2040 Exam 3 Care of Patients with Respiratory Questions

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity.

A, B, D

A client admitted with respiratory difficulty and decreased oxygen saturation keeps pulling off the oxygen mask. What action does the nurse take? a.Stays with the client and replaces the oxygen mask b.Asks the client's spouse to hold the oxygen mask in place c.Restrains the client per facility policy d.Contacts the health care provider and requests sedation Restlessness and confusion are clinical manifestations of hypoxemia. It is important that the nurse stay with the client, ensure that the oxygen is maintained, and attempt to calm the client. Because of the client's restlessness, the nurse cannot delegate care to the spouse. Requesting a sedative might adversely affect the client's respiratory status further. Restraining the client could increase restlessness and increase oxygen demand.

A

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the client's hands. d. Sedate the client immediately. The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain and confusion can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary, but not as a first step

A

The nurse is assessing arterial blood gases (ABGs). The client with which ABG reading requires the nurse's immediate attention? a.pH, 7.32; PaCO2, 55 mm Hg; PaO2, 70 mm Hg b.pH, 7.45; PaCO2, 42 mm Hg; PaO2, 70 mm Hg c.pH, 7.48; PaCO2, 38 mm Hg; PaO2, 60 mm Hg d.pH, 7.55; PaCO2, 32 mm Hg; PaO2, 50 mm Hg This client has the most severe hypoxia and respiratory alkalosis, indicated by low partial pressure of arterial carbon dioxide (PaCO2) values on ABG analysis.

A

The nurse is caring for a client who is intubated with an endotracheal tube and on a mechanical ventilator. The client is able to make sounds. What is the nurse's first action? a.Check cuff inflation on the endotracheal tube. b.Listen carefully to the client. c.Call the health care provider. d.Auscultate the lungs. If the client has the cuff on the endotracheal tube inflated, the cuff should prevent air from going around the cuff and through the vocal cords. If the client can talk with the cuff inflated, the cuff probably has a leak, causing it to become deflated and allowing air to pass through. The risk is that the client will not receive the prescribed tidal volume.

A

The nurse is caring for a client who is receiving mechanical ventilation accompanied by positive end-expiratory pressure (PEEP). What assessment findings require immediate intervention? a.Blood pressure drop from 110/90 mm Hg to 80/50 mm/Hg b.Pulse oximetry value of 96% c.Arterial blood gas (ABG): pH, 7.40; PaO2, 80 mm Hg; PaCO2, 45 mm Hg; HCO3-, 26 mEq/L d.Urinary output of 30 mL/hr Increased intrathoracic pressure can inhibit blood return to the heart and cause decreased cardiac output. This manifests with a drop in blood pressure. The pulse oximetry reading, ABGs, and urinary output are all normal.

A

What is the best way for the nurse to communicate with a client who is intubated and is receiving mechanical ventilation? a.Ask the client to point to words on a board. b.Ask the client to blink for "yes" and "no." c.Have the client mouth words slowly. d.Teach the client some simple sign language. The nurse should have the client point to words on a board to communicate needs. The endotracheal tube is positioned and placement is maintained with tape or some other type of appliance. Asking the client to move his or her mouth and lips could result in possible extubation. Communication is limited and could be misunderstood with blinking. Teaching the client sign language, even simple, would be an involved and unrealistic goal.

A

A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)? (Select all that apply.) a.Oxygen administered at 100%, PaO2 60 b.Increased dyspnea c.Anxiety d.Chest pain e.Pitting pedal edema f.Clubbing of fingertips A client who is developing ARDS presents with a decrease in oxygen despite an increase in the fraction of inspired oxygen. Increased dyspnea goes along with the increased hypoxemia, as does anxiety. Chest pain is not specific to ARDS; although chest pain can occur with ARDS, it occurs with many other conditions as well. Pitting edema would not be an assessment factor that confirms ARDS. Clubbing occurs in chronic, not acute, respiratory conditions.

A, B, C

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.

A, B, C, D

A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the client's bedside. b. Ensure the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more. There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the client's skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.

A, B, D, E

The nurse is caring for a client on a ventilator when the high-pressure alarm sounds. What actions are most appropriate? (Select all that apply.) a.Assess the tubing for kinks. b.Assess whether the tubing has become disconnected. c.Determine the need for suctioning. d.Call the health care provider. e.Call the Rapid Response Team. f.Auscultate the client's lungs. Reasons for a high-pressure alarm include water or a kink impeding airflow or mucus in the airway. The nurse first should assess the client and determine whether he or she needs to be suctioned; then the nurse should auscultate the lungs. The nurse also should assess the tubing for kinks. The high-pressure alarm sounding would not be a reason to call the health care provider or the Rapid Response Team. If the tubing became disconnected, the low-pressure alarm would sound.

A, C, F

A client is admitted to the emergency department several hours after a motor vehicle crash. The car's driver-side airbag was activated during the accident. Which assessment requires the nurse's immediate intervention? a.Disorientation b.Hemoptysis c.Pulse oximetry reading of 94% d.Chest pain with movement ANS: B The nurse should be concerned about possible pulmonary contusion. Interstitial hemorrhage accompanies pulmonary contusion. Bleeding may not be evident at the initial injury, but the client develops hemoptysis and decreased breath sounds up to several hours after injury as bleeding into the alveoli or airways occurs. The pulse oximetry reading is within normal limits and chest pain is expected with movement after chest trauma. Disorientation needs to be investigated, but does not take priority over a breathing problem.

B

A client with severe respiratory insufficiency becomes short of breath during activities of daily living. Which nursing intervention is best? a.Call the Rapid Response Team. b.Decrease involvement in care until the episode is past. c.Cluster morning activities to provide long rest periods. d.Space out interventions to provide for periods of rest. Clients with shortness of breath and decreased oxygen saturation must be monitored closely. Minimal involvement in activities is required if the client is severely short of breath. The nurse should continue to assess the client and can increase involvement in activities if shortness of breath subsides. The Rapid Response Team is not required. Clustering or spacing of activities does nothing to decrease the client's involvement, which is the cause of shortness of breath.

B

A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority? a. Assessing that the ventilator settings are correct b. Ensuring there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse should know and check the settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or may not need suctioning on arrival.

B

The pilot balloon on the endotracheal tube of a client being mechanically ventilated is deflated. What is the nurse's priority action? a.Nothing; this is required during ventilation. b.Inflate the cuff using minimal leak technique. c.Call the Rapid Response Team. d.Increase the tidal volume. The pilot balloon indicates whether the endotracheal tube cuff is inflated or deflated. A deflated balloon means that the cuff is also deflated and a seal is no longer present around the tube to prevent air from escaping. Thus, some of the air being moved into the client's airway by the ventilator is escaping through the client's trachea before it reaches the lower airways and alveoli. The nurse should inflate the cuff. Calling the Rapid Response Team is not necessary, and increasing tidal volume will not improve oxygenation if the cuff is leaking.

B

A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Apply oxygen at 100%. b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines. The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs.

C

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools. The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse.

C

A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? a. Ensure the client has adequate sedation. b. Find another provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the client's oxygen saturation. Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation during the procedure and monitor the client's oxygen saturation, but these do not take priority. Finding another provider is not appropriate at this time.

C

An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b. Ensure all connections are patent. c. Listen to the client's lung sounds. d. Suction the endotracheal tube. When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.

C

The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation and positive end-expiratory pressure (PEEP). The alarm sounds, indicating decreased pressure in the system. What is the nurse's best action? a.Change the client's position. b.Suction the client. c.Assess lung sounds. d.Turn off the pressure alarm. One of the biggest risks in the client with ARDS on mechanical ventilation with PEEP is tension pneumothorax. The nurse needs to assess lung sounds hourly. The alarms on a ventilator should never be turned off. If the client needed to be suctioned, the high-pressure alarm would sound. Changing the client's position would not change the pressure needed to administer a breath.

C

The nurse is caring for several clients on the respiratory floor. Which client does the nurse assess most carefully for the development of acute respiratory distress syndrome (ARDS)? a.Older adult with COPD b.Middle-aged client receiving a blood transfusion c.Older adult who has aspirated his tube feeding d.Young adult with a broken leg from a motorcycle accident The older adult who has aspirated a tube feeding is at high risk and should be assessed closely for the possibility of ARDS. A client with COPD and a middle-aged client with no other risk factors are not at as high a risk for ARDS. The client who has a broken leg from an accident is not at high risk.

C

The pressure reading during inspiration on the ventilator of a client receiving mechanical ventilation is fluctuating widely. What is the nurse's first action? a.Determine whether an air leak is present in the client's endotracheal tube cuff. b.Have the respiratory therapist check the pressure settings. c.Assess the client's oxygenation. d.Manually ventilate the client with a resuscitation bag. A widely fluctuating pressure reading is one indication of inadequate airflow and oxygenation. The nurse's priority is to check the client's oxygenation status. If oxygenation is inadequate, the nurse would assess for a cause while manually ventilating the client and calling for assistance.

C

A client is admitted owing to difficulty breathing. The nurse assesses the client's color, lung sounds, and pulse oximetry reading. The pulse oximetry is 90%. What is the nurse's next action? a.Give an intermittent positive-pressure breathing treatment. b.Administer a rescue inhaler. c.Call for a chest x-ray. d.Assess an arterial blood gas. When clients with respiratory problems are assessed, an arterial blood gas is needed for the most accurate assessment of oxygenation. No indications are known for a breathing treatment or an inhaler, nor does the nurse have enough information to know whether a chest x-ray is warranted.

D

A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority? a. Administer oxygen and reassess. b. Auscultate the client's lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation. This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.

D

A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best? a. "It will increase the motility of the gastrointestinal tract." b. "It will keep the gastrointestinal tract functioning normally." c. "It will prepare the gastrointestinal tract for enteral feedings." d. "It will prevent ulcers from the stress of mechanical ventilation." Stress ulcers occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Zantac is a histamine blocking agent.

D

A client with dyspnea is becoming very anxious. An arterial blood gas (ABG) shows a PaO2 of 93 mm Hg. How does the nurse best intervene? a.Increase the oxygen. b.Administer an antianxiety medication. c.Administer a bronchodilator. d.Assist with relaxation techniques. The nurse should assess the client's oxygenation; however, this client's arterial blood gas documents that the client's hypoxia has resolved. At this time it is not necessary to increase the oxygen or administer a bronchodilator; both of these interventions would be appropriate if the client were hypoxic. The client with respiratory problems should not take an antianxiety medication as a first-line intervention, because this may decrease the respiratory rate and/or alertness. The best intervention at this time is to assist with relaxation techniques.

D

The client receiving mechanical ventilation has become more restless over the course of the shift. Which is the nurse's first action? a.Sedate the client. b.Call the health care provider. c.Assess the client for pain. d.Assess the client's oxygenation. Increasing restlessness in a client being mechanically ventilated may mean that the client is not receiving sufficient oxygen. It can also be a manifestation of pain. When in doubt, determining the adequacy of ventilation has the highest priority. The nurse would not sedate the client until the cause of the restlessness has been addressed. The nurse would call the provider if the cause could not be determined and addressed, or if the client's status deteriorated.

D

The nurse is caring for a client who has been intubated and placed on a ventilator for treatment of acute respiratory distress syndrome (ARDS). Aside from assessing oxygenation, what is the nurse's priority action? a.Assess hemoglobin. b.Administer ferrous sulfate. c.Assess muscle strength. d.Consult with the registered dietitian. The client who is intubated needs nutrition delivered via enteral tube feeding. If nutrition is ignored, the client's respiratory status can deteriorate, because respiratory muscle function can deteriorate.

D

The nurse is caring for a client who is taken off a ventilator and placed on continuous positive airway pressure (CPAP). What intervention is most appropriate for this client? a.Administering antianxiety medications PRN b.Administering a medication to help the client sleep c.Telling the client to relax and let the ventilator do the work d.Making sure the client is breathing spontaneously A requirement for using CPAP is that the client will be able to breathe spontaneously. Antianxiety and sleep medications should not be administered to the client during weaning. Telling the client to relax may be helpful in some cases but does not take priority over ensuring the client's ability to breathe spontaneously.

D

Which assessment finding of a client requires the nurse's immediate action? a.Being intubated for 4 days b.Uneven breath sounds c.Wheezing on auscultation d.Having the endotracheal (ET) tube taped to the lower jaw The endotracheal tube can be taped to the upper lip but should never be taped to the lower jaw because the lower jaw moves too much. The other clients need to be assessed by the nurse, but the one with the ET tube taped to the jaw requires immediate action.

D

What is a Hemoptysis?

coughing up of blood