ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 68 Questions
Question 1 of 5
The nurse is caring for a patient with heart failure requiring a ventricular assist device (VAD) implanted and is waiting for cardiac transplantation. Which of the following actions should the nurse include in the plan of care?
Correct Answer: B
Rationale: The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immuno-suppression is not necessary for nonbiological devices like the VAD.
Question 2 of 5
When assisting with oral intubation of a patient who is receiving mechanical ventilation, place the following actions in the correct order.
Order the Items
Source Container
Correct Answer: B,E,C,D,A
Rationale: The patient is placed in a supine position and preoxygenated with a bag-valve-mask system for 3-5 minutes before intubation. Following the intubation, the cuff on the endotracheal tube is inflated to occlude and protect the airway. Tube placement is assessed first with an end-tidal CO2 sensor, and then with a chest x-ray.
Question 3 of 5
Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's arterial blood gas (ABG) results include a pH of 7.50, PaO2 of 80 mm Hg, PaCO2 of 29 mm Hg, and HCO3 of 23 mmol/L. The nurse will anticipate the need to do which of the following actions based upon these findings?
Correct Answer: B
Rationale: The patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD, increasing the tidal volume would further lower the PaCO2, and the PaCO2 and pH indicate a need to make the ventilator changes.
Question 4 of 5
The family members of a patient who has just been admitted to the intensive care unit (ICU) with multiple traumatic injuries have just arrived in the ICU waiting room. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: Lack of information is a major source of anxiety for family members and should be addressed first. Family members should be prepared for the patient's appearance and the ICU environment before visiting the patient for the first time. ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse.
Question 5 of 5
Which of the following actions should the nurse implement to verify the correct placement of an endotracheal tube (ET) after insertion?
Correct Answer: D
Rationale: End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion also are used, but they are not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured.