Gas Exchange - NCO

After surgery, a client is extubated in the postanesthesia care unit. Which clinical manifestations should the nurse expect if the client is experiencing acute respiratory distress? Select all that apply. 1 Confusion 2 Hypocapnia 3 Tachycardia 4 Constricted pupils 5 Slow respiratory rate

1 Confusion 3 Tachycardia Inadequate cerebral oxygenation produces restlessness and confusion. Tachycardia occurs as the body attempts to compensate for the lack of oxygen. A low carbon dioxide level in the blood (hypocapnia) occurs with hyperventilation, not hypoxia. The pupils dilate, not constrict, with hypoxia. An elevated respiratory rate (tachypnea), not a slow respiratory rate (bradypnea), occurs.

What is the minimum respiratory rate in a normal adolescent? Record your answer using a whole number. _____________________ breaths/minute

16 The minimum respiratory rate in a normal adolescent is 16 breaths/minute.

What would the student nurse claim is an acceptable respiratory rate range in a toddler of 2 years of age? 1 20 to 30 breaths/minute 2 25 to 32 breaths/minute 3 30 to 50 breaths/minute 4 35 to 40 breaths/minute

2 25 to 32 breaths/minute The acceptable respiratory rate range in a toddler is 25-32 breaths/minute. The acceptable range in a child is 20-30 breaths/minute. The respiratory rate in a 6-month-old infant is 30-50 breaths/minute; in newborns, it is 35-40 breaths/minute.

What would be the respiratory rate in two-year-old child? 1 20 2 30 3 40 4 50

2 30 The normal range for the respiratory rate in a two-year-old kid (toddler) is between 25 and 32 breaths per minute. Twenty breaths per minute is the normal respiratory rate in adolescents and adults. The normal respiratory rate in newborns is 40. The normal respiratory rate in infants is 50 breaths per minute.

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, what does the nurse expect to identify? 1 Hypertension 2 Tenacious sputum 3 Altered mental status 4 Slow rate of breathing

3 Altered mental status Altered mental status is secondary to cerebral hypoxia, which accompanies acute respiratory distress syndrome (ARDS); cognition and level of consciousness are reduced. Hypotension occurs because of hypoxia. The sputum is not tenacious, but it may be frothy if pulmonary edema is present. Breathing will be fast and shallow.

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? 1 Administer sedatives around the clock 2 Turn client every four hours 3 Increase ventilator settings as needed 4 Suction as needed

4 Suction as needed The nurse should observe the client's need for tracheal/oral/nasal suctioning every two hours and provide adequate suctioning as needed. The nurse should not administer sedatives around the clock, but administer sedatives as appropriate. The nurse should turn the client every two hours, not four hours. The nurse should not adjust vent settings as needed; however, the nurse should check ventilation settings at least once a shift.

A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs of respiratory acidosis? Select all that apply. 1 Headache 2 Irritability 3 Restlessness 4 Hypertension 5 Lightheadedness

1 Headache 2 Irritability 3 Restlessness Headache is a symptom of cerebral hypoxia associated with early respiratory acidosis [1] [2]. Irritability is a sign of cerebral hypoxia associated with early respiratory acidosis. Restlessness is a sign of cerebral hypoxia associated with early respiratory acidosis. Hypotension, not hypertension, is a key feature of acidosis. Lightheadedness is a symptom of respiratory alkalosis, not acidosis.

A nurse in the pediatric intensive care unit is assessing a 6-month-old infant with bronchiolitis. What physiologic responses to this lower respiratory tract infection does the nurse expect? Select all that apply. 1 Wheezing 2 Bradycardia 3 Sternal retractions 4 Nasal flaring 5 Prolonged expiratory phase

1 Wheezing 3 Sternal retractions 4 Nasal flaring 5 Prolonged expiratory phase Bronchiolitis in most infants is caused by respiratory syncytial virus. Wheezing occurs as the air passages narrow, resulting in the typical whistling sound. As breathing becomes more difficult, the infant must expend more energy and use accessory muscles of respiration to breathe. Nasal flaring is a predominant characteristic of bronchiolitis. The infectious and inflammatory changes narrow the bronchial passage, making it difficult for air to leave the lungs. As a result of increased respiratory effort and decreased oxygen exchange, tachycardia, not bradycardia, develops. Breath sounds are diminished because of edema of the bronchiolar mucosa and filling of the lumina with mucus and exudate.

A toddler who was admitted in acute respiratory distress is now resting quietly. The parents tell the nurse that they must leave. What should the nurse suggest that the parents do? 1 Try to "room in" to decrease the child's anxiety. 2 Plan to visit the child as frequently as possible. 3 Tell the child that they are leaving but will be back tomorrow. 4 Leave while the child is distracted to reduce the upset it may cause.

2 Plan to visit the child as frequently as possible. Because the parents have stated that they must leave, advising them to visit as often as possible takes into consideration the effect that separation will have on the toddler. Suggesting that the parents "room in," or stay in the room with the child, when they have already stated that they must leave may create a sense of guilt or feelings of inadequacy in the parents. Telling the parents to tell the child that they are leaving but will be back tomorrow is inappropriate because a 2-year-old does not understand the concept of time. Leaving when the child is distracted will jeopardize the child's sense of trust in the parents.

A client with a 10-year history of emphysema is admitted in acute respiratory distress. During assessment, what does the nurse expect to identify? 1 Chest pain on inspiration 2 Prolonged expiration with use of accessory muscles 3 Signs and symptoms of respiratory alkalosis 4 Decreased respiratory rate

2 Prolonged expiration with use of accessory muscles Accessory muscles are used during respiration because of the increased rigidity of the chest. Sudden pleuritic chest pain is associated with pulmonary embolism, not emphysema. Respiratory acidosis, not alkalosis, is associated with emphysema because of carbon dioxide retention. Clients with respiratory muscle fatigue breathe with rapid, shallow respirations.

A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? 1 Bradycardia 2 Restlessness 3 Constricted pupils 4 Clubbing of the fingers

2 Restlessness Inadequate oxygenation of the brain from acute respiratory distress may produce restlessness or behavioral changes. The pulse increases with cerebral hypoxia from acute respiratory distress. The pupils dilate with cerebral hypoxia. Clubbing of the fingers is the result of prolonged hypoxia.

The nurse performs a respiratory assessment and auscultates breath sounds that are high pitched, creaking, and accentuated on expiration. Which term best describes the findings? 1 Rhonchi 2 Wheezes 3 Pleural friction rub 4 Bronchovesicular

2 Wheezes Wheezes are one of the most common breath sounds assessed and auscultated in clients with asthma and chronic obstructive pulmonary disease (COPD). Wheezes are produced as air flows through narrowed passageways. Rhonchi are coarse, rattling sounds similar to snoring and are usually caused by secretions in the bronchial airways. A pleural friction rub is an abrasive sound made by two acutely inflamed serous surfaces rubbing together during the respiratory cycle. Bronchovesicular sounds are intermediate between bronchial (upper) and vesicular (lower) breath sounds; they are normal when heard between the first and second intercostal spaces anteriorly and posteriorly between scapulae.

George has eviscerated intestines. EMS personnel have already provided immediate related care. Which immediate intervention is indicated when a person has eviscerated intestines? The eviscerated intestines should be pushed back into the abdominal cavity with a gloved hand The eviscerated intestines should be covered with dry sterile gauze The eviscerated intestines should be covered with moist sterile gauze

The eviscerated intestines should be covered with moist sterile gauze Sterile saline-soaked gauze provides a moist protective barrier for exposed intestines. This moist application helps to prevent tissue damage or bowel necrosis that could result from dryness.

A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to the newborn nursery. What range of resting respiratory rate should the nurse anticipate? 1 20 to 40 breaths/min 2 30 to 60 breaths/min 3 60 to 80 breaths/min 4 70 to 90 breaths/min

2 30 to 60 breaths/min After respiration is established, the normal neonate respiratory rate ranges from 30 to 60 breaths/min with short periods of apnea. Twenty breaths per minute is bradypnea. A respiratory rate faster than 60 breaths/min is tachypnea.

What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply. 1 Crackles 2 Atelectasis 3 Hypoxemia 4 Severe dyspnea 5 Increased pulmonary wedge pressure

1 Crackles 2 Atelectasis 3 Hypoxemia 4 Severe dyspnea Crackles occur as fluid leaks into the alveolar interstitial space. The alveoli collapse from surfactant dysfunction and infiltrate from inflammation. Arterial hypoxemia that does not respond to supplemental oxygen is a characteristic sign of ARDS. Severe dyspnea can occur 12 to 48 hours after the initial onset of ARDS, which usually is an inflammatory trigger. Pulmonary wedge pressure is unaffected in ARDS; pulmonary wedge pressure is elevated in problems with cardiogenic origin.

A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client? 1 Encouraging a fluid intake of 3 L daily 2 Suctioning via the tracheostomy every hour 3 Applying an occlusive dressing over the surgical site 4 Using cotton balls to cleanse the stoma with peroxide

1 Encouraging a fluid intake of 3 L daily Increased fluids help to liquefy secretions, enabling the client to clear the respiratory tract by coughing. Suctioning frequently will irritate the mucosal lining of the respiratory tract, which can result in more secretions. An occlusive dressing will block air exchange; the tracheostomy is now the client's airway. The use of cotton balls around a tracheostomy introduces the risk of aspiration of one of the cotton fibers; gauze should be used.

Which of the following may occur as clinical signs of sepsis? 1 Fever 2 Hypotension 3 Increased heart rate 4 Bradypnea 5 Elevated blood glucose 6 Confusion 7 Thrombocytopenia

1 Fever 2 Hypotension 3 Increased heart rate 5 Elevated blood glucose 6 Confusion 7 Thrombocytopenia Fever occurs with infection and sepsis due to the effect of microbial toxins on the hypothalamus. The body's internal thermoregulatory center in the hypothalamus is reset to a higher level, requiring a higher internal temperature to be reached before heat-reducing mechanisms, such as diaphoresis, begin. Shaking chills, which often accompany fever, increase metabolic rate and are the body's effort to reach this higher temperature setting. In older persons, or persons who are immunocompromised, fever may not develop with infection. The possibility of sepsis should be considered if a patient at risk for sepsis becomes hypotensive. Septic shock is a distributive shock that results in hypotension. Hypotension is associated with increased vascular permeability, pooling of blood in the microcirculation (venous and capillary beds), decreased systemic vascular resistance, and hypoperfusion. With septic shock, cardiac output is normal or increased. This is in contrast to other forms of shock (cardiogenic shock and hypovolemic shock), in which cardiac output is decreased. With sepsis, heart rate increases as a systemic sympathetic response. The possibility of sepsis should be considered if George's heart rate increases to greater than 90 beats per minute. The unexpected onset of hyperglycemia is often an early indicator of sepsis. Early sepsis is often reversible. Septic shock is often fatal. Hypotension and subsequent hypoxia associated with severe sepsis or septic shock commonly cause confusion and restlessness. The possibility of septic shock should be considered if George becomes confused or restless. Thrombocytopenia (low platelet count) may occur with sepsis, especially if the causative agent is a gram-negative bacterium. Thrombocytopenia may be manifested as bleeding tendency or may cause major bleeding.

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? 1 Deflate the cuff on the endotracheal tube for a few minutes every one to two hours. 2 Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. 3 Adjust the temperature of fluid in the humidification chamber depending on the volume of gas delivered. 4 Regulate the positive end-expiratory pressure (PEEP) according to the rate and depth of the client's respirations.

2 Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. The high-pressure alarm signifies increased pressure in the tubing or the respiratory tract; obstruction usually is caused by excessive secretions. Cuff should be inflated; it does not need to be tested this often. Humidification should occur, but the temperature should not be routinely changed. Regulating the PEEP according to the rate and depth of the client's respirations is a dependent function of the nurse and cannot be implemented without a healthcare provider's prescription

Which respiratory infections should the nurse monitor the toddler-age client for based on structural differences during this stage of development? Select all that apply. 1 Bronchiolitis 2 Ear infection 3 Acute sinusitis 4 Laryngotracheobronchitis 5 Inflammation of the tonsils

2 Ear infection 3 Acute sinusitis 5 Inflammation of the tonsils The toddler-age client remains at risk for ear infection (otitis media), acute sinusitis, and inflammation of the tonsils or tonsillitis; therefore, the nurse should assess the toddler-age client for these infections due to the angle of the Eustachian tube in the ear. Bronchiolitis and laryngotracheobronchitis (croup) are more common during infancy.

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. Which clinical finding should the nurse expect when assessing this client? 1 Hypertension 2 Tenacious sputum 3 Altered mental status 4 Slowed rate of breathing

3 Altered mental status Altered mental status is secondary to cerebral hypoxia, which accompanies acute respiratory distress syndrome (ARDS); cognition and level of consciousness are reduced. Hypotension occurs because of cardiac hypoxia. The sputum is not tenacious, but it may be frothy if pulmonary edema is present. Breathing is fast and shallow.

A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? 1 An elevated pH, elevated PCO 2 2 A decreased pH, elevated PCO 2 3 An elevated pH, decreased PCO 2 4 A decreased pH, decreased PCO 2

3 An elevated pH, decreased PCO 2 In respiratory alkalosis the pH level is elevated because of loss of hydrogen ions; the PCO 2 level is low because carbon dioxide is lost through hyperventilation. An elevated pH, elevated PCO 2 is partially compensated metabolic alkalosis. A decreased pH, elevated PCO 2 is respiratory acidosis. A decreased pH, decreased PCO 2 is metabolic acidosis with some compensation.

A client's respiratory status deteriorates, and endotracheal intubation and positive pressure ventilation are instituted. What is the nurse's most immediate intervention at this time? 1 Prepare the client for emergency surgery. 2 Facilitate the client's verbal communication. 3 Assess the client's response to the interventions. 4 Maintain sterility of the ventilation system that is being used.

3 Assess the client's response to the interventions. If a client is not responding to interventions, the plan must be changed to support respiration. Preparing the client for emergency surgery is presumptive; there are insufficient data to conclude that surgery is necessary. Endotracheal intubation does not permit verbal communication. Maintaining sterility of the ventilation system that is being used is important, but it is not the priority.

The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which would be appropriate to include? 1 They are indicative of pleural rubbing. 2 They are signs of bronchial constriction. 3 Crackles are located in the smaller air passages. 4 Crackles are heard during respiratory expiration.

3 Crackles are located in the smaller air passages. Fine crackles (sometimes called rales) are the sounds of fluid bubbling within the smaller airways and alveoli, usually attributable to pulmonary edema. Pleural rubbing causes a sound with a grating quality heard over the anterolateral area of the chest; it is attributable to decreased pleural lubrication. Bronchial constriction causes rhonchi or wheezes. Crackles are heard during inspiration.

The arterial blood gases of a client with chronic obstructive pulmonary disease (COPD) deteriorate, and respiratory failure is impending. Which clinical indicator should the nurse assess first? 1 Cyanosis 2 Bradycardia 3 Mental confusion 4 Distended neck veins

3 Mental confusion Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).

A client is experiencing severe respiratory distress. Which response should the nurse expect the client to exhibit? 1 Tremors 2 Anasarca 3 Bradypnea 4 Tachycardia

Correct 4 Tachycardia The heart rate increases in an attempt to compensate for the lack of oxygen to body cells. Tremors are not associated with respiratory distress; tremors are associated with neurologic problems. Severe generalized edema (anasarca) is not associated with respiratory distress; anasarca is associated with renal failure. An increased respiratory rate (tachypnea), not a decreased respiratory rate (bradypnea), is associated with respiratory distress.

Air embolism is a potentially fatal complication associated with central lines. If air has entered a central line or a patient with a central line suddenly developed signs and symptoms of air embolism, which of the following would you correctly do first? Raise the head of the patient's bed Turn the patient on his left side Perform nasotracheal suctioning Have the patient cough

Turn the patient on his left side Correct If air has entered a central line, or air embolism from a central line is suspected, you should first insure that there is no airflow into the line. After this, the patient should immediately be placed in the Trendelenburg position on his left side. This position should cause any air in the right side of the heart to rise in the upper aspect of the right atrium or ventricle and therefore not pass into the pulmonary circulation, where perfusion and gas exchange would be impaired. In addition, the physician should be notified. Manual aspiration of air may be attempted by the physician, or air may need to be removed under fluoroscopy.