N480 Week 1 and 2

Which client(s) will likely require admission to the intensive care unit?

• Client with 2nd and 3rd degree burns to upper extremities and torso

• Client with cellulitis to lower left leg

• Client with a open skull fracture after a fall

• Client who is terminally ill due to liver cancer

The RN is explaining the process of ARDS to a client. What is the best explanation?

• Alveoli are overexpanded

• Alveoli increases perfusion

• Alveolar spaces are filled with fluid

• Alveoli improves gaseous exchange

Which is a complication of receiving too much PEEP?

• Bradycardia

• Hypovolemia

• Reduced cardiac output

• Increased BP

What would be monitored to determine improvement or worsening acute respiratory failure? Select 2 that apply

• ABG values

• Blood pressure

• Chest x-ray

• Sputum culture and sensitivity results

A chest tube is inserted and it begins to drain some dark red fluid. The RN determines that which are true? Select all that apply

• the chest tube was inserted improperly

• this is an expected result

• an artery was nicked when the chest tube was placed

• the client is experiencing a hemothorax

The nurse understands that the yellow lumen of the PA catheter has which purpose?

• Medication administration

• Measurement of pulmonary artery wedge pressure

• Balloon inflation

• Right atrium pressure measurement

Intervention for client who is intubated and mechanically intubated include:

• Application of leg restraints

• Nasotracheal suctioning

• Oral care

• Side-lying positioning

A PA catheter was just placed and the pt is short of breath. The RN anticipates the provider will order?

• Sedation

• Laboratory tests

• EKG

• Chest X-ray

A client alerts the nurse that his chest tube has accidentally been removed. What is the most appropriate action?

• Reinsert the chest tube that fell out

• Apply an occlusive dressing over the site

• Position the client on his right side

• Position client on his left side

Which client is high risk for a PE?

• An ambulatory client with inflammatory joint disease

• A healthy client who is 6 months pregnant

• An ambulatory client with thrombocytopenia

• A client with a pelvic and hip fracture