Critical Care Exam 2: Pulmonary

The nurse is caring for a patient who was just placed on mechanical ventilation and is observing the patient's vital signs. The nurse knows that positive-pressure ventilation can lead to which problems? (Select all that apply.) a. Decreased cardiac output b. Decreased venous return c. Increased renal function d. Decreased intracranial pressure e. Increased hepatic function

a. Decreased cardiac output b. Decreased venous return Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return to the right side of the heart. Impaired venous return decreases preload, which results in a decrease in cardiac output (CO). As a secondary consequence, hepatic and renal dysfunction may occur. In addition, positive-pressure ventilation impairs cerebral venous return. In patients with impaired autoregulation, positive-pressure ventilation can result in increased intracranial pressure.

Which statement is true regarding oxygen toxicity? a. It can occur in patients who inhale greater than 50% oxygen for more than 24 hours. b. It causes destruction of oxygen-free radicals. c. The most common presenting symptom is respiratory depression. d. Chest radiography is a useful tool for early diagnosis.

a. It can occur in patients who inhale greater than 50% oxygen for more than 24 hours. Oxygen toxicity can occur in any patient who breathes oxygen concentrations of greater than 50% for longer than 24 hours. The administration of higher-than-normal oxygen concentrations produces an overabundance of oxygen-free radicals. The first symptom is substernal chest pain that is exacerbated by deep breathing. Chest radiographs and pulmonary function tests show no abnormalities until symptoms are severe.

Which statement is TRUE regarding tracheostomy tube management? a. Cuff pressure should ensure total tracheal occlusion at all times. b. External humidification should be used to prevent respiratory tract irritation. c. Single-lumen tubes should be used for patients with secretion problems. d. Tracheostomy should be performed after 3 days of intubation.

b. External humidification should be used to prevent respiratory tract irritation. Tracheostomy should be performed if a patient has been intubated or is anticipated to be intubated for longer than 7 to 10 days. Double-lumen tubes have inner cannulas that can quickly be removed if they become obstructed, making the system safer for patients with significant secretion problems. Because the tracheostomy tube bypasses the upper airway system, warming and humidifying of air must be performed by external means. Cuffs can cause damage to the walls of the trachea.

Which would be an expected chest tube assessment finding after thoracic surgery? a. Drainage of 150 mL/h for the first 4 hours after surgery b. Increase in air leak size during the first 24 hours after surgery c. Blood clots that would require careful milking of the chest tubes d. Serous draining in the immediate postoperative period

c. Blood clots that would require careful milking of the chest tubes If blood clots are present in the drainage tubing or an obstruction is present, the chest tubes may be carefully milked. Drainage will initially appear bloody, becoming serosanguineous and then serous over the first 2 to 3 days after surgery. Approximately 100 to 300 mL of drainage will occur during the first 2 hours after surgery, which will decrease to less than 50 mL/h over the next several hours. In the early phase, an air leak is commonly heard. As healing occurs, this leak should disappear.

A patient was admitted with pneumonia. A stat arterial blood gas (ABG) is obtained as the patient appears to be worsening, and the results show a PaO2 of 52 mm Hg. The rapid response team is called, and the patient's oxygen is increased to 100%. Which oxygen delivery system would be most appropriate? a. Nasal cannula b. Face mask c. Nonrebreather circuit d. Air entrainment mask

c. Nonrebreather circuit Oxygen delivery through a nasal cannula or simple face mask is variable and can deliver only 25% to 50% oxygen. An air entrainment mask is designed to provide a fixed FiO2 of 24% to 50%. Only the nonrebreather circuit can deliver the desired 100% FiO2.

Which statement is true regarding complications of noninvasive ventilation (NIV)? a. Masks should allow moderate air leaks for patient comfort. b. Agitation while undergoing NIV should be treated aggressively with sedation. c. When using a full face mask, the patient's hands should not be restrained. d. Placement of a nasogastric tube is contraindicated.

c. When using a full face mask, the patient's hands should not be restrained. Insufflation of the stomach places the patient at risk for aspiration. A nasogastric tube is placed for decompression as necessary. Heavy sedation should be avoided. A patient who requires noninvasive ventilation with a face mask should never be restrained. The patient must be able to remove the mask if it becomes displaced or if the patient vomits. A properly fitted mask minimizes air leakage and discomfort for the patient.

patient on the ventilator has a PaO2 of 95 and an FiO2 of 50%. Calculate the P/F ratio. a. 40 b. 190 c. 475 d. 526

b. 190 The P/F ratio is PaO2 divided by FiO2 or 95 ÷ 50% = 190 in this case.

A patient has the following arterial blood gas (ABG) values: pH, 7.20; PaO2, 106 mm Hg; pCO2, 35 mm Hg; and , 11 mEq/L. What symptom would be most consistent with the ABG values? A. Diarrhea B. Shortness of breath C. Central cyanosis D. Peripheral cyanosis

A. Diarrhea Diarrhea is one mechanism by which the body can lose large amounts of . The other choices are indications of hypoxia, which is not indicated with a PaO2 of 106 mm Hg.

On admission, a patient presents with a respiratory rate of 28 breaths/min, heart rate of 108 beats/min in sinus tachycardia, and a blood pressure of 140/72 mm Hg. The patient's arterial blood gas (ABG) values on room air are PaO2, 60 mm Hg; pH, 7.32; PaCO2, 45 mm Hg; and , 26 mEq/L. What action should the nurse anticipate for this patient? A. Initiate oxygen therapy. B. Prepare for emergency intubation. C. Administer 1 ampule of sodium bicarbonate. D. Initiate capnography.

A. Initiate oxygen therapy. The patient is hypoxemic and oxygen therapy should be initiated at this time. The patient's arterial blood gas (ABG) values do not warrant intubation at this time. Sodium bicarbonate is not indicated because this patient has a normal bicarbonate level. Capnography would not be indicated at this time as the patient's CO2 is normal. A repeat ABG may be ordered to assess the patient's ongoing respiratory status.

On admission, a patient presents with a respiratory rate of 24 breaths/min, pursed-lip breathing, heart rate of 96 beats/min in sinus tachycardia, and a blood pressure of 110/68 mm Hg. The patient's arterial blood gas (ABG) values on room air are PaO2, 70 mm Hg; pH, 7.38; PaCO2, 52 mm Hg; and , 34 mEq/L. What diagnoses would be most consistent with the above arterial blood gas values? A. Acute pulmonary embolism B. Acute myocardial infarction C. Congestive heart failure D. Chronic obstructive pulmonary disease

D. Chronic obstructive pulmonary disease The fact that the level has increased enough to compensate for the increased pCO2 level indicates that this is not an acute condition because the kidneys can take several days to adjust. The other choices would present with a lower level. The values indicate respiratory acidosis, and one of the potential causes is chronic obstructive pulmonary disease. Potential causes for respiratory alkalosis are pulmonary embolism, acute myocardial infarction, and congestive heart failure.

In a patient who is hemodynamically stable, which procedure can be used to estimate the PaCO2 levels? A. PaO2/FiO2 ratio B. A-a gradient C. Residual volume (RV) D. End-tidal CO2

D. End-tidal CO2 Capnography is the measurement of exhaled carbon dioxide (CO2) gas; it is also known as end-tidal CO2 monitoring. Normally, alveolar and arterial CO2 concentrations are equal in the presence of normal ventilation-perfusion (V/Q) relationships. In a patient who is hemodynamically stable, the end-tidal CO2 (PetCO2) can be used to estimate the PaCO2. Normally, the PaO2/FiO2 ratio is greater than 286; the lower the value, the worse the lung function. The A-a gradient is normally less than 20 mm Hg on room air for patients younger than 61 years. This estimate of intrapulmonary shunting is the least reliable clinically, but it is used often in clinical decision making. Residual volume is the amount of air left in the lung after maximal exhalation. A normal value is 1200 to 1300 mL.

Which therapeutic measure would be the most effective in treating hypoxemia in the presence of intrapulmonary shunting associated with acute respiratory distress syndrome (ARDS)? a. Sedating the patient to blunt noxious stimuli b. Increasing the FiO2 on the ventilator c. Administering positive-end expiratory pressure (PEEP) d. Restricting fluids to 500 mL per shift

The purpose of using positive-end expiratory pressure (PEEP) in a patient with acute respiratory distress syndrome is to improve oxygenation while reducing FiO2 to less toxic USNT O levels. PEEP has several positive effects on the lungs, including opening collapsed alveoli, stabilizing flooded alveoli, and increasing functional residual capacity. Thus, PEEP decreases intrapulmonary shunting and increases compliance.

The nurse is providing preprocedural teaching for a patient who is going to have a fiber-optic bronchoscopy. Which statement indicates that more teaching is needed? a. "I will receive medication that will make it okay for me to eat before the procedure." b. "I will receive medication that will make me sleepy and keep my heart rate from dropping." c. "I will need to be on a cardiac monitor before, during, and after the procedure." d. "I will have lab work drawn before the procedure to make sure I am not at risk for bleeding."

a. "I will receive medication that will make it okay for me to eat before the procedure." The patient must be NPO (nothing by mouth) for 6 hours before the procedure and until the gag reflex returns.

A patient presents with absent lung sounds in the left lower lung fields, moderate shortness of breath, and dyspnea. The nurse suspects pneumothorax and notifies the practitioner. Orders for a STAT chest radiography and reading are obtained. Which finding best supports the nurse's suspicions? a. Blackness in the left lower lung area b. Whiteness in the left lower lung area c. Blunted costophrenic angles d. Elevated left hemidiaphragm

a. Blackness in the left lower lung area With a pneumothorax, the pleural edges become evident as one looks through and between the images of the ribs on the film. A thin line appears just parallel to the chest wall, indicating where the lung markings have pulled away from the chest wall. In addition, the collapsed lung will be manifested as an area of increased density separated by an area of radiolucency (blackness).

Which of the following actions is an important part of oral care for an intubated patient? (Select all that apply.) a. Brushing the teeth and tongue with a soft-bristled toothbrush b. Using lemon glycerin swabs on the patient's lips and gums c. Using alcohol-based mouthwash every 2 hours d. Using a tonsil suction to keep secretions cleared out of the mouth e. Providing lip moisturizer as needed

a. Brushing the teeth and tongue with a soft-bristled toothbrush d. Using a tonsil suction to keep secretions cleared out of the mouth e. Providing lip moisturizer as needed Oral care consists of brushing the patient's teeth with a soft toothbrush to reduce plaque, brushing the patient's tongue and gums with a foam swab to stimulate the tissue, and performing deep oropharyngeal suction to remove any secretions that have pooled above the patient's cuff. Lemon glycerin swabs and alcohol-based mouthwashes dry out the mouth and lips and are not recommended.

What risk factors need to be considered when preparing a patient for a thoracentesis? (Select all that apply.) a. Coagulation defects b. Unstable hemodynamics c. Pleural effusion d. Uncooperative patient e. Empyema

a. Coagulation defects b. Unstable hemodynamics d. Uncooperative patient No absolute contraindications to thoracentesis exist, although some risks may contraindicate the procedure in all but emergency situations. These risk factors include unstable hemodynamics, coagulation defects, mechanical ventilation, the presence of an intraaortic balloon pump, and patients who are uncooperative. It is used most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema.

A patient has been admitted with acute asthma. The patient is very anxious and short of breath. It is important to have an accurate SpO2 measurement; however, the patient continues to wring their hands and swing their feet in agitation. Which site might provide the most accurate measure of oxygen saturation? a. Ear b. Toe c. Ankle d. Wrist

a. Ear Constant motion of extremities may mimic arterial pulsations and lead to false readings. The ear would be more stable at this time. Alternatives are the nose and forehead.

What psychologic factors contribute to long-term mechanical ventilation dependence? (Select all that apply.) a. Fear b. Delirium c. Lack of confidence d. Depression e. Trust in the staff

a. Fear b. Delirium c. Lack of confidence d. Depression Psychologic factors contributing to long-term mechanical ventilation dependence include a loss of breathing pattern control (anxiety, fear, dyspnea, pain, ventilator asynchrony, lack of confidence in ability to breathe), lack of motivation and confidence (inadequate trust in staff, depersonalization, hopelessness, powerlessness, depression, inadequate communication), and delirium (sensory overload, sensory deprivation, sleep deprivation, pain medications).

Which interventions minimize the complications associated with suctioning an artificial airway? (Select all that apply.) a. Hyperoxygenate the patient prior to the start of the procedure b. Hyperoxygenate the patient after each pass of the suction catheter c. Limit the duration of each suction pass to 20 seconds d. Instill 5 to 10 mL of normal saline to facilitate secretion removal e. Use intermittent suction to avoid damaging tracheal tissue

a. Hyperoxygenate the patient prior to the start of the procedure b. Hyperoxygenate the patient after each pass of the suction catheter Hyperoxygenation and limiting the number of passes help avoid desaturation. There is no evidence to suggest that intermittent suction reduces damage, and saline instillation can actually increase the risk for infection.

A patient was admitted following an aspiration event on the medical-surgical floor. The patient is receiving 40% oxygen via a simple facemask. The patient has become increasingly agitated and confused. The patient's oxygen saturation has dropped from 92% to 84%. The nurse notifies the practitioner about the change in the patient's condition. What interventions should the nurse anticipate? a. Intubation and mechanical ventilation b. Change in antibiotics orders c. Suction and reposition the patient d. Orders for a sedative

a. Intubation and mechanical ventilation Given the significant drop in oxygen saturation, increasing agitation and confusion, the nurse should anticipate the patient will need to be intubated and mechanically ventilated. Administering antibiotics, suctioning and repositioning, and administering a sedative would not address the development of severe hypoxemia.

Which statement describes the assist-control mode of ventilation? It delivers gas at preset volume, at a set rate, and in response to the patient's inspiratory efforts. a. It delivers gas at preset volume, at a set rate, and in response to the patient's inspiratory efforts. b. It delivers gas at a preset volume, allowing the patient to breathe spontaneously at his or her own volume. c. It applies positive pressure during both ventilator breaths and spontaneous breaths. d. It delivers gas at preset rate and tidal volume regardless of the patient's inspiratory efforts.

a. It delivers gas at preset volume, at a set rate, and in response to the patient's inspiratory efforts. Continuous mandatory (volume or pressure) ventilation (CMV), also known as assist-control (AC) ventilation, delivers gas at preset tidal volume or pressure (depending on selected cycling variable) in response to patient's inspiratory efforts and initiates breath if patient fails to do so within preset time.

Which oxygen delivery device is considered a low-flow system? a. Nasal cannula b. Simple face mask c. Reservoir cannula d. Air-entrainment nebulizer

a. Nasal cannula A low-flow oxygen delivery system provides supplemental oxygen directly into the patient's airway at a flow of 8 L/min or less. Because this flow is insufficient to meet the patient's inspiratory volume requirements, it results in a variable FiO2 as the supplemental oxygen is mixed with room air. A nasal cannula is a low-flow oxygen delivery system.

Which oxygen administration device can deliver oxygen concentrations of 90%? a. Nonrebreathing mask b. Nasal cannula c. Partial rebreathing mask d. Simple mask

a. Nonrebreathing mask With an FiO2 of 55% to 70%, a nonrebreathing mask with a tight seal over the face can deliver 90% to 100% oxygen. It is used in emergencies and short-term therapy requiring moderate to high FiO2.

Which route for endotracheal (ET) tube placement is usually used in an emergency intubation? a. Orotracheal b. Nasotracheal c. Nasopharyngeal d. Trachea

a. Orotracheal An endotracheal tube (ETT) may be placed through the orotracheal or the nasotracheal route. In most situations involving emergency placement, the orotracheal route is used because it is simpler and allows the use of a larger diameter ETT. Nasotracheal intubation provides greater patient comfort over time and is preferred in patients with a jaw fracture.

Medical management of a patient with status asthmaticus includes which treatments? (Select all that apply.) a. Oxygen therapy b. Bronchodilators c. Corticosteroids d. Antibiotics e. Intubation and mechanical ventilation

a. Oxygen therapy b. Bronchodilators c. Corticosteroids e. Intubation and mechanical ventilation Medical management of a patient with status asthmaticus is directed toward supporting oxygenation and ventilation. Bronchodilators, corticosteroids, oxygen therapy, and intubation and mechanical ventilation are the mainstays of therapy.

A patient has been in the progressive care unit for 3 days with a diagnosis of pneumonia. The patient is being treated with antibiotics, 50% oxygen, and vigorous pulmonary toilet. Which diagnostic testing result would indicate early progression of the patient's condition to acute respiratory distress syndrome? a. PaO2/FiO2 ratio of 325 b. Arterial PaO2 of 58 mm Hg c. Arterial PaCO2 of 58 mm Hg d. Arterial blood pH of 7.29

a. PaO2/FiO2 ratio of 325 Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen administration (refractory hypoxemia). The drop in PaO2 is attributable to intrapulmonary shunting secondary to compression, collapse, and flooding of the alveoli and small airways. Initially, the PaCO2 is low as a result of hyperventilation, but eventually the PaCO2 increases as the patient fatigues. The pH is high initially but decreases as respiratory acidosis develops. A ratio of partial pressure of oxygen (PaO2) to fraction of inspired oxygen (FiO2) less than or equal to 300 mm Hg is indicative of acute lung injury.

A static lung compliance of 40 mL/cm H2O is indicative of which disorder? a. Pneumonia b. Bronchospasm c. Pulmonary emboli d. Upper airway obstruction

a. Pneumonia Static compliance is measured under no-flow conditions so that resistance forces are removed. Static compliance decreases with any decrease in lung compliance, such as occurs with pneumothorax, atelectasis, pneumonia, pulmonary edema, and chest wall restrictions. A normal value is 57 to 85 mL/cm of H2O.

Nursing management of the patient with acute lung failure includes which interventions? (Select all that apply.) a. Positioning the patient with the least affected side up b. Providing adequate rest between treatments c. Performing percussion and postural drainage every 4 hours d. Controlling fever e. Pharmaceutical medications to control anxiety

a. Positioning the patient with the least affected side up b. Providing adequate rest between treatments d. Controlling fever e. Pharmaceutical medications to control anxiety The goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Patients with diffuse lung disease may benefit from being positioned with the right lung down because it is larger and more vascular than the left lung. For patients with alveolar hypoventilation, the goal of positioning is to facilitate ventilation. These patients benefit from nonrecumbent positions such as sitting or a semierect position. In addition, semirecumbency has been shown to decrease the risk of aspiration and inhibit the development of hospital-associated pneumonia. Frequent repositioning (at least every 2 hours) is beneficial in optimizing the patient's ventilatory pattern and ventilation/perfusion matching. These include performing procedures only as needed, hyperoxygenating the patient before suctioning, providing adequate rest and recovery time between various procedures, and minimizing oxygen consumption. Interventions to minimize oxygen consumption include limiting the patient's physical activity, administering sedation to control anxiety, and providing measures to control fever.

Which nursing intervention should be used to optimize oxygenation and ventilation in the patient with acute lung failure? a. Provide adequate rest and recovery time between procedures. b. Position the patient with the good lung up. c. Suction the patient every hour. d. Avoid hyperventilating the patient.

a. Provide adequate rest and recovery time between procedures. Providing adequate rest and recovery time between various procedures prevents desaturation and optimizes oxygenation. In acute lung failure, the goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Hyperventilate the patient before suctioning; suction patients as needed.

Ventilation-perfusion (V/Q) scans are ordered to evaluate the possibility of which of the following? a. Pulmonary emboli b. Acute myocardial infarction c. Emphysema d. Acute respiratory distress syndrome

a. Pulmonary emboli This test is ordered for the evaluation of pulmonary emboli. Electrocardiography or cardiac enzymes are ordered to evaluate for myocardial infarction; arterial blood gas analysis, chest radiography, and pulmonary function tests are ordered to evaluate for emphysema. Chest radiography and hemodynamic monitoring are ordered for evaluation of acute respiratory distress syndrome.

Severe coughing and shortness of breath during a thoracentesis are indicative of what complication? a. Re-expansion pulmonary edema b. Pleural infection c. Pneumothorax d. Hemothorax

a. Re-expansion pulmonary edema Re-expansion pulmonary edema can occur when a large amount of effusion fluid (~1000 to 1500 mL) is removed from the pleural space. Removal of the fluid increases the negative intrapleural pressure, which can lead to edema when the lung does not re-expand to fill the space. The patient experiences severe coughing and shortness of breath. The onset of these symptoms is an indication to discontinue the thoracentesis.

When assessing an intubated patient, the nurse notes normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest. What problem should the nurse suspect? a. Right mainstem intubation b. Left pneumothorax c. Right hemothorax d. Gastric intubation

a. Right mainstem intubation The finding of normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest in a newly intubated patient is probably caused by a right mainstem intubation.

Mr. G requires neuromuscular blockade to facilitate mechanical ventilation. Which statement is true about providing nursing care to paralyzed patients? a. Special safety precautions are needed as patients are unable to react to the environment. b. Pain medication is not required because neuromuscular blocking agents have an analgesic effect. c. Patients under the influence of neuromuscular blocking agents are not aware of activity around them. d. There is no mechanism for monitoring the level of blockade.

a. Special safety precautions are needed as patients are unable to react to the environment. Neuromuscular blocking agents only halt skeletal muscle movement and do not inhibit pain or awareness; they must be administered together with a sedative or anxiolytic agent. Patient safety is another concern because these patients cannot react to the environment. Special precautions are taken to protect patients at all times. The level of neuromuscular blockade can be monitored with a peripheral nerve stimulator.

What two pathogens are most frequently associated with ventilator-associated pneumonia? a. Staphylococcus aureus and Pseudomonas aeruginosa b. Escherichia coli and Haemophilus influenzae c. Acinetobacter baumannii and Haemophilus influenzae d. Klebsiella spp. and Enterobacter spp.

a. Staphylococcus aureus and Pseudomonas aeruginosa Pathogens that can cause hospital-associated pneumonia (HAP) include Escherichia coli, H. influenzae, methicillin-sensitive S. aureus, S. pneumoniae, P. aeruginosa, Acinetobacter baumannii, methicillin-resistant S. aureus (MRSA), Klebsiella spp., and Enterobacter spp. Two of the pathogens most frequently associated with ventilator-associated pneumonia (VAP) are S. aureus and P. aeruginosa.

The nurse is admitting a patient with severe community-acquired pneumonia. Select all interventions that are appropriate for this patient. a. Start intravenous (IV) antibiotics. b. Place the patient on the monitor and obtain vital signs. c. Obtain sputum cultures and laboratory work. d. Inquire about allergies and current medications. e. Start a peripheral IV.

a. Start intravenous (IV) antibiotics. b. Place the patient on the monitor and obtain vital signs. c. Obtain sputum cultures and laboratory work. d. Inquire about allergies and current medications. e. Start a peripheral IV. Assess the patient and establish any allergies (to Betadine or ChloraPrep for IV insertion and antibiotics) and current medications. (Is the patient already on antibiotics?) Start the peripheral IV and obtain the laboratory work and sputum culture before starting the antibiotics.

What are the clinical manifestations associated with oxygen toxicity? (Select all that apply.) a. Substernal chest pain that increases with deep breathing b. Moist cough and tracheal irritation c. Pleuritic pain occurring on inhalation, followed by dyspnea d. Increasing CO2 e. Sore throat and eye and ear discomfort

a. Substernal chest pain that increases with deep breathing c. Pleuritic pain occurring on inhalation, followed by dyspnea e. Sore throat and eye and ear discomfort A number of clinical manifestations are associated with oxygen toxicity. The first symptom is substernal chest pain that is exacerbated by deep breathing. A dry cough and tracheal irritation follow. Eventually, definite pleuritic pain occurs on inhalation followed by dyspnea. Upper airway changes may include a sensation of nasal stuffiness, sore throat, and eye and ear discomforts.

What are the most common presenting signs and symptoms associated with a pulmonary embolism (PE)? a. Tachycardia and tachypnea b. Hemoptysis and evidence of deep vein thromboses c. Apprehension and dyspnea d. Right ventricular failure and fever

a. Tachycardia and tachypnea The patient with a pulmonary embolism may have any number of presenting signs and symptoms, with the most common being tachycardia and tachypnea. Additional signs and symptoms that may be present include dyspnea, apprehension, increased pulmonic component of the second heart sound (P1N), fever, crackles, pleuritic chest pain, cough, evidence of deep USNT O vein thrombosis, and hemoptysis. Syncope and hemodynamic instability can occur as a result of right ventricular failure.

What condition develops when air enters the pleural space from the lung on inhalation and cannot exit on exhalation? a. Tension pneumothorax b. Sucking chest wound c. Open pneumothorax d. Pulmonary interstitial empyema

a. Tension pneumothorax A tension pneumothorax develops when air enters the pleural space from either the lung or the chest wall on inhalation and cannot escape on exhalation. Open pneumothorax is a laceration in the parietal pleura that allows atmospheric air to enter the pleural space; it occurs as a result of penetrating chest trauma. Pulmonary interstitial emphysema is air in the pulmonary interstitial space.

The nurse is caring for a patient who has experienced a pulmonary embolism (PE). Which statement is an important physiologic concept for the nurse to remember about this condition? a. The major hemodynamic compromise after PE is pulmonary hypertension. b. Hypercoagulability is the most significant predisposing factor for PE. c. Pulmonary system effects include bronchoconstriction and decreased alveolar dead space. d. Pulmonary vasodilation occurs as a result of mediators released at the injury site.

a. The major hemodynamic compromise after PE is pulmonary hypertension. Of the three predisposing factors (ie, hypercoagulability, injury to vascular endothelium, and venous stasis), endothelial injury appears to be the most significant. The effects on the pulmonary system are increased alveolar dead space, bronchoconstriction, and compensatory shunting. The major hemodynamic consequence of a pulmonary embolism (PE) is the development of pulmonary hypertension, which is part of the effect of a mechanical obstruction when more than 50% of the vascular bed is occluded. In addition, the mediators released at the injury site and the development of hypoxia cause pulmonary vasoconstriction, which further exacerbates pulmonary hypertension.

A patient presents moderately short of breath and dyspneic. A chest radiographic examination reveals a large right pleural effusion with significant atelectasis. The practitioner would be most likely to prescribe which procedure? a. Thoracentesis b. Bronchoscopy c. Ventilation-perfusion (V/Q) scan d. Repeat chest radiograph

a. Thoracentesis Thoracentesis is a procedure that can be performed at the bedside for the removal of fluid or air from the pleural space. It is used most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema. No evidence is present that would necessitate a V/Q scan. A bronchoscopy cannot assist in fluid removal. A problem with this chest radiograph is not indicated.

Which of the following are complications of endotracheal tubes? (Select all that apply.) a. Tracheoesophageal fistula b. Cricoid abscess c. Tracheal stenosis d. Tube obstruction e. Hemorrhage

a.Tracheoesophageal fistula b. Cricoid abscess c. Tracheal stenosis e. Hemorrhage Complications of endotracheal tubes include tube obstruction, tube displacement, sinusitis and nasal injury, tracheoesophageal fistula, mucosal lesions, laryngeal or tracheal stenosis, and cricoid abscess. Hemorrhage is a complication of tracheostomy tubes.

A patient is placed on a ventilator after cardiac arrest. What pressure should be maintained in the patient's cuff to prevent complications? a. 10 to 20 mm Hg b. 20 to 30 mm Hg c. 30 to 40 mm Hg d. 40 and 50 mm Hg

b. 20 to 30 mm Hg Cuff pressures are maintained within 20 to 30 mm Hg (27 to 41 cm H2O) because greater pressures decrease blood flow to the capillaries in the tracheal wall and lesser pressures increase the risk of aspiration.

Which patient would be considered hypoxemic? a. A 70-year-old man with a PaO2 of 72 b. A 50-year-old woman with a PaO2 of 65 c. An 84-year-old man with a PaO2 of 96 d. A 68-year-old woman with a PaO2 of 80

b. A 50-year-old woman with a PaO2 of 65 Normal PaO2 is 80 to 100 mm Hg in persons younger than 60 years. The formula for determining PaO2 for a person older than 60 years of age is 80 mm Hg minus 1 mm Hg for every year of age above 60 years of age, for example, 70 years old = 80 mm Hg - 10 mm Hg = 70 mm Hg; 84 years old = 80 mm Hg - 20 mm Hg = 60 mm Hg; and 68 years old = 80 mm Hg - 8 mm Hg = 72 mm Hg.

A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure limit alarm keeps alarming. What would cause this problem? a. A leak in the patient's endotracheal (ET) tube cuff b. A kink in the ventilator tubing c. The patient is disconnected from the ventilator d. A faulty oxygen filter

b. A kink in the ventilator tubing High-pressure alarms will sound because of improper alarm setting; airway obstruction resulting from patient fighting ventilator (holding breath as ventilator delivers Vt); patient circuit collapse; kinked tubing; the endotracheal tube in the right mainstem bronchus or against the carina; cuff herniation; increased airway resistance resulting from bronchospasm, airway secretions, plugs, and coughing; water from the humidifier in the ventilator tubing; and decreased lung compliance resulting from tension pneumothorax, change in patient position, acute respiratory distress syndrome, pulmonary edema, atelectasis, pneumonia, or abdominal distention.

Which statement is correct concerning endotracheal tube cuff management? a. The cuff should be deflated every hour to minimize pressure on the trachea. b. A small leak should be heard on inspiration if the cuff has been inflated using the minimal leak technique. c. Cuff pressures should be kept between 20 to 30 mm Hg to ensure an adequate seal. d. Cuff pressure monitoring should be done once every 24 hours.

b. A small leak should be heard on inspiration if the cuff has been inflated using the minimal leak technique. Cuff pressures are monitored at a minimum of every shift and are maintained within 20 to 30 mm Hg because greater pressures decrease blood flow to the capillaries in the tracheal wall and lesser pressures increase the risk of aspiration. Pressures greater than 30 mm Hg (41 cm H2O) should be reported to the physician. Cuffs are not routinely deflated because this increases the risk of aspiration. The minimal leak technique is no longer recommended.

A patient is admitted with shortness of breath. Temperature is 39.5° C, blood pressure is 160/82 mm Hg, heart rate is 115 beats/min, and respiratory rate is 26 breaths/min. Chest radiography confirms the presence of right upper lobe pneumonia. Arterial blood gases reveal the following:pH 7.27, PaCO2 64 mm Hg, HCO3 33 mEq/L, PaO2 50 mm Hg. These findings are indicative of which disorder? a. Obstructive lung disease b. Acute lung failure c. Restrictive lung disease d. Acute respiratory distress syndrome

b. Acute lung failure Diagnosing and following the course of respiratory failure is best accomplished by arterial blood gas (ABG) analysis. ABG analysis confirms the level of PaCO2, PaO2, and blood pH. Acute lung failure is generally accepted as being present when the PaO2 is less than 60 mm Hg. If the patient is also experiencing hypercapnia, the PaCO2 will be greater than 45 mm Hg. In patients with chronically elevated PaCO2 levels, these criteria must be broadened to include a pH less than 7.35.

A mechanically ventilated patient has a fever, P/F ratio of 230, and a pulmonary artery occlusive pressure of 15 mm Hg. The patient is coughing and triggering the high-pressure alarm on the ventilator. The radiologist has notified the nurse that the patient's feeding tube is in the right lung, and the patient has developed bilateral infiltrates on the radiograph. The nurse is concerned that the patient is developing what problem? a. Acute pulmonary embolism b. Adult respiratory distress syndrome c. Pneumothorax d. Inadequate nutrition

b. Adult respiratory distress syndrome The patient is showing signs of acute respiratory distress syndrome brought on by the direct lung injury from the misplaced feeding tube. There is no evidence of a pulmonary embolism. A pneumothorax would have shown up on the radiograph as a unilateral problem, not a diffuse infiltrate. Nutrition is not the immediate concern at this moment.

A patient with pneumonia has been in the unit for 3 days. The medical plan includes antibiotics and oxygen therapy. Which finding would indicate the patient is developing acute respiratory distress syndrome (ARDS)? a. Sputum cultures are positive for Streptococcus pneumoniae. b. Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen. c. Chest radiography shows evidence of pulmonary hypertension. d. High probability ventilation-perfusion scan.

b. Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen.

A patient's pulse oximeter alarm goes off. The monitor reads 82%. What is the first action the nurse should perform? a. Prepare to intubate. b. Assess the patient's condition. c. Turn off the alarm and reapply the oximeter sensor. d. Increase O2 level to 4L/NC.

b. Assess the patient's condition The first nursing action would be to assess the patient to see if there is a change in his or her condition. If the patient is stable, then the nurse would turn off the alarm and reapply the oximeter sensor. The pulse oximeter cannot differentiate between normal and abnormal hemoglobin. Elevated levels of abnormal hemoglobin falsely elevate the SpO2. The ability of a pulse oximeter to detect hypoventilation is accurate only when the patient is breathing room air. Because most critically ill patients require some form of oxygen therapy, pulse oximetry is not a reliable method of detecting hypercapnia and should not be used for this purpose.

For which situation does a patient with acute lung failure require a bronchodilator? a. Excessive secretions b. Bronchospasms c. Thick secretions d. Fighting the ventilator

b. Bronchospasms Bronchodilators aid in smooth muscle relaxation and are of particular benefit to patients with airflow limitations. Mucolytics and expectorants are no longer used because they have been found to be of no benefit in this patient population.

A trauma victim has sustained right rib fractures and pulmonary contusions. Auscultation reveals decreased breath sounds on the right side. Bulging intercostal muscles are noted on the right side. Heart rate (HR) is 130 beats/min, respiratory rate (RR) is 32 breaths/min, and breathing is labored. In addition to oxygen administration, what procedure should the nurse anticipate? a. Thoracentesis b. Chest tube insertion c. Pericardiocentesis d. Emergent intubation

b. Chest tube insertion The patient is experiencing a pneumothorax and will need immediate chest tube insertion. Chest tubes are inserted into the pleural space to remove fluid or air, reinstate the negative intrapleural pressure, and re-expand a collapsed lung.

The sputum culture obtained on admission shows Streptococcus pneumoniae in a patient with a history of coronary artery disease and alcoholism. The nurse suspects the patient has developed which problem? a. Hospital-acquired pneumonia (HAP) b. Community-acquired pneumonia (CAP) c. Health care associated pneumonia d. Ventilator-associated pneumonia (VAP)

b. Community-acquired pneumonia (CAP) The patient has community-acquired pneumonia (CAP). The culture was obtained on admission, S. pneumoniae is a commonly acquired pathogen, and the patient has comorbidities that could lead to CAP. The patient was not in the hospital longer than 48 hours or on the ventilator, and there is no mention of the radiography report describing the location of the pneumonia.

A patient with chronic obstructive pulmonary disease (COPD) requires intubation. After the practitioner intubates the patient, the nurse auscultates for breath sounds. Breath sounds are questionable in this patient. Which action would best assist in determining endotracheal tube placement in this patient? a. Stat chest radiographic examination b. End-tidal CO2 monitor c. Ventilation-perfusion (V/Q) scan dPulmonary artery catheter insertion

b. End-tidal CO2 monitor Although a stat chest radiography examination would be helpful, it has a long turnaround time, and the patient's respiratory status can deteriorate quickly. An end-tidal CO2 monitor gives an immediate response, and the tube can then be reinserted without delay if incorrectly placed. The other tests are not for endotracheal tube placement.

A patient was admitted with acute lung failure secondary to pneumonia. What is the single most important measure to prevent the spread of infection between staff and patients? a. Place the patient in respiratory isolation. b. Ensure everyone is using proper hand hygiene. c. Use personal protective equipment. d. Initiate prompt administration of antibiotics.

b. Ensure everyone is using proper hand hygiene. Proper hand hygiene is the single most important measure available to prevent the spread of bacteria from person to person.

Patient safety precautions when working with oxygen include which action? a. Observing for signs of oxygen-associated hyperventilation b. Ensuring the oxygen device is properly positioned c. Removal of all oxygen devices when eating d. Administration of oxygen at the nurse's discretion

b. Ensuring the oxygen device is properly positioned Patient safety precautions when working with oxygen involve administration of oxygen and monitoring of its effectiveness. Activities include restricting smoking, administering supplemental oxygen as ordered, observing for signs of oxygen-induced hypoventilation, monitoring the patient's ability to tolerate removal of oxygen while eating, and changing the oxygen delivery device from a mask to nasal prongs during meals as tolerated.

A patient was taken to surgery for a left lung resection. The patient returned to the unit 30 minutes ago. Upon completion of the assessment, the nurse notices that the chest tube has drained 150 mL of red fluid in the past 30 minutes. The nurse contacts the physician and suspects that the patient has developed what complication? a. Pulmonary edema b. Hemorrhage c. Acute lung failure d. Bronchopleural fistula

b. Hemorrhage Hemorrhage is an early, life-threatening complication that can occur after a lung resection. It can result from bronchial or intercostal artery bleeding or disruption of a suture or clip around a pulmonary vessel. Excessive chest tube drainage can signal excessive bleeding. During the immediate postoperative period, chest tube drainage should be measured every 15 minutes; this frequency should be decreased as the patient stabilizes. If chest tube loss is greater than 100 mL/h, fresh blood is noted, or a sudden increase in drainage occurs, hemorrhage should be suspected.

A bronchoscopy is indicated for a patient with what condition? a. Pulmonary edema b. Ineffective clearance of secretions c. Upper gastrointestinal bleed d. Instillation of surfactant

b. Ineffective clearance of secretions Bronchoscopy visualizes the bronchial tree. If secretions are present, they can be removed by suctioning and sent for culture to help adjust antibiotic therapy.

Which medication can cause bronchospasms and should be administered with a bronchodilator? a. Beta-2 agonist b. Mucloytics c. Anticholinergic agents d. Xanthines

b. Mucloytics Mucolytics may be administered with a bronchodilator because it can cause bronchospasms and inhibit ciliary function. Treatment is considered effective when bronchorrhea develops and coughing occurs. Beta-2 agonists are used to relax bronchial smooth muscle and dilate airways to prevent bronchospasms. Anticholinergic agents are used to block the constriction of bronchial smooth muscle and reduce mucus production. Xanthines are used to dilate bronchial smooth muscle and reverse diaphragmatic muscle fatigue.

A patient has been on a non-rebreathing mask at 10 L/min for 4 days and is complaining of a dry cough, a stuffy nose, and substernal chest pain (pain score 6 of 10) that increases with deep breathing. The chest radiograph shows no changes, and the 12-lead electrocardiography (ECG) findings are normal. The nurse suspects the patient is experiencing which disorder? a. Hypercapnia b. Oxygen toxicity c. Unstable angina d. Absorption atelectasis

b. Oxygen toxicity The patient is experiencing oxygen toxicity from breathing high concentrations of oxygen for several days. Symptoms include substernal chest pain that is exacerbated by deep breathing, dry cough, nasal stuffiness, sore throat, and eye and ear discomforts. Symptoms of hypercapnia include headache and drowsiness. Although the patient has substernal chest pain that increases with deep breathing, this is not a sign of angina because the electrocardiography (ECG) findings are normal. Absorption atelectasis is manifested by decreased breath sounds and increased respiratory rate.

Which diagnostic criteria is indicative of mild adult respiratory distress syndrome (ARDS)? a. Radiologic evidence of bibasilar atelectasis b. PaO2/FiO2 ratio less than or equal to 200 mm Hg c. Pulmonary artery wedge pressure greater than 18 mm Hg d. Increase in static and dynamic compliance

b. PaO2/FiO2 ratio less than or equal to 200 mm Hg The Berlin Definition of ARDS is as follows: timing—within 1 week of known clinical insult or new or worsening respiratory symptoms; chest imaging—bilateral opacities not fully explained by effusions, lobar or lung collapse, or nodules; origin of edema—respiratory failure not fully explained by cardiac failure or fluid overload; need objective assessment to exclude hydrostatic edema if no risk factor present; oxygenation—mild (200 mg Hg less than PaO2/FiO2 less than or equal to 300 mm Hg with positive end-respiratory airway pressure (PEEP) or constant positive airway pressure greater than or equal to 5 cm H2O), moderate (100 mg Hg less than PaO2/FiO2 less than or equal to 200 mm Hg with PEEP greater than or equal to 5 cm H2O), or severe (PaO2/FiO2 less than or equal to 100 mm Hg with PEEP greater than or equal to 5 cm H2O). The mortality rate for ARDS is estimated to be 34% to 58%.

Which mode of ventilation uses low tidal volume in conjunction with normal respiratory rates to limit the effects of barotrauma in patients with adult respiratory distress syndrome (ARDS)? a. Assist control (A/C) ventilation b. Permissive hypercapnia c. Pressure control ventilation (PCV) d. Continuous positive airway pressure (CPAP)

b. Permissive hypercapnia Permissive hypercapnia is the mode with normal rates (not increased) and small tidal volumes to allow the CO2 levels to increase. Assist control (A/C) ventilation has a preset tidal volume that the patient gets from the ventilator whether he or she breathes extra or allows the machine to deliver all breaths. Pressure control ventilation (PCV) sets an inspiratory pressure rather than a tidal volume. Continuous positive airway pressure (CPAP) delivers oxygen and a pressure above baseline to keep the alveoli inflated and prevent atelectasis.

What nursing interventions should be included in the nursing management of the patient receiving a neuromuscular blocking agent? a. Withholding all sedation and narcotics b. Protecting the patient from the environment c. Keeping the patient supine d. Speaking to the patient only when necessary

b. Protecting the patient from the environment Patient safety is a major concern for the patient receiving a neuromuscular blocking agent because these patients are unable to protect themselves from the environment. Special precautions should be taken to protect the patient at all times.

What is the major hemodynamic consequence of a massive pulmonary embolus? a. Increased systemic vascular resistance leading to left heart failure b. Pulmonary hypertension leading to right heart failure c. Portal vein blockage leading to ascites d. Embolism to the internal carotids leading to a stroke

b. Pulmonary hypertension leading to right heart failure The major hemodynamic consequence of a pulmonary embolus is the development of pulmonary hypertension, which is part of the effect of a mechanical obstruction when more than 50% of the vascular bed is occluded. In addition, the mediators released at the injury site and the development of hypoxia cause pulmonary vasoconstriction, which further exacerbates pulmonary hypertension.

A patient was admitted with acute lung failure. The patient has been on a ventilator for 3 days and is being considered for weaning. Which criteria would indicate that the patient is ready to be weaned? a. FiO2 greater than 50% b. Rapid shallow breathing index less than 105 c. Minute ventilation greater than 10 L/min d. Vital capacity/kg greater than or equal to 15 mL

b. Rapid shallow breathing index less than 105 The rapid shallow breathing index (RSBI) has been shown to be predictive of weaning success. To calculate the RSBI, the patient's respiratory rate and minute ventilation are measured for 1 minute during spontaneous breathing. The measured respiratory rate is then divided by the tidal volume (expressed in liters). An RSBI less than 105 is considered predictive of weaning success. If the patient meets criteria for weaning readiness and has an RSBI less than 105, a spontaneous breathing trial can be performed.

What chest radiography finding is consistent with a left pneumothorax? a. Flattening of the diaphragm b. Shifting of the mediastinum to the right c. Presence of a gastric air bubble d. Increased radiolucency of the left lung field

b. Shifting of the mediastinum to the right Shifting of the mediastinal structures away from the area of involvement is a sign of a pneumothorax.

A patient who is short of breath is being prepared for a thoracentesis for a left pleural effusion. Which position would be most appropriate to place this patient during the procedure? a. Lying on his right side with his back flush to the edge of the bed b. Sitting on the side of the bed with his arms supported on the bedside table c. Lying prone with the head of the bed in Trendelenburg to facilitate drainage of fluids d. Lying supine with both arms place beneath the head

b. Sitting on the side of the bed with his arms supported on the bedside table Sitting on the side of the bed provides easy access to the chest wall. If the patient is unable to sit, then the side-lying position with affected side down would be preferable. The Trendelenburg position should never be used.

The nurse is suctioning a patient's endotracheal tube and notices that the heart rate is dropping from 100 to 52 beats/min. What is the priority action? a. Increase the oxygen on the ventilator. b. Stop suctioning and give the patient some extra breaths. c. Administer atropine 0.5 mg intravenously (IV) per protocol. d. Increase the patient's IV fluids.

b. Stop suctioning and give the patient some extra breaths. The patient is experiencing a vagal response to suctioning. The procedure should be stopped immediately, and the patient should be provided extra breaths either manually or on the ventilator. Extra breaths will hyperoxygenate the patient and hopefully reverse the vagal response. Atropine is appropriate only if the patient is symptomatic and hyperoxygenation fails to reverse the bradycardia. Increasing IV fluids may or may not have any effect on the situation. Because the ventilator is already on 100% FiO2 (as part of the procedure for suctioning), the oxygen cannot be increased any higher.

A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. When entering the room, the ventilator inoperative alarm sounds. What action should the nurse take FIRST? a. Troubleshoot the ventilator until the problem is found. b. Take the patient off the ventilator and manually ventilate. c. Call the respiratory therapist for help. d. Silence the ventilator alarms until the problem is resolved.

b. Take the patient off the ventilator and manually ventilate. Ensure emergency equipment is at bedside at all times (eg, manual resuscitation bag connected to oxygen, masks, suction equipment or supplies), including preparations for power failures. If the ventilator malfunctions, the patient should be removed from the ventilator and ventilated manually with a manual resuscitation bag.

A nurse is working with a nursing student taking care of patient with continuous pulse oximetry. Which action indicates the nursing student needs further education with this device? a. The student checks the patient's capillary refill prior to placement of the probe. b. The student places a digit probe on the patient's ear lobe. c. The student places a digit probe on the patient's great toe. d. The student covers the probe with a towel.

b. The student places a digit probe on the patient's ear lobe. Placement of a digit probe on the patient's ear indicates the student nurse needs further education. Probes should only be used on their designated locations. Digit probes are placed on fingers or toes and not earlobes. Earlobe probes are used on earlobes. Checking for capillary refill is an appropriate practice as the selected area for monitoring must have adequate blood flow. Covering the probe with a towel or blanket is appropriate as excessive light can cause interference.

Which ventilator phase variable initiates the change from exhalation to inspiration? a. Cycle b. Trigger c. Flow d. Pressure

b. Trigger The phase variable that initiates the change from exhalation to inspiration is called the trigger. Breaths may be pressure triggered or flow triggered based on the sensitivity setting of the ventilator and the patient's inspiratory effort or time triggered based on the rate setting of the ventilator.

Depending on the patient's risk for the recurrence of pulmonary embolism (PE), how long may a patient remain on warfarin once they are discharged from the hospital? a. 1 to 3 months b. 3 to 6 months c. 3 to 12 months d. 12 to 36 months

c. 3 to 12 months The patient should remain on warfarin for 3 to 12 months depending on his or her risk for thromboembolic disease.

What does an intrapulmonary shunting value of 35% indicate? a. Normal gas exchange of venous blood b. An abnormal finding indicative of a shunt-producing disorder c. A serious and potentially life-threatening condition d. Metabolic alkalosis

c. A serious and potentially life-threatening condition A shunt greater than 10% is considered abnormal and indicative of a shunt-producing disorder. A shunt greater than 30% is a serious and potentially life-threatening condition that requires pulmonary intervention.

Which oxygen therapy device should is used in a patient requiring the delivery of a precise low FiO2? a. Simple mask b. Nasal cannula c. Air-entrainment mask d. Partial rebreathing mask

c. Air-entrainment mask An air-entrainment mask is used in patients requiring the delivery of a precise low FiO2. A simple mask, partial rebreathing mask, and nasal cannula are not able to provide as precise level of oxygen as an air-entrainment mask.

A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. Which criteria would indicate that the patient is not tolerating weaning? a. A decrease in heart rate from 92 to 80 beats/min b. An SpO2 of 92% c. An increase in respiratory rate from 22 to 38 breaths/min d. Spontaneous tidal volumes of 300 to 350 mL

c. An increase in respiratory rate from 22 to 38 breaths/min Weaning intolerance indicators include (1) a decrease in level of consciousness; (2) a systolic blood pressure increased or decreased by 20 mm Hg; (3) a diastolic blood pressure greater than 100 mm Hg; (4) a heart rate increased by 20 beats/min; (5) premature ventricular contractions greater than 6/min, couplets, or runs of ventricular tachycardia; (6) changes in ST segment (usually elevation); (7) a respiratory rate greater than 30 breaths/min or less than 10 breaths/min; (8) a respiratory rate increased by 10 breaths/min; (9) a spontaneous tidal volume less than 250 mL; (10) a PaCO2 increased by 5 to 8 mm Hg or pH less than 7.30; (11) an SpO2 less than 90%; (12) use of accessory muscles of ventilation; (13) complaints of dyspnea, fatigue, or pain; (14) paradoxical chest wall motion or chest abdominal asynchrony; (15) diaphoresis; and (16) severe agitation or anxiety unrelieved with reassurance.

A patient has been admitted following a motor vehicle collision in which the patient sustained multiple abrasions and bruising across the chest. Suddenly, the patient complains of difficulty breathing, the O2 saturation has dropped dramatically, there are decreased breath sounds on the left, and it appears that there is some tracheal deviation. What would be your next logical action? a. Notify the patient's practitioner and prepare for a stat V/Q scan. b. Start the patient on O2 at 4 L/min nasal cannula and prepare an aminophylline drip. c. Call the rapid response team and prepare for emergency insertion of a chest tube. d. Notify the patient's practitioner of these changes.

c. Call the rapid response team and prepare for emergency insertion of a chest tube. The signs and symptoms are classic indications of development of a pneumothorax. The characteristics that particularly differentiate this diagnosis are the bruising on the chest after motor vehicle accident (MVA) and the deviated trachea.

Use of oxygen therapy in the patient who is hypercapnic may result in which situation? a. Oxygen toxicity b. Absorption atelectasis c. Carbon dioxide retention d. Pneumothorax

c. Carbon dioxide retention Deoxygenated hemoglobin carries more CO2 compared with oxygenated hemoglobin. Administration of oxygen increases the proportion of oxygenated hemoglobin, which causes increased release of CO2 at the lung level. Because of the risk of CO2 accumulation, all patients who are chronically hypercapnic require careful low-flow oxygen administration.

What medication may be included in the preprocedural medications for a diagnostic bronchoscopy? a. Aspirin for anticoagulation b. Vecuronium to inhibit breathing c. Codeine to decrease the cough reflex d. Cimetidine to decrease hydrochloric acid secretion

c. Codeine to decrease the cough reflex Preprocedural medications for a diagnostic bronchoscopy may include atropine and intramuscular codeine. Whereas atropine lessens the vasovagal response and reduces the secretions, codeine decreases the cough reflex. When a bronchoscopy is performed therapeutically to remove secretions, decreased cough and gag reflexes are present, which may impair secretion clearance.

What is one strategy to prevent ventilator-associated pneumonia (VAP)? a. Maintain the head of the bed at 10 degrees. b. Perform oral care with peroxide daily. c. Conduct a spontaneous awakening trial daily. d. Assess readiness to extubate biweekly.

c. Conduct a spontaneous awakening trial daily. One strategy to prevent ventilator-associated pneumonia (VAP) is to conduct a spontaneous awakening trial daily. The head of the bed should be maintained at 30 to 45 degrees. Oral care should be performed with chlorhexidine. Readiness to extubate should be assessed at least daily.

A patient is intubated, and sputum for culture and sensitivity is ordered. Which of the following is important for obtaining the best specimen? a. After the specimen is in the container, dilute thick secretions with sterile water. b. Apply suction when the catheter is advanced to obtain secretions from within the endotracheal tube. c. Do not apply suction while the catheter is being withdrawn because this can contaminate the sample with sputum left in the endotracheal tube. d. Do not clear the endotracheal tube of all local secretions before obtaining the specimen.

c. Do not apply suction while the catheter is being withdrawn because this can contaminate the sample with sputum left in the endotracheal tube. To prevent contamination of secretions in the upper portion of the endotracheal tube, do not apply suction while the catheter is being withdrawn. Clear the endotracheal or tracheostomy tube for all local secretions, avoiding deep airway penetration. This will prevent contamination with upper airway flora. Do not dilute thick secretions with sterile water. This will compromise the specimen.

A patient with a tracheostomy requires a sputum sample for further analysis. Which statement regarding this procedure is correct? a. Using the side of the tracheostomy tube as a guide, slide the suction catheter as far as it will go without forcing it. b. Apply suction to the catheter until secretions return to the sputum trap, continuing to apply suction as you withdraw the catheter. c. Do not attempt to flush the catheter with sterile water. d. Maintain the specimen at room temperature until transported to the laboratory.

c. Do not attempt to flush the catheter with sterile water. Contact with the inside of the tracheostomy tube and applying suction upon catheter withdrawal may contaminate the specimen with secretions from the upper airways. It is not necessary to "clear" the suction catheter with sterile water. This may dilute the specimen and render results that are not useful. After the specimen has been obtained, it should be refrigerated if immediate transport to the laboratory is not available.

Which finding confirms the diagnosis of a pulmonary embolism (PE)? a. Low-probability ventilation-perfusion (V/Q) scan b. Negative pulmonary angiogram c. High-probability V/Q scan d. Absence of vascular markings on the chest radiograph

c. High-probability V/Q scan A definitive diagnosis of a pulmonary embolism requires confirmation by a high-probability ventilation-perfusion (V/Q) scan, an abnormal pulmonary angiogram or computed tomography scan, or strong clinical suspicion coupled with abnormal findings on lower extremity deep venous thrombosis studies.

What nursing intervention can minimize the complications of suctioning? a. Inserting the suction catheter no more than 5 inches b. Premedicating the patient with atropine c. Hyperoxygenating the patient with 100% oxygen d. Increasing the suction to 150 mm Hg

c. Hyperoxygenating the patient with 100% oxygen Hypoxemia can be minimized by giving the patient three hyperoxygenation breaths (breaths at 100% FiO2) with the ventilator before the procedure and again after each pass of the suction catheter.

What is the medical treatment for a pneumothorax greater than 15%? a. Systemic antibiotics to treat the inflammatory response b. An occlusive dressing to equalize lung pressures c. Interventions to evacuate the air from the pleural space d. Mechanical ventilation to assist with re-expansion of the collapsed lung

c. Interventions to evacuate the air from the pleural space A pneumothorax greater than 15% requires intervention to evacuate the air from the pleural space and facilitate re-expansion of the collapsed lung. Interventions include aspiration of the air with a needle and placement of a small-bore (12 to 20 Fr) or large-bore (24 to 40 Fr) chest tube.

Which pulmonary function test measures inspiratory muscle strength? a. Tidal volume b. Vital capacity c. Maximal inspiratory pressure d. Minute ventilation

c. Maximal inspiratory pressure Maximal inspiratory pressure is used to evaluate the strength of inspiratory muscles and is often used to determine readiness to wean from mechanical ventilation. Tidal volume measures the volume of air inhaled after a normal inhalation, vital capacity is the maximum amount of air that can be exhaled after a maximal inhalation, and minute ventilation is the volume of air expired per minute.

Which statement is true regarding the use of prone positioning in a patient with acute respiratory distress syndrome (ARDS)? a. It can be used safely in all patients. b. A strict schedule of turning every 2 hours must be adhered to for greatest success. c. Prone positioning improves perfusion to less damaged areas of the lung. d. It is not useful in mobilizing secretions.

c. Prone positioning improves perfusion to less damaged areas of the lung. In acute respiratory distress syndrome (ARDS), the dependent areas of lung tissue are most affected. The prone position allows perfusion of the healthier tissue. It is contraindicated in patients with head and spinal trauma and may cause edema. Care must be taken to keep the eyes moist and taped shut while the patient is prone to avoid corneal ulcerations.

The physician orders rotation therapy for a patient experiencing acute lung injury. Which technique should be used for the therapy to be effective? a. Rotate patient 30 degrees side to side for 10 minutes every hour b. Prone patient for 2 hours every 6 hours c. Rotate patient 40 degrees per side for at least 18 hours per day d. Prone patient for 6 hours and supine for 6 hours

c. Rotate patient 40 degrees per side for at least 18 hours per day Studies have found that to achieve benefits, rotation must be aggressive, and the patient must be at least 40 degrees per side, with a total arc of at least 80 degrees, for at least 18 hours a day. Rotating the patient 30 degrees has not been shown to be effective. Placing the patient prone is not a form of rotation therapy. No clear standards are available on how long a patient should be placed prone.

A patient was admitted in acute lung failure. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. Which test would the nurse expect the practitioner to order to identify the infectious pathogen? a. CBC with differential b. Wound culture of surgical site c. Sputum Gram stain and culture d, Urine specimen

c. Sputum Gram stain and culture A sputum Gram stain and culture are done to facilitate the identification of the infectious pathogen. In 50% of cases, though, a causative agent is not identified. A diagnostic bronchoscopy may be needed, particularly if the diagnosis is unclear or current therapy is not working. In addition, a complete blood count (CBC) with differential, chemistry panel, blood cultures, and arterial blood gas analysis is obtained.

Which airway would be the most appropriate for a patient requiring intubation longer than 21 days? a. Oropharyngeal airway b. Esophageal obturator airway c. Tracheostomy tube d. Endotracheal intubation

c. Tracheostomy tube Although no ideal time to perform the procedure has been identified, it is commonly accepted that if a patient has been intubated or is anticipated to be intubated for longer than 7 to 10 days, a tracheostomy should be performed.

What is an indication for a pneumonectomy? a. Peripheral granulomas b. Bronchiectasis c. Unilateral tuberculosis d. Single lung abscess

c. Unilateral tuberculosis A pneumonectomy is the removal of entire lung with or without resection of the mediastinal lymph nodes. Indications include malignant lesions, unilateral tuberculosis, extensive unilateral bronchiectasis, multiple lung abscesses, massive hemoptysis, and bronchopleural fistula.

The nurse is discussing the pharmacologic treatment of a pulmonary embolism (PE) with a nursing student. Which statement made by the nursing student indicates that the education was effective? a. "Heparin is administered to break down the existing clots." b. "Heparin is titrated to achieve a prothrombin time of two to three times the control value." c. "Heparin should be continued until the warfarin is started." d. "rt-PA can be used to treat patients with massive pulmonary embolism and hemodynamic instability."

d. "rt-PA can be used to treat patients with massive pulmonary embolism and hemodynamic instability." Recombinant tissue-type plasminogen activator (rt-PA) is a fibrinolytic reserved for severe pulmonary embolism (PE). Heparin is administered to prevent further clots from forming and has no effect on the existing clot. The heparin should be adjusted to maintain the activated partial thromboplastin time (aPTT) in the range of two to three times of upper normal. Warfarin should be started at the same time, and when the international normalized ratio (INR) reaches 3.0, the heparin should be discontinued. The INR should be maintained between 2.0 and 3.0.

To select the correct size of an oropharyngeal airway, the nurse should ensure the airway extends from which area to which area? a. Tip of the nose to the ear lobe b. Middle of the mouth to the ear lobe c. Tip of the nose to the middle of the trachea d. Corner of the mouth to the angle of the jaw

d. Corner of the mouth to the angle of the jaw An oropharyngeal airway's proper size is selected by holding the airway against the side of the patient's face and ensuring that it extends from the corner of the mouth to the angle of the jaw. If the airway is improperly sized, it will occlude the airway. Nasopharyngeal airways are measured by holding the tube against the side of the patient's face and ensuring that it extends from the tip of the nose to the ear lobe.

Which statement is true regarding status asthmaticus? a. Initial arterial blood gas levels indicate severe hypoxemia and respiratory acidosis. b. Low-flow oxygen therapy should be used cautiously in patients with asthma. c. Small, frequent doses of bronchodilators should be started immediately. d. Corticosteroids, although useful in the treatment of status asthmaticus, usually require 6 to 8 hours to take effect.

d. Corticosteroids, although useful in the treatment of status asthmaticus, usually require 6 to 8 hours to take effect. The onset of action of corticosteroids is 6 to 8 hours. A patient in status asthmaticus often initially presents with alkalosis caused by tachypnea and hyperventilation, but as fatigue sets in, hypoventilation and hypercapnia result in acidosis. These patients often require high-flow oxygen therapy and high-dose bronchodilator

You are caring for a patient admitted with asthma. During your assessment, you would expect to find which abnormality? a. "Funnel chest" b. Right tracheal shift c. Dull percussive sounds d. Decreased fremitus

d. Decreased fremitus Structural changes associated with asthma interfere with the normal vibrations created during breathing, resulting in decreased sensation upon palpation.

A patient has been admitted with the diagnosis of acute respiratory distress syndrome (ARDS). Arterial blood gasses (ABGs) revealed an elevated pH and decreased PaCO2. The patient is becoming fatigued, and the practitioner orders a repeat ABG. Which set of results would be indicative of the patient's current condition? a. Elevated pH and decreased PaCO2 b. Elevated pH and elevated PaCO2 c. Decreased pH and decreased PaCO2 d. Decreased pH and elevated PaCO2

d. Decreased pH and elevated PaCO2 Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen administration (refractory hypoxemia). Initially, the PaCO2 is low as a result of hyperventilation, but eventually the PaCO2 increases as the patient fatigues. The pH is high initially but decreases as respiratory acidosis develops.

Which blood gas parameter is the acid-base component that reflects kidney function? a. pH b. PaO2 c. PaCO2 d. HCO3 ̄

d. HCO3 ̄ The bicarbonate ( ) is the acid-base component that reflects kidney function. The bicarbonate is reduced or increased in the plasma by renal mechanisms. The normal range is 22 to 26 mEq/L. pH measures the hydrogen ion concentration of plasma. PaO2 measures partial pressure of oxygen dissolved in arterial blood plasma. PaCO2 measures the partial pressure of carbon dioxide dissolved in arterial blood plasma.

Determination of oxygenation status by oxygen saturation alone is inadequate. What other value must be known? a. pH b. PaCO2 c. HCO3- d. Hemoglobin (Hgb)

d. Hemoglobin (Hgb) Proper evaluation of the oxygen saturation level is vital. For example, an SaO2 of 97% means that 97% of the available hemoglobin is bound with oxygen. The word available is essential to evaluating the SaO2 level because the hemoglobin level is not always within normal limits and oxygen can bind only with what is available.

Patients with left-sided pneumonia may benefit from placing them in which position? a. Reverse Trendelenburg b. Supine c. On the left side d. On the right side

d. On the right side Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Because gravity normally facilitates preferential ventilation and perfusion to the dependent areas of the lungs, the best gas exchange would take place in the dependent areas of the lungs. Thus, the goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position.

Which cause of hypoxemia is the result of blood passing through unventilated portions of the lungs? a. Alveolar hypoventilation b. Dead space ventilation c. Intrapulmonary shunting d. Physiologic shunting

d. Physiologic shunting Hypoxemia is the result of impaired gas exchange and is the hallmark of acute respiratory failure. Hypercapnia may be present, depending on the underlying cause of the problem. The main causes of hypoxemia are alveolar hypoventilation, ventilation-perfusion (V/Q) mismatching, and intrapulmonary shunting. Intrapulmonary shunting occurs when blood passes through a portion of a lung that is not ventilated. Physiologic shunting is normal and not a cause of hypoxemia.

What nursing intervention can facilitate the prevention of aspiration? a. Observing the amount given in the tube feeding b. Assessing the patient's level of consciousness c. Encouraging the patient to cough and to breathe deeply d. Positioning a patient in a semirecumbent position

d. Positioning a patient in a semirecumbent position Semirecumbency has been shown to decrease the risk of aspiration and inhibit the development of hospital-associated pneumonia.

Which statement best describes the effects of positive-pressure ventilation on cardiac output? a. Positive-pressure ventilation increases intrathoracic pressure, which increases venous return and cardiac output. b. Positive-pressure ventilation decreases venous return, which increases preload and cardiac output. c. Positive-pressure ventilation increases venous return, which decreases preload and cardiac output. d. Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return and cardiac output.

d. Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return and cardiac output. Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return to the right side of the heart. Impaired venous return decreases preload, which results in a decrease in cardiac output.

What is the preset positive pressure used to augment the patient's inspiratory effort known as? a. Positive end-expiratory pressure (PEEP) b. Continuous positive airway pressure (CPAP) c. Pressure control ventilation (PCV) d. Pressure support ventilation (PSV)

d. Pressure support ventilation (PSV) Preset positive pressure used to augment the patient's inspiratory efforts is known as pressure support ventilation. With continuous positive airway pressure, positive pressure is applied during spontaneous breaths; the patient controls rate, inspiratory flow, and tidal volume. Positive end-expiratory pressure is positive pressure applied at the end of expiration of ventilator breaths.

Which clinical manifestation is associated with the exudative phase of acute respiratory distress syndrome (ARDS)? a. Increased work of breathing b. Increasing agitation c. Fine crackles d. Respiratory alkalosis

d. Respiratory alkalosis Respiratory alkalosis is one finding associated with the exudative phase of acute respiratory distress syndrome (ARDS). Increasing agitation, fine crackles, and increased work of breathing are associated with the fibroproliferative phase of ARDS.

Which ABG values would indicate a need for oxygen therapy? a. PaO2 of 80 mmHg b. PaCO2 of 35 mmHg c. HCO3- of 24 mEq d. SaO2 of 87%

d. SaO2 of 87% The amount of oxygen administered depends on the pathophysiologic mechanisms affecting the patient's oxygenation status. In most cases, the amount required should provide an arterial partial pressure of oxygen (PaO2) of greater than 60 mm Hg or an arterial hemoglobin saturation (SaO2) of greater than 90% during both rest and exercise.

A patient was admitted after a left pneumonectomy. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. What action should the nurse take next? a. Lavage the airway with normal saline. b. Place the patient supine in a semi-Fowler position. c. Manually ventilate the patient. d. Suction the airway.

d. Suction the airway. When aspiration is witnessed, emergency treatment should be instituted to secure the airway and minimize pulmonary damage. The patient's head should be turned to the side, and the oral cavity and upper airway should be suctioned immediately to remove the gastric contents.

A patient is admitted with signs and symptoms of a pulmonary embolus (PE). What diagnostic test most conclusive to determine this diagnosis? a. ABG b. Bronchoscopy c. Pulmonary function test d. V/Q scan

d. V/Q scan A ventilation-perfusion (V/Q) scan is the most conclusive test for a pulmonary embolus. Arterial blood gas (ABG) analysis tests oxygen levels in the blood, bronchoscopy is to used view the bronchi, and pulmonary function tests are used to measure lung volume.

Supplemental oxygen administration is usually effective in treating hypoxemia related which situation? a. Physiologic shunting b. Dead space ventilation c. Alveolar hyperventilation d. Ventilation-perfusion mismatching

d. Ventilation-perfusion mismatching Supplemental oxygen administration is effective in treating hypoxemia related to alveolar hypoventilation and ventilation-perfusion mismatching. When intrapulmonary shunting exists, supplemental oxygen alone is ineffective. In this situation, positive pressure is necessary to open collapsed alveoli and facilitate their participation in gas exchange. Positive pressure is delivered via invasive and noninvasive mechanical ventilation.