Egan's Chapter 19 - Analysis and Monitoring of Gas Exchange and Chapter 28 - Pulmonary Vascular Disease
Calcium Channel Blockers
-High-dose calcium channel blockers -work to relax blood vessel walls. This encourages more blood flow. -Amlodipine and nifedipine
Types of PH
...
27. You are asked to calibrate an O2 analyzer. Which of the following gases would you use for this procedure?
1. 100% oxygen 3. 21% oxygen (room air)
62. Which of the following are true about a blood gas analyzer's waste fluids?
1. A strong disinfectant should be added to waste fluid containers. 2. Waste fluids should be handled as if they were blood samples. 3. Waste fluids should be treated as potentially infectious.
1/2 Which of the following risk factors are associated with an increase in the incidence of pulmonary embolism?
1. Advanced age 2. Immobilization 3. Multiple injuries from trauma
22. After obtaining an arterial blood sample, what should you do?
1. Apply pressure to the puncture site until bleeding stops. 2. Place the sample in a transport container with ice slush. 4. Mix the sample by rolling and inverting the syringe.
12. Precautions and/or possible complications of arterial puncture include which of the following?
1. Arteriospasm 2. Embolization 3. Infection 4. Hemorrhage
5. Which of the following conditions predispose a patient to venous thromboembolic disease?
1. Carcinoma 3. Trauma 4. Thrombocytosis
10. Which of the following conditions contribute to the development of hypoxemia in a patient with pulmonary emboli?
1. Cardiogenic shock 3. Intrapulmonary shunt 4. Mismatch
86. To avoid thermal injury with transcutaneous blood gas monitor sensors, what should you do?
1. Carefully monitor the sensor temperature. 3. Regularly rotate the sensor site.
74. While analyzing a blood gas control sample, you notice a trending of several PCO2 values above the 2 SD range over the last six control samples run. What corrective action would you consider at this time?
1. Check the function of the PCO2 electrode. 3. Repair or replace any failed components.
41. Which of the following physical examination findings are found in patients with primary pulmonary hypertension?
1. Cyanosis 2. Diastolic heart murmur 4. Loud second heart sound (P2)
Which of the following changes would occur if an arterial blood sample of a patient breathing room air were exposed to a large air bubble?
1. Decreased PCO2 3. Increased PO2
38. Which of the following can help avoid the problem of arterial blood sample contamination with air? 1. Discarding frothy samples
1. Discarding frothy samples 2. Fully expelling any bubbles 4. Capping syringe quickly
34. To avoid the dilution effects caused by too much sodium heparin during ABG sampling of an adult, what should you do?
1. Ensure a sample volume greater than 2 ml. 2. Use dry heparin instead. 3. Fill the needle dead space only.
38. What drugs are classified as a prostanoid?
1. Epoprostenol 2. Iloprost 3. Treprostinil
11. Which of the following are reasons for finding an alternative site for arterial puncture?
1. Failed Allen test 2. History of peripheral vascular disease 4. Presence of a surgical shunt
8. Which of the following sites are used for arterial blood sampling by percutaneous needle puncture?
1. Femoral 2. Radial 3. Brachial
17. Which of the following Centers for Disease Control and Prevention (CDC) barrier precautions would you use when obtaining an arterial blood gas (ABG) through percutaneous puncture?
1. Gloves 2. Protective eyewear
16. Which of the following are the main components of Virchow's triad?
1. Hypercoagulable states 2. Vessel wall abnormalities 4. Venous stasis
94. You are monitoring a nurse acquiring a capillary blood sample from an infant. The nurse immediately punctures the infant's heel with a lancet and then squeezes the puncture site to increase the flow of blood. What mistakes has the nurse made while obtaining the capillary blood sample?
1. Inadequate warming of the capillary bed 2. Squeezing of the puncture site
56. Possible complications of capillary blood gas sampling include which of the following?
1. Infection 2. Hematoma 3. Hemorrhage
1. Which of the following are true about invasive versus noninvasive monitoring?
1. Invasive procedures require insertion of a device into the body. 3. Physiologic monitoring can be either invasive or noninvasive. 4. Invasive procedures provide more accurate data but carry greater risks.
9. Why is the radial artery the preferred site for arterial blood sampling?
1. It is near the surface and easy to palpate and stabilize. 2. The ulnar artery normally provides good collateral circulation. 3. The radial artery is not near any large veins
30. Which of the following indicates venous admixture during arterial puncture?
1. Need to use syringe suction. 3. Small sample volumes.
20. What chart information should be checked before performing artery puncture?
1. Patient's primary diagnosis and history 2. Presence of bleeding disorders or blood-borne infections 3. Anticoagulant or thrombolytic drug prescriptions 4. Respiratory care orders (e.g., O2 therapy)
48. A physician requests that you obtain and set up an arterial line system for invasive monitoring of blood pressure. Which of the following equipment would you gather?
1. Pressurized intravenous bag 2. Continuous flush device 3. Arterial catheter
32. Most pre-analytical ABG errors can be avoided by ensuring that the sample is which of the following?
1. Properly anticoagulated. 2. Obtained anaerobically. 3. Analyzed within 15 to 30 min.
83. Before attaching a transcutaneous blood gas monitor sensor to a patient, what should you do?
1. Provide a specified warm-up time and set the probe temperature. 2. Check the membrane and prepare a sensor with an adhesive ring and gel. 3. Prepare the monitoring site (remove excess hair and clean the skin).
25. You return to a patient's room 20 min after drawing an ABG. Which of the following should you check at this time?
1. Puncture site for hematoma 2. Adequacy of distal circulation
69. When inspecting an internal quality-control plot for a blood gas analyzer, you notice several data points sporadically appearing outside the 2 standard deviation (SD) range. This represents what type of analytic error? 1. Random error
1. Random error 3. Imprecision
72. When analyzing a blood gas control sample, you notice that the result falls outside the 2 SD range. How could you verify that this was a random error (error of imprecision)?
1. Repeat the analysis on a different analyzer. 3. Rerun the control sample a second time.
10. Clinical indications for arterial blood analysis include which of the following?
1. Sudden, unexplained dyspnea 2. Cardiopulmonary resuscitation 3. Changes in ventilator settings
50. A mixed venous blood sample obtained from a pulmonary artery catheter sample has a PO2 of 85 mm Hg and a hemoglobin saturation of 95%. Which of the following is likely?
1. The pulmonary artery catheter balloon was not deflated. 3. The blood sample was withdrawn too quickly.
90. Indications for pulse oximetry include which of the following?
1. To assess changes in HbO2 during certain procedures 3. To comply with external regulations or recommendations 4. To monitor the adequacy of HbO2 saturation
79. Transcutaneous blood gas monitoring is indicated when what need exists?
1. To continuously analyze gas exchange in infants or children 2. To quantify the real-time responses to bedside interventions 3. To continuously monitor for hyperoxia in newborn infants
15. Purposes of a needle-capping device include which of the following?
1. To isolate the sample from air exposure 2. To help prevent needlestick injuries
57. Before a sample of capillary blood is taken, what should you do to the site?
1. Warmed to 42° C for 10 min. 2. Squeezed lightly until blanched.
55. Capillary puncture should be performed at or through what location?
2. Areas with new signs of infection 3. The heal of neonates
18. Which of the following findings on a chest radiograph are consistent with pulmonary embolism
2. Elevation of the diaphragm 3. Enlargement of the heart shadow 4. Pleural effusion
17. Which of the following physical examination findings are consistent with the diagnosis of pulmonary embolism?
2. Inspiratory crackles on auscultation 3. Loud P2 4. Tachypnea
95. Which of the following guidelines should you adhere to when performing pulse oximetry?
2. Make sure that the sensors are the correct size and are properly applied. 3. Avoid using pulse oximetry to monitor hyperoxia in neonates. 4. Whenever possible, validate the initial SpO2 against the actual SaO2.
58. A blood gas analyzer measures which of the following?
2. PCO2 3. PO2 4. pH
13. Which of the following should be monitored during the sampling of arterial blood?
2. Presence of pulsatile blood return 3. Presence of air bubbles or clots in sample 4. Appearance of puncture site
59. Components of a laboratory blood gas analyzer include which of the following?
2. Reagent containers 3. Calibrating gas tanks 4. Waste container
43. What ECG findings are typically seen in patients with idiopathic pulmonary artery hypertension?
2. Right-axis deviation 3. Right ventricular hypertrophy
1/2 Approximately what percentage of patients who die from pulmonary embolism are not suspected before death?
70%
98. What is the most common source of error and false alarms with pulse oximetry?
ANS: B Patient motion artifact probably is the most common source of error and false alarms.
PH Due to left heart disease
Causes include systolic/diastolic dysfunction and valvular disease such as mitral stenosis -Pulmonary venous obstruction
Most common medication for PH
Epoprostenol (Flolan or Veletri), Ventavis
(T/F) The presence of previous chronic obstructive pulmonary disease (COPD) reduces the diagnostic usefulness of scans in acute pulmonary embolism
False The presence of previous chronic obstructive pulmonary disease (COPD) reduces the diagnostic usefulness of scans in acute pulmonary embolism.
3. How does the Clark polarographic O2 electrode function?
It uses O2 to produce a reduction-oxidation reaction.
Side effects of vasodilators
Jaw pain, leg cramps, nausea, diarrhea, and headache.
Vasodilators to know?
Prostaglandin I2 or PGI2 -Via I.V. = vasodilator of a ALL vascular beds -Via aerosol = selectively dilates pulmonary vascular bed
What is pulmonary hypertension?
Pulmonary arterial pressure rises to a level that is too high for a given cardiac output. Often self-perpetuating
T/F 2. Most hospitalized patients who are immobile need prophylaxis for venous thromboembolism.
True: Most hospitalized patients who are immobile need prophylaxis for venous thromboembolism.
Pulmonary arterial hypertension is characterized by?
Vascular remodeling and cellular proliferation that leads to narrowing and obstruction of small pulmonary arteries.
47. What is the 5-year survival rate for patients with untreated idiopathic pulmonary artery hypertension (IPAH)?
a. 33%
23. Why is the D-dimer test not routinely performed on hospital inpatients suspected of having pulmonary emboli?
a. A high D-dimer only suggests the presence of comorbidities.
54. What is the most important factor contributing to the onset of pulmonary hypertension in the patient with COPD?
a. Alveolar hypoxia
36. Pulmonary artery hypertension (PAH) is not typically associated with which of the following conditions?
a. Amyotrophic lateral sclerosis
14. Which of the following patient parameters does not need to be assessed as part of arterial blood sampling?
a. Blood pressure
33. What drug would be the treatment of choice for pulmonary emboli?
a. Heparin
11. What is the main hemodynamic consequence of pulmonary emboli?
a. Increased pulmonary vascular resistance
37. What is the initial event in the pathogenesis of idiopathic pulmonary artery hypertension (IPAH)?
a. Insult to the pulmonary endothelium
6. What percentage of patients with pulmonary embolism have pulmonary infarction as a complication?
a. Less than 10%
24. How does impedance plethysmography determine the presence or absence of deep vein thrombosis?
a. Notes resistance to electrical current associated with blood flow.
48. Unless there are contraindications, what treatment is given universally to all patients with idiopathic pulmonary artery hypertension (IPAH)?
a. Oral anticoagulation
7. You are asked to provide continuous monitoring of the FiO2 provided by a humidified O2 delivery system using a galvanic cell analyzer. Where would you install the analyzer's sensor?
a. Proximal to the heated humidifier
46. What is the most common pulmonary function abnormality found in patients with idiopathic pulmonary artery hypertension (IPAH)?
a. Reduced diffusing capacity of the lungs (DLCO)
1/2 Where in the lung is pulmonary embolism most frequently observed?
a. Right lower lobe
29. When performing a percutaneous needle puncture of the radial artery, you get only a small spurt of blood. Which of the following is the best action at this time?
a. Slowly withdraw the needle until a pulsatile flow fills the syringe.
8. Death from massive pulmonary embolism is the result of:
a. cardiovascular collapse.
35. A practitioner forgets to ice an ABG sample and leaves it at room temperature for 45 min. Which of the following parameters can you predict will increase in this sample during that period?
a. 1 only PCO2
19. Approximately what percentage of patients with pulmonary embolism have a normal ECG?
a. 10% to 15% The ECG is frequently abnormal in patients with pulmonary embolism (87% of the time)
70. The total instrument error (inaccuracy) of a blood gas analyzer equals which of the following?
a. Bias + imprecision
91. What is the greatest hazard of pulse oximetry?
a. False results leading to incorrect decisions
54. What is the best site for capillary puncture in an infant?
a. Lateral aspect of the heel's plantar surface
85. You must immediately begin monitoring the oxygenation status of an infant admitted to the emergency department in severe respiratory distress. Which of the following approaches would you select?
a. Pulse oximetry (SpO2)
To measure PCO2, blood gas analyzers use what electrode?
a. Severinghaus
76. The advantage that point-of-care testing has over traditional laboratory testing is that point-of-care testing:
a. reduces turnaround time.
16. After obtaining an arterial blood sample through percutaneous puncture using a syringe that does not have a capping safety device, what should you do?
b. "Scoop" the needle cap up with one hand, then plug the syringe.
Under ideal conditions, electrochemical oxygen (O2) analyzers have approximately what degree of accuracy?
b. 2%
13. What is the critical value for mean pulmonary arterial pressure, above which the right ventricle fails and death may ensue?
b. 40 mm Hg
22. A D-dimer test is performed in a patient in whom a pulmonary embolism is suspected. The value comes back at 379 mg/L. What does this suggest?
b. Almost completely rules out pulmonary embolism.
14. What treatment is initiated in patients suspected of pulmonary emboli, and continued until pulmonary emboli is ruled out?
b. Anticoagulation
21. Which of the following describes the correct procedure for an Allen test?
b. Compress both the radial and ulnar arteries, and then release the ulnar artery.
9. Which of the following pathophysiologic changes in the lung is not typically associated with pulmonary embolism?
b. Decreased ciliary mobility
4. Where do most pulmonary emboli originate?
b. Deep veins of the legs
15. What is the most frequent symptom found in patients with confirmed pulmonary emboli?
b. Dyspnea
40. What are the two most common symptoms associated with primary pulmonary hypertension?
b. Dyspnea and angina
52. What type of drug is Bosentan?
b. Endothelin antagonists
51. What IV infusion has been found to improve exercise capacity, hemodynamic variables, and survival in patients with severe IPAH?
b. Epoprostenol
31. What is the fastest way to achieve therapeutic levels of heparin in the treatment of acute deep venous thrombi?
b. Follow established nomogram
30. Which of the following medications would be standard therapy to treat acute deep venous thrombi?
b. Heparin
31. If patient pain or anxiety occurs during arterial puncture, which of the following will probably occur?
b. Hyperventilation
21. Which of the following arterial blood gas findings is seen in most patients with pulmonary embolism?
b. Hypoxemia
28. A patient suffering from traumatic brain injury in the ICU has a PtO2 (tissue oxygen) value of 10 to 15 mm Hg, what does this indicate?
b. Ischemic brain damage
4. Which of the following is false about the galvanic fuel cell O2 analyzer?
b. It requires an external power source (alternating current line or batteries).
49. Why is the use of oxygen to maintain oxygen saturations greater than 90% particularly important in the management of idiopathic pulmonary artery hypertension?
b. Low alveolar oxygen causes vasoconstriction.
7. Most pulmonary infarctions associated with thromboembolic obstruction occur in which part of the lung?
b. Lung bases
27. Which of the diagnostic tests for pulmonary embolism is likely the safest and the most consistently accurate?
b. MRI
53. In what type of IPAH patient is lung transplantation indicated?
b. Patients not responding to vasodilators with significant cardiac dysfunction
24. Before performing puncture or cannulation of the radial artery, what should you do?
b. Perform the Allen test to ensure collateral circulation.
68. Statistically derived limits for internal quality control of blood gas samples are usually set at what appropriate level?
b. 2 standard deviations from the mean
84. What is the appropriate interval for changing the site for a transcutaneous blood gas monitor sensor?
b. 2 to 6 hr
92. Pulse oximeter readings are generally unreliable at saturations below what level?
b. 80%
46. Before connecting the sample syringe to an adult's arterial line stopcock, what would you do?
b. Aspirate 1 to 2 ml of fluid or blood using a waste syringe.
64. How is the accuracy of a blood gas analyzer determined?
b. Comparing the analyzer's measurements to known values
71. Which of the following factors contributing to imprecision (random) errors during blood gas analysis?
b. Contaminated buffers
33. Which of the following would you expect to occur if too much heparin was used in gathering an ABG sample from a patient breathing room air?
b. Decrease in PCO2
36. When analyzing an ABG sample from a patient with acute respiratory distress syndrome and refractory hypoxemia, you notice a PaO2 of 141 mm Hg and a PaCO2 of 14 mm Hg. Which of the following analytic errors should you suspect?
b. Exposure of the blood sample to air
80. Which of the following is not a common tissue injury to be on guard for at the site of transcutaneous blood gas electrode placement?
b. Hematomas
63. What is the process of testing a new blood gas analyzer to confirm a manufacturer's claims?
b. Performance validation
73. Which of the following factors does not contributing to bias (systematic) errors during blood gas analysis?
b. Statistical probability
77. Which of the following is false about transcutaneous blood gas monitoring?
b. Transcutaneous blood gas monitoring is most accurate when used with older adults.
89. Which of the following will result in falsely low HbO2 readings with a pulse oximeter?
b. Vascular dyes
All of the following are true about capillary blood gas sampling except:
b. a capillary sample PO2 provides a fairly close estimate of actual arterial oxygenation.
47. After obtaining an arterial blood sample from an arterial line, you would do all of the following except:
b. aspirate at least 5 ml of fluid or blood (dead space or waste).
60. Which blood gas analyzer electrode uses a separate reference electrode?
b. pH
43. A PaO2 below what value would be considered moderate hypoxemia?
c 55 mm Hg
12. What percentage of the pulmonary vascular bed must be occluded by emboli before pulmonary hypertension occurs?
c. 50%
96. For continuous monitoring of adults and children, you should set a pulse oximeter's low alarm in what range?
c. 88% to 92%
26. Which of the following is true regarding the use of CT with contrast for diagnosing pulmonary embolism (PE)?
c. Can only identify the medium to large PE
50. Why are calcium-channel blockers not used in all patients with idiopathic pulmonary artery hypertension?
c. Only a small percentage of IPAH patients respond.
55. What therapy has been proven to improve survival in patients with COPD and pulmonary hypertension?
c. Oxygen
25. In patients suspected of having pulmonary emboli in which noninvasive studies do not give a definite diagnosis, what diagnostic procedure is the test of choice?
c. Pulmonary angiography
5. While checking a polarographic (Clark) electrode, you determine that the device fails to read 100% when exposed to pure O2. Which of the following actions would be the proper first step?
c. Replace the analyzer's batteries.
34. A patient with pulmonary emboli has severe hypoxemia, acute right-sided heart failure, and shock. What treatment should be given at this time?
c. Streptokinase
44. What is a normal level for CaO2?
c. 18 to 20 ml/100 ml
93. Under ideal conditions, pulse oximeter readings patients usually fall in what range of those obtained with invasive hemoximetry?
c. 3% to 5%
53. When is capillary blood gas sampling indicated?
c. ABG analysis is needed, but arterial access is not available.
67. How often should blood gas calibration verification by control media take place?
c. At least two levels of control media should be analyzed every 8 hr.
97. Which of the following can cause false high readings when using a pulse oximeter?
c. Carboxyhemoglobin
87. While monitoring an active infant through a transcutaneous blood gas system, you notice a rapid rise in PtcO2 from 63 to 145 mm Hg. At that same time, the (PtcCO2) drops from 35 to 7 mm Hg. What is the most appropriate action in this case?
c. Check the sensor for air leaks or dislodgment.
82. To validate patient readings obtained from a transcutaneous blood gas monitor, what should you do?
c. Compare the monitor's readings to those obtained with a concurrent ABG sample.
40. Because of an extremely low PO2, you suspect that an arterial blood sample taken from a patient's brachial artery might have been contaminated with venous blood. Which of the following might help to confirm your suspicion?
c. Cross-check the sample with an SpO2 reading.
Through which pulmonary artery catheter port would you obtain a mixed venous blood sample?
c. Distal (catheter tip) port
65. What media are used to calibrate a blood gas analyzer's gas electrodes?
c. Precision mixtures of O2 and CO2
75. What is the quality control procedure of analysis and reporting on externally provided control media with unknown values?
c. Proficiency testing
42. An outpatient scheduled for an arterial blood sample enters the pulmonary lab 20 min late and out of breath, having run up four flights of stairs. What should you do?
c. Wait 5 min before taking the sample.
39. On average, how long does the diagnosis of idiopathic pulmonary artery hypertension (IPAH) follow the onset of the disease?
d. 2 years
23. How long should you wait before drawing an ABG on a chronic obstructive pulmonary disease (COPD) patient whose FiO2 has just been changed?
d. 20 to 30 min
18. What size needle would you recommend to obtain an ABG sample through percutaneous puncture of an infant?
d. 25 gauge
During calibration of a Clark polarographic O2 analyzer, you cannot get the sensor to read 100% when exposed to 100% O2, even after adjusting its calibration control. The unit has new batteries. Which of the following actions would be correct?
d. Change the sensor or electrode.
35. At rest, what level does the mean pulmonary artery pressure need to reach before it is considered pulmonary hypertension?
d. Greater than 25 mm Hg
29. Which of the following medications should be used in the hospital for prophylactic deep venous thrombosis therapy?
d. Heparin
28. Prophylactic deep venous thrombosis (DVT) therapy would be most important in which of the following patient groups?
d. Patients with hip replacements
26. When performing an Allen test on the left hand of a patient, you notice that the palm, fingers, and thumb remain blanched for more than 15 sec after pressure on the ulnar artery is released. What should you do?
d. Perform the Allen test on the right hand.
42. Which of the following radiographic findings is not typical for patients with primary pulmonary hypertension?
d. Pleural effusion
44. What ECG finding is most often associated with right-sided heart failure and pulmonary hypertension?
d. Right-axis deviation
20. What are the two most common findings on the electrocardiogram (ECG) in the patient with pulmonary embolism?
d. Tachycardia and depressed ST segment
32. What is the most commonly used oral anticoagulant?
d. Warfarin
19. Required equipment and supplies for percutaneous arterial blood sampling of an adult include all of the following except:
d. local anesthetic.
41. You determine that a blood gas sample that requires analysis has been sitting in ice slush for 90 min. What should you do?
d. Discard the sample and notify the appropriate clinician.
66. To ensure that the output of a blood gas analyzer is both accurate and linear across the range of measured values, a calibration procedure must measure what?
d. Parameters with known input values at two points
78. In which of the following patients would transcutaneous blood gas monitoring most likely provide inaccurate or erroneous results?
d. Patient in hypovolemic shock
45. To assess gas exchange at the tissues, you would obtain a blood sample from which of the following?
d. Pulmonary artery (balloon-inflated)
99. During continuous monitoring of an active 5-year-old patient with a finger pulse oximetry probe, you obtain frequent and repeated false low HbO2 alarms (<90%). Which of the following would be the best action to take in this situation?
d. Relocate the sensor to a more stable location.
39. Analysis of an arterial blood sample taken from a healthy athlete reveals a pH of 7.36, a PCO2 of 45 mm Hg, and a PO2 of 43 mm Hg. Which of the following analytic errors should you suspect?
d. Sample admixture with venous blood
88. Oximetry is the measurement of blood hemoglobin saturations using what technique?
d. Spectrophotometry
45. What is the most important noninvasive diagnostic test for evaluation of a patient with idiopathic pulmonary artery hypertension (IPAH)?
d. V/Q scan The most important noninvasive test for IPAH is the lung scan, which helps to rule out the possibility of chronic thromboembolic pulmonary hypertension (a mimic of IPAH).
81. The transcutaneous blood gas electrode should not be placed on the:
d. thigh.
Surgical intervention PH
•Atrial septostomy -open-heart surgery -an opening between the left and right chambers to relieve the pressure on the right. •Transplantation
Diuretics
•Help eliminate excess fluid -This reduces the amount of work of the heart. -Limit fluid buildup in the lungs.
Idiopathic PAH (formerly primary pulmonary hypertension, PPH)
•Heritable •Drug/toxin induced •Associated with: -Connective tissue diseases -HIV infection -Portal hypertension -Systemic to pulmonary shunts -Schistosomiasis -Chronic hemolytic anemia