Page 469 - Critical Care Nursing Demystified

454 CRITICAL CARE NURSING DeMYSTIFIED

Chapter 2

1. A. Although reality orientation with spiritual care as well as turning the client and pre-
venting ulcers are important, the patient can still feel pain/anxiety, so administering
medications to reduce those is critical.
2. C. There is much the critical care nurse can do to prevent VAP. Keeping the HOB elevated
can prevent vomiting and aspiration. Antiulcer medications are important, although
hydrochloric acid blockers can increase alkaline vomitus and promote VAP. It is well
documented in the literature that poor oral hygiene and unsterile suctioning proce-
dures can increase VAP.
3. D. Crackles are soft popping sounds heard in the lung periphery during auscultation.
Gurgles are heard in the larger airways and indicate mucus in the larger airways. Stridor
is a harsh, snoring sound that indicates imminent airway closure.
4. D. In early respiratory failure, all vital signs are elevated except the patient’s tempera-
ture. The other choices are seen in late failure.
5. A. Chest tubes are usually placed in a partial lung removal such as a lobectormy or
segmental resection. In a pneumonectomy, the place where the lung was needs to fill
in with exudate so a chest tube is usually not placed.
6. C. Crepitus is the popping felt when a nurse is palpating around a chest tube that has
leaked air into the subcutaneous tissues. Tactile fremitus is the vibration a nurse feels
when palpating a chest wall. Stridor is a harsh, loud sound that indicates impending Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
airway closure, and elastic turgor is when the skin stays elevated when you pinch it.
7. D. The nonrebreather supplies almost 100% oxygen as it has a reservoir that traps oxy-
gen and when the patient exhales, his or her CO flows out of two valves on either side
2
of the mask.
8. A. The pH is below 7.35, which indicates an acidosis. The CO is above 45, so the patient
2
is retaining CO , indicating the acidosis is respiratory. The HCO is 22, which indicates
2 3
a normal value, so the kidneys are not compensating for this problem. Therefore, the
patient is in an uncompensated respiratory acidosis with hypoxemia.
9. C. PEEP causes an increase in intrathoracic pressure and therefore decreases the
amount of blood from entering the heart. This can cause a drop in BP. Shock is not a
complication of PEEP. This drop is too significant to be a patient’s anxiety or sympa-
thetic stimulation. Barotrauma can be caused by PEEP, but it usually is in the form of a
pneumothorax.
10. B. Always support the patient first by manually ventilating him with a BVM device
with the oxygen up to the highest setting. No other answer is acceptable as the first
priority.