Ch 31 Disorders of Ventilation and Gas Exchange

A diagnosis of tension pneumothorax would be suspected in which physical assessment finding?

Correct Answer: Deviated trachea Rationale:Physical assessment findings of a deviated trachea and neck vein distention would indicate a tension pneumothorax. Asymmetry of the chest during inspiration would suggest a spontaneous pneumothorax. Both would need to be confirmed by radiology. The remaining options are nonspecific and occur in many conditions.

Infants and small children have asthma and need to be medicated, just as adults do. There are special systems manufactured for the delivery of inhaled medications to children. At what age is it recommended that children may begin using a metered-dose inhaler (MDI) with a spacer?

a. 3 to 5 years

Many pharmaceutical agents may cause pulmonary damage. The nurse knows the following cardiac medication has been associated with toxic effects in the lungs:

a. Amiodarone

What etiologic determinants are important in the development of the pneumoconioses? (Select all that apply.)

a. Chemical nature of the dust particle b. Size of dust particle e. Ability of particle to incite lung destruction

Chronic obstructive pulmonary disease (COPD) is a combination of disease processes. What disease processes have been identified as being part of COPD?

b. Chronic obstructive bronchitis and emphysema

Cystic fibrosis (CF) is an autosomal recessive disorder involving the secretion of fluids in specific exocrine glands. The genetic defect in CF inclines a person to chronic respiratory infections from a small group of organisms. Which organisms create chronic infection in a child with cystic fibrosis?

d. Pseudomonas aeruginosa and Staphylococcus aureus

Which diagnosis puts a client at risk for developing an immunologic form of interstitial lung disease?

Correct Answer: Rheumatoid arthritis Rationale:Rheumatoid arthritis is a risk factor for the development of immunologic lung disease. Cancer is a risk for therapeutic agent-related interstitial lung disease when certain chemo drugs are used as treatment. Asbestosis is a risk for occupational /environmental inhalant interstitial lung disease. Septicemia increases the risk of acute respiratory distress syndrome.

A client with pulmonary arterial hypertension asks the health care provider, "Why are you giving me sildenafil? It is my lungs that are my problem, not erectile dysfunction." Which statement by the health care provider is the most appropriate response?

Correct Response: "Sildenafil causes vasodilation, which will help treat the high pressure in your lung vessels." Rationale:Sildenafil acts in a manner similar to nitric oxide to produce vasodilation, and is another treatment for pulmonary arterial hypertension. It is not being prescribed for erectile dysfunction in this population of clients. Health care providers should not assume a client is experiencing erectile dysfunction, unless the client has verbalized this directly to them.

When CO2 levels in the blood rise, a state of hypercapnia occurs in the body. What factors contribute to hypercapnia? Select all that apply.

Correct Response: - Abnormalities in respiratory function - Disturbance in gas exchange function - Changes in neural control of respiration - Alteration in carbon dioxide production Rationale:Hypercapnia refers to an increase in carbon dioxide levels. In the clinical setting, four factors contribute to hypercapnia: alterations in carbon dioxide production, disturbance in the gas exchange function of the lungs, abnormalities in respiratory function of the chest wall and respiratory muscles, and changes in neural control of respiration. A decrease in carbon dioxide production does not cause hypercapnia.

An adult client reports to the emergency department with shortness of breath. Which additional clinical finding(s) leads the health care provider to suspect the client has a moderate-sized pulmonary embolism? Select all that apply.

Correct Response: - Blood-tinged sputum - Apprehensive, especially when asked to lie flat Rationale:Pulmonary embolism manifestations depend on the size and location of the obstruction. Clients with moderate-sized emboli often present with breathlessness accompanied by pleuritic pain, apprehension, slight fever, and cough productive blood-tinged sputum. Sputum that is green-colored is abnormal and usually due to pneumonia. A fever higher than 103°F (39.4°C) is considered more than a "slight" fever. Pleural friction rub is an abnormal lung sound, which is caused by inflammation of the pleural layer of the lungs rubbing together. Pleural friction rub is heard on inspiration and expiration and sounds like a low-pitch harsh/grating noise.

A 25-year-old client with cystic fibrosis presents to the clinic in obvious respiratory distress. Following physical exam, the health care provider suspects bronchiectasis based on which assessment findings? Select all that apply.

Correct Response: - Blood-tinged sputum - Wheezing throughout the lung fields - Copious amounts of foul-smelling purulent sputum Rationale:Bronchiectasis is usually manifested by a chronic productive cough, often with several 100 mL of foul-smelling, purulent sputum a day. Hemoptysis is common. Dyspnea and wheezing occur in about 75% of clients. Crushing substernal chest pain and next vein distention are more suggestive of pulmonary emboli or myocardial infarction with right-sided heart failure.

Which clients are at greatest risk of developing an occupational lung disease? Select all that apply.

Correct Response: - Bricklayer - Coal miner - Slate industry worker - Flour miller Rationale:Pneumoconioses are the occupational lung diseases caused by inhalation of inorganic dust and particles. This category includes silicosis that affects hard rock miners, foundry workers, sandblasters, pottery makers, and slate workers. Other types of pneumoconiosis affect coal miners, asbestos miners, talc miners and people who inhale talc. Hypersensitivity pneumonitis is the result of exposure to inhaled organic compounds and is found in farm workers pigeon breeders, millers, and sugar cane workers.

What manifestations would the nurse expect to find when assessing a client with a right pleural effusion? Select all that apply.

Correct Response: - Diminished right breath sounds - Dyspnea on exertion - Hypoxemia Rationale:Pleural effusion may vary according to the cause. Classic signs include diminished breath sounds over the affected area, and dyspnea as seen with increased effort or rate of breathing. Hypoxemia may occur due to reduced surface area for gas exchange. When there is infection, the signs and symptoms can include fever and elevated white blood cell (WBC) count. Pleuritic chest pain is present with inflammation that is commonly caused by infection.

Which clinical manifestations should the nurse expect to find during physical assessment of a client diagnosed with bronchiectasis? Select all that apply:

Correct Response: - Low hemoglobin levels - Recurrent chest infections - Production of purulent sputum Rationale:Chest infections, copious production of purulent sputum, and anemia are all associated with bronchiectasis. A barrel chest is more commonly evident with emphysema and recent surgery is not a noted factor.

A client with a history of heart failure and COPD (caused by 60 pack/year smoking) presents to the clinic reporting difficulty breathing. Auscultation of breath sounds reveal absent/diminished breath sounds in the right lower lobe. Which other manifestations lead the health care provider to suspect the client may have developed atelectasis? Select all that apply.

Correct Response: - Respiratory rate—32; pulse rate—122 beats/min. - Using accessory muscles to help him breathe. - "Having a hard time catching my breath." Rationale:Atelectasis is caused most commonly by airway obstruction rather than a vascular obstruction. The clinical manifestations of atelectasis include tachypnea (respiratory rate of 32), tachycardia (pulse rate of 122), dyspnea (hard time catching breath), cyanosis, signs of hypoxemia, diminished chest expansion, absence of breath sounds, and intercostal retractions (use of accessory muscles). Both chest expansion and breath sounds are decreased on the affected side. There may be intercostal retraction (pulling in of the intercostal spaces) over the involved area during inspiration. Urine production is not related to atelectasis. Copious green sputum is associated with infection.

Which statements concerning hypoxemia are true? Select all that apply.

Correct Response: -Normally, serum lactate levels are between 0.5-1 mmol/L (4.5-9.0 mg/dL) -The condition depends on the body's ability to adapt to lowered oxygen levels. - The brain is vulnerable to hypoxia. -When hypoxemia occurs, metabolic acidosis is a possible outcome. Rationale:Hypoxemia produces its effects through tissue hypoxia and the compensatory mechanisms that the body uses to adapt to the lowered oxygen level. Body tissues vary considerably in their vulnerability to hypoxia. Tissues with the greatest need are the brain, lungs, and heart. If the PO2 of the tissues falls below a critical level, aerobic metabolism ceases and anaerobic metabolism takes over, with formation and release of lactic acid, resulting in increased serum lactate levels and metabolic acidosis. The normal range of serum lactate levels is 1 - 0.5 mmol/L (9.0 - 4.5 mg/dL) in non-acutely ill people.

A client has developed chronic hypoxia and has developed pulmonary hypertension (HTN). The nurse recognizes that the most likely cause of pulmonary hypertension would be:

Correct Response: Constriction of the pulmonary vessels in response to hypoxemia Rationale:Pulmonary HTN occurs as a result of chronic hypoxia. In response to hypoxia, the pulmonary vessels constrict. The pulmonary vessels differ from the systemic circulation vessels, which dilate in response to hypoxia and hypercapnia. Smooth muscle hypertrophy and proliferation of the vessel intima occur in pulmonary HTN.

The nurse needs to assess the oxygen status of a client who is suddenly experiencing shortness of breath. The most appropriate noninvasive measurement technique would be:

Correct Response: Pulse oximetry Rationale:Noninvasive measurements of arterial O2 saturation of hemoglobin can be obtained using an instrument called the pulse oximeter. Sensors that can be placed on the finger, toe, ear, or forehead are available. Although pulse oximetry is not as accurate as arterial blood gas measurements, it provides the means for noninvasive and continuous monitoring of O2 saturation, which is a useful indicator of respiratory and circulatory status.

A child is brought to the emergency department with an asthma attack. Assessment revealed the use of accessory muscles, a weak cough, audible wheezing sound, moist skin, and tachycardia. Which drug will the nurse anticipate administering first?

Correct Response: Short-acting beta 2-adrenergic agonists such as albuterol (SABA) Rationale:The quick-relief medications such as SABA (e.g., albuterol, levalbuterol, pirbuterol) relax bronchial smooth muscle and provide prompt relief of symptoms, usually within 30 minutes. They are administered by inhalation (i.e., metered-dose inhaler or nebulizer), and their recommended use is in alleviating acute attacks of asthma

The nurse is caring for four clients. Select the client at risk for the development of a pulmonary embolism.

Correct Response:A 62-year-old male who is postoperative for repair of a fractured femur Rationale:A client with surgery to the lower extremities is at higher risk for the development of deep vein thrombosis that could lead to a pulmonary embolism. There is increased risk for pulmonary embolism among users of oral contraceptives, particularly in women who smoke, but not with the use of IUD.

Which physiologic dysfunction is the most common cause of hypercapnia?

Correct Response:Alterations in respiratory rate Correct Response:Alterations in respiratory rate Rationale:Hypercapnia refers to an increase in carbon dioxide levels. In the clinical setting, four factors contribute to hypercapnia: alterations in carbon dioxide production, disturbance in the gas exchange function of the lungs, abnormalities in function of the chest wall and respiratory muscles, and changes in neural control of respiration. Alterations in respiratory function or the respiratory rate decrease minute volume, which is the most common cause of hypercapnia.

Which diagnosis will present the highest risk for hypercapnic/hypoxemic respiratory failure?

Correct Response:Drug overdose Rationale:A client diagnosed with drug overdose has the greatest risk of developing hypercapnic/hypoxemic respiratory failure. Severe pneumonia and atelectasis presents a risk for simple hypoxemic respiratory failure, whereas impaired diffusion is a possible outcome for pulmonary edema.

Which factors increase the risk that a client will develop chronic obstructive pulmonary disease (COPD)? Select all that apply.

Correct Response:History of tobacco use, History of asthma Rationale:Smoking is the primary cause of chronic obstructive pulmonary disease (COPD). Additional causes are a hereditary deficiency of alpha1-antitrypsin and asthma. Obesity may contribute to respiratory distress, but is not a cause of COPD. Myocardial infarction (MI) and diabetes mellitus are contributing factors to heart disease, not COPD.

A 40-year-old male presents to the emergency department reporting chest pain and shortness of breath. The health care provider suspects a pulmonary embolism and orders several diagnostic tests. Select the test that would require further follow-up.

Correct Response:Positive D-dimer Rationale:The D-dimer test is a good indicator that a clotting disorder has occurred. A positive result indicates a need to be further investigated for possible pulmonary embolism given the client's symptoms. The elevated CPK-MB and EKG may indicate cardiac abnormalities.

The nurse develops a plan to prevent atelectasis in a postsurgical client. Which intervention will be effective?

Correct Response:Supervision of hourly deep-breathing exercises Rationale:Ambulation, deep-breathing exercises and changing body positions help to prevent postoperative atelectasis. An abdominal binder may restrict full diaphragmatic movement. Calf-pumping exercises and elastic stockings are designed to prevent blood clots, but do not assist in lung expansion. IV antibiotics prevent and treat infection, but do not aid lung expansion.

There can be many reasons for a patient to fall, a respiratory disease is usually involved. present with hypoxemia. For a client's PO2 to Often, patients have involvement from more than one mechanism. Which of the following will result in hypoxemia? (Select all that apply.)

a. Decreased oxygen in air d. Disease in respiratory system f. Dysfunction of neurologic system

Acute respiratory failure is commonly signaled by varying degrees of hypoxemia and hypercapnia. Respiratory acidosis develops manifested by what?

a. Increased cerebral blood flow

Pleuritis, an inflammatory process of the pleura, is common in infectious processes that spread to the pleura. Which are the drugs of choice for treating pleural pain?

a. Indomethacin

A pulmonary embolism occurs when there is an obstruction in the pulmonary artery blood flow. Classic signs and symptoms of a pulmonary embolism include dyspnea, chest pain, and increased respiratory rate. What is a classic sign of pulmonary infarction?

b. Pleuritic pain

Pulmonary hypertension is usually caused by long-term exposure to hypoxemia. When pulmonary vessels are exposed to hypoxemia, what is their response?

b. Pulmonary vessels constrict

Acute lung injury/acute respiratory distress syndrome (ALI/ARDS) is distinguishable between the two by the extent of hypoxemia involved. What is the clinical presentation of ARDS? (Select all that apply.)

b. Rapid onset d. Increase in respiratory rate e. Hypoxemia refractory to treatment

Atelectasis is the term used to designate an incomplete expansion of a portion of the lung. Depending on the size of the collapsed area and the type of atelectasis occurring, you may see a shift of the mediastinum and trachea. Which way does the mediastinum and trachea shift in compression atelectasis?

c. Away from the affected lung

Bronchiectasis is considered a secondary COPD, and, with the advent of antibiotics. it is not a common disease entity. In the past, bronchiectasis often followed specific diseases. Which disease did it not follow?

c. Chickenpox

Talc lung can occur from injected or inhaled talc powder that has been mixed with heroin, methamphetamine, or codeine as a filler. What are people with talc lung very susceptible to?

c. Interstitial lung disease

The management of cor pulmonale is directed at the underlying lung disease and heart failure. Why is low-flow oxygen therapy a part of the management of cor pulmonale?

c. Reduces pulmonary hypertension and polycythemia associated with chronic lung disease