Respiratory Adaptive Quiz

The nurse, while assessing a patient who just underwent a central venous access catheter insertion, notices cyanosis and absence of breath sounds on the same side. What complication should the nurse suspect?

Cyanosis and absence of breath sounds on one side are findings in patients with a tension pneumothorax. Patients with a flail chest may experience paradoxical chest movements. Patients with a hemothorax may have massive blood loss. Patients with pulmonary contusions would have decreased breath sounds or crackles and wheezes.

A patient on mechanical ventilation has a sudden onset of respiratory distress. The nurse auscultates absent breath sounds on the right side and observes a shift of the trachea to the left. The patient is cyanotic and has distended neck veins. Which priority action by the nurse is correct?

Notify the Rapid Response Team

A patient has a Pao2 of 55 mm Hg, an arterial oxygen saturation of 85%, and a hemoglobin of 9.2 g/dL. The patient also has normal lung function and clear breath sounds but has exertional dyspnea. What does the nurse suspect the patient is experiencing?

Oxygenation failure Patients with normal lung function who are hypoxic most likely have ventilatory failure. This patient is anemic, which results in decreased oxygen-carrying capability due to a deficiency in red blood cells and hemoglobin. Patients with pulmonary embolism have changes in lung function. Respiratory distress occurs when there is increased work of breathing, but without hypercapnia or hypoxia. Ventilatory failure occurs when there is lung dysfunction with normal perfusion.

The nurse is teaching a patient recovering from a pulmonary embolism who will take warfarin for several weeks about long-term management of medications. Which statement by the patient indicates a need for further teaching?

Patients should avoid straining at stool but should take an oral stool softener and not use an enema, which can cause trauma to rectal tissues. To prevent excessive bruising, patients should apply ice for 1 hour if bumped. Dental work should not be performed without consulting the provider. Patients on warfarin will need regular international normalized ratio (INR) levels to monitor for drug effectiveness and bleeding risk.

A patient receiving mechanical ventilation and anticoagulant medication after experiencing a pulmonary embolism appears tense and is unable to sleep or rest. Which action does the nurse take next?

Patients who have a pulmonary embolism are usually anxious. The nurse should communicate with the patient to explain interventions and offer reassurance that appropriate measures are being taken. If that is not effective, a sedative may be ordered to help the patient rest. The patient's anxiety is not related to pain. Telling the patient's family that the patient is unstable will increase the level of anxiety for everyone involved.

Which parameters should the nurse monitor in patients with a flail chest? Select all that apply.

Patients with a flail chest are at increased risk for hypovolemia or shock. Therefore, fluid intake, vital signs such as blood pressure, and electrolyte balance should be monitored in this patient. This helps to manage the patient's condition immediately. Monitoring for blood loss would be beneficial in managing patients who have sustained a hemothorax. Monitoring arterial blood gases would be beneficial for patients with tension pneumothorax.

A patient transported to the emergency department after a motor vehicle crash has a heart rate of 115 beats/min, blood pressure of 88/59 mm Hg, shortness of breath, cyanosis, and paradoxical chest movement. What does the nurse do first to treat this condition?

Patients with a flail chest are initially treated with oxygen, pain management, and promotion of lung expansion through deep-breathing, positioning, and airway clearance. Oxygen is always administered first.

Which statement is true about a patient with flail chest?

Patients with flail chest are generally stabilized with positive-pressure ventilation. Patients with severe hypoxemia are managed with positive end-expiratory pressure. Surgical stabilization is performed in extreme cases of flail chest. Patients with lung contusion should be given intravenous fluids as prescribed.

Which findings may signify pulmonary contusion in a patient who was in an automobile accident? Select all that apply.

Patients with pulmonary contusion are characterized by a dry cough and tachycardia. Hemoptysis may occur with pulmonary embolism. Bradycardia does not manifest in pulmonary contusion. The sound of percussion in a patient with pulmonary contusion is always dull. Hyperresonance on percussion occurs in patients with pneumothorax.

A patient has severe pain from three rib fractures after a workplace accident. To facilitate adequate respiration, the nurse discusses which intervention with the provider?

Patients with severe pain often do not take deep breaths and thus do not maintain adequate ventilation. An intercostal nerve block is used for severe pain. Opioid analgesics suppress respiration and should be avoided. Splinting with tape is not done unless the fracture is complex, when seven or more ribs are involved, or if a flail chest is present. Mechanical ventilation is used as a last intervention after others have been attempted.

Which type of chest trauma causes asymmetry of the thorax and hemodynamic instability?

Patients with tension pneumothorax have distended neck veins, asymmetry of the thorax, and hemodynamic instability. Flail chest, hemothorax, and pneumothorax do not cause asymmetry of the thorax and hemodynamic instability.

Which type of trauma indicates splinting of the chest as the treatment modality?

Splinting may be indicated in a patient with rib fracture for stabilization. Splinting in a patient with a flail chest may result in the further reduction of the patient's ability to exert the extra effort to breathe. Pneumothorax and tension pneumothorax do not require chest splinting.

Which intervention is preferred for extreme cases of flail chest?

Surgical stabilization is used only in extreme cases of flail chest. Splinting is not recommended because it further reduces the patient's ability to exert effectively to breathe and may contribute later to failure to wean from ventilator support. Providing humidified oxygen prevents the upper airway from drying out and may be used in patients with a flail chest, but it is the main intervention for patients with a severe flail chest. Patients with a flail chest and severe hypoxemia and hypercarbia are intubated and mechanically ventilated with PEEP.

Which type of chest trauma causes asymmetry of the thorax and hemodynamic instability?

Tension pneumothorax Patients with tension pneumothorax have distended neck veins, asymmetry of the thorax, and hemodynamic instability. Flail chest, hemothorax, and pneumothorax do not cause asymmetry of the thorax and hemodynamic instability.

The nurse is caring for four patients. Which patient is at risk for tension pneumothorax?

Tension pneumothorax may be caused by the insertion of central venous access catheters as indicated in Patient A. Flail chest may occur due to blunt chest trauma or as a complication of cardiopulmonary resuscitation, as in the case of Patient B. Pulmonary contusion may result due to rapid deceleration during a car accident, as with Patient C. Severe blunt trauma, as Patient D suffered, or rapid deceleration can cause tracheobronchial trauma.

The nurse coming on shift prepares to perform an initial assessment of a sedated ventilated patient. Which are priorities for the nurse to carry out? Select all that apply.

The first priority when caring for a critically ill patient is to assess airway and breathing. Alarm settings should be confirmed each shift, more frequently if necessary. Confirming that the patient cannot speak ensures that air is going through the endotracheal tube and not around it. Auscultating for equal bilateral breath sounds assists in confirming that the tube is above the carina. Having visitors remain with the patient may promote comfort and prevent confusion. Routine tracheostomy care is performed according to schedule, not necessarily as part of an initial assessment.

A 70-kg patient receiving manual ventilation is becoming agitated and restless. The nurse determines that the endotracheal tube is in place, notes an oxygen saturation of 97%, and ventilator settings include a pressure of 12 cm H2O, a tidal volume of 600 mL, and a flow rate of 30 L/min. Which action by the nurse is correct?

The first step when a patient becomes agitated or restless, after checking the ventilator settings, is to increase the flow rate and then reassess the patient. This patient's tidal volume is appropriate. Patients who are ready to be weaned from the ventilator make respiratory efforts against the ventilator. These are not necessarily signs of delirium typical of "ICU psychosis," and the nurse should first attempt to evaluate the cause of the agitation.

A patient with chronic obstructive pulmonary disease (COPD) suddenly becomes dyspneic with a respiratory rate of 32 breaths/min and an oxygen saturation of 94%. The patient appears pale and anxious and is using accessory muscles to breathe. What is the nurse's priority action?

The patient has developed respiratory distress. Even though the oxygen saturation level is within normal limits, a more accurate assessment of hypoxemia is with arterial blood gases. Giving high-flow oxygen with a Venturi mask may increase anxiety and cause oxygen-induced hypercapnia in patients with COPD. Unless the patient exhibits signs of respiratory failure with hypoxemia and cyanosis, notifying the Rapid Response Team is not necessary. A chest x-ray may be indicated after the patient is stabilized to help determine the cause of the respiratory distress.

The nurse is caring for a patient who is on mechanical ventilation. The ventilator alarm sounded, and the nurse intervened by inserting an oral airway. What did the high pressure alarm indicate?

The patient is coughing and biting on the oral endotracheal tube. Inserting an oral airway helps prevent the patient from coughing and biting on the oral endotracheal tube. Providing an oral airway reduces the cough and biting because it does not involve provision of a tube into the trachea. When the patient has a decreased airway size, the nurse should auscultate the patient's breath sounds and collaborate with respiratory therapy. When the patient has increased mucus secretions, suction should be provided. When decreased compliance of the lungs is experienced, the nurse should evaluate the underlying cause and try to alleviate the problem.

The nurse has extubated a patient who was receiving mechanical ventilation for several days. A few hours after extubation, the patient reports a sore throat and cough and the nurse notes a hoarse voice. Which action by the nurse is correct?

The patient is experiencing signs of throat irritation and should be provided with measures to minimize discomfort. Incentive spirometry is necessary for lower airway problems to prevent pneumonia. The Rapid Response Team should be notified if the patient experiences stridor or other signs of airway obstruction. Racemic epinephrine is used to treat stridor.

Which activity performed by the patient post-extubation indicates ineffective learning about measures to improve gas exchange?

The patient should sit in a semi-Fowler's position rather than lying down for resting after extubation because it reduces the risk of fluid accumulation and aspiration immediately after extubation. Limiting speech helps reduce the irritation of vocal cords. Using the spirometer every 2 hours promotes gas exchange and is advisable. Taking deep breaths every half-hour improves gas exchange.

A patient who is intubated and on mechanical ventilation begins to develop respiratory distress. What is the next priority action for the nurse?

The priority is to provide ventilation using a bag-valve-mask device to determine if the problem is with the patient or the ventilator. This information is necessary before calling the health care provider or the Rapid Response Team. Changing the ventilator settings does not provide immediate information about the cause of the distress (patient or machine).

The nurse is assessing a patient who is receiving mechanical ventilation with positive end-expiratory pressure (PEEP). Which findings would cause the nurse to suspect a left-sided tension pneumothorax?

The trachea is deviated to the right side and cyanosis is present.

What is the correct sequence of events in their order of occurrence, after tracheobronchial trauma?

Tracheal laceration in tracheobronchial trauma may result in massive air leaks. This allows the entrance of air into the mediastinum. The development of extensive subcutaneous emphysema follows.

A patient who sustains a neck injury from hitting the steering wheel in a motor vehicle collision is admitted to the emergency department. Which type of chest trauma is most likely to occur in this patient?

Tracheobronchial trauma typically occurs when a victim strikes his or her neck against the steering wheel during a car crash because of trauma to the mainstream bronchi. A hemothorax commonly occurs after blunt trauma or penetrating injuries due to massive blood loss. Any chest injury that results in air entry into the pleural space may cause a pneumothorax. A pulmonary contusion occurs most often by rapid deceleration during car crashes.

A patient is being mechanically ventilated after abdominal surgery via synchronized intermittent mandatory ventilation with a set rate of 10 breaths per minute. The patient is sedated and not breathing spontaneously. His most recent arterial blood gas (ABG) results are: pH = 7.32; Pao2= 85 mm Hg; Paco2= 55 mm Hg. What is the nurse's interpretation of these results?

Ventilation is inadequate; respiratory acidosis is present

The student nurse, under the supervision of a registered nurse, is caring for a chronic obstructive pulmonary disease (COPD) patient who is on mechanical ventilation. Which statement of the student nurse needs correction?

"I will provide the patient with a carbohydrate-rich diet. Patients with COPD require a reduction of dietary carbohydrates. During metabolism, carbohydrates are broken down to glucose, which then produces energy, carbon dioxide, and water. Excess carbohydrate loads increase carbon dioxide production that the patient cannot exhale, resulting in hypercarbic respiratory failure. Administering proton-pump inhibitors is beneficial to the patient to prevent stress ulcers because the patient may be unable to consume if there are mouth ulcerations. This affects the patient's nutritional status. Providing the patient with formulas that have high fat content will combat imbalances in nutrition. Monitoring electrolytes is useful in detecting any electrolyte imbalances.

A patient was intubated 30 minutes ago for acute respiratory distress syndrome (ARDS) and possible sepsis. Place the orders for this patient in the sequence the nurse should perform them.

ABGs should be analyzed first before the other assessments/actions are carried out. A baseline of sputum cultures should then be obtained before medications are administered. Then levofloxacin can be given. Patient and family education on communication methods is important but is the lowest priority here.

A 5-foot, 2-inch tall 38-year-old woman who weighs 110 lb is being mechanically ventilated at a tidal volume of 400 mL and a respiratory rate of 16 breaths per minute. Her most recent arterial blood gas (ABG) results are: pH = 7.33; Pao2= 85 mm Hg; Paco2= 55 mm Hg. What is the nurse's next action?

Auscultate bilateral breath sounds to check endotracheal tube placement. Tidal volume may be calculated by multiplying the patient's body weight in kilograms by 7 or 10 or by adding a zero to the weight in kg. This patient weighs 50 kg, so an adequate tidal volume would be 350 to 500 mL. The settings of the ventilator are correct, but the patient continues to exhibit respiratory acidosis as evidenced by a low pH, low Pao2, and elevated Paco2. The nurse should auscultate breath sounds and check placement of the endotracheal tube to see if both lungs are being ventilated. Because the patient has respiratory acidosis, she is not compensating and not stable. Until the nurse completely assesses the patient and ensures adequate ventilation, requesting sodium bicarbonate is not warranted. Weaning is not begun until patients are stable and making attempts to breathe on their own.

A patient who does not wish to be mechanically ventilated is extremely dyspneic and is developing respiratory muscle fatigue. For comfort, what measure might the nurse suggest for this patient?

Bilevel positive airway pressure (BiPap) provides noninvasive pressure support ventilation and may be used for patients with respiratory muscle fatigue to avoid more invasive measures, such as mechanical ventilation. An aerosolized bronchodilator will not help prevent respiratory muscle fatigue. Frequent repositioning may increase respiratory effort. A Venturi mask will not help reduce dyspnea or reduce respiratory muscle fatigue.

Which components belong to the ventilator bundle approach to prevent ventilator-associated pneumonia (VAP)? Select all that apply.

Continuous removal of subglottic secretions, elevating the head of the bed at least 30 degrees whenever possible, and handwashing before and after contact with a patient are all part of a VAP bundle. Antibiotics are not given prophylactically; they are given on the basis of cultures to prevent an increase in drug-resistant organisms. A nasogastric tube is not part of the VAP bundle. If a patient is going to be mechanically ventilated for a prolonged period of time, postpyloric or gastrostomy tubes are preferred over nasogastric tubes for nutrition. Placing a patient in a negative airflow room is not part of the VAP bundle. The patient does not require this room.

A patient has been admitted for a pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care?

Daily platelet counts are a safety priority in assessing for thrombocytopenia; heparin -induced thrombocytopenia is a possible side effect. Avoiding the use of dental floss is important during anticoagulation therapy, but it is not the priority. Adequate staffing and notifying radiology are not the priority.

Which is associated with "paradoxical chest wall movement"?

Flail chest results in paradoxical chest wall movement. It is the inward movement of the thorax during inspiration with outward movement during expiration. Bilateral separation of the ribs from their cartilage causes flail chest. Tension pneumothorax deviates the trachea away from the side of the injury. Forceful entry of air into the chest cavity causing collapse of the affected lung is related to tension pneumothorax.

In order to improve oxygenation for a client with a bad left lung, how should the nurse position the patient?

Good lung down

When caring for a patient with pulmonary embolism, which blood gas result does the nurse anticipate early in the course of the disease?

Hyperventilation triggered by hypoxia and pain first leads to respiratory alkalosis, indicated by a low partial pressure of arterial carbon dioxide (Paco2 of 30) and a high pH (7.46). No compensation is present as the HCO3- (26) is normal, and hypoxemia is present, consistent with PE. A pH of 7.24 is acidotic, a Pao2 of 56 reflects hypoxemia, and no compensation is present with a normal HCO3-(26); this blood would be found in a person in acute respiratory failure owing to hypoventilation and hypoxemia. A pH between 7.35 and 7.45, Paco2 of 35 to 45, HCO3- of 22 to 26, and Pao2 greater than 75 all reflect a normal blood gas. A pH of 7.47 and an HCO3- of 30 are alkalotic, indicating metabolic alkalosis; a Paco2 of 35 is normal (indicating lack of compensation) and a Pao2 of 75 is normal.

The nurse is developing a plan of care for a patient with pulmonary embolism (PE). Which patient problem does the nurse establish as the priority?

Hypoxemia related to ventilation-perfusion mismatch

Which condition may manifest in a patient with a completely collapsed lung due to entry of air into the chest cavity?

In patients with tension pneumothorax, air enters forcefully into the chest cavity, resulting in increased pressure. This rise in the pressure may result in the complete collapse of the lungs. Flail chest occurs due to the fracture of two or more ribs in two or more places. Pulmonary contusion causes hemorrhage and edema between the alveoli. This reduces both lung movement and the area available for gaseous exchange, thus resulting in hypoxemia. Tracheobronchial trauma causes extensive air leakage, leading to subcutaneous emphysema.

All of these nursing actions are included in the plan of care for a patient who has just been extubated. Which action should the nurse delegate to unlicensed assistive personnel (UAP)?

Keep the head of the bed elevated.

Which statements are true regarding uncomplicated rib fractures? Select all that apply.

Management of uncomplicated rib fractures is simple because the fractured ribs reunite spontaneously. The patient experiences pain while breathing, which can be managed with pain medication. When ribs are fractured, the force also drives bone ends into the chest, so there is a risk for deep chest injury, such as contusion, pneumothorax, or hemothorax. Patients with uncomplicated rib fractures may have severe pain, so an intercostal nerve block is the best option in managing the pain. Splinting reduces breathing depth and clearance of secretion and is not recommended.

Which condition may require the use of a combination of multiple chest tubes and serial radiography monitoring as a treatment modality?

Multiple chest tubes may be used in a patient with a hemothorax to empty the pleural space of accumulated blood. Serial radiographic assessment is also necessary to determine the treatment's effectiveness. A flail chest, pneumothorax, and tension pneumothorax do not utilize a combination of multiple chest tubes and serial radiographs.

Which intervention is preferred for extreme cases of flail chest?

Surgical stabilization

A patient who is receiving packed red blood cells to treat anemia has a respiratory rate of 25 breaths/min, intercostal retractions with breathing, and clear breath sounds. Which action by the nurse is correct?

Patients receiving transfusions are at risk for transfusion-related acute lung injury (TRALI). Early signs are hyperpnea and increased work of breathing; this should be reported immediately so that treatment can be initiated. These symptoms may be signs of increased anxiety, but the nurse should report the findings to the provider since rapid treatment of TRALI is essential to prevent serious effects. Until the patient is evaluated for the presence of TRALI, an anxiolytic medication is not indicated.

A patient who is taking warfarin after an acute a pulmonary embolism is transferred from the ICU after 5 days of heparin therapy. The nurse reviews the patient's electronic medical record and notes an international normalized ratio (INR) of 3.4. After notifying the provider of this result, which order does the nurse expect for this patient?

Phytonadione (vitamin K) is the antidote for warfarin. This patient has a prolonged coagulation time as evidenced by the increased INR, which should be between 2.5 and 3.0; this may be increased for patients with chronic pulmonary embolus. Protamine sulfate is the antidote for heparin. Increasing the warfarin dose will only increase the coagulation time, as will resuming the heparin.

A patient with chronic obstructive pulmonary disease (COPD) reports acute difficulty breathing and right-side pleuritic pain. Auscultation reveals decreased breath sounds in the right lung field compared to the left lung field. Which possible condition does the nurse contact the provider for based on these assessment data?

Pneumothorax

Which traumatic condition of the chest may lead to subcutaneous emphysema?

Pneumothorax

What is the sequence of events related to pneumothorax in the order of their occurrence?

Pneumothorax is associated with chest injury or trauma that causes air to enter into the pleural space. Large amounts of air in the pleural space results in an increase of pressure in the chest, reducing the vital capacity of the lungs.

The nurse is caring for a group of patients. Which patients should be monitored closely for respiratory failure? Select all that apply.

Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome (ARDS); abdominal distention also ensues, which can limit respiratory excursion. Opiates, which can depress the brainstem, present risk factors for respiratory failure. Patients with cervical and thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect intercostal muscles are affected. All of these patients should be monitored closely for respiratory failure. Cocaine is a stimulant, which would not cause respiratory failure unless a stroke ensued.

A patient who was just transferred to the ICU after developing a pulmonary embolism is receiving anticoagulant therapy and oxygen. The nurse notes clear breath sounds, an oxygen saturation of 95%, and a heart rate of 78 beats/min. The patient reports feeling scared that something bad will happen. What is the nurse's priority action for this patient?

Reassure the patient that the treatment is working.

What is the correct order of events occurring in a patient with pulmonary contusion?

Respiratory failure may develop in a patient with pulmonary contusion. Hemorrhage and edema occur in and between the alveoli, thereby reducing both lung movement and the area available for gas exchange. The patient experiences hypoxia and dyspnea. Hazy opacity in the lobes or lung parenchyma can develop over time.

What contributes to a patient with flail chest on mechanical ventilation showing a failure to wean off the mechanical ventilation?

Splinting is contraindicated in patients with flail chest as it may further reduce the ability to exert the extra effort to breathe and may contribute later to the failure to wean off mechanical ventilation. Performing tracheal suction is beneficial in clearing the nasal secretions. Elevating the head of the patient's bed does not interrupt the patient's capacity to wean from ventilator. Providing positive pressure ventilation is indicated for the stabilization of flail chest.

Which term is used to refer to the damage to the alveoli by an inflammatory response?

Biotrauma

The patient with which condition is in greatest need of immediate intubation?

Intubation may be indicated for the patient who is hypoventilating and has decreased breath sounds. Suctioning, rather than intubation, is indicated for difficulty swallowing secretions and for thick, purulent secretions and crackles (consistent with pneumonia). Intubation is indicated for the patient with an O2 saturation of less than 90% and other symptoms of hypoxemia or hypercarbia.