Respiratory

The nurse is a first responder after a gas explosion at an apartment complex. Which patient does the nurse mark to be treated first?

The nurse is first on the scene following a multivehicle accident. After activating emergency services and verifying the safety of the scene, the nurse begins the triage process. The first patient is unconscious and not breathing. Which action does the nurse take first?

The postpartum nurse is supervising new parents placing their newborn into the car seat to drive home during a snowstorm. Which observation is most concerning?

The registered nurse on the medical-surgical floor is delegating tasks to an unlicensed assistive personnel, certified medication assistant, and a licensed practical/vocational nurse. Which task does the nurse delegate to the LPN/LVN?

Following an apartment fire, the patient is brought to the emergency department by ambulance. The patient has third degree burns on the anterior bilateral lower legs and thighs, abdomen, and anterior bilateral arms. Soot is noted on the face; the patient appears to be speaking normally. Place the actions in the order the nurse performs them.

Following an explosion at a factory, the patient is brought by ambulance to the emergency department. The patient has soot on the face and around the mouth and is coughing up black sputum. He verbalizes severe pain in his leg and his voice is noted to be a hoarse whisper. Further assessment reveals full thickness burns to the arms and hands and partial thickness burns to the legs. Shrapnel appears to have been embedded in the patient’s thigh. While moving the leg to assess the inner thigh, a piece of shrapnel shifts and the patient begins bleeding profusely from the wound. The patient cries out in pain and requests pain relief. Which action does the nurse take first?

The nurse is planning care for a patient who sustained third degree burns over 42% of the body during an industrial accident the previous day. The patient is intubated, sedated, and chemically paralyzed. Which patient problem is most important for the nurse to address?

Several tenants from an apartment building are brought to the emergency department with concern for carbon monoxide poisoning. One patient presents with reddish-purple skin, a blood pressure of 94/48 mmHg, heart rate of 118 bpm, and altered consciousness (arouses when his name is shouted). The nurse anticipates testing will reveal which carbon monoxide level?

The nurse is supervising the unlicensed assistive personnel (UAP) in the care of the patient who underwent surgical therapy for lung cancer in the right lower lobe one day prior. Which patient positions, if helped into by the UAP, prompt the nurse to intervene and provide additional education? Select all that apply.  

The nurse is providing discharge education to the patient who has a tracheostomy following a total laryngectomy. Which instruction does the nurse give the patient to maintain airway patency?   

The nurse learns the patient has a tracheoesophageal fistula following a resection of laryngeal cancer. How does the nurse interpret this information?  

The patient is brought to the emergency department following a gunshot wound to the right chest. The patient is noted to have tracheal deviation to the left side with absent breath sounds on the right. Review of the chest radiograph indicates a large amount of free air in the superior chest as well as fluid in the inferior chest. Which procedure is performed first? 

The 72-year-old patient is brought via the ambulance to the emergency department after his wife observed him collapsing after dinner. At the scene, emergency medical service (EMS) personnel determined he was in asystole, and began cardiopulmonary resuscitation (CPR). An advanced airway was placed and a peripheral intravenous catheter was inserted. The defibrillator was placed and read ventricular fibrillation; a shock was administered, chest compressions were restarted, and a 1 mg epinephrine dose was administered via peripheral IV. Upon arrival to the emergency department, the patient was found to be in pulseless electrical activity after 5 complete rounds of CPR (including epinephrine, defibrillation, and 30:2 chest compressions to ventilated breaths ratio). The nurse advocates for which intervention?

The 4-year-old patient with a history of sickle cell disease is brought to the emergency room complaining of severe chest pain and cough. Upon assessment, the nurse notes a respiratory rate of 32, a temperature of 39.1°C, and a heart rate of 128 bpm. Which test results does the nurse anticipate? Select all that apply.

The 1-year-old with sickle cell disease is in crisis following gastroenteritis. While hospitalized, the patient abruptly exhibits seizures, decreased level of consciousness, right-sided facial asymmetry when crying, coughing and sputtering during a bottle feeding, and decreased movement of the right leg and arm. The nurse contacts the provider and prepares to provide which initial interventions? Select all that apply.  

The nurse is preparing to care for a baby antenatally diagnosed with type C esophageal atresia with tracheoesophageal fistula. Which interventions are the priority in the first day after birth?  

The nurse overhears a colleague preparing a dose of naltrexone. The nurse offers to assist and ensures the colleague takes which actions? Select all that apply.  

The 58-year-old patient presents to the clinic for a follow-up appointment. Upon assessment, the nurse notes expiratory wheezes across all lung fields. Review the patient’s chart to determine the most likely cause of this new symptom.

The nurse reviews the patient’s chart and advocates for which intervention?

The 48-year-old patient is brought via ambulance to the emergency room after being found unresponsive by her son. She has a prescription for transdermal fentanyl patches for treatment of cancer pain related to her breast cancer that has metastasized to her pelvis. The patient’s heart rate is 72 bpm, respiratory rate is 4 breaths per minute, and her oxygen saturation is 88%. Her arterial blood gas results are: pH 7.21, PaCO₂ 72 mmHg, PaO₂ 74, HCO₃¯ 23. A thorough assessment reveals 2 fentanyl patches on the patient’s skin. The nurse advocates for which initial action?  

The 23-year-old patient is brought to the emergency department after contacting emergency services to report profound weakness that started in his feet and worsened and spread cranially over the past few days. He reports severe diarrhea after a camping trip a week ago. Upon assessment, strength, sensation, and deep tendon reflexes are significantly reduced, with the lower extremities more severely affected than his upper extremities. Vital signs are normal and the patient seems to be breathing well. There is increased protein in the cerebrospinal fluid found after a lumbar puncture. The patient is admitted to the intensive care unit for further management and observation. The ICU nurse includes which interventions in the plan of care? Select all that apply.  

The 50-year-old previously healthy patient complains of shortness of breath, especially on exertion or when laying down to sleep. She takes over-the-counter allergy medicine for seasonal allergies and melatonin to help her sleep sometimes. Her vital signs are heart rate of 64 bpm, respirations 22, oxygen saturation 99%, and blood pressure 114/68 mmHg. Her assessment is notable for crackles over the bilateral lung bases and a moderate diastolic apical murmur. The nurse prepares the patient for which initial tests? Select all that apply. 

The patient with well-controlled chronic obstructive pulmonary disorder presents with a 3 day history of increased cough with sputum production, fever, and malaise. Upon assessment, breath sounds are clear after coughing and the patient appears to breathe comfortably with no retractions or nasal flaring. His chest x-ray is clear and his screening complete blood count is largely normal, with exception of a white blood cell count of 16. The nurse anticipates the provider to order which medication(s)? Select all that apply. 

The 20-year-old patient with asthma presents to the emergency department with increased work of breathing and severe wheezing after exposure to household dust and mold. The patient used the albuterol inhaler 6 times in the previous 4 hours with minimal relief. Upon inspection, the nurse notes extensive accessory respiratory muscle use with moderate supraclavicular retractions and nasal flaring. The nurse auscultates expiratory wheezing in all lung fields. The patient is afebrile, normotensive, significantly tachypneic, and mildly tachycardic. The nurse anticipates which findings on a chest x-ray?

The 20-year-old patient with asthma presents to the emergency department with increased work of breathing and severe wheezing after exposure to household dust and mold. The patient used the albuterol inhaler 6 times in the previous 4 hours with minimal relief. Upon inspection, the nurse notes extensive accessory respiratory muscle use with moderate supraclavicular retractions and nasal flaring. The nurse auscultates expiratory wheezing in all lung fields. The patient is afebrile, normotensive, significantly tachypneic, and mildly tachycardic. The chest x-ray is clear. The nurse prepares to administer which medication first? 

The patient with human immunodeficiency virus and a CD4 count of 158 has a purified protein derivative (PPD) skin test performed and is found to have a 7-mm induration with circumferential erythema. Which statement does the nurse make to the patient?  

The 71-year-old previously healthy patient is admitted to the hospital for dehydration after 3 days of malaise and productive cough with green sputum. Right lower lobe consolidation is noted on x-ray. Leukocytosis is revealed by a complete blood count. Vitals are notable for a temp of 40.4°C, heart rate of 122 bpm, respiratory rate of 22, and blood pressure of 104/62 mm Hg. Oxygen saturation is 84% on room air, but improves to 100% with 2L 100% FiO2 via nasal cannula. The nurse prepares to administer which medications? Select all that apply.

The nurse is teaching a community class on cardiopulmonary resuscitation (CPR). Which rationale is best to give the class for the difference between infant CPR with one rescuer, infant CPR with two rescuers, adult CPR with one rescuer, and adult CPR with two rescuers?

The nurse performs an electrocardiogram on a patient and notes right axis deviation. The nurse suspects the patient has which undiagnosed condition? 

The neonate is found to have a hemoglobin of 26 g/dL on the first day of life. Which additional findings does the nurse anticipate in this patient? Select all that apply.