Sole Ch 9
The nurse is caring for a patient who is mechanically ventilated. As part of the nursing care, the nurse understands that a) communication with intubated patients is often difficult b) controlled ventilation is the preferred mode for most patients c) patients with chronic obstructive pulmonary disease wean easily from mechanical ventilation d) wrist restraints are applied to all patients to avoid self-extubation
A Communication difficulties are common because of the artificial airway.
Which of the following devices is best suited to deliver 65% oxygen to a patient who is spontaneously breathing? a) Face mask with non-rebreathing reservoir b) Low-flow nasal cannula c) Simple mask d) Venturi mask
A Face masks with reservoirs (partial rebreathing and non-rebreathing reservoir masks) provide oxygen concentration of 60% or higher. The addition of the reservoir increases the amount of oxygen available to the patient during inspiration and allows for the delivery of concentrations of 35% to 60% (partial rebreather) or 60% to 80% (nonrebreather), depending on the flowmeter setting, the fit of the mask, and the patient's respiratory pattern.
A patient's ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from 0.6 to 0.7, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patient's 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
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.
A patient's 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 patient's 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
A The endotracheal tube can become dislodged during repositioning and is likely to be in the right mainstem bronchus. It is important to reassess breath sounds after the retaping procedure.
The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (Select all that apply.) a) Coughing or attempting to talk b) Disconnection from the ventilator c) Kinks in the ventilator tubing d) Need for suctioning e) Spontaneous breathing
A, C, D Coughing, kinks, and mucus in the airway can cause the inspiratory pressure to increase; ventilator disconnects result in low-volume alarms.
The nurse is assisting with endotracheal intubation of the patient and recognizes that the procedure will be done in what order: a) assess balloon on endotracheal tube for symmetry and leaks b) assess lung fields for bilateral expansion c) inflate balloon of endotracheal tube d) insert endotracheal tube with laryngoscope and blade e) suction oropharynx
A, E, D, C, B Intubation is done systematically by the physician, therapist, or anesthetist. Equipment is gathered and assessed (e.g., balloon/cuff on endotracheal tube). The patient is hyperoxygenated and secretions are suctioned from the oropharynx to visualize the vocal cords. The tube is inserted, and the balloon is inflated once the tube is in place. The position of the tube is assessed after intubation through auscultation of breath sounds, carbon dioxide testing, and chest x-ray.
The provider orders the following mechanical ventilation settings for a patient who weighs 75 kg. The patient's spontaneous respiratory rate is 22 breaths/min. Which 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
D Assist/control ventilation may result in respiratory alkalosis, especially when the patient is breathing at a higher rate that the ventilator rate. Each time the patient initiates a spontaneous breath—in this case 22 times per minute—the ventilator will deliver 600mL of volume.
Current guidelines recommend the oral route for endotracheal intubation. The rationale for this recommendation is that nasotracheal intubation is associated with a greater risk for a) basilar skull fracture b) cervical hyperextension c) impaired ability to "mouth" words d) sinusitis and infection
D Nasotracheal intubation is associated with an increased risk for sinusitis, which may contribute to ventilator-associated infection.
One of the early signs of hypoxemia on the nervous system is a) cyanosis b) restlessness c) agitation d) tachypnea
B Decreased oxygenation to the nervous system may result in restlessness and agitation — early signs of hypoxemia.
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
B Oxygen saturation value reflects the saturation of the hemoglobin.
A PaCO2 of 48 mm Hg is associated with a) hyperventilation b) hypoventilation c) increased absorption of O2 d) increased excretion of HCO3
B PaCO2 rises in patients with hypoventilation.
A 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
B The PaO2 of 65 mm Hg is lower than normal range (80 to 100 mm Hg), indicating hypoxemia. The high PaCO2 indicates respiratory acidosis. The elevated bicarbonate indicates metabolic alkalosis. Because the pH is normal, the underlying acid-base alteration is compensated. Given the patient's 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 which potential cause of this difficult weaning? 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
B The low hemoglobin level will decrease oxygen-carrying capacity and may make weaning difficult.
A patient is admitted to the cardiac surgical intensive care unit after cardiac surgery with the following arterial blood gas (ABG) levels. What action by the nurse is best? pH: 7.4 PaCO2: 40 mm Hg Bicarbonate: 24 mEq/L PaO2: 95 mm Hg O2 saturation: 97% Respirations: 20 breaths/min a) Call the provider to request rapid intubation b) Document the findings and continue to monitor c) Request that another set of ABGs be drawn and run d) Correlate the patient's O2 saturation with the ABGs
B These are normal values. All parameters are within normal limits. No action other than documentation and continued observation is warranted.
The nurse is assisting with endotracheal intubation and understands that correct placement of the endotracheal tube in the trachea would be identified by which of the following? (Select all that apply.) a) Auscultation of air over the epigastrium b) Equal bilateral breath sounds upon auscultation c) Position above the carina verified by chest x-ray d) Positive detection of carbon dioxide (CO2) through CO2 detector devices e) Fogging of the ETT
B, C, D The position of the tube is assessed after intubation through auscultation of breath sounds, carbon dioxide testing, and chest x-ray. Auscultation of air over the epigastrium indicates placement in the esophagus rather than the trachea. Fogging of the ET tube does not indicate correct placement.
Select all of the factors that may predispose the patient to respiratory acidosis. (Select all that apply.) a) Anxiety and fear b) CNS depression c) DKA d) NG suctioning e) Overdose of sedatives
B, E Central nervous system depression and drug overdose may result in hypoventilation and cause respiratory acidosis.
The primary mode of action of neuromuscular blocking agents is a) analgesia b) anticonvulsant c) paralysis d) sedation
C Neuromuscular blocking agents cause respiratory muscle paralysis. They do not have sedative, analgesic, or anticonvulsant effects.
The nurse notes that the patient's arterial blood gas levels indicate hypoxemia. The patient is not intubated and has a respiratory rate of 22 breaths/min. The nurse's first intervention to relieve hypoxemia is to: a) call the provider for an emergency intubation procedure b) obtain an order for bilevel positive airway pressure (BiPAP) c) notify the provider of values and obtain a prescription for oxygen d) suction secretions from the oropharynx
C Oxygen is administered to treat or prevent hypoxemia. Oxygen should be considered a first-line treatment in cases of hypoxemia.
A mode of pressure-targeted ventilation that provides positive pressure to decrease the workload of spontaneous breathing through the endotracheal tube is a) CPAP b) PEEP c) pressure support ventilation d) T-piece adapter
C Pressure support (PS) is a mode of ventilation in which the patient's spontaneous respiratory activity is augmented by the delivery of a preset amount of inspiratory positive pressure.
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 ICP b) depresses the cough reflex c) is done as indicated by patient assessment d) is more effective if preceded by saline instillation
C Suctioning is performed as indicated by patient assessment. Suctioning is associated with increases in intracranial pressure; therefore, it is important to hyperoxygenate the patient before 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.
When assessing the patient for hypoxemia, the nurse recognizes that an early sign of the effect of hypoxemia on the cardiovascular system is a) heart block b) restlessness c) tachycardia d) tachypnea
C Tachycardia can occur as a compensatory mechanism to increase cardiac output and oxygenation.
The nurse is assessing the exhaled tidal volume (EVT) in a mechanically ventilated patient. The rationale for this assessment is to a) assess for tension pneumothorax b) assess the level of positive end-expiratory pressure c) compare the tidal volume delivered with the tidal volume prescribed d) determine the patient's work of breathing
C The EVT is assessed to determine if the patient is receiving the tidal volume that is prescribed.
A patient has coronary artery bypass graft surgery and is transported to the surgical intensive care unit at noon and is placed on mechanical ventilation. Interpret the initial arterial blood gas levels pH: 7.31 PaCO2: 48 mm Hg Bicarbonate: 22 mEq/L PaO2: 115 mm Hg O2 saturation: 99% a) Normal arterial blood gas levels with a high oxygen level b) Partly compensated respiratory acidosis; normal oxygen c) Uncompensated metabolic acidosis with high oxygen levels d) Uncompensated respiratory acidosis; hyperoxygenated
C The high PaO2 level reflects hyperoxygenation; the PaCO2 and pH levels show respiratory acidosis. The respiratory acidosis is uncompensated as indicated by a pH of 7.31 (acidosis) and a normal bicarbonate level. No metabolic compensation has occurred.
A patient's 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 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
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 spontaneous 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
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 is caring for a mechanically ventilated patient and is charting outside the patient's room when the ventilator alarm sounds. What is the priority order for the nurse to complete these actions: a) check quickly for possible causes of the alarm that can be fixed b) after troubleshooting, connect back to mechanical ventilator and reassess patient c) go to patient's bedside d) manually ventilate the patient while getting a respiratory therapist
C, A, D, B 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. Once the problem has been corrected, the patient must be reassessed.
The nurse is caring for a mechanically ventilated patient. The providers are considering performing a tracheostomy because the patient is having difficulty weaning from mechanical ventilation. Related to tracheostomy, the nurse understands which of the following? a) Patient outcomes are better if the tracheostomy is done within a week of intubation b) Percutaneous tracheostomy can be done safely at the bedside by the respiratory therapist c) Procedures performed in the operating room are associated with fewer complications d) The greatest risk after a percutaneous tracheostomy is accidental decannulation
D Optimal timing of tracheostomy is not yet known. Percutaneous procedures done at the bedside are not associated with any higher risks than those done in the operating room. Trained physicians safely perform percutaneous tracheostomies at the bedside. The greatest risk for percutaneous tracheostomy is accidental decannulation because the trachea is not surgically attached.
Positive end-expiratory pressure (PEEP) is a mode of ventilatory assistance that produces the following condition: a) Each time the patient initiates a breath, the ventilator delivers a full preset tidal volume b) For each spontaneous breath taken by the patient, the tidal volume is determined by the patient's ability to generate negative pressure c) The patient must have a respiratory drive, or no breaths will be delivered d) There is pressure remaining in the lungs at the end of expiration that is measured in cm H2O
D PEEP is the addition of positive pressure into the airways during expiration. PEEP is measured in centimeters of water.
The nurse is caring for a patient whose ventilator settings include 15 cm H2O of positive end-expiratory pressure (PEEP). What complication does the nurse assess the patient for? 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
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.
Pulse oximetry measures a) ABGs b) Hgb values c) oxygen consumption d) oxgen saturation
D Pulse oximetry measures oxygen saturation in the peripheral tissues.
A patient presents to the emergency department demonstrating agitation and complaining of numbness and tingling in his fingers. His arterial blood gas levels reveal the following: pH 7.51, PaCO2 25, HCO3 25. The nurse interprets these blood gas values as: a) compensated metabolic alkalosis b) normal values c) uncompensated respiratory acidosis d) uncompensated respiratory alkalosis
D The low PaCO2 and high pH values show respiratory alkalosis. The bicarbonate level is normal.
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. What adjustments may need to be made to the patient's ventilator settings? a) Add positive end-expiratory pressure (PEEP) b) Add pressure support c) Change to assist/control ventilation at a rate of 4 breaths/min d) Increase the synchronized intermittent mandatory ventilation respiratory rate
D The morphine caused respiratory depression. As a result, the frequency and depth of respiration is compromised, which can lead to respiratory acidosis. The respiratory rate on the mechanical ventilator needs to be increased
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 patient's oxygen saturation is decreasing and heart rate and respiratory rate are increasing. The nurse's 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
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 amount of effort needed to maintain a given level of ventilation is termed a) compliance b) resistance c) tidal volume d) work of breathing
D Work of breathing is the amount of effort needed to maintain a given level of ventilation.
