Case study 71-73

A client was admitted with a diagnosis of respiratory failure 3 weeks ago. She required an artificial airway (tracheostomy) to help clear secretions. The previous shift nurse reports that the client had a very restless night with a drop in O2 saturation level several times despite O2 being set at 40% via trach collar. The previous shift nurse also reports that the client experienced tachycardia and tachypnea during the night.

The nurse immediately checks on the client and finds that she appears anxious with these vital signs:

Blood pressure: 130/90 mm Hg Heart rate: 116 (sinus tachycardia) Respiratory rate: 24 and labored Temperature: 99.6° F (axillary) O2 saturation: 91% on 40% O2 via trach collar
Which finding(s) requires nursing intervention? Select all that apply.

The nurse is caring for a client in the emergency room who has been diagnosed with shock. The client has a history of an abscessed tooth that has not yet been removed. Which type of shock does the nurse suspect?

The nurse is caring for a client with a pneumothorax who has a chest tube connected to a closed drainage system with suction. Which of the following actions should the nurse include in the plan of care?

Case study 71-73

A client was admitted with a diagnosis of respiratory failure 3 weeks ago. She required an artificial airway (tracheostomy) to help clear secretions. The previous shift nurse reports that the client had a very restless night with a drop in O2 saturation level several times despite O2 being set at 40% via trach collar. The previous shift nurse also reports that the client experienced tachycardia and tachypnea during the night.

The nurse immediately checks on the client and finds that she appears anxious with these vital signs:

Blood pressure: 130/90 mm Hg Heart rate: 116 (sinus tachycardia) Respiratory rate: 24 and labored Temperature: 99.6° F (axillary) O2 saturation: 91% on 40% O2 via trach collar
Which finding(s) requires nursing intervention? Select all that apply.

After assessing four clients, which will the triage nurse identify to be seen first in the ED?

Which patient problems are most commonly encountered by the health care team in the emergency department? Select all that apply

The nurse is assessing a client with a chest tube following a pneumonectomy. Which assessment finding requires nursing intervention?

The doctor writes an order for a liquid oral medication. The order says to administer 15 mg by mouth every 4 hours as needed for sore throat. Pharmacy dispenses you with 30 mg/3ml. How many ml will you administer per dose?

A client with COPD has all of the following ABG changes from earlier today. Which change alerts the nurse to take immediate action to prevent harm?

An adult patient is admitted to the ICU with Acute Respiratory Distress Syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm is frequently being triggered. Which of the following interventions would the nurse do first? 1.25 Points

A 32-year-old client with a history of asthma presents to the emergency department in severe respiratory distress. The client is using accessory muscles, is unable to speak in complete sentences, and has an SpO2 of 88% on room air. Peak flow measurement is 25% of predicted. Despite three consecutive nebulizer treatments with albuterol, the client shows minimal improvement. Which finding indicates the client is progressing to status asthmaticus requiring immediate escalation of care?