NCLEX-PN Test #19 3 Flashcards

A client on a mechanical ventilator suddenly develops increasing peak airway pressures, decreased breath sounds on the left, tracheal deviation to the right, and hypotension. What complication does the nurse suspect?

Answer: Left-sided tension pneumothorax

Tension pneumothorax presents with: tracheal deviation AWAY from the affected side (to the right = left-sided tension pneumo), absent breath sounds on the affected side, hypotension (obstructive shock), rising peak airway pressures on the ventilator, and cyanosis. It requires immediate needle decompression (2nd intercostal space, midclavicular line) — it is rapidly fatal.

The nurse is caring for a client with adult respiratory distress syndrome (ARDS). Which ventilator strategy is the standard of care?

Answer: Lung-protective ventilation with low tidal volume (6 mL/kg of ideal body weight) and PEEP

ARDSnet lung-protective ventilation uses low tidal volumes (6 mL/kg IBW) to prevent ventilator-induced lung injury (volutrauma, barotrauma), PEEP (positive end-expiratory pressure) to recruit collapsed alveoli, and titrating FiO₂ to maintain SpO₂ 88–95%. High tidal volumes worsen ARDS by overdistending injured lung units.

A client is being weaned from mechanical ventilation and extubated. Within 30 minutes, the client develops inspiratory stridor. What does this indicate?

Answer: Post-extubation laryngeal edema causing upper airway obstruction

Post-extubation stridor is inspiratory high-pitched sound caused by laryngeal or subglottic edema, which can progress to complete airway obstruction. It is an emergency: notify the provider immediately, administer racemic epinephrine nebulizer and/or IV dexamethasone as ordered, apply supplemental oxygen, and prepare for possible re-intubation.

A client with a pulmonary embolism has been started on a heparin infusion. The nurse notes the aPTT is 28 seconds (sub-therapeutic). What is the appropriate action?

Answer: Notify the provider — the heparin dose likely needs to be increased per protocol

Therapeutic aPTT for heparin therapy is 60–100 seconds (1.5–2.5× normal). An aPTT of 28 seconds is sub-therapeutic, meaning the client is not adequately anticoagulated and remains at risk for further clot extension. The provider must be notified to increase the heparin dose per protocol or weight-based heparin nomogram.

A client with severe community-acquired pneumonia has a PaO₂/FiO₂ ratio of 150. What does this value indicate?

Answer: Moderate to severe ARDS — meets criteria for ARDS diagnosis

The P/F ratio (PaO₂/FiO₂) categorizes ARDS severity: Mild ARDS = 200–300 (with PEEP ≥5 cmH₂O); Moderate ARDS = 100–200; Severe ARDS = 400. This client requires lung-protective mechanical ventilation. (Berlin Definition 2012).

The PN is caring for a client receiving continuous oxygen via nasal cannula at 4 L/min. The client's SpO₂ is 96%. Which assessment finding indicates the oxygen therapy is achieving its goal?

Answer: The client is alert, oriented, and their lips and nailbeds are pink

SpO₂ 96% with alert orientation, pink lips and nailbeds, and a comfortable respiratory rate indicates adequate oxygenation is being maintained. Drowsiness can indicate CO₂ retention (especially in COPD). Elevated PaCO₂ indicates CO₂ retention. Decreasing SpO₂ indicates oxygen therapy is insufficient. Clinical assessment of oxygenation combines SpO₂ with neurological and color assessment.