ADULTS 4 EXAM 1

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You are caring for a patient who has been on a mechanical ventilator for several days. Which weaning parameter tells you whether the patient has enough muscle strength to breathe without assistance? A. Tidal volume B. Minute ventilation C. Forced vital capacity D. Negative inspiratory force

*D. Negative inspiratory force* The negative inspiratory force measures inspiratory muscle strength. Tidal volume, vital capacity, and minute ventilation assess the patient's respiratory endurance. Reference: 1712

*A nurse is orienting a newly licensed nurse who is caring for a client that is receiving mechanical ventilation, which has been placed on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse demonstrates an understanding of PSV?* A. "It keeps the alveoli open and prevents atelectasis." B. "It permits spontaneous ventilation to decrease the work of breathing." C. "It is used with clients who have difficulty weaning from the ventilator." D. "It delivers a preset ventilatory rate and tidal volume to the client."

*B. "It permits spontaneous ventilation to decrease the work of breathing."*

What conditions would BiPAP be more beneficial than CPAP?

- COPD - CA - Pneumonia - Neuromuscular disorders (ALS, etc) - DNR/DNI Patients

*What are some side effects of Cyclosporine?*

*Nephrotoxicity*-elevated BUN and Creatinine (big one). AVOID NSAIDS. Hepatotoxicity-elevated ALT/AST and serum bilirubin Infection-Esp. BK virus-associated nephropathy *Hirsutism*-promotes hair growth, assure patient its reversible. Drug-Food-GRAPEFRUIT JUICE Drug-Drug-Anti-fungal ketoconazole increases levels by preventing metabolism, actually used to lower dose and cost. (*Neur*otoxicity-common with Tracolimus, another Calci*neurin* drug)

*ORGANS*

What are the clinical signs of hypoxemia?

*RAT BED:* (NCLEX Mnemonic) R-Restlessness A-Anxiety T-Tachycardia/Tachypnea (early) B-Bradycardia (late) E-Extreme Restlessness D-Dyspnea/Dysrythmias Class: Dysrhythmias, Dusky skin/Cyanosis, Changes in mental status and LOC

*Patient self-regulates the rate and depth of spontaneous respirations, but may also receive preset volume and frequency breaths by ventilator with this mode?*

*SIMV*

What is Tracheomalasia?

*Stridor* that appears at birth or shortly after. Weakness of the tracheal walls, or abnormally shaped cartilage rings cause tracheal collapse on inspiration (STRIDOR). Usually dissipates when put in prone position. Can result in airway collapse on inspiration.

Placing a child prone with their neck hyperextended is good for pediatric patients with __________ ? HINT: It reduces stridor.

*Tracheomalasia*

Priority Decision: When a patient is admitted to the emergency department following a head injury, the nurse's first priority in management of the patient once a patent airway is confirmed is? a. maintaining cervical spine precautions. b. determining the presence of increased ICP. c. monitoring for changes in neurologic status. d. establishing IV access with a large-bore catheter.

*a. maintaining cervical spine precautions.*

The nurse detects the early onset of hypoxemia in the patient who experiences? a. restlessness. b. hypotension. c. central cyanosis. d. cardiac dysrhythmia

*a. restlessness.*

*Which of the following accurately describes rejection following transplantation?* a.Hyperacute rejection can be treated with OKT3. b.Acute rejection can be treated with sirolimus or tacrolimus. c.Chronic rejection can be treated with tacrolimus or cyclosporine. d.Hyperacute reaction can usually be avoided if crossmatching is done before the transplantation.

*d.Hyperacute reaction can usually be avoided if crossmatching is done before the transplantation.* Acute can be *treated* with OKT3 and PREVENTED with immunosuppressants*

A patient with intracranial pressure monitoring has pressure of 12 mm Hg. The nurse understands that this pressure reflects? a.a severe decrease in cerebral perfusion pressure. b.an alteration in the production of cerebrospinal fluid. c.the loss of autoregulatory control of intracranial pressure. d.a normal balance between brain tissue, blood, and cerebrospinal fluid.

*d.a normal balance between brain tissue, blood, and cerebrospinal fluid.*

*Why are more than one immunosuppressant often given?*

*lower doses can be used, achieving effective suppression while preventing infection*

What are some guidelines to prevent VAP?

1. Hand Hygiene 2. Avoid intubation; use noninvasive positive pressure when possible 3. Minimize duration of ventilation 4. Minimize use of sedation 5. Encourage mobility when appropriate 6. regular oral care 7. Continuous Subglottic suction with high risk patients. 8. HOB 30 degrees

For each of the following state whether it is hypoxemic or hypercapnic respiratory failure? 1. Pneumonia 2. Myasthenia gravis exacerbation 3. Pulmonary embolism 4. Complete C3 spinal cord injury 5. Asthma 6. Smoke inhalation 7. Heart failure with pulmonary edema

1. hypoxemic 2. hypercapnic 3. hypoxemic 4. hypercapnic 5. BOTH 6. hypoxemic 7. hypoxemic

Describe the minimal occluding volume technique? Describe the minimal leak technique?

-Air is added by inflating the cuff until no air can be heard escaping during peak inspiratory pressure (end of ventilator inspiration). -The MLT is similar except that the air is removed from the cuff until a slight air leak is ascultated at peak inflation *both techniques aim to reduce the risk of tracheal damage due to high cuff pressures*

APIC guidelines for minimizing preventing Ventilator Associated Pneumonia (VAP)?

-Avoid intubation if possible -Limit duration -Limit sedation -Encourage exercise and mobilization -Provide routine oral care -Use ET tubes with subglottic secretion drainage for -high risk patients -Elevate HOB to 30-40 degrees -Change ventilator circuit only if visibly soiled or malfunctioning

Hypoxemic Respiratory Failure is defined as a PaO2 of less than ____ while receiving an FiO2 of ___ or more?

60 mm Hg, 60% (refractory hypoxemia, namely doesn't reposed to oxygen therapy)

A cross match is used to screen for viable donors. What is an absolute contraindication to transplantation?

A *positive cross match* between recipient plasma and donor lymphocytes is a contraindication and indicates that hyper acute rejection would occur.

What signs and symptoms would a patient exhibit who has a subdural hematoma?

Appears Drowsy and confused - Ipsilateral pupil dilates & becomes fixed

A nursing is caring for a client who has a closed-head injury with ICP readings range from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply.) A. Suction the endotracheal tube. B. Hyperventilate the client. C. Elevate the client's head on two pillows. D. Administer a stool softener. E. Keep the client well hydrated.

B, D

Which of these signs indicate a possible need for suction? (Select all that apply)? A. The "High Pressure" alarm is sounding on the ventilator. B. Coarse breath sounds are heard over trachea and/or bronchi. C. Patient's respiratory rate increases. D. Patient has a sustained cough. E. Patient has a sudden drop in SpO2.

ALL

The purpose of adding PEEP to positive-pressure ventilation is to? A. increase FIO2 in an attempt to wean the patient and avoid O2 toxicity. B. determine whether the patient is in synchrony with the ventilator or needs to be paralyzed. C. increase functional residual capacity and improve oxygenation. D. determine whether the patient is able to be weaned and avoid the risk of pneumomediastinum.

C. increase functional residual capacity and improve oxygenation.

An External Ventricular Drain is a way to remove ____ and lower ____ ?

CSF, ICP

What is the purpose of a cuff on an ET tube?

Cuff seals the ET tube inside of the trachea and the balloon inflates to prevent air from leaking out around the tube and past the vocal cords. *Under-Inflation* can cause escape of ventilating gases and/or Aspiration *Over-Inflation* can cause Tracheomalacia or Tracheal damage DOES NOT SECURE IT IN PLACE LIKE A FOLEY CATHETER!!!!! THERE ARE TIES THAT GO AROUND THE MOUTH!

The drug regimen for prevention of organ rejection includes what 3 classes of drugs used in combination?

Cytotoxic, Calcineurin and Corticosteroid THINK Tri-Cell the 3 C's of t-CELL suppression. And yes, steroids cause T-Cell suppression in so many ways.

A type of IV fluid that decreases ICP in order to raise CPP is _________ ?

Hypertonic Saline (3-23%)

PEEP stands for ______ ______ ______ ______ ? This improves oxygenation by preventing alveolar collapse.

POSITIVE END EXPIRATORY PRESSURE (PEEP)

Interpret the following arterial blood gases? pH 7.48 PaO2 68 mm Hg PaCO2 34 mm Hg HCO3- 22 mEq/L (on 6L/NC)

Uncompensated Respiratory Alkalosis with Hypoxemia

Pulse oximeters read the saturation of hemoglobin. If carbon monoxide has a higher level of affinity for hemoglobin then would a pulse oximeter show normal readings during carbon monoxide poisoning?

YES. This is why it is not always good indication of oxygenation.

Patient self-regulates the rate and depth of spontaneous respirations, but may also receive preset volume and frequency breaths by ventilator with this mode?

SIMV: "SIMV is a mode that allows your father to breathe on his own while receiving a preset number of breaths from the ventilator. He can breathe as much or as little as he wants beyond what the ventilator will breathe for him." SIMV stands for synchronized intermittent mandatory ventilation, a mode of ventilation in which the ventilator delivers a present tidal volume at a preset frequency in synchrony with the patient's spontaneous breathing. Between ventilator-delivered breaths, the patient is able to breathe spontaneously, receiving the preset FIO2 but self-regulate the rate and depth of those breaths.

The nurse notes that a patient's endotracheal tube, which was at the 22-cm mark at the lips, is now at the 27-cm mark. The patient is anxious and restless. Which action should the nurse take next? A. Offer reassurance to the patient. B. Bag the patient with an FiO2 of 100%. C. Listen to the patient's breath sounds. D. Notify the patient's health care provider.

*B. Bag the patient with an FiO2 of 100%.*

A nurse is caring for a client who has increased ICP and a new prescription for mannitol (Osmitrol). For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria

*B. Hyponatremia*

A transplant recipient is receiving cyclosporine (Sandimmune). Which response should a nurse expect if the medication is having the desired effect? A. Increased antibody response B. Increased natural killer (NK) cellular activity C. Suppression of T lymphocytes D. Suppression of hepatic metabolism of steroids

*C. Suppression of T lymphocytes* Immunosuppressants inhibit T-lymphocyte synthesis through inhibition of calcineurin, thus reducing the immune response to organ transplants. Increased antibody response, increased NK cellular activity, and suppression of hepatic metabolism of steroids are not actions of cyclosporine. AVOID GRAPEFRUIT JUICE

A patient with increased ICP has mannitol (Osmitrol) prescribed. Which option is the best indication that the drug is achieving the desired therapeutic effects? A. Urine output increases from 30 mL to 50 mL/hour. B. Blood pressure remains less than 150/90 mm Hg. C. The LOC improves. D. No crackles are auscultated in the lung fields.

*C. The LOC improves.* LOC is the most sensitive indicator of ICP. Mannitol is an osmotic diuretic that works to decrease the ICP by plasma expansion and an osmotic effect. Although *the other options may indicate a therapeutic effect of a diuretic*, they are not the main reason this drug is given. ATI HAD A QUESTION WHERE INCREASED DIURESIS WAS LISTED AS AN INDICATION OF A "THERAPEUTIC EFFECT". Reference: 1433

*The nursing management of a patient with an artificial airway includes?* A. maintaining endotracheal tube cuff pressure at 30 cm H2O. B. routine suctioning of the tube at least every 2 hours. C. observing for cardiac dysrhythmias during suctioning. D. preventing tube dislodgement by limiting mouth care to lubrication of the lips.

*C. observing for cardiac dysrhythmias during suctioning.* Potential complications associated with suctioning include hypoxemia, bronchospasm, increased intracranial pressure, dysrhythmias, hypertension, hypotension, mucosal damage, pulmonary bleeding, pain, and infection. Closely assess the patient before, during, and after the suctioning procedure. If the patient does not tolerate suctioning (e.g., decreased arterial oxygenation, increased or decreased blood pressure, sustained coughing, development of dysrhythmias), stop the procedure, and manually hyperventilate the patient with a bag-valve mask and 100% oxygen.

*Preset tidal volume delivered at set frequency and more frequently when the patient attempts to inhale?*

*CMV* or Assist-Control (Lewis)

A sudden transient mechanical head injury with disruption of neural activity and a change in the LOC is known as a ________ ?

*CONCUSSION*

*Nephrotoxicity, Hepatotoxicity and Neurotoxicity are common with this class of immunosuppressant?*

*Calcineurin drugs like Cyclosporine and Tacrolimus* Neurotoxicity is more with Tacrolimus.

_______ = Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP)

*Cerebral Perfusion Pressure (CPP)* AS ICP increases CPP decreases

*A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following should the nurse include in the teaching?* A. Apply a vest restraint if self-extubation is attempted. B. Monitor ventilator settings every 8 hr. C. Document tube placement in centimeters at the angle of jaw. D. Assess breath sounds every 1 to 2 hr.

*D. Assess breath sounds every 1 to 2 hr.*

*The patient who had idiopathic pulmonary fibrosis had a bilateral lung transplantation. Now he is experiencing airflow obstruction that is progressing over time. It started with a gradual onset of exertional dyspnea, nonproductive cough, and wheezing. What are these manifestations signs of in the lung transplant patient?* A. Pulmonary infarction B. Pulmonary hypertension C. Cytomegalovirus (CMV) D. Bronchiolitis obliterans (BOS)

*D. Bronchiolitis obliterans (BOS)* This is chronic rejection that is caused by infiltration of the organ by large numbers of T-cells and B-cells, causing fibrosis and scarring.

You must lose consciousness for it to be a concussion? A. True B. False

*FALSE*

Steps to extubate a patient?

1. Elevate HOB 2. Hyperoxygenate 3. Suction 4. Deflate Cuff 5. Remove during peak of *deep inspiration*

VAP is pneumonia that occurs ___ hours or more after intubation?

*What is Cushing's (reflex) Triad?*

A late sign of Increasing ICP in which vital signs change such that there is 1) hypertension with a widening pulse pressure, 2) bradycardia and 3) irregular breathing

Does Acute Respiratory Failure result in Acidosis or Alkalosis?

Acidosis

*What is the difference between acute and chronic rejection?*

Acute occurs in the first 6 months. Chronic occurs after 6 months and can happen years later. The article say that patients take immunosuppressants for their entire lives. Acute (but not hyperacute) can be treated whereas chronic usually irreversible.

What is one advantage and one disadvantage of volume-cycled ventilation?

Advantage-A known minute ventilation is delivered regardless of airway resistance or lung compliance. Disadvantage-Barotrauma can result in patients with airway resistance or poor lung compliance since the legs are forced to expand

List strategies that will facilitate communication for patients receiving mechanical ventilation.

Alphabet Board

List some clinical manifestations of respiratory distress in children? Hint: My tummy hurts

Appearance: Dusky, clubbing of fingers or toes; Nasal Flaring, expiratory grunting. LOC: irritable, anxious, change in behavior. GI Symptoms: Resp Distress accompanied by abdominal pain from using accessory muscles.

What is an intracerebral hematoma?

Bleeding that is occurring with the brain tissue. Usually in Frontal and Temporal lobes. size and location determine patient outcome

The nurse is caring for a patient who has become extremely anxious and agitated. If ABGs were to be analyzed, which of the following pH values would the nurse expect to find with this patient? A. 7.45 B. 7.35 C. 7.50 D. 7.20

C. 7.50

Positive pressure applied throughout the entire respiratory cycle of spontaneously breathing patient ___________ ?

CPAP

_____ happens when the normal compensatory mechanisms to control IICP fail?

Cushing's Triad (This is a late sign and the brains last effort to supply the brain with blood).

Which of the following is a type of noninvasive positive pressure ventilation? A. Continuous Mandatory Ventilation (CMV) B. Volume Cycled Ventilation C. Pressure Cycled Ventilation D. Bilevel Positive Airway Pressure (BiPAP)

D. Bilevel Positive Airway Pressure (BiPAP) A-C are *invasive* positive pressure ventilation

Which option is the most sensitive indication of increased ICP? A. Papilledema B. Cushing's triad C. Projectile vomiting D. Change in the level of consciousness (LOC)

D. Change in the level of consciousness (LOC)

D. Negative inspiratory force You also assess B, C and D but they are measures of endurance and not muscle strength

Acute respiratory failure in a patient with chronic lung disease would most likely be indicated by ABG results of? A. PaO2 52 mm Hg, PaCO2 56 mm Hg, pH 7.4. B. PaO2 46 mm Hg, PaCO2 52 mm Hg, pH 7.36. C. PaO2 48 mm Hg, PaCO2 54 mm Hg, pH 7.38. D. PaO2 50 mm Hg, PaCO2 54 mm Hg, pH 7.28.

D. PaO2 50 mm Hg, PaCO2 54 mm Hg, pH 7.28.

The patient's spontaneous respiratory rate is 42 breaths/min. What arterial blood gas abnormality may occur if the patient continues to be tachypneic on a ventilator? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

D. Respiratory alkalosis

Which provides more viable organs Donation after Brain Death (DBD) or Donation after Circulatory Death (DCD)?

DBD-heart continues to pump blood so perfusion is maintained until the time of procurement. More organs can be harvested too.

A posturing during late IICP when a patinets hands curl up towards the center of the torso?

Decorticate posturing (towards the COR=deCORticate)

ERASE

The severity of TBI is determined by _______ and ______ ?

GCS, Degree or duration of time spent unconscious or neurologically impaired.

What could cause an oximetry to have incorrect oxygenation readings?

Hypercapnia (increased CO2 in blood) oximetry only read saturation of Hgb, not necessarily O2 saturation; could be CO2 that is saturating the hemoglobin

________ respiratory failure is defined as a PaCO2 of greater than 48 mm Hg in combination with academia (pH less than 7.35)?

Hypercapnic

A myasthenia gravis exacerbation would likely cause this type of respiratory failure?

Hypercapnic Respiratory Failure

A pulmonary embolism would likely cause this type of respiratory failure?

Hypoxemic

_________ respiratory failure is defined as a Pa02 of less than 60 mm Hg while receiving an Fi02 of 60% or more?

Hypoxemic

What are the 2 most common side effects of drugs used to prevent organ rejection?

Infection, Malignancies

*What are the classic signs of an Epidural Hematoma, a bleed that occurs between the dura and the skull?*

Initial period of unconsciousness then a brief lucid interval followed by decrease in LOC

What does IPAP stand for?

Inspiratory Positive Airway Pressure

The drug muromonab-CD3 prevents organ rejection by A. decreasing lymphocyte proliferation. B. inhibiting purine synthesis of T cells. C. interfering with the function of T lymphocytes. D. interfering with DNA, RNA, and protein synthesis. Rationale

Muromonab is an anti-antigen receptor antibody that interferes with the function of the T lymphocyte, the pivotal cell in the response to graft rejection. Reference: 230

A nurse is providing information to a client who has chronic rejection of a transplanted kidney. Which of the following statements should the nurse include? A. "Immediate removal of the donor kidney is planned." B. "Monitoring electrolytes frequently determines kidney status." C. "Scheduled kidney biopsies determine kidney status." D. "Restarting dialysis depends on marked azotemia." E. "Plan to have the immunosuppressive medication increased."

NOT A-this is for hyper-acute rejection BCDE

When assessing a patient weaning from a ventilator the muscle strength is assessed by measuring the _________, which should be greater than ____ cm H20?

Negative Inspiratory Force (NIF), 20 cm H20

What does OPO stand for and what is their role?

Organ Procurement Organization (OPO) They are the ones that discuss transplantation with the family and not until AFTER death. This is an ethical issue.

*Identify key assessments for determining the oxygenation and ventilation status of a mechanically ventilated patient.*

Oxygen Saturation (SpO2), Respiratory Rate, ABGs, Heart rate and rhythm, Mental Status RAT BED: Restlessness, Anxiety, Tachycardia/Tachypnea (Early) Bradycardia, Extreme Restlessness, Dyspnea (Late) MORE: -Dysrythmias -Dusky skin/Cyanosis (Late)

*Positive pressure applied to airway during exhalation?*

PEEP

How does Poiseulle's Law explain the effect of airway edema on an infants respiratory airway resistance and work of breathing?

Poiseulle's law states that resistance is inversely proportional to the fourth power of the airway radius. This means that as the radius decreases by a factor of 1 the resistance increases by a factor of 4. Therefore, 1 mm of edema in an infants airway increases resistance 16 fold.

What are some positions that help with ARDS?

Prone, Continuous Lateral Rotation Therapy and Lateral Position with the "good" lung down

What are some late signs of respiratory distress in children?

RR goes from tachypenia and drops. Body is no longer able to compensate. Bradycardia, apnea/gasping

List the GCS score for the following: Severe TBI Moderate TBI Mild TBI

Severe 3-8 Moderate 9-12 Mild 13-15

Exudate in the alveoli can cause ____ of blood and lead to ______?

Shunting, Hypoxemic Respiratory Failure

Infection is a significant cause of morbidity and mortality in kidney transplant patients. What are at least three reasons for this?

Suppression of the bodies normal defense mechanisms by: 1. Surgery 2. The immunosuppressive medications 3. The effects of end-stage renal disease

*Uncal, Central and Tonsillar* herniation all cause downward pressure on the brainstem, affecting the respiratory centers of the brain? A. True B. False

TRUE

Premature infants with BPD often grow out of it? T/F

TRUE

The lungs of newborns are poorly compliant? TRUE/FALSE

TRUE This is why Pressure-Cycled Ventilation is better.

*What is the function of the United Network of Organ Sharing (UNOS)?*

The mission of UNOS is to advance organ availability and transplantation to support patients through education, technology and policy development. THEY MANAGE THE WAITING LIST

The Monroe-Kellie Doctrine states that?

The sum of the volumes of the brain, CSF and blood remain constant.

How does a newborn increase minute ventilation?

They increase respiratory rate since lungs are poorly complaint.

*Mycophenolate mofetil (CellCept) * is an immunosuppressant used for organ transplant. What class of drug is it? What is the MOA? What are the main side effects?

This is a cytotoxic (anti proliferative) drug. It works by inhibiting cell proliferation. Side effects include pancytopenia. It inhibits all cell proliferation, preventing rejection of organs. *CellCept=THINK CELLinterCEPT* It intercepts T-Cells.

*Sirolimus (Rapamune)* is an immunosuppressant used for organ transplant. What class of drug is it? What is the MOA? What are the main side effects?

This is a cytotoxic (anti proliferative) drug. It works by inhibiting cell proliferation. Side effects include pancytopenia. It inhibits all cell proliferation, preventing rejection of organs. There is increased risk of infection and malignancy.

What is ICP and what is the normal pressure?

Total pressure exerted by blood, brain and CSF fluid. Normal 0-15 mm Hg

______ -cycled ventilation delivers a preset number of breaths at a preset tidal volume.

Volume-Cycled The flow and volume remain the same, only the pressure changes. This is why volume-cycled ventilation guarantees a minute ventilation but pressure can still change. Also forces lungs to expand to a set volume so barotrauma is a complication.

What does it mean that an infants CHEST WALL is very compliant?

When the diaphragm contracts it sucks in the chest walls.

The nurse suspects the early stage of ARDS in any seriously ill patient who? a. develops respiratory acidosis. b. has diffuse crackles and rhonchi. c. exhibits dyspnea and restlessness. d. has a decreased PaO2 and an increased PaCO2

c. exhibits dyspnea and restlessness.

The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations does NOT indicate an increased ICP? a. fever b. oriented to name only c. narrowing pulse pressure d. dilated right pupil > left pupil e. decorticate posturing to painful stimulus

c. narrowing pulse pressure NOT C: WIDENING pulse pressure

A patient has a PaO2 of 50 mm Hg and a PaCO2 of 42 mm Hg because of an intrapulmonary shunt. The patient is most likely to respond best to? a. oxygen administration at a FiO2 of 100%. b. administration of oxygen per nasal cannula at 1 to 3 L/min. c. clearance of airway secretions with coughing and suctioning. d. positive pressure ventilation.

d. positive pressure ventilation.

erase

*In caring for the patient with ARDS, the most characteristic sign the nurse would expect the patient to exhibit is?* a. increased PAWP. b. bronchial breath sounds. c. progressive hypercapnia. d. refractory hypoxemia.

*d. refractory hypoxemia.*

Which option indicates a sign of Cushing's triad, an indication of increased intracranial pressure (ICP)? A. Heart rate increases from 90 to 110 beats/minute B. Kussmaul respirations C. Temperature over 100.4° F (38° C) D. Heart rate decreases from 75 to 55 beats/minute

*D. Heart rate decreases from 75 to 55 beats/minute*

What are some late signs of increased ICP?

*- Severe deterioration in LOC - Decorticate/Decerebrate posturing* - Ipsilateral or bilateral (herniation) pupil becomes dilated and fixed - Projectile vomiting - Hemiplegia - Brainstem reflexes absent: gag, swallowing, respiratory

Which of the following is the best diagnostic test to determine craniocerebral trauma? A. CT scan B. MRI C. PET D. Transcranial Doppler

*A. CT scan*

*Six days after a heart-lung transplant, the patient develops a low-grade fever and a decreased SpO2 with exercise. The nurse recognizes that this may indicate?* a. a normal response to extensive surgery. b. a frequently fatal cytomegalovirus infection. c. acute rejection that can be treated with corticosteroids. d. obliterative bronchiolitis that plugs terminal bronchioles.

*c. acute rejection that can be treated with corticosteroids.*

If a ventilator alarm sounds and the patient is experiencing respiratory distress you should ________ whereas if they are not you should __________ ?

-Use ambu bag and 100% FiO2 -Trouble shoot the alarm

*Identify four indications for mechanical ventilation?*

1) Apnea or impending inability to breath 2) Acute respiratory failure 3) Severe Hypoxia 4) Respiratory muscle fatigue Lewis page 1703

The nurse is assessing the level of consciousness of a client who suffered a head injury. She uses the Glasgow Coma Scale and determines that the client's score is 15. Which responses did the nurse assess in this client? Select all that apply. 1. spontaneous eye opening 2. tachypnea, bradycardia, and hypotension 3. unequal pupil size 4. orientation to person, place, and time 5. motor response to pain localized 6. incomprehensible sounds

Answers: 1, 4, 5 The Glasgow Coma Scale assesses level of consciousness by testing and scoring three observations: eye opening, motor response, and verbal stimuli response. Clients are scored on their best responses and these scores are totaled. The highest score is 15. The highest responses in these three categories are spontaneous eye opening, obeying motor commands, and orientation to time, place, and person.

HOLD!

H-High pressure= O-Obstruction L-Low pressure= D-Disconnection

Delivery of small tidal volumes at a rapid respiratory rate?

HFV

LO: Describe the correct procedure for maintaining cuff pressures on an endotracheal or tracheostomy

The *minimal occluding volume (MOV) technique* and the *minimal leak technique (MLT)* are both used to maintain cuff pressure as to not damage the trachea. -Under Inflation-results in the escape of ventilating gases and/or aspiration. -Over Inflation-results in tracheal damage and/or tracheomalacia

*What is the purpose of the Uniform Anatomical Gift Act?*

The UAGA is a federal law that regulates the means by which organs can legally harvested for donation and transplantation, making them uniform state by state. It states that if a patient has not decided to be a donor the family may decide.

*Azathioprine (Imran)* is an immunosuppressant used for organ transplant. What class of drug is it? What is the MOA? What are the main side effects?

A patient on a positive pressure ventilator has the following ventilator settings: • Mode= CMV • RR (f)= 12 • TV(VT)=500mL His actual respiratory rate is 20. What is this patient's minute ventilation?

*10,000 mL/min* RR X TV = Minute Ventilation 20 X 500 mL = 10,000 mL/min

A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized. B. Insert nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start uid replacement.

*A. Keep neck stabilized.*

*Hypercapnic Respiratory Failure is defined as?*

*A PaCO2 of 48 mm Hg or more in combination with academia (pH less than 7.35)*

A week after kidney transplantation, a client develops a temperature of 101F, the blood pressure is elevated, and the kidney is tender. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse suspects which complication? A. Acute rejection B. Kidney infection C. Chronic rejection D. Kidney obstruction

*A. Acute rejection* ACUTE=6 months or less CHRONIC=6 months or longer

You are providing care for an elderly patient who has a low PaO2 as a result of worsening left-sided pneumonia. Which nursing intervention will help the patient mobilize his secretions? A. Augmented coughing or huff coughing B. Positioning the patient to lie on his left side C. Frequent and aggressive nasopharyngeal suctioning D. Application of noninvasive positive-pressure ventilation (NIPPV)

*A. Augmented coughing or huff coughing* Augmented coughing and huff coughing techniques may aid the patient in the mobilization of secretions. If placed in a side-lying position,*the patient should be positioned on his right side (good lung down)*. Suctioning may be indicated, but it should always be performed cautiously because of the risk of hypoxia. *NIPPV is NOT appropriate in the treatment of patients with excessive secretions. It causes secretions as a complication!*

*What is the standard to evaluate the degree of impaired consciousness for a patient with an acute head trauma?* A. Best eye opening, verbal response, and motor response B. National Institutes of Health (NIH) Stroke Scale C. Romberg test D. Widening pulse pressure, bradycardia, and respirations

*A. Best eye opening, verbal response, and motor response* The Glasgow Coma Scale (GCS) is a standardized tool used to assess the degree of impaired consciousness, and it consists of three components. The NIH stroke scale is used for a suspected stroke and includes other components of cranial nerve assessment, motor testing, and sensory testing. The Romberg test measures balance and is used for suspected cerebellar dysfunction. *The components in the last option are Cushing's triad and an indication of increased ICP, not LOC.*

What is the standard to evaluate the degree of impaired consciousness for a patient with an acute head trauma? A. Best eye opening, verbal response, and motor response B. National Institutes of Health (NIH) Stroke Scale C. Romberg test D. Widening pulse pressure, bradycardia, and respirations

*A. Best eye opening, verbal response, and motor response* The Glasgow Coma Scale (GCS) is a standardized tool used to assess the degree of impaired consciousness, and it consists of three components. The NIH stroke scale is used for a suspected stroke and includes other components of cranial nerve assessment, motor testing, and sensory testing. The Romberg test measures balance and is used for suspected cerebellar dysfunction. The components in the last option are Cushing's triad and an indication of increased ICP, not LOC.

*The patient is on mechanical ventilation. The patient is starting to become restless, dusky, and an alarm is sounding. What actions should you take?* A. Disconnect the patient from the ventilator and begin manual ventilations. B. Hyperventilate the patient with 100% oxygen and then suction the patient. C. Assess both lungs to determine adequate air movement and sedate the patient. D. Call a respiratory therapist to check ventilator settings and suction the patient.

*A. Disconnect the patient from the ventilator and begin manual ventilations.* If the machine is possibly malfunctioning, disconnect the patient from the mechanical ventilator and provide manual ventilations until the problem can be determined and resolved.

*The patient reports falling when he gets his foot "stuck" in a crack in the sidewalk, hitting his head when he fell, and "passing out". The paramedics found the patient walking at the scene and talking before transporting the patient to the hospital. In the emergency department, the patient starts to lose consciousness. This is a classic scenario for which complication?* A. Epidural hematoma B. Subdural hematoma C. Subarachnoid bleed D. Diffuse axial injury

*A. Epidural hematoma* The classic sign of an epidural is an initial period of unconsciousness at the scene and a brief lucid interval followed by a decrease in LOC. A subdural hematoma often results from injury to the brain and veins and develops more slowly. The classic sign or symptom of subarachnoid hemorrhage is a patient describing "the worst headache of my life." Diffuse axonal injury is widespread axonal damage occurring after a traumatic brain injury.

Which is a classic finding for a patient with ARDS? A. Hypoxemia despite increased oxygen administration B. Bronchodilators ordered to relieve airway spasms C. Development of Kussmaul respirations D. Development of Cheyne-Stokes respirations

*A. Hypoxemia despite increased oxygen administration* The hallmark of ARDS is hypoxemia despite increased FIO2 by mask, cannula, or endotracheal tube. Bronchodilators are used for asthma. Kussmaul respirations are caused by metabolic acidosis in diabetic ketoacidosis. Cheyne-Stokes respirations are a stairstep respiratory pattern with periods of apnea related to the body being stimulated by high CO2 levels to breathe. It is seen in patients with increased intracranial pressure. Reference: 1758

Preventing which problem is a priority nursing goal for a patient who had cranial surgery today? A. Pain B. Increased ICP C. Infection D. Malnutrition

*B. Increased ICP*

*A. Keep neck stabilized.* CORRECT: The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist. The priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be ruled out.

A nurse monitors a patient who takes azathioprine (Imuran) for which adverse effects? (Select all that apply.) A. Leukopenia B. Thrombocytopenia C. Alopecia D. Nephrotoxicity E. Red urine color

*A. Leukopenia B. Thrombocytopenia C. Alopecia* Azathioprine is a cytotoxic medication used to suppress the immune response. *It is toxic to all proliferating cells.* Cytotoxic medications usually are reserved for patients who have not responded to safer immunosuppressants. Nephrotoxicity and red-colored urine are not adverse reactions associated with azathioprine.

The nurse will monitor a patient with acute kidney injury for which of the following acid-base imbalances? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

*A. Metabolic acidosis* (The kidneys reabsorb bicarbonate HCO 3- to compensate for respiratory acidosis. If the kidneys are failing they can't do this)

*Which of the following nursing actions should be implemented in the care of a patient who is experiencing increased intracranial pressure (ICP)?* A. Monitor fluid and electrolyte status astutely. B. Position the patient in a high Fowler's position. C. Administer vasoconstrictors to maintain cerebral perfusion. D. Maintain physical restraints to prevent episodes of agitation.

*A. Monitor fluid and electrolyte status astutely.* Fluid and electrolyte disturbances can have an adverse effect on ICP and must be monitored vigilantly. The head of the patient's bed should be kept at 30 degrees in most circumstances, and physical restraints are not applied unless absolutely necessary. Vasoconstrictors are not typically administered in the treatment of ICP.

*The purpose of adding PEEP to positive-pressure ventilation is to?* A. increase functional residual capacity and improve oxygenation. B. increase FIO2 in an attempt to wean the patient and avoid O2 toxicity. C. determine whether the patient is in synchrony with the ventilator or needs to be paralyzed. D. determine whether the patient is able to be weaned and avoid the risk of pneumomediastinum.

*A. increase functional residual capacity and improve oxygenation.* PEEP is a ventilatory maneuver in which positive pressure is applied to the airway during exhalation. This increases functional residual capacity (FRC) and often improves oxygenation, with restoration of lung volume that normally remains at the end of passive exhalation. Reference: 1706-1707

*In preparing a patient in the ICU for oral endotracheal intubation, the nurse?* A. places the patient supine with the head extended and neck flexed. B. tells the patient that the tongue must be extruded while the tube is inserted. C. positions the patient supine with the head hanging over the edge of the bed to align the mouth and trachea. D. informs the patient that while it will not be possible to talk during insertion of the tube, speech will be possible after it is correctly place

*A. places the patient supine with the head extended and neck flexed.* "SNIFFING POSITION"

The most common early clinical manifestations of ARDS that the nurse may observe are? a.dyspnea and tachypnea. b.cyanosis and apprehension. c.hypotension and tachycardia. d.respiratory distress and frothy sputum.

*A.dyspnea and tachypnea.*

*What is one thing to use with caution in children with tracheomalasia?*

*Albuterol-can cause relaxation of smooth muscle which equals greater risk for airway collapse*

Which patient is most likely going into respiratory failure? A. A patient who report that he feels short of breath while eating B. A patient with the following arterial blood gas values over the past 3 hours: pH 7.50, 7.45, and 7.40 C. A patient with an oxygen saturation value of 93% D. A patient with chronic obstructive pulmonary disease (COPD) who has distant breath sounds

*B. A patient with the following arterial blood gas values over the past 3 hours: pH 7.50, 7.45, and 7.40* Manifestations of respiratory failure are related to the extent of change in PaO2 or PaCO2, the rapidity of change, and ability to compensate. It is important to monitor trends. Shortness of breath is a subjective report, and it can have many causes. A single borderline oxygen saturation reading is not as indicative of failure as a negative trend. Because of air trapping with COPD, the breath sounds are typically distant.

What distinguishes hypercapnic respiratory failure from hypoxemic respiratory failure? A. Low oxygen saturation despite administration of supplemental oxygen B. Acidemia for which the body cannot compensate C. Respiration rate greater than 30 breaths/minute D. Heart rate increases above 100 beats/minute

*B. Acidemia for which the body cannot compensate* Hypercapnic respiratory failure is *PaCO2 greater than 48 mm Hg in combination with acidemia*. The body cannot compensate for the acidemia. Hypoxemic respiratory failure is a PaO2 less than 60 mm Hg despite receiving an inspired oxygen concentration greater than or equal to 60%. The respiratory rate and heart rate are not part of the definitions of these two conditions.

Which medication does the nurse identify as a monoclonal antibody used to inhibit allograft rejection in transplant recipients? A. Mycophenolate mofetil (CellCept) B. Tacrolimus (Prograf) C. Sirolimus (Rapamune) D. Basiliximab (Simulect)

*B. Basiliximab (Simulect)* Basiliximab is a Monoclonal Anti-Body (ENDS in -MAB) that blocks the activation of T cells. It is used in the prophylaxis of organ rejection in the first 6 months after renal transplantation. Mycophenolate mofetil (CellCept) suppresses B- and T-lymphocyte proliferation. Tacrolimus (Prograf) and sirolimus (Rapamune) suppress T lymphocytes. *ENDS IN -MUS it will SUpreSS* ENDS in MAB-Monoclonal Anti-Body (MAB).

You are caring for a patient admitted with a subdural hematoma after a motor vehicle accident. Which change in vital signs would you interpret as a manifestation of increased intracranial pressure? A. Tachypnea B. Bradycardia C. Hypotension D. Narrowing pulse pressure

*B. Bradycardia* Changes in vital signs indicative of increased ICP are known as Cushing's triad, which consists of INCREASING SYSTOLIC PRESSURE with a WIDENING pulse pressure, BRADYCARDIA with a full and bounding pulse, and irregular respirations.

*A patient who takes cyclosporine (Sandimmune) also is receiving ketoconazole (Nizoral). The nurse should expect which therapeutic outcome from the combined medications?* A. Improved glomerular filtration rate B. Inhibition of cyclosporine metabolism C. Decreased risk of lymphoma occurrence D. Decreased risk of bacterial and viral infections

*B. Inhibition of cyclosporine metabolism* *Ketoconazole is an anti-fungal that RAISES cyclosporine levels and can INCREASE the risk of toxicity*. HOWEVER, some physicians administer ketoconazole with cyclosporine, because this greatly *reduces the cost of cyclosporine treatment*; the dosage of cyclosporine may be reduced by up to 88%. An improved glomerular filtration rate, decreased risk of lymphoma occurrence, and decreased risk of bacterial and viral infections are not effects of cyclosporine.

*What is proper management of a cuffed endotracheal (ET) tube?* A. Instill 3 mL of saline down the ET tube to prevent and/or loosen secretions. B. Maintain minimal occluding volume by inflating the cuff until no air leak is detected. C. Routinely suction the patient to limit the production of secretions. D. Reposition the ET tube every 2-3 days to avoid damage to the oral pharyngeal cavity.

*B. Maintain minimal occluding volume by inflating the cuff until no air leak is detected.* The minimal occluding volume technique inflates the cuff until no air leak is auscultated over the trachea at peak inspiratory pressure. The cuff pressure is checked to ensure it is *between 20 and 25 mm Hg*. Saline is no longer instilled into ET the tube. Patients are not routinely suctioned but only when there is a need. The tube is repositioned every 24 hours.

*A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?* A. Simple mask B. Non-rebreather mask C. Face tent D. Nasal cannula

*B. Non-rebreather mask* A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2. *Less safe than re-breather because no way for air to escape if malfunctioning.*

The primary advantage of pressure controlled ventilation over volume controlled ventilation is: A. The tidal volume is constant B. The peak alveolar pressure is constant C. Oxygenation is improved D. The minute ventilation is constant

*B. The peak alveolar pressure is constant*

*Which response can be expected in a patient with low oxygen concentration and acidosis?* A. Decreased cerebral fluid flow with decreased cerebral pressure B. Vasodilation with increased cerebral pressure C. Systemic hypotension with decreased cerebral pressure D. Cerebral tissue hypertrophy with increased cerebral pressure

*B. Vasodilation with increased cerebral pressure*

*The mother of a 20-month-old boy tells the nurse that he has a barking cough at night. His temperature is 37° C. The nurse suspects croup and should recommend:* A. controlling fever with acetaminophen and calling if the cough gets worse during the night. B. trying a cool-mist vaporizer at night and watching for signs of difficulty breathing. C. trying over-the-counter cough medicine and coming to the clinic in the morning if there is no improvement. D. admitting to the hospital and observing for impending epiglottis.

*B. trying a cool-mist vaporizer at night and watching for signs of difficulty breathing.* The child does not have a temperature to manage. Because the child is not having difficulty breathing, the nurse should teach the parents the signs of respiratory distress and tell them to come to the emergency room if they develop. Cool mist is recommended to provide relief. Cough suppressants are not indicated. This is characteristic of laryngotracheobronchitis, not epiglottitis.

A disease in infants that is characterized by dependency on oxygen?

*BPD*

Which instruction should be the priority for the nurse to teach a patient scheduled to start taking sirolimus (Rapamune)? A. "A lipid-lowering medication can be given to lower cholesterol levels." B. "There might be some joint pain, diarrhea, and rash with this medicine." C. "You'll need to notify your doctor if you experience any sore throat or fever." D. "Take this medication with food, but you'll need to avoid taking it with grapefruit juice."

*C. "You'll need to notify your doctor if you experience any sore throat or fever."* Sirolimus is an immunosuppressant approved only for preventing renal transplant rejection. *It raises the risk of infection*, and patients need to take precautions to avoid sources of contagion. Side effects include rash, joint pain, diarrhea, and increased levels of cholesterol, and taking sirolimus with grapefruit juice inhibits the drug's metabolism; these are lower levels of priority than the infection risk.

*For which patient would NIPPV be an appropriate intervention to promote oxygenation?* A. A patient's whose cardiac output and blood pressure are unstable B. A patient whose respiratory failure is caused by a head injury with loss of consciousness C. A patient who is experiencing respiratory failure as a result of the progression of a neuromuscular disease like myasthenia gravis. D. A patient with a diagnosis of cystic fibrosis and who is producing copious secretions

*C. A patient who is experiencing respiratory failure as a result of the progression of a neuromuscular disease like myasthenia gravis.*

A patient with increased ICP is being monitored in the intensive care unit (ICU) with a fiberoptic catheter. Which order is a priority for you? A. Perform hourly neurologic checks. B. Take a complete set of vital signs. C. Administer the prescribed mannitol (Osmitrol). D. Give an H2-receptor blocker.

*C. Administer the prescribed mannitol (Osmitrol).* I THINK THE CATHETER RECORDS DATA. The priority is to treat the known existing problem, and mannitol is the only thing that can do that. *Because the patient is having the current pressure measured with objective numbers, treating the known problem is a priority over additional assessments*. H2-blockers are given when corticosteroids are administered to help prevent gastrointestinal bleeding, but they are not a priority compared with the treatment of ICP.

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing interventions? A. Water-seal chamber has 5 cm of water. B. No new drainage in collection chamber C. Chest tube with a loose-fitting dressing D. Small pneumothorax at CT insertion site

*C. Chest tube with a loose-fitting dressing*

What pathophysiologic condition can result in ARDS? A. Airway spasms and vasoconstriction B. Copious exudates production C. Damage to the alveolar-capillary membrane D. Change in the inspiratory-to-expiratory ratio

*C. Damage to the alveolar-capillary membrane* In ARDS, there is damage to the alveolar-capillary membrane, although the exact mechanism is not known. The damage results in increased pulmonary capillary membrane permeability, destruction of elastic and collagen, formation of pulmonary microemboli, and pulmonary artery vasoconstriction. These changes produce increased fluid accumulation and decreased lung compliance. Temporary narrowing of the airway is seen in asthma. Exudate production is seen with pneumonia or chronic obstructive pulmonary disease (COPD). The cause does not involve a change in ventilation, although there may eventually be some alteration due to respiratory distress.

*What action best helps to prevent ventilator-associated pneumonia (VAP)?* A. Routinely changing the patient's ventilator circuit tubing B. Elevating the head of the bed (HOB) to at least 90 degrees C. Draining the water collected in tubing away from the patient D. Using the minimal leak technique with a cuffed endotracheal tube.

*C. Draining the water collected in tubing away from the patient* Water that collects in the ventilator tubing should be drained away from the patient as it collects. Other measures include elevating the HOB to a minimum of 30 to 45 degrees and no routine changing of circuit tubing. *The minimal leak technique is related to avoiding tracheal trauma* not VAP.

A 55 year old patient in the ICU has been admitted for potential organ rejection after a recent kidney transplant. What is the most likely sign/symptom the patient would demonstrate? A. Increased urine output B. Decreased BUN/creatinine C. Elevated creatinine D. Elevated platelet count

*C. Elevated creatinine*

After an oral endotracheal (ET) tube is inserted, the patient is biting down on the tube, causing an obstruction. What action should be taken? A. Consider nasal ET intubation. B. Plan for a tracheostomy. C. Give the patient a bite block. D. Provide comfort with oral care.

*C. Give the patient a bite block.*

*C. Give the patient a bite block.* Patients often obstruct the ET tube by biting down on it. Sedation and pain management, along with the use of a bite block or oropharyngeal airway can be used to avoid this. Oral ET intubation is preferred over nasal ET intubation. A tracheostomy is done if long-term intubation is expected. Oral care is important but will not directly address problem.

*You are caring for a patient who is admitted with a barbiturate overdose. The patient is unresponsive, with a blood pressure of 90/60 mm Hg, apical pulse of 110 beats/minute, and respiratory rate of 8 breaths/minute. Based on the initial assessment findings, you recognize that the patient is at risk for which type of respiratory failure?* A. Hypoxemic respiratory failure related to shunting of blood B. Hypoxemic respiratory failure related to diffusion limitation C. Hypercapnic respiratory failure related to alveolar hypoventilation D. Hypercapnic respiratory failure related to increased airway resistance

*C. Hypercapnic respiratory failure related to alveolar hypoventilation* NOTE: Drug overdose is hypercapnic respiratory failure

A child is brought to the emergency department after sustaining a blow to the head while playing football. The nurse performs a neurological assessment to determine if the child has an acute head injury. What should the nurse assess first? A. Ocular signs B. Muscular strength C. Level of consciousness D. Injuries to the scalp area

*C. Level of consciousness* even mild changes

A post kidney transplant patient taking tacrolimus (Prograf) begins to experience tremors of her right hand and questions the nurse about the reason. The nurse knows that: A. The patient should report the tremors to her physician because it may be indicative of a grand mall seizure. B. If the tremors are accompanied by numbness they may indicate that the patient has developed a brain tumor, a serious adverse effect of immunosuppression. C. Neurological toxicity can develop with tacrolimus therapy and often presents as tremor, numbness and tingling. D. The tremors are most likely an indication of pronounced the hypocalcemia that has persisted since she was in renal

*C. Neurological toxicity can develop with tacrolimus therapy and often presents as tremor, numbness and tingling.*

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow Coma Scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response

*C. Oxygen saturation* CORRECT: Using the airway, breathing, and circulation (ABC) priority-setting framework, assessment of oxygen saturation is the priority action. Brain tissue can only survive for 3 min before permanent damage occurs.

Preset positive pressure used to augment the patient's inspiratory effort is known as: A. Positive end-expiratory pressure (PEEP) B. Continuous positive airway pressure (CPAP) C. Pressure support ventilation (PSV) D. Continuous Mandatory Ventilation (CMV)

*C. Pressure support ventilation (PSV)*

*Which intervention is key to preventing ventilator-associated pneumonia as a complication in a patient with acute respiratory distress syndrome (ARDS)?* A. Scheduled prophylactic nasopharyngeal suctioning B. Instilling normal saline down the endotracheal tube to loosen secretions C. Providing frequent mouth care and oral hygiene D. Using high tidal volumes on the ventilator

*C. Providing frequent mouth care and oral hygiene* A frequent complication of ARDS is ventilator-associated pneumonia. *Preventative strategies include elevating head-of-bed 30-45 degrees and strict infection control measures such as frequent HAND WASHING, use of in-line suction, and frequent mouth care and oral hygiene. Suctioning is done ONLY as needed to prevent stimulating excess secretions*. Instilling normal saline does not loosen secretions and can cause hypoxia. It is not recommended. High tidal volumes can lead to barotrauma. Reference: 1759

*A humidified atmosphere is recommended for a young child with an upper respiratory tract infection because this environment facilitates:* A. liquefying secretions. B. improving oxygenation. C. promoting ventilation. D. soothing inflamed mucous membrane.

*D. soothing inflamed mucous membrane.* The size of the droplets is too large to liquefy secretions. No additional oxygen is provided with humidified air. The humidity has no effect on ventilation. By humidifying the inspired air, the membranes inflamed by the infection and dry air are soothed

*During suctioning of the endotracheal tube, the patient has a SpO2 value of 86% and is using accessory muscles. What action should you take?* A. Increase the suction to quickly obtain retained mucus. B. Continue the procedure because these signs are expected. C. Stop suctioning and hyperventilate with 100% oxygen. D. Twirl the catheter while applying intermittent suction.

*C. Stop suctioning and hyperventilate with 100% oxygen.* If the patient does not tolerate suctioning (e.g., decreased SpO2, increased or decreased blood pressure, sustained coughing, development of dysrhythmias), stop the procedure, and manually hyperventilate the patient with a bag-valve mask and 100% oxygen.

A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which if the following is the appropriate nursing intervention? A. Continue to suction B. Notify the physician immediately C. Stop the procedure and reoxygenate the client D. Ensure that the suction is limited to 15 seconds

*C. Stop the procedure and reoxygenate the client* During suctioning, the nurse should *monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing*. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.

*C. The LOC improves.* LOC is the most sensitive indicator of ICP. Mannitol is an osmotic diuretic that works to decrease the ICP by plasma expansion and an osmotic effect. Although the other options may indicate a therapeutic effect of a diuretic, they are not the main reason this drug is given.

The nurse is assessing coping in a female patient that had a liver transplant 5 months ago. Which assessment is most important to report to the physician? A. The patient is expressing fears of organ rejection even though the laboratory values are normal. B. The patient is concerned about facial hair that has appeared since starting on steroids. C. The patient is withdrawn and only sleeping for 3 hours per night due to posttraumatic stress. D. The patient is expressing concern with the ability to pay for medications and follow up health care.

*C. The patient is withdrawn and only sleeping for 3 hours per night due to posttraumatic stress.*

A patient receiving mechanical ventilation is very anxious and agitated, and neuromuscular blocking agents are used to promote ventilation. The nurse recognizes that? A. The patient will be too sedated to be aware of the details of care. B. Caregivers should be encouraged to provide stimulation and diversion. C. The patient should always be addressed and explanations of care given. D. Communication will not be possible with the use of neuromuscular blocking agents

*C. The patient should always be addressed and explanations of care given.*

*Interpret arterial blood gases:pH 7.31PaCO2 48 mm Hg HCO3- 23 mEq/L PaO2 100 mm Hg?* A. Normal arterial blood gasses B. Partly compensated respiratory acidosis C. Uncompensated respiratory acidosis D. Uncompensated metabolic acidosis

*C. Uncompensated respiratory acidosis*

Which of the following interventions is most likely to prevent or limit barotrauma in the patient with ARDS who is mechanically ventilated? a. Decreasing PEEP b. Increasing the tidal volume c. Use of permissive hypercapnia d. Use of positive pressure ventilation

*C. Use of permissive hypercapnia* To avoid barotrauma and minimize risks associated with elevated plateau and peak inspiratory pressures, the patient with ARDS is often ventilated with *smaller tidal volumes* and various amounts of PEEP to minimize oxygen requirements and intrathoracic pressures. One result of this protocol is an elevation in PaCO2, also called *permissive hypercapnia because the PaCO2 is allowed to rise above normal limits.* PPV, especially volume controlled ventilation causes barotrauma. CMV, SIMV.

Which is part of the nursing management for ARDS? A. Aggressive use of intravenous (IV) fluids B. Administration of a β-blocker C. Use of positive end-expiratory pressure (PEEP) D. Use of the lateral recumbent position

*C. Use of positive end-expiratory pressure (PEEP)* In ARDS, higher levels of PEEP may be used. It increases the functional residual capacity (FRC) and opens collapsed alveoli. The issues in ARDS treatment are respiratory related, not fluid deficit. β-Blockers are part of myocardial infarction management, not ARDS. Some ARDS patients do better when placed in a PRONE position instead of a supine position. *In the supine position, the heart places pressure on the pleural cavity.* Changing the patient to a prone position allows air-filled, nonatelectatic alveoli in the ventral portion of the lung to become dependent. Reference: 1760

You are alerted to a possible acute subdural hematoma in the patient who? A. has a linear skull fracture crossing a major artery. B. has focal symptoms of brain damage with no recollection of a head injury. C. develops decreasing LOC and a headache within 48 hours of a head injury. D. has an immediate loss of consciousness with a brief lucid interval followed by decreasing LOC.

*C. develops decreasing LOC and a headache within 48 hours of a head injury.* An acute subdural hematoma manifests within 24 to 48 hours of the injury. The signs and symptoms are similar to those associated with brain tissue compression by increased intracranial pressure (ICP) and include decreasing LOC and headache.

The drug muromonab-CD3 prevents organ rejection by? A. decreasing lymphocyte proliferation. B. inhibiting purine synthesis of T cells. C. interfering with the function of T lymphocytes. D. interfering with DNA, RNA, and protein synthesis.

*C. interfering with the function of T lymphocytes.*

Maintenance of fluid balance in the patient with ARDS involves? a.hydration using colloids. b.administration of surfactant. c.mild fluid restriction and diuretics as necessary. d.keeping the hemoglobin at levels above 12 g/dL (120 g/L).

*C. mild fluid restriction and diuretics as necessary.*

When providing oral care to a patient on mechanical ventilation you should use hydrogen peroxide with a 1.5% hydrogen peroxide solution? A. True B. False

*False* This is irritating to the mucous membranes

*In the state of Minnesota* family can overrule first person consent? A. True B. False

*False* Lewis says they can but textbook not specific to Minnesota

*A patient has an oral endotracheal (ET) tube inserted to relieve an upper airway obstruction and to facilitate secretion removal. The first responsibility of the nurse immediately following placement of the tube is to?* A. suction the tube to remove secretions. B. secure the tube to the face with adhesive tape. C. place an end tidal CO2 detector on the ET tube. D. assess for bilateral breath sounds and symmetric chest movement.

*C. place an end tidal CO2 detector on the ET tube.* Detects the CO2 that is emitted from the lungs. If the detector is not detecting CO2 it is in the esophagus. Think about it, before securing it they need to know its in the trachea.

You monitor the patient with mechanical positive-pressure ventilation (PPV) for? A. paralytic ileus because pressure on the abdominal contents affects bowel motility. B. diuresis and sodium depletion because of increased release of atrial natriuretic peptide. C. signs of cardiovascular insufficiency because pressure in the chest impedes venous return. D. respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO2 levels.

*C. signs of cardiovascular insufficiency because pressure in the chest impedes venous return.* PPV can affect circulation because of the transmission of increased mean airway pressure to the thoracic cavity. With increased intrathoracic pressure, thoracic vessels are compressed. This results in decreased venous return to the heart, decreased left ventricular end-diastolic volume (preload), decreased cardiac output, and hypotension. HYPOTENSION+TOO MUCH PRESSURE. This can happen if you turn the PEEP up too high.

*A family member asks you what SIMV means on the settings of the mechanical ventilator attached to her husband. Which statement best describes this mode of ventilation?* A. "SIMV provides additional inspiratory pressure so that your husband does not have to work as hard to breathe, enabling better oxygenation and a quicker recovery with fewer complications." B. "SIMV allows the ventilator to totally control breathing. It prevents your husband from hyperventilating or hypoventilating, ensuring the best oxygenation possible." C. "SIMV allows your husband to breathe on his own, but the ventilator controls how deep a breath he receives. The ventilator can sense when your husband wants a breath and delivers it." D. "SIMV allows your husband to breathe on his own while receiving a preset number of breaths from the ventilator. He can breathe as much or as little as he wants beyond what the ventilator provides for him."

*D. "SIMV allows your husband to breathe on his own while receiving a preset number of breaths from the ventilator. He can breathe as much or as little as he wants beyond what the ventilator provides for him."* With synchronized intermittent mandatory ventilation (SIMV), the ventilator delivers a preset tidal volume at a preset frequency in synchrony with the patient's spontaneous breathing. *Between ventilator-delivered breaths, the patient is able to breathe spontaneously, receiving the preset FIO2 but self-regulating the rate and depth of those breaths.*

Which nursing action should be implemented in the care of a patient who is experiencing increased ICP? A. Position the patient in a high-Fowler's position. B. Administer vasoconstrictors to maintain cerebral perfusion. C. Maintain physical restraints to prevent episodes of agitation. D. Carefully monitor fluid and electrolyte status.

*D. Carefully monitor fluid and electrolyte status.* *Raising the head of the bed above 30 degrees may decrease the cerebral perfusion pressure (CPP) by lowering systemic blood pressure. They use vasopressors not vasoconstrictors.*

*The ventilator low-pressure alarm is sounding. What action(s) should you do first?* A. Silence the alarm and suction the patient. B. Disconnect the patient and manually ventilate. C. Assess breath sounds and hyperventilate the patient. D. Check all tube connections.

*D. Check all tube connections.* If patient is in respiratory distress you would start with an Bambu bag if not you would trouble shoot the alarm. The question doesn't mention any distress. Most accidental disconnections in critical care settings are discovered by low-pressure alarms. The most frequent site for disconnection is between the endotracheal tube and the adapter. NCLEX: VENT ALARMS *HOLD-High, Obstruction, Low, Disconnection*

*What action best helps to prevent ventilator-associated pneumonia (VAP)?* A. Routinely changing the patient's ventilator circuit tubing B. Elevating the head of the bed (HOB) to at least 90 degrees C. Using the minimal leak technique with a cuffed endotracheal tube. D. Draining the water collected in tubing away from the patient

*D. Draining the water collected in tubing away from the patient* WHY NOT A? Change the ventilator circuit only if visibly soiled or malfunctioning. WHY NOT B? Elevate the HOB to 30-40 degrees WHY NOT C? The minimal leak technique is related to endotracheal trauma not pneumonia. WHY D? Water that collects in the tubing should be drained away from the patient as it collects. This makes sense that it would cultivate bacteria.

The patient had a blunt head injury. What is most important for you to do before the patient's discharge? A. Have the patient sign the discharge papers. B. Teach the patient how to perform the Glasgow Coma Scale (GCS). C. Tell the patient to return if he has a headache. D. Ensure there is a responsible adult to check on the patient.

*D. Ensure there is a responsible adult to check on the patient.*

You would be concerned about which item on the breakfast tray of the patient receiving cyclosporine? A. Eggs B. Milk C. Yogurt D. Grapefruit juice

*D. Grapefruit juice*

*D. Heart rate decreases from 75 to 55 beats/minute* Cushing's triad is systolic HYPERTENSION with a widening pulse pressure, BRADYCARDIA with a full and bounding pulse, and SLOWED RESPIRATIONS. The rise in blood pressure is an attempt to maintain cerebral perfusion, and it is a neurologic emergency because decompensation is imminent. The other options are not part of Cushing's triad.

*A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patient's GCS score as?* a. 6. b. 7. c. 9. d. 1

*b. 7.* -Does not open eyes to any stimulus=1 point -Incomprehensible words or sounds=2 points (1 for no sound) -Flexion in response to painful stimuli without abnormal posturing = 4 points

*A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient's condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for the cause. Which condition triggers the high pressure alarm?* A. A disconnected ventilator tube B. An endotracheal cuff leak C. A change in the oxygen concentration without resetting the oxygen level alarm D. Kinking of the ventilator tubing

*D. Kinking of the ventilator tubing* Conditions that trigger the high pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolus, mucus plugging, water in the tube, coughing or biting on endotracheal tube, and the patient's being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an endotracheal cuff leak would trigger the low pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would tigger the oxygen alarm.

*Which intervention will limit complications associated with open suctioning for an adult with a tracheostomy tube who is on a mechanical ventilator?* A. Perform subglottal suctioning before suctioning the tracheostomy tube. B. Assure that the suction vacuum is set at 60 to 80 mm Hg before suctioning. C. Lightly coat the distal end of the suction catheter with water-soluble lubricant before suctioning. D. Limit each suctioning pass to 10 seconds or less.

*D. Limit each suctioning pass to 10 seconds or less.*

*When planning care for a patient on a mechanical ventilator, you understand that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?* A. Increased FIO2 administration B. Increased inflation of the lungs C. Prevention of barotrauma to the lung tissue D. Prevention of alveolar collapse during expiration

*D. Prevention of alveolar collapse during expiration* PEEP is positive pressure that is applied to the airway during exhalation. The additional pressure prevents the alveoli from collapsing, thus improving oxygenation and reducing the FIO2 requirement. Reference: 1706-1707

The nurse is assessing the patient post-liver transplant. What assessment indicates that the liver is functioning correctly? A. An increased INR level. B. A rise in lactic dehydrogenase. C. Clay colored bowel movements. D. Production of thick dark green bile in the T tube.

*D. Production of thick dark green bile in the T tube.*

*A nurse is caring for a patient who has an endotracheal (ET) tube in place. Which of the following is an appropriate component of ET tube care for this patient?* A. Provide oral and nasal care every 12 hours B. Applying the securing tape over the patients ears C. maintaining a cuff pressure of 30 mm Hg D. Reposition the ET tube every 8 hours

*D. Reposition the ET tube every 8 hours* Why not A? Provide oral care every 2-4 hours Why not B? The tape is secured over the patient's mouth according to the picture in lecture. Putting it over the ears can cause pressure ulcers. Why not C? 20-25 mm Hg is the normal range for cuff pressure. Too much pressure and the trachea can become damaged. Too little pressure and air can escape during ventilation. Why D? Repositioning the tube every 8 hours helps prevent irritation.

Which patient is having the most difficulty breathing? A. The patient who reports one-pillow orthopnea B. The patient with an inspiratory to expiratory ratio of 1:2 C. The patient who speaks a sentence before breathing D. The patient with paradoxic breathing

*D. The patient with paradoxic breathing* Paradoxic breathing indicates severe distress. The thorax and abdomen normally move outward on inspiration and inward on exhalation. During paradoxic breathing, the abdomen and chest move in the opposite manner, and the pattern results from maximal use of the accessory muscles of respiration.

*The nurse uses the minimal occluding volume to inflate the cuff on an endotracheal tube to minimize the incidence of?* A. Accidental extubation. B. Infection. C. Hypoxemia. D. Tracheal necrosis.

*D. Tracheal necrosis.*

*Which response can be expected in a patient with low oxygen concentration and acidosis?* A. Decreased cerebral fluid flow with decreased cerebral pressure B. Systemic hypotension with decreased cerebral pressure C. Cerebral tissue hypertrophy with increased cerebral pressure D. Vasodilation with increased cerebral pressure

*D. Vasodilation with increased cerebral pressure*

During a cardiac arrest, the physician inserts an endotracheal (ET) tube. The carbon dioxide indicator does not change color. What action should be done next? A. Watch for bilateral chest movement. B. Listen to both lung bases while the patient is ventilated. C. Check for an improvement in pulse oximetry. D. Withdraw the ET tube, and reintubate.

*D. Withdraw the ET tube, and reintubate.* If the indicator does not detect carbon dioxide, the tube is in the esophagus and needs to be reinserted. The other options are observations or actions taken when the tube is properly placed.

Metabolic and nutritional needs of the patient with increased ICP are best met with? A. enteral feedings that are low in sodium. B. the simple glucose available in D5W IV solutions. C. a fluid restriction that promotes a moderate dehydration. D. balanced, essential nutrition in a form that the patient can tolerate.

*D. balanced, essential nutrition in a form that the patient can tolerate.* Patient is in hypermetabolic and hyper catabolic state. D5W is free water and would increase edema. Maintain patient normovolemic.

The oxygen delivery system chosen for the patient in acute respiratory failure should? a.always be a low-flow device, such as a nasal cannula. b.correct the PaO2 to a normal level as quickly as possible. c.administer positive pressure ventilation to prevent CO2 narcosis. d.maintain the PaO2 at ≥60 mm Hg at the lowest O2 concentration possible.

*D. maintain the PaO2 at ≥60 mm Hg at the lowest O2 concentration possible.*

A 4-year-old girl is brought to the emergency room. She has a "froglike" croaking sound on inspiration, is agitated, and is drooling. She insists on sitting upright. The nurse should: A. examine her oral pharynx and report to the physician. B. make her lie down and rest quietly. C. auscultate her lungs and make preparations for placement in a mist tent. D. notify the physician immediately and be prepared to assist with a tracheostomy or intubation.

*D. notify the physician immediately and be prepared to assist with a tracheostomy or intubation.* Examination of the oral pharynx may cause total obstruction. The child assumes a tripod position to facilitate breathing. Forcing the child to lie down will increase the respiratory distress and anxiety. Preparation should be made to care for her if an obstruction occurs. *Sitting upright, drooling, agitation, and a froglike cough indicate epiglottitis*. This is a medical EMERGENCY, and tracheostomy or intubation may be necessary.

*Explain the physiology of hyperacute rejection, acute rejection, and chronic rejection?*

*Hyperacute (antibody-mediated, humoral) Rejection* occurs over *minutes to hours* after transplant because blood vessels are rapidly destroyed. It occurs when the recipient has pre-existing antibodies to the donor's HLA's. It cannot be treated and the organ must be removed. The crossmatches they perform checks for the likelihood of this. *Acute Rejection* most commonly manifests in the first 6 months after transplant. This is cell-mediated immunity and occurs because the donor's lymphocytes (T-Cells and B-cells) attack the donor tissue or organ. This type of rejection CAN be treated and reversed with higher doses of corticosteroids and monoclonal antibodies. This is why immunosuppressants are given and why they all affect the T-Cells and B-Cells. *Chronic Rejection* is a process that occurs over months to years and is irreversible. The reasons for this are not entirely known but it can occur from repeated episodes of acute rejection. The transplanted organ is infiltrated with large numbers of T-Cells and B-Cells characteristic of an ongoing, low-grade cell-mediated injury. *FIBROSIS and SCARRING* occur. In hearts this causes accelerated coronary artery disease and in lungs bronchiolitis obliterans (BOS).

Smoke inhalation would likely cause this type of respiratory failure?

*Hypoxemic (Carbon Monoxide binds to hemoglobin with higher affinity than oxygen!!!!)* NOTE: they could have normal O2 SATs!

*Positive pressure applied only during inspiration that supplies a rapid flow of gas?*

*PSV* -opposite of PEEP

If you give a child albuterol and their stridor gets worse you should start looking for __________ ?

*Tracheomalsia* (TRACHEOSTOMY AND CPAP)

_______-inflation of the cuff leads to *escape of gases* and/or aspiration and _______ -inflation of the cuff leads to tracheal damage and/or *tracheomalacia.*

*Under, Over*

A kidney transplant recipient complains of having fever, chills, and dysuria over the course of the past 2 days. What is the first action that the nurse should take? a. Assess temperature and initiate workup to rule out infection. b. Provide warm cover for the patient and give 1 g acetaminophen orally. c. Reassure the patient that this is common after transplantation. d. Notify the nephrologist that the patient has developed symptoms of acute rejection.

*a. Assess temperature and initiate workup to rule out infection.* ASSESS before implementing. TIP: whenever the other options are all actions and there is one assessment do the one assessment.

*A patient in acute respiratory failure is receiving assist-control mechanical ventilation with a peak end-expiration. A pressure (PEEP) of 10 cm H2O. A sign that alerts the nurse to undesirable effects of increased airway and thoracic pressure is?* a. decreased BP. b. decreased PaO2. c. increased crackles. d. decreased spontaneous respirations.

*a. decreased BP.*

After endotracheal intubation and mechanical ventilation have been started, a patient in respiratory failure becomes very agitated and is breathing asynchronously with the ventilator. It is most important for the nurse to first? a. evaluate the patient's pain level, ABGs, and electrolyte values. b. sedate the patient to unconsciousness to eliminate patient awareness. c. administer the PRN vecuronium (Norcuron) to promote synchronous ventilations. d. slow the rate of ventilations provided by the ventilator to allow for spontaneous breathing by the patient.

*a. evaluate the patient's pain level, ABGs, and electrolyte values.*

The nurse plans long-term goals for the patient who has had a heart transplant with the knowledge that a common cause of death in heart transplant patients during the first year is? a. infection. b. heart failure. c. embolization. d. malignant condition

*a. infection.* need for long-term immunosuppression means infection is major cause of death. Malignancies are a long-term complication of suppression.

*A patient with a massive hemothorax and pneumothorax has absent breath sounds in the right lung. To promote improved V/Q matching, the nurse positions the patient?* a. on the left side. b. on the right side. c. in a reclining chair bed. d. supine with the head of the bed elevated.

*a. on the left side.* GOOD LUNG DOWN!!!!!!!!!

*A patient has a PaO2 of 50 mm Hg and a PaCO2 of 42 mm Hg because of an intrapulmonary shunt. The patient is most likely to respond best to?* a. positive pressure ventilation. b. oxygen administration at a FiO2 of 100%. c. administration of oxygen per nasal cannula at 1 to 3 L/min. d. clearance of airway secretions with coughing and suctioning.

*a. positive pressure ventilation.*

*During the immediate postoperative care of the recipient of a kidney transplant, the nurse expects to?* a. regulate fluid intake hourly based on urine output. b. find urine-tinged drainage on the abdominal dressing. c. medicate the patient frequently for incisional flank pain. d. remove the urinary catheter to evaluate the ureteral implant

*a. regulate fluid intake hourly based on urine output.*

Although acute respiratory distress syndrome (ARDS) may result from direct lung injury or indirect lung injury as a result of systemic inflammatory response syndrome (SIRS), the nurse is aware that ARDS is most likely to occur in the patient with a host insult resulting from? a. septic shock. b. oxygen toxicity. c. multiple trauma. d. prolonged hypotension

*a. septic shock.*

An ESRD patient receiving hemodialysis is considering asking a relative to donate a kidney for transplantation. In assisting the patient to make a decision about treatment, the nurse informs the patient that? a. successful transplantation usually provides better quality of life than that offered by dialysis. b. if rejection of the transplanted kidney occurs, no further treatment for the renal failure is available. c. the immunosuppressive therapy that is required following transplantation causes fatal malignancies in many patients. d. hemodialysis replaces the normal functions of the kidneys and patients do not have to live with the continual fear of rejection.

*a. successful transplantation usually provides better quality of life than that offered by dialysis.* In lecture they mention that the survival rates are higher too!

The best patient response to treatment of ARDS occurs when initial management includes? a. treatment of the underlying condition. b. administration of prophylactic antibiotics. c. treatment with diuretics and mild fluid restriction. d. endotracheal intubation and mechanical ventilation.

*a. treatment of the underlying condition.*

*The nurse determines that alveolar hypoventilation is occurring in a patient on a ventilator when?* a. the patient develops cardiac dysrhythmias. b. auscultation reveals an air leak around the ET cuff. c. ABG results show a PaCO2 of 32 mm Hg and a pH of 7.47. d. the patient tries to breathe faster than the ventilator setting.

*b. auscultation reveals an air leak around the ET cuff.*

*The nurse recognizes the presence of Cushing's triad in the patient with?* a. increased pulse, irregular respiration, increased BP. b. decreased pulse, irregular respiration, increased pulse pressure. c. increased pulse, decreased respiration, increased pulse pressure. d. decreased pulse, increased respiration, decreased systolic

*b. decreased pulse, irregular respiration, increased pulse pressure.*

The nurse recognizes the presence of Cushing's triad in the patient with? a. increased pulse, irregular respiration, increased BP. b. decreased pulse, irregular respiration, increased pulse pressure. c. increased pulse, decreased respiration, increased pulse pressure. d. decreased pulse, increased respiration, decreased systolic BP.

*b. decreased pulse, irregular respiration, increased pulse pressure.*

When weaning a patient from a ventilator, the nurse plans? a. to decrease the delivered FIO2 concentration. b. intermittent trials of spontaneous ventilation followed by ventilatory support to provide rest. c. substitution of ventilator support with a manual resuscitation bag if the patient becomes hypoxemia. d. to implement weaning procedures around the clock until the patient does not experience ventilatory fatigue

*b. intermittent trials of spontaneous ventilation followed by ventilatory support to provide rest.*

A patient in the progressive stage of shock has rapid, deep respirations. The nurse determines that the patient's hyperventilation is compensating for a metabolic acidosis when the patient's arterial blood gas results include? a. pH 7.42, PaO2 80 mm Hg. b. pH 7.38, PaCO2 30 mm Hg. c. pH 7.48, PaO2 69 mm Hg. d. pH 7.32, PaCO2 48 mm Hg.

*b. pH 7.38, PaCO2 30 mm Hg.*

*In caring for the patient with ARDS, the most characteristic sign the nurse would expect the patient to exhibit is?* a. increased PAWP. b. refractory hypoxemia. c. bronchial breath sounds. d. progressive hypercapnia.

*b. refractory hypoxemia.* Hypoxemia that does not respond to oxygenation is a hallmark of ARDS. The exact definition is a PaO2 of 60 mm Hg while receiving an FiO2 of 60% or more.

*Hypercapnic respiratory failure is most likely to occur in the patient who has?* a. rapid, deep respirations in response to pneumonia. b. slow, shallow respirations as a result of sedative overdose. c. large airway resistance as a result of severe bronchospasm. d. poorly ventilated areas of the lung caused by pulmonary edema

*b. slow, shallow respirations as a result of sedative overdose.* A-pneumonia is hypoxemic B-Lewis says Asthma is hypoxemic, lecture said both D-pulmonary edema is hypoxemic

A client who had an infratentorial craniotomy is admitted to the intensive care unit after discharge from the postanesthesia care unit. Frequent assessments reveal that the client's intracranial pressure is increasing. The nurse should first: a.Notify the surgeon b.Elevate the head of the bed c.Reduce the flow rate of IV fluid d.Administer the next dose of osmotic diuretic early

*b.Elevate the head of the bed*

Patients with a heart transplantation are at risk for which of the following complications in the first year after transplantation (select all that apply)? a.Cancer b.Infection c.Rejection d.Vasculopathy e.Sudden cardiac death

*b.Infection* *c.Rejection* *e.Sudden cardiac death* (MOST COMMON IN FIRST YEAR) a.Cancer d.Vasculopathy (LATER ON THESE ARE MORE COMMON)

*Although his oxygen saturation is above 92%, an orally intubated, mechanically ventilated patient is restless and very anxious. What intervention should be used first to decrease the risk of accidental extubation?* a. Obtain an order and apply soft wrist restraints. b. Remind the patient that he needs the tube inserted to breathe. c. Administer sedatives and have a caregiver stay with the patient. d. Move the patient to an area close to the nurses' station for closer observation.

*c. Administer sedatives and have a caregiver stay with the patient.*

A nurse is caring for a child who sustained a head injury from a fall. The nurse avoids which of the following in the care of the child? a. Restrict oral fluids. b. Elevate the head of the bed. c. Coughing and deep breathing. d. Perform neurological assessments.

*c. Coughing and deep breathing.*

An unconscious patient with increased ICP is on ventilatory support. The nurse notifies the health care provider when arterial blood gas (ABG) measurement results reveal a? a. pH of 7.43. b. SaO2 of 94%. c. PaO2 of 50mm Hg. d. PaCO2 of 30 mm Hg.

*c. PaO2 of 50mm Hg.* 80-100 ref range

*Increased ICP in the left cerebral cortex caused by intracranial bleeding causes displacement of brain tissue to the right hemisphere beneath the falx cerebri. The nurse knows that this is referred to as?* a. uncal herniation. b. tentorial herniation. c. cingulate herniation. d. temporal lobe herniation

*c. cingulate herniation.* lateral displacement of brain tissue beneath the fall cerebra that separates the two hemispheres. Uncal herniation is downward and compresses the brainstem.

*c. exhibits dyspnea and restlessness.*

*The nurse suctions the patient's ET tube when the patient?* a. has peripheral crackles in all lobes. b. has not been suctioned for 2 hours. c. has coarse rhonchi over central airways. d. needs stimulation to cough and deep-breathe.

*c. has coarse rhonchi over central airways.*

Respiratory failure can be defined as? a. the absence of ventilation. b. any episode in which part of the airway is obstructed. c. inadequate gas exchange to meet the metabolic needs of the body. d. an episode of acute hypoxemia caused by a pulmonary dysfunction

*c. inadequate gas exchange to meet the metabolic needs of the body.*

A patient with a massive hemothorax and pneumothorax has absent breath sounds in the right lung. To promote improved V/Q matching, the nurse positions the patient? a. in a reclining chair bed. b. on the right side with the good lung up. c. on the left side with the good lung down. d. supine with the head of the bed elevated.

*c. on the left side with the good lung down.*

While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. The nurse should? a. use restraints to protect the patient from injury. b. administer CNS depressants to lightly sedate the patient. c. perform the exercises less frequently because posturing can increase ICP. d. continue the exercises because they are necessary to maintain musculoskeletal function.

*c. perform the exercises less frequently because posturing can increase ICP.* DECORTICATE (flexion of wrists and adduction of hands hands towards the core) and DECEREBRATE (all four limbs in rigid extension) posturing is a LATE sign of increased ICP and should be avoided. LIMIT STIMULI THAT INCREASES ICP like SUCTIONING, TURNING and AGITATION.

*Prone positioning is considered for a patient with ARDS who has not responded to other measures to increase PaO2. The nurse knows that this strategy?* a. increases the mobilization of pulmonary secretions. b. decreases the workload of the diaphragm and intercostal muscles. c. promotes perfusion of nonatelectatic alveoli in the anterior portion of the lung. d. promotes opening of atelectatic alveoli in the upper portion of the lung.

*c. promotes perfusion of nonatelectatic alveoli in the anterior portion of the lung.*

*A common combination of immunosuppressive agents used to prevent rejection of transplanted organs is?* a. cyclosporine, sirolimus, and muromonab-CD3. b. everolimus, mycophenolate mofetil, and sirolimus. c. tacrolimus, prednisone, and mycophenolate mofetil. d. prednisone, polyclonal antibodies, and cyclosporine.

*c. tacrolimus, prednisone, and mycophenolate mofetil.* Rationale: Standard immunotherapy involves the use of three different immunosuppressants that act in different ways: a calcineurin inhibitor (cyclosporin, tacrolimus), a corticosteroid, and the antimetabolite mycophenolate mofetil. Although cyclosporin is still used, tacrolimus is the most frequently prescribed calcineurin inhibitor.

CN III originating in the midbrain is assessed by the nurse for an early indication of pressure on the brainstem by? a. assessing for nystagmus. b. testing the corneal reflex. c. testing pupillary reaction to light. d. testing for oculocephalic (doll's eyes) reflex.

*c. testing pupillary reaction to light.*

*c. testing pupillary reaction to light.* Pupils constricting is part of the oculomotor nerve (CN III) Ipsilateral pupil dilation on the side of the brain injury and fixed pupils suggest IICP. III, IV and VI all contribute to EOM

*The nurse is alerted to a possible acute subdural hematoma in the patient who?* a.has a linear skull fracture crossing a major artery. b.has focal symptoms of brain damage with no recollection of a head injury. c.develops decreased level of consciousness and a headache within 48 hours of a head injury. d.has an immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness.

*c.develops decreased level of consciousness and a headache within 48 hours of a head injury.* D-this is an epidural hematoma

*A patient has a nursing diagnosis of risk for ineffective cerebral tissue perfusion related to cerebral edema. An appropriate nursing intervention for the patient is?* a. maintaining hyperventilation to a PaCO2 of 15 to 20 mm Hg. b. clustering nursing activities to provide periods of uninterrupted rest. c. routine suctioning to prevent accumulation of respiratory secretions. d. avoiding positioning the patient with neck and hip flexion.

*d. avoiding positioning the patient with neck and hip flexion.* WHY NOT A? Hyperventilating causes increased ICP. Too much O2 or too much CO2 causes IICP so Ventilate to NORMOcapnia (35-45). WHY NOT B? clustering cares would cause increased ICP WHY NOT C? routine suctioning causes increased ICP WHY D?

Prone positioning is considered for a patient with ARDS who has not responded to other measures to increase PaO2. The nurse knows that this strategy? a. increases the mobilization of pulmonary secretions. b. decreases the workload of the diaphragm and intercostal muscles. c. promotes opening of atelectatic alveoli in the upper portion of the lung. d. better matches perfusion and ventilation.

*d. better matches perfusion and ventilation*

When assessing the body functions of a patient with increased ICP, the nurse should initially assess? a. corneal reflex testing. b. extremity strength testing. c. pupillary reaction to light. d. circulatory and respiratory status

*d. circulatory and respiratory status*

*d. circulatory and respiratory status.*

*The earliest signs of increased ICP the nurse should assess for include?* a. Cushing's triad. b. unexpected vomiting. c. dilated pupil with sluggish response to light. d. decreasing level of consciousness (LOC).

*d. decreasing level of consciousness (LOC).* Why not A? late sign of IICP Why not B? projectile vomiting is a late sign Why not C? ipsilateral pupil becomes dilated and non-reactive to light. Late sign.

*A patient rapidly progressing toward end-stage renal disease asks about the possibility of a kidney transplant. In responding to the patient, the nurse knows that contraindications to kidney transplantation include?* a. hepatitis C infection. b. coronary artery disease. c. refractory hypertension. d. extensive vascular disease

*d. extensive vascular disease* Hepatitis C is NOT a contraindication to transplantation. This makes sense given that poor perfusion of the new kidney would cause AKI and Renal failure all over again.

*In caring for a patient in ARF, the nurse recognizes that noninvasive positive-pressure ventilation (NIPPV) may be indicated for a patient who?* a. is comatose and has high oxygen requirements. b. has copious secretions that require frequent suctioning. c. responds to hourly bronchodilator nebulization treatments. d. is alert and cooperative but has increasing respiratory exhaustion.

*d. is alert and cooperative but has increasing respiratory exhaustion.*

When mechanical ventilation is used for the patient with ARDS, PEEP is often applied to? a. permit smaller tidal volumes with permissive hypercapnia. b. promote complete emptying of the lungs during exhalation. c. permit extracorporeal oxygenation and carbon dioxide removal outside the body. d. prevent alveolar collapse and open up collapsed alveoli.

*d. prevent alveolar collapse and open up collapsed alveoli.*

*While suctioning the ET tube of a spontaneously breathing patient, the nurse notes that the patient develops bradycardia with premature ventricular contractions. The nurse should?* a. stop the suctioning and assess the patient for spontaneous respirations. b. attempt to resuction the patient with reduced suction pressure and pass time. c. stop the suctioning and ventilate the patient with slow, small-volume breaths using a bag-valve-mask (BVM) device. d. stop suctioning and ventilate the patient with a BVM device with 100% oxygen until the HR returns to baseline.

*d. stop suctioning and ventilate the patient with a BVM device with 100% oxygen until the HR returns to baseline.*

Skull radiographs and a computed tomography (CT) scan provide evidence of a depressed parietal fracture with a subdural hematoma in a patient admitted to the emergency department following an automobile accident. In planning care for the patient, the nurse anticipates that? a. the patient will receive life-support measures until the condition stabilizes. b. immediate burr holes will be made to rapidly decompress the intracranial cavity. c. the patient will be treated conservatively with close monitoring for changes in neurologic status. d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium.

*d. the patient will be taken to surgery for a craniotomy for evacuation of blood and decompression of the cranium.*

*A patient with intracranial pressure monitoring has pressure of 12 mm Hg. The nurse understands that this pressure reflects?* a.a severe decrease in cerebral perfusion pressure. b.an alteration in the production of cerebrospinal fluid. c.the loss of autoregulatory control of intracranial pressure. d.a normal balance between brain tissue, blood, and cerebrospinal fluid.

*d.a normal balance between brain tissue, blood, and cerebrospinal fluid.* 5-15 mm Hg normal. A sustained pressure above 15 is abnormal.

Broncho-pulmonary Dysplasia (BPD) is common in ______ infants?

*premature*

Open-suctioning requires ________ technique?

*sterile*

To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action by the nurse is to _______________

*use an end-tidal CO2 monitor to check for placement in the trachea.* Rationale: End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion also are used, but they are not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured.

*What is the difference between CPAP and BiPAP?*

-CPAP provides a continuous pressure and the same amount of pressure during inspiration and expiration and does not include oxygen. Pressures are in "cm of water". 10 cm of H20 means enough pressure to move a volume of water 10 cm. -BiPAP provides a different pressure during inspiration than expiration and includes oxygen. Inspiratory pressures are generally higher than expiratory pressures.

What are the advantages and disadvantages of Pressure-Cycled ventilation?

-Limits peak pressures and prevents barotrauma. Improves oxygenation in patients with non-compliant lungs (neonates and adults with ARDS) -The volume of air delivered by the ventilator varies with lung compliance so minute ventilation is not guaranteed.

What is pressure-cycled ventilation?

A type of ventilation in which the ventilator is programmed to deliver a preset number of breaths at a preset pressure for a duration of time

What are the 2 main treatments during the intermediate phase of the TBI, where inflammation is the main physiological change?

1. Hyperosmolar Agents 2. Decompressive Craniotomy (excess blood out of brain)

During a brain injury, what nutritional therapy considerations must be considered?

1. Patients in hyper metabolic and hyper catabolic state 2. Increase need for glucose *DON'T GIVE D5W THOUGH* 3. keep patient normovolemic (IV NS 0.9%) IF ICP IS HIGH HYPER-OSMOLAR AGENTS MAY BE USED DURING INTERMEDIATE STAGES TO REDUCE SWELLING FROM EDEMA AND MAINTAIN CPP

A normal balance between brain tissue, blood, and cerebrospinal fluid is reflected by an intracranial pressure of ____ to ___ ?

5-15 mm Hg (0-15)

Which of these signs indicate a possible need for suction? (Select all that apply) A. The "High Pressure" alarm is sounding on the ventilator. B. Coarse breath sounds are heard over trachea and/or bronchi. C. Patient's respiratory rate increases. D. Patient has a sustained cough. E. Patient has a sudden drop in SpO2.

A, B, C, D, E

*A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply.)?* A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension

A, B, D

You are providing care for a patient who has been admitted to the hospital with a head injury who requires regular neurologic vital signs. Which assessments are components of the patient's score on the Glasgow Coma Scale (select all that apply)? A. Eye opening B. Abstract reasoning C. Best verbal response D. Best motor response E. Cranial nerve function

A, C, D The three dimensions of the Glasgow Coma Scale are eye opening, best verbal response, and best motor response.

A type of ventilation that delivers preset tidal volumes at a preset rate? A. Continuous Mandatory Ventilation (CMV) B. Volume Cycled Ventilation C. Pressure Cycled Ventilation D. Bilevel Positive Airway Pressure (BiPAP)

A. Continuous Mandatory Ventilation (CMV) THINK CMV-Continuous Mandatory Volume

When assessing a patient for adverse effects of cyclosporine (Sandimmune), it is most important for the nurse to review which laboratory findings? (Select all that apply.) A. Creatinine level B. Hemoglobin level C. Platelet count D. Bilirubin level E. White blood cell (WBC) count

A. Creatinine level D. Bilirubin level E. White blood cell (WBC) count ' B and C would be true of *cytotoxic drugs* like Azathioprine, which causes bone marrow suppression and pancytopenia. Cyclosporine is an immunosuppressant medication used to prevent organ rejection. Adverse effects include significant *nephrotoxicity, hepatotoxicity, and infection risk*. The hemoglobin level and the platelet count are not adversely affected by cyclosporine, which is a Calcineurin drug. They would be affected by a cytotoxic drug, which affects all proliferation of cells. This drug targets T-Cells so it would cause impairment. Tacrolimus also has neurotoxicity*

Which signs and symptoms differentiate hypoxemic respiratory failure from hypercapnic respiratory failure (select all that apply)? A. Cyanosis B. Tachypnea C. Morning headache D. Paradoxic breathing E. Pursed-lip breathing

A. Cyanosis B. Tachypnea D. Paradoxic breathing

The patient reports falling when his foot got "stuck" on a crack in the sidewalk, hitting his head when he fell, and "passing out". The paramedics found the patient walking at the scene and talking before transporting the patient to the hospital. In the emergency department, the patient starts to lose consciousness. This is a classic scenario for which complication? A. Epidural hematoma B. Subdural hematoma C. Subarachnoid bleed D. Diffuse axial injury

A. Epidural hematoma

A nurse monitors a patient who takes azathioprine (Imuran) for which adverse effects? (Select all that apply.) A. Leukopenia B. Thrombocytopenia C. Alopecia D. Nephrotoxicity E. Red urine color

A. Leukopenia B. Thrombocytopenia C. Alopecia Azathioprine is a cytotoxic medication used to suppress the immune response. It is toxic to all proliferating cells. Cytotoxic medications usually are reserved for patients who have not responded to safer immunosuppressants. *Nephrotoxicity* is an AE of a Calcineurin drugs like Cyclosporine and Tacrolimus along with Neurotoxicity and Hepatotoxicity.

The nurse is preparing to administer the first dose of intravenous muromonab-CD3 (Orthoclone). Which premedication will the nurse administer? A. Methylprednisolone sodium (Solu-Medrol) B. Diphenhydramine (Benadryl) C. Acetaminophen (Tylenol) D. Meperidine (Demerol)

A. Methylprednisolone sodium (Solu-Medrol) Methylprednisolone sodium, a glucocorticoid, is administered intravenously 30 minutes before injection of muromonab-CD3 to prevent or minimize a first-dose adverse reaction. Diphenhydramine or acetaminophen would not be as effective as a steroid to minimize an adverse immune system reaction. Meperidine is a pain medication.

Which of the following are considered accepted positioning options for the patient in ARDS? (Select all that apply) A. Prone position B. Continuous lateral rotation therapy C. Supine with the HOB flat D. Lateral positon with the "good" lung up E. Lateral position with the "good" lung down.

A. Prone position B. Continuous lateral rotation therapy E. Lateral position with the "good" lung down.

The survival rates for kidney transplants is higher than dialysis? A. True B. False

A. True

An infant with a congenital heart defect is receiving palivizumab (Synagis). The purpose of this is to: A. prevent respiratory syncytial virus (RSV) infection. B. make isolation of infant with RSV unnecessary. C. prevent secondary bacterial infection. D. decrease toxicity of antiviral agents.

A. prevent respiratory syncytial virus (RSV) infection. Synagis is a monoclonal antibody specific for RSV. Monthly administration is expected to prevent infection with RSV. The goal of this drug is prevention of RSV. It will not affect the need to isolate the child if RSV develops. The antibody is specific to RSV, not bacterial infection. This will have no effect on antiviral agents.

A nurse is planning postoperative care for a client who had kidney transplant surger y. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Obtain daily weights B. Assess dressings for bloody drainage C. Replace hourly urine output with IV fluids D. Position in semi-Fowler's E. Monitor serum electrolytes

ABCE

What is a seizure prevention strategy used for patients that have suffered a severe TBI?

Administer anti-epileptic drugs for the first 7 days as a prophylactic measure to avoid seizures. perform a routine EEG.

What is a common drug alert for cyclosporine, a drug used to prevent organ rejection?

Avoid Grapefruit Juice

A nurse is planning care for a client who is receving mechanical ventilation. Which mode of ventilation increases the effort of the client's respiratory muscles? (Select all that apply.) A. Assist-control B. Synchronized intermittent mandatory ventilation C. Continous positive aiway pressure D. Pressure support ventilation E. Independent lung ventilation

B, C, D Sychronized intermittent mandatory ventilation (SIMV) requires that the client generate force to take spontaneous breaths. Continous positive airway pressure (CPAP) requires that the client generate force to take spontaneous breaths. Pressure support ventilation requires that the client generate force to take spontaneous breaths.

B, D I THOUGHT HYPERVENTILATION WAS DISCOURAGED? Hyperventilation of the client will prevent hypercarbia, which can cause vasodilation with a secondary increase in ICP. Administration of a stool softener will decrease the need to bear down (Valsalva maneuver) during bowel movements, which can increase ICP. Not C because: Hyper exion of the client's neck with pillows carries the risk of increasing ICP and should be avoided. must elevate whole HOB not just head of patient

A nurse is caring for a client who is experiencing respiratory distress. Which of the following are early clinical manifestations of hypoxemia? (Select all that apply.)? A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure

B,E

B. "It permits spontaneous ventilation to decrease the work of breathing."

The patient with chronic obstructive pulmonary disease (COPD) is intubated and on a mechanical ventilator. What sign or symptom requires immediate intervention? A. Urine output of 400 mL in 8 hours B. Absent breath sounds on one side C. Pitting edema of 1+ D. Gastric distention

B. Absent breath sounds on one side

In a person having an acute rejection of a transplanted kidney, what would help you understand the course of events (select all that apply)? A. A new transplant should be considered. B. Acute rejection can be treated with OKT3. C. Acute rejection usually leads to chronic rejection. D. Corticosteroids are the most successful drug used to treat acute rejection. E. Acute rejection is common after a transplant and can be treated with drug therapy.

B. Acute rejection can be treated with OKT3. E. Acute rejection is common after a transplant and can be treated with drug therapy. Acute rejection is treatable and does not usually require a new transplant. Monoclonal antibodies such as muromonab-CD3 (Orthoclone OKT3) are used for preventing and treating acute rejection episodes. *Calcineurin inhibitors are the most effective immunosuppressants available to treat (more like prevent) organ rejection.* It is not uncommon to have at least one acute rejection episode, especially with organs from deceased donors. *Acute episodes are usually reversible with additional immunosuppressive therapy that may include increased corticosteroid doses or polyclonal or monoclonal antibodies.*

B. Hyponatremia

Vasogenic cerebral edema increases ICP by A. shifting fluid in the gray matter. B. altering the endothelial lining of cerebral capillaries. C. leaking molecules from the intracellular fluid to the capillaries. D. altering the osmotic gradient flow into the intravascular component. Rationale

B. altering the endothelial lining of cerebral capillaries. Vasogenic cerebral edema occurs mainly in the white matter and is caused by changes in the endothelial lining of cerebral capillaries.

A set of arterial blood gases obtained on admission without supplemental oxygen shows pH 7.35; PaCO2 55 mm Hg; bicarbonate 30 mEq/L; PaO2 82 mm Hg. These blood gases reflect: A. compensated metabolic acidosis. B. compensated respiratory acidosis C. partially compensated respiratory acidosis. D. normal arterial blood gases.

B. compensated respiratory acidosis

An 8‐year‐old boy is diagnosed with a mild concussion and is to be discharged home. The mother is instructed to check her child for responsiveness every 2 hours and to wake him up for this assessment after he goes to sleep. She telephones the nurse that she is afraid to allow him to go to sleep. How should the nurse respond? Select all that apply. a. "You can bring him to the hospital before bedtime, if you prefer." b. "If your son becomes difficult to awaken, bring him to the hospital." c. "There is no need to worry because your son is past the critical period." d. "Awakening your son throughout the night should alert you to any change."

BOTH B and D B. "If your son becomes difficult to awaken, bring him to the hospital." D. "Awakening your son throughout the night should alert you to any change."

Which interventions should you perform before suctioning a patient who has an endotracheal tube using open-suction technique (select all that apply)? A. Put on clean gloves. B. Administer a bronchodilator. C. Perform a cardiopulmonary assessment. D. Hyperoxygenate the patient for 30 seconds. E. Instill 3 mL of normal saline into the tube to loosen secretions.

C, D Suctioning is preceded by a thorough assessment and hyperoxygenation for 30 seconds. Sterile, not clean, gloves are necessary, and it is not necessary to administer a bronchodilator. Instillation of normal saline into the tube is not accepted practice. Reference: 1701

Which factor indicates that a tracheotomy would be preferable to endotracheal intubation? A. The patient is unable to clear secretions. B. The patient is at high risk for aspiration. C. A long-term airway is probably necessary. D. An upper airway obstruction is impairing the patient's ventilation.

C. A long-term airway is probably necessary.

C. Oxygen saturation

What sign would make you suspect the cause of increased ICP involves the hypothalamus? A. Contralateral hemiparesis B. Ipsilateral pupil dilation C. Rise in temperature D. Decreased urine output

C. Rise in temperature

A nurse is teaching diet recommendations to a client who had a kidney transplant and is taking cyclosporine (Neoral). Which of the following recommendations should the nurse include in the teaching? A. Decrease protein rich foods B. Drink grapefruit juice C. Take a magnesium supplement D. Restrict intake of bananas and raisins

C. Take a magnesium supplement

After interpreting ABGs as respiratory acidosis the nurse SBARs the surgeon with the results and with a recommendation to: A. keep the current ventilator settings. B. decrease the FiO2 C. increase the respiratory rate D. decrease the respiratory rate E. decrease the tidal volume

C. increase the respiratory rate

What is lung compliance?

Compliance is how well the lungs comply to air entering (poor compliance means overly stretchy and resistant and high lung compliance means not enough recoil to expel air, resulting in air trapping)

Which of the following is NOT a cause of hypoxemic respiratory failure? A. Ventilation/Perfusion Mismatch B. Shunt C. Diffusion Limitation D. Airway and alveoli abnormalities

D. Airway and alveoli abnormalities Airways abnormalities have more to do with ventilation and hence CO2. ABC-all cause hypoxemic respiratory failure.

D. Bronchiolitis obliterans (BOS) Cytomegalovirus (CMV)-most common viral infection in lung transplant patients-fever, bone marrow suppression, hepatitis, enteritis, and pneumonitis. Drug therapy for this includes a Cytotoxic drug (azathioprine or mycophenolate) a Calcineurin drug (cyclosporine or tacrolimus) and a Steroid (Prednisone). Pulmonary hypertension is a common indication for lung transplantation, along with alpha-1 Antitrypsin deficiency, COPD, pulmonary fibrosis and cystic fibrosis.

Which of the following is not a means of preventing VAP? A. Encouraging exercise and mobilization B. Providing regular oral care C. Elevating head of bed 30-40 degrees D. Changing the ventilator circuit daily

D. Changing the ventilator circuit daily

Paralysis of lateral gaze indicates a lesion of cranial nerve A. II. B. III. C. IV. D. VI.

D. VI. Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) are responsible for eye movement. The lateral rectus eye muscle is innervated by cranial nerve VI and is the primary muscle that is responsible for lateral eye movement.

What is the classic chest x-ray finding in a patient with late-stage ARDS? A. Hyperinflation B. Infiltrates in the bases C. Deflated lung on one side D. White lung

D. White lung The chest x-ray image often shows a white-out effect, sometimes called white lung, because consolidation and infiltrates are widespread throughout the lungs, leaving few recognizable air spaces. Hyperinflation typically is seen in chronic obstructive lung disease. There can be some effusions or infiltrates initially with ARDS, but it is more extensive in the late stages and is not only in the bases. Unilateral lung deflation is pneumothorax.

The nursing management of a patient with an artificial airway includes A. maintaining endotracheal tube cuff pressure at 30 cm H2O. B. routine suctioning of the tube at least every 2 hours. C. preventing tube dislodgement by limiting mouth care to lubrication of the lips. D. observing for cardiac dysrhythmias during suctioning.

D. observing for cardiac dysrhythmias during suctioning.

You monitor the patient with mechanical positive-pressure ventilation (PPV) for? A. paralytic ileus because pressure on the abdominal contents affects bowel motility. B. diuresis and sodium depletion because of increased release of atrial natriuretic peptide. C. respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO2 levels. D. signs of cardiovascular insufficiency because pressure in the chest impedes venous return.

D. signs of cardiovascular insufficiency because pressure in the chest impedes venous return. High levels of PEEP and positive pressure ventilation decrease venous return and thus cardiac output by decreasing preload. Hypotension can result.

What is a disadvantage of CMV?

Diaphragm muscle atrophy (ALLbreaths are assisted to the preset volume, even ones triggered by patient. Decreases WOB but also causes atrophy)

Q2. Each of the three components of the Glasgow Coma Scale have a number of steps. Which of these are the correct combinations? Eyes 5 Verbal 4 Motor 6 Eyes 4 Verbal 5 Motor 5 Eyes 4 Verbal 5 Motor 6

Eyes 4 Verbal 5 Motor 6

T or F Due to anatomy developments, newborns are dedicated mouth breathers until about 6 months of life?

False Dedicated Nose breathers

You should routinely suction a patient who is intubated? A. True B. False

False ASSESS patient routinely to determine need for suctioning, but do not suction routinely. Indications to suction include: visible secretions in ET tube, sudden onset of respiratory distress, HIGH PRESSURE alarm sounding on ventilator.

T or F If you are oxygenating well, then you are ventilating well?

False You can oxygenate a dead guy, but can't ventilate them.

Which of the 4 main Vasopressors cause bradycardia and which cause tachycardia?

Neosynephrine - Bradycardia DDL (Dobutamine, Dopamine, Levophed) - Tachycardia

If someone is diagnosed with a mild TBI what must be decreased in order to improve rest for the patient?

No Electronics Reducing workload and tasks that increase cognitive demand, such as computers, video games, and technology.

*What is Poiseulle's Law?*

Resistance is inversely proportional to the fourth power of the airway radius (resistance increases as the radius decreases). So as the radius decreases by a factor of 1 the resistance INCREASES by a factor of 4.

What is RSV? And how does it present itself?

Respiratory Syncytial Virus - Usually looks like a common cold. Affects cells in small airway -> mucous obstruction to airway -> hyperinflation, atelectasis, wheezing, pneumonia

The following ventilator settings are ordered for a patient that is 80 kg: -Mode: CMV - FiO2: 50% - Tidal Volume (VT): 550 - Respiratory Rate (f): 12 - PEEP: 5 - Pressure Support (PS): 8 Thirty minutes after intubation the following blood gasses are obtained: - pH 7.49 - PaO2 157mm Hg - PaCO2 28 mm Hg - HCO3 23 mEq/L What would you recommend and why?

The ABG's suggest respiratory alkalosis. The PaO2 is way higher than normal 80-100. The patient is receiving too much oxygen. The tidal volume is 550 mL. The tidal volume should be 6-10 mL per kg of body weight. That means that for a patient that is 80 kg the range would be 480-640 mL. This is within that range. The oxygen level is 50% and room air is 21% so you would recommend that they turn down the O2 based on that ABG.

T or F Decreasing CSF to decrease ICP is okay to preform because the body remakes CSF every 6-8 hours.

True

*Acute rejection is mediated by the recipients lymphocytes?* A. True B. False

True This is *reversible* by raising the steroid dose or adding a monoclonal antibody.

Complete the following statements related to the patient with an endotracheal tube. a. After inflating an endotracheal (ET) tube cuff, the nurse monitors the cuff pressure every____hours with a manometer to verify that the cuff pressure is____mm Hg. b. Equipment that should be at the bedside for all patients undergoing endotracheal intubation includes _______equipment and a _____. c. A catheter used to suction an ET tube should be no larger than_____the diameter of the ET tube. d. When suctioning an ET tube, the nurse uses a suction pressure of____mm Hg. e. During ET tube suctioning, each suction pass should be no longer than____seconds. f. To prevent hypoxemia during ET tube suctioning, the nurse always ________the patient before and after suctioning

a. 8 hours, 20-25 mm Hg b. suctioning, BMV c. half d. 100-120 mm Hg e. 10 seconds f. hyperoxygenate for 30 seconds

Which of the following are cytotoxic anti-proliferative drugs for organ transplant? a. Azathioprine (Imuran) b. Cyclosporine (Sandimmune, Neoral) c. Mycophenolate Mofetil (Cellcept) d. Prednisone (Deltasone) e. Sirolimus (Rapamune) f. Tacrolimus (Prograf)

a. Azathioprine (Imran) c. Mycophenolate Mofetil (Cellcept) e. Sirolimus (Rapamune)

A patient is suspected of having a cranial tumor. The signs and symptoms include memory deficits, visual disturbances, weakness of right upper and lower extremities, and personality changes. The nurse recognizes that the tumor is most likely located in the? a.frontal lobe. b.parietal lobe. c.occipital lobe. d.temporal lobe.

a.frontal lobe.

During admission of a patient with a severe head injury to the emergency department, the nurse places the highest priority on assessment for? a.patency of airway. b.presence of a neck injury. c.neurologic status with the Glasgow Coma Scale. d.cerebrospinal fluid leakage from the ears or nose.

a.patency of airway.

*Chronic rejection is irreversible and occurs at least 6 months after transplant. The organ is infiltrated by large numbers of B-cells and T-cells and causes fibrosis and scarring. In heart transplant this is manifested as _________ and in lung transplants this is known as _________ ?*

accelerated coronary artery disease, *Bronchiolitis Obliterates (BOS)*. There is no therapy for this type of rejection.

A patient with an intracranial problem does not open his eyes to any stimulus, has no verbal response except moaning and muttering when stimulated, and flexes his arm in response to painful stimuli. The nurse records the patient's GCS score as? a. 6. b. 7. c. 9. d. 11.

b. 7.

Which of the following are Calcineurin inhibitors? a. Azathioprine (Imuran) b. Cyclosporine (Sandimmune, Neoral) c. Mycophenolate Mofetil (Cellcept) d. Prednisone (Deltasone) e. Sirolimus (Rapamune) f. Tacrolimus (Prograf)

b. Cyclosporine (Sandimmune, Neoral) f. Tacrolimus (Prograf)

In a person having an acute rejection of a transplanted kidney, which of the following would help the nurse understand the course of events (select all that apply)? a. A new transplant should be considered. b.Acute rejection can be treated with OKT3. c.Acute rejection usually leads to chronic rejection. d.Corticosteroids are the most successful drugs used to treat acute rejection. e.Acute rejection is common after a transplant and can be treated with drug therapy.

b.Acute rejection can be treated with OKT3. e.Acute rejection is common after a transplant and can be treated with drug therapy.

A nursing measure that is indicated to reduce the potential for seizures and increased intracranial pressure in the patient with bacterial meningitis is? a.administering codeine for relief of head and neck pain. b.controlling fever with prescribed drugs and cooling techniques. c.keeping the room darkened and quiet to minimize environmental stimulation. d.maintaining the patient on strict bed rest with the head of the bed slightly elevated.

b.controlling fever with prescribed drugs and cooling techniques.

The nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to? a.keep the head of the bed flat. b.elevate the head of the bed to 30 degrees. c.maintain patient on the left side with the head supported on a pillow. d.use a continuous-rotation bed to continuously change patient position.

b.elevate the head of the bed to 30 degrees.

The nurse on the clinical unit is assigned to four patients. Which patient should she assess first? a.Patient with a skull fracture whose nose is bleeding b.Elderly patient with a stroke who is confused and whose daughter is present c.Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10 scale d.Patient who had a craniotomy for a brain tumor who is now 3 days postoperative and has had continued emesis

c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-to-10 scale This indicates IICP

c.mild fluid restriction and diuretics as necessary.

Which of the following accurately describes rejection following transplantation? a. Hyperacute rejection can be treated with OKT3. b. Acute rejection can be treated with sirolimus or tacrolimus. c. Chronic rejection can be treated with tacrolimus or cyclosporine. d. Hyperacute reaction can usually be avoided if crossmatching is done before the transplantation.

d. Hyperacute reaction can usually be avoided if crossmatching is done before the transplantation. A positive crossmatch result indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation. If transplanted, the organ would undergo hyperacute rejection.

*The nurse uses the minimal occluding volume to inflate the cuff on an endotracheal tube to minimize the incidence of?* a. Infection. b. Hypoxemia. c. Accidental extubation. d. Tracheal necrosis.

d. Tracheal necrosis. -Under Inflation-results in the escape of ventilating gases and/or aspiration. -Over Inflation-results in tracheal damage and/or tracheomalacia 20-25 mm Hg is the normal range.

The evaluation team for cardiac transplantation determines that the patient who would most benefit from a new heart is? a. a 24-year-old man with Down syndrome who has received excellent care from parents in their 60s. b. a 46-year-old single woman with a limited support system who has alcohol-induced cardiomyopathy. c. a 60-year-old man with inoperable coronary artery disease who has not been compliant with lifestyle changes and rehabilitation programs. d. a 52-year-old woman with end-stage coronary artery disease who has limited financial resources but is emotionally stable and has strong social support

d. a 52-year-old woman with end-stage coronary artery disease who has limited financial resources but is emotionally stable and has strong social support *no contraindications

Successful achievement of patient outcomes for the patient with cranial surgery would best be indicated by the? a. ability to return home in 6 days. b. ability to meet all self-care needs. c. acceptance of residual neurologic deficits. d. absence of signs and symptoms of increased ICP

d. absence of signs and symptoms of increased ICP

The nurse recognizes that a factor commonly responsible for sodium and fluid retention in the patient on mechanical ventilation is? a. increased ADH release. b. increased release of atrial natriuretic factor. c. increased insensible water loss via the airway. d. decreased renal perfusion with release of renin.

d. decreased renal perfusion with release of renin.

The nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to? a.keep the head of the bed flat. b.maintain patient on the left side with the head supported on a pillow. c.use a continuous-rotation bed to continuously change patient position. d.elevate the head of the bed to 30 degrees.

d.elevate the head of the bed to 30 degrees.

To inflate the cuff of an endotracheal tube (ET) when the patient is on mechanical ventilation, the nurse ______________

injects air into the cuff until a slight leak is heard only at peak inflation. rationale: The minimal occluding volume technique involves injecting air into the cuff until an air leak is present only at peak inflation. The volume to inflate the cuff varies with the ET and the patient's size. Cuff pressure should be maintained at 20 to 25 mm Hg. An accurate assessment of cuff pressure cannot be obtained by palpating the pilot balloon.

ADULTS 4 EXAM 1

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