Chapter 34: Care of Critically Ill Patients with Respiratory Problems

Chapter 34: Care of Critically Ill Patients with Respiratory Problems

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus. The client’s international normalized ratio (INR) is 2.0. What is the nurse’s best action?

ANS:  D

The client who is being treated for pulmonary embolism usually continues on heparin and warfarin until the INR reaches a therapeutic level between 2 and 3. Heparin can then be discontinued because warfarin is therapeutic.

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—Pharmacological Agents)

MSC:  Integrated Process: Nursing Process (Implementation)

2. The nurse is caring for a postoperative client who suddenly reports difficulty breathing and sharp chest pain. After notifying the Rapid Response Team, what is the nurse’s priority action?

ANS:  A

The client’s immediate need is to have oxygen applied. The nurse should then assess the client’s pulse oximetry.

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

MSC:  Integrated Process: Nursing Process (Implementation)

3. It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurse’s priority action?

ANS:  A

Airway and breathing are the top priority. The nurse would also need to monitor for bleeding when administering fibrinolytic therapy, and would monitor the IV site as well. Teaching the client is also a need, however. Oxygenation is the highest priority.

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)

MSC:  Integrated Process: Nursing Process (Implementation)

4. A client with a large pulmonary embolism is receiving alteplase (Activase). The nurse notes frank red blood in the Foley catheter drainage bag. What is the nurse’s first action?

ANS:  D

Alteplase is a fibrinolytic agent that dissolves formed clots. The drug has an impact on clots outside the pulmonary embolism, and the client is at great risk for hemorrhage and shock. The nurse should realize the potential for a severe problem and should call the health care provider immediately for orders. The other actions would not be appropriate first actions in this situation.

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)           MSC:              Integrated Process: Nursing Process (Analysis)