Chapter 06 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 06 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

Question 1

Type: MCSA

A patient in the emergency department (ED) becomes suddenly unresponsive. CPR is initiated. Arterial blood gas results reveal pH 7.225, PaCO₂ 55, HCO₃ 15, PaO₂ 45, SaO₂ 76 percent. The nurse would prepare for which priority intervention?

1. Call for a rapid response team.
2. Auscultate the patient’s lungs.
3. Place the patient on a 50 percent humidified mask.
4. Administer endotracheal intubation.

Correct Answer: 4

Rationale 1: This situation is not uncommon in the ED and personnel should be prepared to intervene without the support of a rapid response team.

Rationale 2: Auscultation of the lungs is not the priority.

Rationale 3: A humidified mask will not be effective for the patient who is not ventilating well.

Rationale 4: The patient is unresponsive. Based on the blood gas results, it is obvious that the patient is suffering from acute ventilatory failure and is in urgent need of intubation and mechanical ventilation.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6-1

 

Question 2

Type: MCMA

An adult patient has suffered a respiratory arrest and requires endotracheal intubation. The nurse should obtain which equipment for this procedure?

 

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Topical anesthetic
2. Magill forceps
3. Cuffless endotracheal tube
4. Oxygen cannula
5. Water-soluble lubricant

Correct Answer: 1,2,5

Rationale 1: A topical anesthetic may be administered to decrease gagging.

Rationale 2: Magill forceps may be used to help guide the tube through the larynx.

Rationale 3: Since this patient is an adult a soft-cuffed ET tube will be used.

Rationale 4: Although an oxygen source would be appropriate for providing manual bagging of the patient, a nasal cannula is useless for this patient.

Rationale 5: Water-soluble lubricant can be used to help advance the endotracheal tube.

Global Rationale:

 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6-2

 

Question 3

Type: MCSA

A patient aspirated while eating and suffered a respiratory arrest. A code blue was called, the obstruction was removed, but the patient required endotracheal intubation. Postintubation the nurse hears breath sounds bilaterally, but the carbon dioxide monitor indicates a higher than expected level. Which patient history could account for this discrepancy?

1. The patient’s original admittance diagnosis was dehydration.
2. The patient’s wife reports, “We were talking and laughing when he choked.”
3. The patient has history of calcium deficiency requiring dietary supplementation.
4. The patient’s wife says, “He had some heartburn earlier, so the nurse had given him a lemon-lime soda to drink with his supper.”

Correct Answer: 4

Rationale 1: Dehydration would not result in high carbon dioxide levels.

Rationale 2: Laughing and talking while eating could explain why the obstruction occurred, but would not explain why the discrepancy between auscultation and carbon dioxide monitor.

Rationale 3: Calcium deficiency is not related to the discrepancy in this scenario.

Rationale 4: Drinking a carbonated beverage just before intubation can cause a false positive carbon dioxide monitor report.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-2