Clinical Concepts III Test 2
A ______will be more specific in the diagnosis of pulmonary contusion than a chest x-ray
A chest CT
adult ARDS treatment:
ABGs, Suctioning, Ventilator with 02 therapy at increasingly higher Fi02 until refractory hypoxemia sets in
Loss of pulmonary function, either acute or chronic, that results in hypoxemia or hypercarbia.
ACUTE RESPIRATORY FAILURE
assessment findings in ARF:
AMS, CONFUSION, MORNING HEADACHE, CYANOSIS OF THE ORAL MUCOSA, LIPS, AND NAIL BEDS, USE OF ACCESSORY MUSCLES, PURSED-LIP BREATHING, NASAL FLARING, ASHEN SKIN, RAPID BREATHING, COLD, CLAMMY SKIN, ASYMMETRICAL CHEST MOVEMENT, DIMINISHED OR ABSENT BREATH SOUNDS, WHEEZES (IN ASTHMA), RHONCHI (IN BRONCHITIS), CRACKLES (IN PULMONARY EDEMA), MYOCLONUS, & SEIZURES (WITH SEVERE HYPOXEMIA)
On initial assessment, the nurse notes the fluid in the suction control chamber is at the 16cm level. The best action by the nurse is:
Add sterile water to bring the level up to 20cm level
A client is admitted to the emergency department with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first?
Administer 100% oxygen by mask.
The nurse is caring for a client following a wedge resection. While the nurse is assessing the client's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem?
Air Leak
Which is a potential complication of a low pressure in the endotracheal tube cuff?
Aspiration Pneumonia
A nonverbal client has just finished undergoing a bronchoscopy procedure and writes that he want to eat lunch now. Which intervention is necessary for the nurse to complete at this time?
Assess for a cough reflex.
A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?
Assessing the client's respiratory status, orientation, and skin color
A set tidal volume and respiratory rate. The patient is able to over breathe the vent. When the patient over breathes the vent it senses it and delivers a fixed amount of tidal volume. If the patient is too weak to take spontaneous breaths, the vent will deliver a set amount of respirations.
Assist Control Ventilation
A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?
Blood-tinged sputum
high pitched & loud, heard over trachea and larynx
Bronchial lung sounds
moderate in pitch and amplitude, heard over major bronchi
Bronchovesicular lung sounds
pediatric ARDS treatment:
Chest Physiotherapy (CPT), "sniffing position", Suctioning...2 person team limit to max 5 sec!!!, TPN (NPO) during periods of increased dyspnea
The nurse is caring for a client in the ICU who is receiving mechanical ventilation. Which nursing measure is implemented in an effort to reduce the client's risk of developing ventilator-associated pneumonia (VAP)?
Cleaning the client's mouth with chlorhexidine daily
Delivers a set tidal volume and respiratory rate. The ventilator does ALL the work. Patient needs to be sedated or paralyzed.
Controlled Mandatory Ventilation
VENTILATION BUT NO PERFUSION
DEAD SPACE
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?
Deflating the cuff before removing the tube
A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan?
Encourage the client's communication attempts by allowing him time to select or write words.
the term used to describe normal respiratory rate, depth and pattern
Eupneic
A client on mechanical ventilation is receiving pancuronium I.V. as needed. Which assessment finding indicates that the client needs another pancuronium dose?
Fighting the ventilator
A patient is about to have their chest tube removed by the physician. As the nurse is assisting with the removal, which of the following actions will the nurse perform? select all that apply.
Gather all supplies needed which will include a petroleum gauze dressing per physician preference, place the patient in semi-fowler's, have the patient take a deep breath, exhale, and bear down during the removal of the tube, pre-medicate prior to removal as ordered by the physician.
The BEST position for the client who has a chest tube in the apex of the right lung is:
HOB elevated to semi Fowler's position
WITH PACO2 GREATER THAN 50 MMHG
HYPERCAPNIC (TYPE II)
THE MOST COMMON, WITH PAO2 LESS THAN 60 MMHG WITH NORMAL OR LOW PACO2
HYPOXEMIC (TYPE I)
Delivers a set tidal volume at a set rate that is set at the lowest setting to support and maintain appropriate ABGs. The set tidal volume will be delivered regardless of the patient's efforts or timing of the patient's respiratory cycle.
Intermittent Mandatory Ventilation
A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back. The client is unconscious and not breathing. What technique should the nurse use to open the client's airway?
Jaw-thrust
While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. What should the nurse do next?
Mark the area with a skin pencil at the outer periphery of the crackling.
Following thoracic surgery, what would be included in the care plan for a client at risk for impaired gas exchange? Select all that apply.
Monitor vital signs frequently, Reinforce preoperative breathing exercises, & Elevate head of bed 30 to 40 degrees as tolerated.
A nurse is assisting an anesthetist during the intubation of a client. The anesthetist visualizes the vocal cords with the laryngoscope and says to the nurse, "This is an easy one. Why don't you give it a try?" indicating that the nurse should insert the endotracheal tube. What would be the most appropriate response by the nurse?
"This procedure is not within my scope of practice."
formula for pack years
#pks/day X number of years smoked
corticosteroids:
(a) fluticasone (Flovent) (b) dexamethasone (Decadron) (c) prednisone (d)methylprednisolone (SoluMedrol)
bronchodilators beta-agonists:
1. albuterol (Proventil,Ventolin 2. metaproterenol (Alupent) 3. salmeterol (Serevent)
Generally, the nurse should notifiy the physician if the drainage from a chest tube is more than:
100 mL/hr of red bloody fluid
The amount of drainage from a mediastinal chest tube is expected to be:
100ml. the first 2-3 hr, with a total of 500-800ml. in 24 hr
4 phases of symptoms ARDS in adults:
1: dyspnea/tachycardia, 2: early pulmonary edema, 3. hypoxemia (2-10 days), 4. irreversible fibrosis "Late ARDS"
The fluid level in the suction control chamber regulates the amount of negative pressure (suction) throughout the system. Although the fluid level is determined by the physician, this fluid level is usually filled to the:
20 cm level
the 5 Ps of ARDS:
Perfusion, Positioning, Protective Lung Ventilation, Protocol Weaning, Preventing Complications
Identifying ARDS>>
Persistent hypoxemia with oxygen at 100%, Decreased pulmonary compliance, Dyspnea (No history CHF), Non-cardiac associated bilateral pulmonary edema, Dense pulmonary infiltrates on CXR (white-out), Presence of an acute condition (trauma or sepsis)
The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition?
Pneumothorax
The clinical finding of pink, frothy sputum may be an indication of which condition?
Pulmonary edema
PERFUSION BUT NO VENTILATION
SHUNTING
When assisting the client to a chair, the chest drainage unit is accidently cracked when the bed is placed in the low position. The BEST intervention by the nurse is:
Set up a new chest drainage unit and clamp the chest tube while attaching to the new unit
You are a clinic nurse caring for a client who is 2 months post laryngectomy. What is a nursing diagnosis pertaining to this client?
Social Isolation related to change in body image, tracheal stoma, and change in or loss of speech
A client experienced a pneumothorax after the placement of a central venous pressure line. Which of the following assessments supports a diagnosis of pneumothorax?
Sudden, sharp pain on the affected side.
A set tidal volume is delivered at a set rate in synchronization of the patient's on initiated spontaneous breath. If the patient under breathes the vent- it will initiate a breath. If the patient over-breathes the vent it will not supplement the breaths with a set amount of volume.
Synchronized Intermittent Mandatory Ventilation
The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample?
Take deep breaths and cough forcefully.
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?
Tension pneumothorax
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation?
The chest tube system is functioning properly.
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?
The patient is hypoxic from suctioning.
When the nurse is making rounds at night, a client complains that he can not go to sleep with the constant loud bubbling noise of his chest tube set up. The unit is attached to wall suction. The best action by the nurse is:
Turn the wall suction down until gentle bubbling is heard in the suction control chamber
is a diagnostic test that shows areas of pulmonary dead spacing and shunting.
V/Q Scan (Lung scan)
low and soft, heard over peripheral lung fields as air flows through smaller bronchioles and alveoli
Vesicular lung sounds
A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has:
a possible hematologic problem.
nonspecific pulmonary response to a variety of pulmonary and nonpulmonary insults to the lung; characterized by interstitial infiltrates, alveolar hemorrhage, atelectasis, decreased compliance, and refractory hypoxemia
acute respiratory distress syndrome (ARDS)
The water seal chamber of chest drainage units, such as Pleur-Evac or Argyle's Aqua-Seal, allows:
air to escape and not re-enter the pleural space
A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. This change occurred because:
airways are so swollen that no air can get through
If a chest tube is inserted to drain or remove air from the lung, the chest tube would be placed:
anteriorly at the lung apex
If fluid is expected to be drained from around the heart, such as following open heart surgery, the chest tube placement would be:
anteriorly in the lower mediastinum
Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?
baseline ABGs
A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should:
check the tubing to ensure that the client is not lying on it or kinking it.
Prior to removing a chest tube, the physician will confirm lung re-expansion by:
chest x-ray
The nurse would suspect an air leak in the system when:
continuous bubbling occurs in the water seal chamber
After suctioning a client's tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent:
depriving the client of sufficient oxygen supply
A client is admitted to the emergency department with crushing chest injuries sustained in a car accident. Which sign indicates a possible pneumothorax?
diminished or absent breath sounds on the affected side
The nurse understands that a client with acute respiratory distress related to asthma may experience?
dyspnea, wheezing, and polycythemia.
(PaCO2) to greater than 50 mm Hg with a PH of less than 7.35
hypercapnia
Respiratory alkalosis can occur as a result of
hyperventilation
PaO2 to less than 50 mm Hg with a PH of less than 7.35
hypoxemia
anticholinergics:
ipratropium bromide (Atrovent) triotropium (Spiriva)
Which mental status change may occur when a client with pneumonia is first experiencing hypoxia?
irritability
The first chamber of most chest drainage units:
is a fluid collection chamber for chest drainage
To accurately record the volume of chest drainage at the end of each shift, the nurse would:
mark fluid level with date and time at beginning and end of each shift, then record shift volume in chart
Prolonged nasal gastric suctioning may result in
metabolic alkalosis
If a chest tube is inserted to drain fluid from the lung, the chest tube would be placed:
mid-axillary line at 5th intercostal space
When the suction control chamber is filled with sterile water to the 20 cm. level, how much pressure is created throughout the system?
minus 20 cm of water pressure
The lungs and the thorax create a:
negative pressure system
A chest tube has been inserted after an attempted subclavian line insertion led to a pneumothorax. Twenty-four hours later, the nurse suspects the lung has reinflated when:
no change has occurred in the fluid collection chamber in the last 4 hr
A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely? Select all that apply
o Level of consciousness o Vital signs o Arterial blood gases
The occupational health nurse is assessing new employees at a company. What would be important to assess in employees with a potential occupational respiratory exposure to a toxin? Select all that apply.
o Type of respiratory protection used o Time frame of exposure o Breath sounds o Intensity of exposure
The best rationale for not using safety pins to secure the chest drain tubing to the bed is
pins may puncture the tubing causing an air leak
While helping a client with a chest tube reposition in bed, the chest tube becomes dislodged. What is your immediate nursing intervention?
place a sterile dressing over the site and tape it on three sides and notify the doctor.
The nurse understands which patient position best improves oxygenation with ARDS?
prone
The client should be instructed not to smoke, use bronchodilators, small-dose metered inhalers or aerosol therapy for six hours prior to which test?
pulmonary function test
When transporting a client with a chest tube by stretcher or gurney, the chest drain unit should be
secured below chest level
The client is postoperative for a total laryngectomy and has recovered from anesthesia. The client's respirations are 32 breaths/minute, blood pressure is 102/58, and pulse rate is 104 beats/minute. Pulse oximetry is 90%. The client is receiving humidified oxygen. To aid in the client's respiratory status, the nurse places the client in which of the following positions
semi-fowlers
adult vs peds ARDS treatment medication:
steroids, antibiotics, & NSAID, vs. artificial surfactant
symptoms of oxygen toxicity:
substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates on x-ray
The third chamber of most chest drainage units is for:
suction control
The nurse is teaching the client about the use of a MDI. The nurse instructs the client as follows:
take a slow, deep inhalation from the device, activate the MDI once, and it is not necessary to hold your breath after using
what happens when there is a physiological one-way valve within the lung. Air enters into the pleural spaces during expiration but cannot leave?
tension pneumothorax
A patient is receiving positive pressure ventilation and has a chest tube. When assessing the water seal chamber, what do you expect to find?
the water in the chamber will decrease during inspiration and increase with expiration.
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?
total laryngectomy
It is essential to secure the connection between the catheter (chest tube) and the tubing of the chest drainage unit to prevent accidental separation and/or air leaks. One acceptable method for doing this is:
use adhesive tape and place in a spiral fashion at the connection sites
The client's chest tube dressing has fallen off. In redressing the chest tube insertion site, the nurse would:
use sterile vasoline (petroleum) gauze and 4x4s with tape occluding the entire dressing
Which type of ventilator has a preset volume of air to be delivered with each inspiration?
volume-controlled
In most chest drainage units, the second chamber serves as:
water seal chamber
When the nurse suspects an air leak in the system, location of the leak can be assessed by:
with 2 padded clamps, place one clamp nearest the chest insertion site, then place 2nd clamp distal to 1st. Continue alternating clamps down the tubing until bubbling stops. Air leak is between proximal and distal clamps.
S&S of ARDS in child:
•Tachypnea = 80-120-Labored with retractions •Cyanosis if 02 sat 80-85% (unless anemic) •AcidosisMetabolic or respiratory LATE = exhaustion! Bradypnea until resp arrest...Followed by cardiac arrest...
