Exam #2 Respiratory

CM of respiratory failure

•Restlessness, confusion, agitation, and combative behavior suggest inadequate O2 delivery to the brain and should be fully investigated.

Left shift on oxyhemoglobin dissociation curve

•alkalosis •abnormally low paO2 in blood/ alkalosis

ETCO2 monitoring (capnography)

•used during ventilator management to assess trends in lung ventilation. confirm correct tube placement within the airway immediately after intubation

High PEEP in ARDS--contraindications

-can cause barotrauma and volutrauma

If your patient has a lot of secretions what do you NOT want them on?

CPAP

Who should the nurse assess first?

pt. extubated who hasn't urinated in last 6 hrs.

How do you know if someone is having heart failure?

Check BNP

When you enter a patients room and you see alarms going off when patient is sedated or looks "ok" what should you do first?

Check machines. Are they plugged in? Are they working properly?

When to suction?

Only do it when the patient absolutely NEEDS it!

If the pulmonary pressure is too high what is going on?

PEEP is too high

hypoxemic respiratory failure

PaO 2 less than 60 mm Hg when the patient is receiving an inspired O 2 concentration of 60% or more.

ARDS

PaO2/FIO2 < or equal to 200

PSV

Pressure support ventilation Patient sets their own volume, pressure This is what you will use to wean someone off being ventilated Watch out for barotrauma

When patient has fluid in their heart what position do you NOT want them in?

Prone position. Also, you are the only one who can do this, not an LVN, CNA.

How to monitor oxygenation status at the bed side?

Pulse ox

What is important to do on a physical assessment for someone in respiratory failure?

Put pulse ox on!

PRVC---why would you prefer this instead of other modes?

Risk of barotrauma much lower

Pressure Controlled Ventilation

The amount of pressor we need to delivery.

Hypoxia S/S

agitated, altered mental status

What is a late sign of respiratory failure?

cyanosis and clubbing of the fingers

Pathophysiology 3 things for ARDS

decrease compliance, impaired gas exchange, pulmonary hypotension

VAP bundle multiple choice

elevate HOB 30-45 degrees, daily sedation vacation to assess if we can take them off vent, Venous thromboembolism prophylaxis (SEDS), daily oral care, suction only when needed, early nutrition, standard precautions.

hypercapnia

excessive carbon dioxide in the blood which means you will be hypo-ventilating

Poor peripheral perfusion (high doses of pressor medication) reducing low peripheral blood flow

first thing you do is look at your O2 sat in the initial stages

Shunting-intrapulmonary

fluid in alveoli- (oxygen cannot pass through) blood has no oxygen picked up. Most common type

Right shift on oxyhemoglobin disassociation curve

Abnormally high PO2/ acidosis

Question about ARDS and lab to clarify that it isn't heart failure

BNP

Volume assist control

We regulate how much volume the pt takes with each breath

What to watch out for with high ventilation?

Volu-trauma

The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following? a. Management and protection of the airway b. Prevention of gastric aspiration c. Prevention of skin breakdown and nerve damage d. Psychological support to patient and family

ANS: A All are important, but protection of the airway is the most important intervention if the patient is placed in the prone position.

A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? a. Elevate head of bed to 30 to 45 degrees. b. Suction the endotracheal tube every 2 to 4 hours. c. Limit the use of positive end-expiratory pressure. d. Give enteral feedings at no more than 10 mL/hr.

ANS: A Elevation of the head decreases the risk for aspiration.

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO 2 ) from 94% to 88%. Which action should the nurse take next? a. Increase the oxygen flow rate. b. Suction the patient's oropharynx. c. Instruct the patient to cough and deep breathe. d. Help the patient to sit in a more upright position.

ANS: A Increasing oxygen flow rate will usually improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism.

The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? a. Decreasing PaO2 levels despite increased FiO2 administration b. Elevated alveolar surfactant levels c. Increased lung compliance with increased FiO2 administration d. Respiratory acidosis associated with hyperventilation

ANS: A Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels are often diminished in ARDS. Compliance decreases in ARDS. In early ARDS, hyperventilation may occur along with respiratory alkalosis.

A patients ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from .60 to .70, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patients blood pressure drops from 120/76 mm Hg to 90/60 mm Hg. What is the most likely cause of this decrease in blood pressure? a. Decrease in cardiac output b. Hypovolemia c. Increase in venous return d. Oxygen toxicity

ANS: A Positive end-expiratory pressure increases intrathoracic pressure and may result in decreased venous return. Cardiac output decreases as a result, and is reflected in the lower blood pressure. It is essential to assess the patient to identify optimal positive end-expiratory pressurethe highest amount that can be applied without compromising cardiac output.

A patients ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from .60 to .70, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patients blood pressure drops from 120/76 mm Hg to 90/60 mm Hg. What is the most likely cause of this decrease in blood pressure? a. Decrease in cardiac output b. Hypovolemia c. Increase in venous return d. Oxygen toxicity

ANS: A Positive end-expiratory pressure increases intrathoracic pressure and may result in decreased venous return. Cardiac output decreases as a result, and is reflected in the lower blood pressure. It is essential to assess the patient to identify optimal positive end-expiratory pressurethe highest amount that can be applied without compromising cardiac output. Although hypovolemia can result in a decrease in blood pressure, there is no indication that this patient has hypovolemia. As noted, higher levels of positive end-expiratory pressure may cause a decrease, not an increase, in venous return. Oxygen toxicity can occur in this case secondary to the high levels of oxygen needed to maintain gas exchange; however, oxygen toxicity is manifested in damage to the alveoli.

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is accurate? a. "PEEP will push more air into the lungs during inhalation." b. "PEEP prevents the lung air sacs from collapsing during exhalation." c. "PEEP will prevent lung damage while the patient is on the ventilator." d. "PEEP allows the breathing machine to deliver 100% oxygen to the lungs."

ANS: B By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation.

The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia? a. Bradycardia b. Change in sputum characteristics c. Hypoventilation and respiratory acidosis d. Pursed-lip breathing

ANS: B Change in the character of sputum may signal the development of a respiratory infection in the patient with COPD. Additional symptoms include anxiety, wheezing, chest tightness, tachypnea, tachycardia, fatigue, malaise, confusion, fever, and sleeping difficulties.

. The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration? a. Hyperventilation and respiratory acidosis b. Hypoventilation and respiratory acidosis c. Hypoventilation and respiratory alkalosis d. Respiratory acidosis and normal oxygen levels

ANS: B Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and respiratory acidosis. The overdose depresses the respiratory drive, which results in hypoventilation, not hyperventilation.

he nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)? a. Increased oxygen saturation via pulse oximetry b. Increased peak inspiratory pressure on the ventilator c. Normal chest radiograph with enlarged cardiac structures d. PaO2/FiO2 ratio > 300

ANS: B Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation decreases in ARDS. Chest x-ray study will show progressive infiltrates. In ARDS, a PaO2/FiO2 ratio less than 200 is a criterion.

Oxygen saturation (SaO2) represents: a. alveolar oxygen tension. b. oxygen that is chemically combined with hemoglobin. c. oxygen that is physically dissolved in plasma. d. total oxygen consumption.

ANS: B Oxygen saturation value reflects the saturation of the hemoglobin.

A 65-year-old patient is admitted to the progressive care unit with a diagnosis of community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease and diabetes. 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 65 mm Hg. These blood gases reflect: a. hypoxemia and compensated metabolic alkalosis. b. hypoxemia and compensated respiratory acidosis. c. normal oxygenation and partly compensated metabolic alkalosis. d. normal oxygenation and uncompensated respiratory acidosis.

ANS: B The PaO2 of 65 mm Hg is lower than normal range (80-100 mm Hg), indicating hypoxemia. The high PaCO2indicates respiratory acidosis. The elevated bicarbonate indicates metabolic alkalosis. Because the pH is normal, the underlying acid-base alteration is compensated. Given the patients history of chronic pulmonary disease and a pH that is at the lower end of normal range, it can be determined that this patient is hypoxemic with fully compensated respiratory acidosis.

A patient is having difficulty weaning from mechanical ventilation. The nurse assesses the patient for a potential cause of this difficult weaning, which includes: a. cardiac output of 6 L/min. b. hemoglobin of 8 g/dL. c. negative sputum culture and sensitivity. d. white blood cell count of 8000.

ANS: B The low hemoglobin level will decrease oxygen-carrying capacity and may make weaning difficult. A cardiac output of 6 L/min is normal. A negative sputum culture indicates absence of lower respiratory infection, which should promote rather than hinder weaning. A white blood cell count of 8000 is normal and indicates absence of infection, which should promote rather than hinder weaning.

A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? a. The patient's PaO 2 is 50 mm Hg and the SaO 2 is 88%. b. The patient has subcutaneous emphysema on the upper thorax. c. The patient has bronchial breath sounds in both the lung fields. c. The patient has a first-degree atrioventricular heart block with a rate of 58.

ANS: B The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP.

Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmonary disease (COPD), the patient's arterial blood gas (ABG) results include a pH of 7.50, PaO2 of 80 mm Hg, PaCO2 of 29 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to a. increase the FIO2. b. decrease the respiratory rate. c. increase the tidal volume (VT) .d. leave the ventilator at the current settings.

ANS: BThe patient's PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD, increasing the tidal volume would further lower the PaCO2, and the PaCO2 and pH indicate a need to make the ventilator changes.

The basic underlying pathophysiology of acute respiratory distress syndrome results from: a. a decrease in the number of white blood cells available. b. damage to the right mainstem bronchus. c. damage to the type II pneumocytes, which produce surfactant. d. decreased capillary permeability.

ANS: C Acute respiratory distress syndrome results in damage to the pneumocytes, increased capillary permeability, and noncardiogenic pulmonary edema.

. To evaluate the effectiveness of ordered interventions for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse? a. Chest x-ray b. Oxygen saturation c. Arterial blood gas analysis d. Central venous pressure monitoring

ANS: C Arterial blood gas (ABG) analysis is most useful in this setting because ventilatory failure causes problems with CO 2 retention, and ABGs provide information about the PaCO 2 and pH.

A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation? a. Emergency tracheostomy and mechanical ventilation b. Mechanical ventilation via an endotracheal tube c. Noninvasive positive-pressure ventilation (NPPV) d. Oxygen at 100% via bag-valve-mask device

ANS: C Noninvasive measures are often recommended in the initial treatment of the patient with chronic obstructive pulmonary disease to prevent intubation and ventilator dependence. The history of chronic obstructive pulmonary disease increases the risk for ventilator dependence, so noninvasive options are a priority.

The nurse notes that the patients arterial blood gas levels indicate hypoxemia. The patient is not intubated and has a respiratory rate of 22 breaths/min. The nurses first intervention to relieve hypoxemia is to: a. call the physician for an emergency intubation procedure. b. obtain an order for bilevel positive airway pressure (BiPAP). c. notify the provider of values and obtain order for oxygen. d. suction secretions from the oropharynx.

ANS: C Oxygen is administered to treat or prevent hypoxemia. Oxygen should be considered a first-line treatment in cases of hypoxemia. Emergency intubation is not warranted at this time. BiPAP may be considered if administration of supplemental oxygen does not correct the hypoxemia. There is no indication that the patient requires suctioning.

PRVC (pressure regulated volume control)

Each breath IS ASSISTED, though this machine takes into account lung compliance and administers amount of tidal volume that each pt needs at any given time; As the pt's lungs strengthen, the ventilator will decrease the amount of pressure used. KNOW: that decreases the chance of barotrauma and volumetrauma

Pulmonary embolus, what do you do first?

Elevate HOB

Old people--something question

First thing you do is give fluids

Patient intubated, which process do you not want to start?

Giving perinatal nutrition!

If patient self excubates

Have bag at bed side ready to go!

Pt. receiving a neuromuscular blocker drug, what order should concern the nurse?

IV opioids

PaO2

free oxygen molecules in your blood stream-not attached to hemoglobin--80-100% best way to test this is with ABG

Shunting-anatomical

not going through lungs (alveoli)-going through heart

SaO2 (Oxygen Saturation)

oxygen attached to hemoglobin Goal is over 60% with patient with ARDS Normal value-80-100%

Your doing an assessment on a patient and on auscultation of the lungs you hear diminished lung sounds. What concerns you?

pnuemothorax

12 years on steroid

temperature answer

Acute Respiratory Failure Nursing and Inter-professional Management for situations such as CF/ any mucal secretions

•Adequate fluid intake (2 to 3 L/day) keeps secretions thin and easier to remove.

Nursing diagnosis for acute respiratory failure

•Impaired gas exchange related to alveolar hypoventilation, intrapulmonary shunting, V/Q mismatch, and diffusion impairment

A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO 2 ) 80%, tidal volume 450, rate 16/minute, and positive end-expiratory pressure (PEEP) 5 cm. Which assessment finding is most important for the nurse to report to the health care provider? a. Oxygen saturation 99% b. Respiratory rate 22 breaths/minute c. Crackles audible at lung bases d. Heart rate 106 beats/minute

ANS: A The FIO 2 of 80% increases the risk for oxygen toxicity. Because the patient's O 2 saturation is 99%, a decrease in FIO 2 is indicated to avoid toxicity.

A patients endotracheal tube is not secured tightly. The respiratory care practitioner assists the nurse in taping the tube. After the tube is retaped, the nurse auscultates the patients lungs and notes that the breath sounds over the left lung fields are absent. The nurse suspects that: a. the endotracheal tube is in the right mainstem bronchus. b. the patient has a left pneumothorax. c. the patient has aspirated secretions during the procedure. d. the stethoscope earpiece is clogged with wax.

ANS: A The endotracheal tube can become dislodged during repositioning and is likely in the right mainstem bronchus. It is important to reassess breath sounds after the retaping procedure.

A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to improve gas exchange? a. On the left side b. On the right side c. In the tripod position d. In the high-Fowler's position

ANS: A The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion.

A patient with acute respiratory distress syndrome (ARDS) is placed in the prone position. When prone positioning is used, which information obtained by the nurse indicates that the positioning is effective? a. The patient's PaO 2 is 89 mm Hg, and the SaO 2 is 91%. b. Endotracheal suctioning results in clear mucous return. c. Sputum and blood cultures show no growth after 48 hours. d. The skin on the patient's back is intact and without redness.

ANS: A The purpose of prone positioning is to improve the patient's oxygenation as indicated by the PaO 2 and SaO 2 .

KNOW THIS QUESTION! When admitting a patient with possible respiratory failure with a high PaCO 2 , which assessment information should be immediately reported to the health care provider? a. The patient is somnolent. b. The patient complains of weakness. c. The patient's blood pressure is 164/98. b. The patient's oxygen saturation is 90%.

ANS: A Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO 2 and respiratory failure.

Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.) a. Increase functional residual capacity b. Prevent collapse of unstable alveoli c. Improve arterial oxygenation d. Open collapsed alveoli

ANS: A, B, C, D Ventilatory support for ARDS typically includes PEEP to restore functional residual capacity, open collapsed alveoli, prevent collapse of unstable alveoli, and improve arterial oxygenation.

The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.) a. Drain condensate from the ventilator tubing away from the patient. b. Elevate the head of the bed 30 to 45 degrees. c. Instill normal saline as part of the suctioning procedure. d. Perform regular oral care with chlorhexidine.

ANS: A, B, D Condensate should be drained away from the patient to avoid drainage back into the patients airway. Prevention guidelines recommend elevating the head of bed at 30 to 45 degrees. Regular antiseptic oral care, with an agent such as chlorhexidine, reduces oropharyngeal colonization. Normal saline is not recommended as part of the suctioning procedure, and it may increase the risk for infection.

A patient with respiratory failure has hemodynamic monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 10 cm H2O. Which information indicates that a change in the ventilator settings may be required? a. The arterial line shows a blood pressure of 90/46. b. The pulmonary artery pressure (PAP) is decreased. c. The cardiac monitor shows a heart rate of 58 beats/min. d. The pulmonary artery wedge pressure (PAWP) is increased.

ANS: AThe hypotension indicates that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and cardiac output (CO). The other assessment data would not be caused by mechanical ventilation.

Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates the need for suctioning? a. The respiratory rate is 32 breaths/min. b. The pulse oximeter shows a SpO2 of 93%. c. The patient has not been suctioned for the last 6 hours. d. The lungs have occasional audible expiratory wheezes.

ANS: AThe increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that it is needed, not on a scheduled basis.

A patient admitted with acute respiratory failure has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action is a priority for the nurse to include in the plan of care? a. Encourage use of the incentive spirometer. b. Offer the patient fluids at frequent intervals. c. Teach the patient the importance of ambulation. d. Titrate oxygen level to keep O 2 saturation >93%.

ANS: B Because the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake.

The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider? a. Blood urea nitrogen (BUN) level 32 mg/dL b. Red-brown drainage from orogastric tube c. Scattered coarse crackles heard throughout lungs d. Arterial blood gases: pH 7.31, PaCO 2 50, PaO 2 68

ANS: B The nasogastric drainage indicates possible gastrointestinal bleeding and/or stress ulcer, and should be reported.

The oxygen saturation (SpO 2 ) for a patient with left lower lobe pneumonia is 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is a priority for the nurse to take? a. Position the patient on the left side. b. Assist the patient with staged coughing. c. Place a humidifier in the patient's room. d. Schedule a 2-hour rest period for the patient.

ANS: B The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation.

A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an oxygen saturation (SpO 2 ) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? a. Administration of 100% oxygen by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of continuous positive pressure ventilation (CPAP)

ANS: B The patient's lethargy, low respiratory rate, and SpO 2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate.

A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with a. obtaining a ventilation-perfusion scan. b. drawing blood for arterial blood gases. c. insertion of a pulmonary artery catheter. d. positioning the patient for a chest x-ray.

ANS: C Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema).

. Intrapulmonary shunting refers to: a. alveoli that are not perfused. b. blood that is shunted from the left side of the heart to the right and causes heart failure. c. blood that is shunted from the right side of the heart to the left without oxygenation. d. shunting of blood supply to only one lung.

ANS: C Shunting refers to blood that is not oxygenated in the lungs.

The nurse is caring for a patient with an endotracheal tube. The nurse understands that endotracheal suctioning is needed to facilitate removal of secretions and that the procedure: a. decreases intracranial pressure. b. depresses the cough reflex. c. is done as indicated by patient assessment. d. is more effective if preceded by saline instillation to loosen secretions.

ANS: C Suctioning is performed as indicated by patients assessment. Suctioning is associated with increases in intracranial pressure; therefore, it is important to hyperoxygenate the patient prior to suctioning to reduce this complication. Suctioning can stimulate the cough reflex rather than depress this reflex. Saline instillation is associated with negative physiological outcomes and is not recommended as part of the suctioning procedure; it does not loosen secretions, which is a common misperception.

A patients status worsens and needs mechanical ventilation. The pulmonologist wants the patient to receive 10 breaths/min from the ventilator but wants to encourage the patient to breathe spontaneously in between the mechanical breaths at his own tidal volume. This mode of ventilation is called: a. assist/control ventilation b. controlled ventilation c. intermittent mandatory ventilation d. positive end-expiratory pressure

ANS: C The intermittent mandatory ventilation mode allows the patient to breathe spontaneously between breaths. The patient will receive a preset tidal volume at a preset rate. Any additional breaths that he initiates will be at his spontaneous tidal volume, which will likely be lower than the ventilator breaths.

A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min. He receives a dose of morphine sulfate, and his respirations decrease to 4 breaths/min. Which acid-base disturbance will likely occur? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: C The morphine caused respiratory depression. As a result, the frequency and depth of respiration is compromised, which can lead to respiratory acidosis.

The nurse documents the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? a. Give the scheduled IV antibiotic. b. Give the PRN acetaminophen (Tylenol). c. Obtain oxygen saturation using pulse oximetry. d. Notify the health care provider of the patient's vital signs.

ANS: C The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing.

The nurse notes thick, white respiratory secretions for a patient who is receiving mechanical ventilation. Which intervention will be most effective in resolving this problem? a. Suction the patient every hour. b. Reposition the patient every 2 hours. c. Add additional water to the patient's enteral feedings. d. Instill 5 mL of sterile saline into the endotracheal tube (ET) before suctioning.

ANS: CBecause the patient's secretions are thick, better hydration is indicated.

The physician orders the following mechanical ventilation settings for a patient who weighs 75 kg. The patients spontaneous respiratory rate is 22 breaths/min. What arterial blood gas abnormality may occur if the patient continues to be tachypneic at these ventilator settings? Settings: Tidal volume: 600 mL (8 mL per kg) FiO2: 0.5 Respiratory rate: 14 breaths/min Mode assist/control Positive end-expiratory pressure: 10 cm H2O a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: D Assist/control ventilation may result in respiratory alkalosis, especially when the patient is breathing at a high rate. Each time the patient initiates a spontaneous breathin this case 22 times per minutethe ventilator will deliver 600 mL of volume.

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which action will the nurse anticipate taking next? . a. Increase the tidal volume and respiratory rate. b.. b. Increase the fraction of inspired oxygen (FIO 2 ). c. Perform endotracheal suctioning more frequently. d. Lower the positive end-expiratory pressure (PEEP).

ANS: D Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased.

In assessing a patient, the nurse understands that an early sign of hypoxemia is: a. clubbing of nail beds b. cyanosis c. hypotension d. restlessness

ANS: D Central nervous system signs, such as restlessness, are early indications of low oxygen levels. Clubbing is a sign of chronic hypoxemia. Cyanosis is a late sign of hypoxemia. Tachycardia and increased blood pressure, not hypotension, may be seen early in hypoxemia.

The nurse is caring for a patient whose ventilator settings include 15 cm H2O of positive end-expiratory pressure (PEEP). The nurse understands that although beneficial, PEEP may result in: a. fluid overload secondary to decreased venous return. b. high cardiac index secondary to more efficient ventricular function. c. hypoxemia secondary to prolonged positive pressure at expiration. d. low cardiac output secondary to increased intrathoracic pressure

ANS: D Positive end-expiratory pressure, especially at higher levels, can result in a decreased cardiac output and index secondary to increased intrathoracic pressure, which impedes venous return. Fluid overload is not an expected finding. The cardiac index would likely decrease, not increase, along with cardiac output. PEEP is used to treat hypoxemia; it does not cause it.

Pulse oximetry measures: a. arterial blood gases. b. hemoglobin values. c. oxygen consumption. d. oxygen saturation.

ANS: D Pulse oximetry measures oxygen saturation in the peripheral tissues. It does not measure arterial blood gases, but it does estimate the PaO2 that is obtained via a blood gas analysis. It does not measure hemoglobin levels or oxygen consumption.

The nurse is caring for a mechanically ventilated patient and notes the high pressure alarm sounding. The nurse cannot quickly identify the cause of the alarm and notes the patients oxygen saturation is decreasing and heart rate and respiratory rate are increasing. The nurses priority action is to: a. ask the respiratory therapist to get a new ventilator. b. call the rapid response team to assess the patient. c. continue to find the cause of the alarm and fix it. d. manually ventilate the patient while calling for a respiratory therapist.

ANS: D The nurse must quickly assess the patient and determine possible causes of the alarm. If the cause is not assessed within seconds, the nurse must manually ventilate the patient and secure assistance in troubleshooting the problem.

The nurse is caring for a 78-year-old patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider? a. Scattered crackles bilaterally in the posterior lung bases. b. Persistent cough that is productive of blood-tinged sputum. c. Temperature of 101.5° F (38.6° C) after 2 days of IV antibiotic therapy. d. Decreased oxygen saturation to 90% with 100% O 2 by non-rebreather mask.

ANS: D The patient's low SpO 2 despite receiving a high fraction of inspired oxygen (FIO 2 ) indicates the possibility of acute respiratory distress syndrome (ARDS).

After receiving change-of-shift report on a medical unit, which patient should the nurse assess first? a. A patient with cystic fibrosis who has thick, green-colored sputum b. A patient with pneumonia who has crackles bilaterally in the lung bases c. A patient with emphysema who has an oxygen saturation of 90% to 92% d. A patient with septicemia who has intercostal and suprasternal retractions

ANS: D This patient's history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation.

To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action by the nurse is to a. auscultate for the presence of bilateral breath sounds .b. obtain a portable chest radiograph to check tube placement. c. observe the chest for symmetrical movement with ventilation. d. use an end-tidal CO2 monitor to check for placement in the trachea.

ANS: DEnd-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.

If you are taking a patient off of mechanical ventilation what would make you stop?

Hemoglobin is at 8/ or dysrythmia Two questions similar asked. One will be hemoglobin and one will be dysrhythmia.

First line measure to prevent atelectasis?

Incentive spirometry

SIMV

Its synchronized with you--intermittent--only works when you don't! If you don't it will give you a mandatory ventilation. Type of weaning mode to get you have the ventilator

PC/IRV--- PRESSURE CONTROLLED/ INVERSE-RATIO VENTILATION

KNOW: that its a neuromuscular agent and patient must have an order for sedatives.

If respiratory rate goes up into the 30's, what could this indicate?

May need suctioning

With someone who has had some sort of facial trauma what ventilation support are you not going to give them?

Noninvasive PPV- BiPAP or CPAP

One about FiO2 100% and which is a bad sign

Sat dropping to 92%

What causes ARDS (select all)

Sepsis and aspiration

When you are suctioning someone and you see that they have a dysrhythmia what do you do first?

Stop immediately and put 100% oxygen on them

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires immediate action by the nurse?

There is no sedation medication ordered

When is CPAP used?

To wean off from ventilator

When you put ET (endotracheal tube) in someone for the first time what is the first thing you do?

You check the end tidal volume

You have a patient on a mechanical ventilator and you notice there CO2 is very low, what do you do?

You decrease the respiration rate

What do you do if your patient has a high PIP?

You need to suction them. Could be a fluid obstruction.

Doctor places a chest tube in a patient. What should the drainage system show you in a patient who has pneumothorax?

You should see air bubbles. NOT fluid.