usually requires intubation and mechanical ventilation. Oxygen by nasal cannula would likely be insufficient. Deep suctioning and nebulizers may be indicated, but the priority is to secure the airway.
The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration?
- A. A resident who suffered a severe stroke several weeks ago
- B. A resident with mid-stage Alzheimers disease
- C. A 92-year-old resident who needs extensive help with ADLs
- D. A resident with severe and deforming rheumatoid arthritis
Correct Answer: A
Rationale: Aspiration may occur if the patient cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. These reflexes are often affected by stroke. A patient with mid-stage Alzheimers disease does not likely have the voluntary muscle problems that occur later in the disease. Clients that need help with ADLs or have severe arthritis should not have difficulty swallowing unless it exists secondary to another problem.