AH II Resp AQ + Chest Trauma (Exam 1)

A family member of a patient who has acute respiratory distress syndrome (ARDS) asks the nurse how long it will take for the patient to get better. The nurse reviews the medical record and notes that the patient has been receiving mechanical ventilation for 3 weeks. Which information would the nurse provide to the family member? "Multisystem organ changes occur at 2 weeks." "After 2 weeks, some lung changes may be irreversible." "Patients who are ventilator dependent usually die." "Recovery may be complete, but it will take months."

"After 2 weeks, some lung changes may be irreversible." Rationale Pulmonary fibrosis with progression occurs after 10 days of onset of ARDS. Patients who survive to this point will have permanent lung changes and may remain ventilator dependent indefinitely. Although many patients die, telling the family member this initially will destroy any hope for a good outcome; this must be discussed with the health care provider, the nurse, and possibly the palliative care team. Multisystem organ changes are more likely but have not necessarily occurred. Recovery is rarely complete at this stage.

Which term is used to refer to alveolar damage from an inflammatory response?

-Bilevel positive airway pressure (BiPAP)

Which drug increases cardiac output by improving myocardial contractility?

-Milrinone -positive inotropic drug that increases the contractility of the cardiac musculature, increasing CO

biotrauma

-alveolar damage from an inflammatory response -lung problem that occurs when a patient is on mechanical ventilation

Symptoms of tension pneumothorax

-asymmetry -tracheal deviation toward the unaffected side -dyspnea -absent breath sounds -jugular venous distention (JVD) -cyanosis -hyperresonance to percussion over the affected area

Flow-by ventilation

-beneficial for patients in whom weaning from mechanical ventilation is needed

BiPAP

-provides noninvasive pressure support ventilation by nasal mask or face mask -most often used for pt with sleep apnea

Which expiratory volume value signifies a poor prognosis in patients with deep chest trauma? 10 mL/kg 15 mL/kg 20 mL/kg 25 mL/kg

10 mL/kg Rationale An expiratory volume of less than 15 mL/kg is considered to be a sign of poor prognosis. The chances of survival are very bleak. An expiratory volume of 15 mL/kg, 20 mL/kg, and 25 mL/kg indicate fair prognosis in patients with chest trauma.

Which drug is an antidote for heparin?

Protamine sulfate

atelectrauma

shear injury to alveoli while opening and closing

barotrauma

when damage to lungs is caused by excessive pressure

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is on mechanical ventilation. Which plan stated by the nurse needs correction? "I will provide the patient with a carbohydrate-rich enteral formula." "I will administer proton pump inhibitors to the patient." "I will provide the patient with formulas that have a high fat content." "I will regularly monitor the calcium and magnesium levels of the patient."

"I will provide the patient with a carbohydrate-rich enteral formula." Rationale 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 tolerate carbohydrates-rich nutrition if there are peptic ulcerations. Providing the patient with formulas that have high fat content will combat imbalances in nutrition. Monitoring electrolytes is useful in detecting any electrolyte imbalances in patients receiving enteral or parenteral nutrition.

SIMV

-synchronized intermittent mandatory ventilation -coordinates breathing between the ventilator and the patient and is not required in a patient with sleep apnea bc continuous flow is needed

Which patient is at high risk for developing a pulmonary embolism (PE)? A. 67-year-old man who works on a farm B. 45-year-old man admitted for a heart attack C. 23-year-old woman with a bleeding disorder D. 25-year-old woman who frequently flies internationally

25-year-old woman who frequently flies internationally Rationale People who engage in prolonged and frequent air travel are at high risk for PE. A 67-year-old man who works on a farm is not at high risk because he has an active lifestyle. A heart attack is usually caused by a thrombus or occlusion of the coronary arteries, not of the legs, where a venous clot could later become a PE. PE is a clotting disorder, not a bleeding disorder.

Which patient outcome is the priority during the initial phase of treatment for a pulmonary embolism? A. Reduced level of anxiety B. Effective coping strategies C. Free from bleeding episodes D. Adequate gas exchange

Adequate gas exchange Rationale During the initial phase of treatment, oxygenation and gas exchange are the primary concerns. After anticoagulant therapy is initiated, and for the duration of anticoagulant therapy, bleeding is a concern. Anxiety and coping are a concern at all times but do not represent life-threatening problems.

A patient is receiving mechanical ventilation via an endotracheal tube. The patient remains ventilator dependent for 2 weeks after the initial intubation and shows no signs of readiness to wean from the ventilator. Which information would the nurse tell the patient's family about the plan of care? "Your loved one may be ventilator dependent indefinitely." "A tracheostomy will be performed to minimize complications from the tube." "We will insert a nasotracheal tube to make the patient more comfortable." "The health care provider will order bilevel positive airway pressure (BiPAP) to help with weaning."

A tracheostomy will be performed to minimize complications from the tube Rationale Patients who require an artificial airway longer than 10 to 14 days will often need a tracheostomy to help minimize tracheal and vocal cord damage and to continue to remove secretions and provide ventilation and oxygenation. BiPAP is not used to wean patients from ventilators. Nasotracheal tubes carry the same risks as endotracheal tubes and are less comfortable. It is too early to tell whether the patient will be ventilator dependent for a prolonged period of time.

The nurse is assessing a patient with possible pulmonary embolism (PE). For which symptom would the nurse assess? Select all that apply. One, some, or all responses may be correct. A. Productive cough B. Bloody sputum C. Inspiratory chest pain D. Dizziness and fainting E. Shortness of breath (SOB) worsening over the last 2 weeks

A, B, C, D Rationale PE may cause a dry or productive cough with bloody sputum (hemoptysis). Syncope, hypotension, and fainting are symptoms associated with PE. Sharp, pleuritic, inspiratory chest pain is also characteristic of PE. Sudden, not gradual, SOB occurs with PE.

Which patient would the nurse monitor closely for respiratory failure? Select all that apply. One, some, or all responses may be correct. A. Patient with a brainstem tumor B. Patient with acute pancreatitis C. Patient with a T3 spinal cord injury D. Patient using patient-controlled analgesia E. Patient experiencing cocaine intoxication

A, B, C, D Rationale 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.

Which precautionary measure would the nurse plan to take while a patient is on heparin sodium therapy? Select all that apply. One, some, or all responses may be correct. A. Monitor the platelet count. B. Have the antidote, vitamin K, readily available. C. Monitor the partial thromboplastin time (PTT). D. Monitor the international normalized ratio (INR). E. Have the antidote, protamine sulfate, readily available.

A, C, E Rationale Monitoring the platelet count daily helps detect any heparin-induced thrombocytopenia because a decrease in platelet count is a common adverse effect caused by the use of heparin sodium. Regular monitoring of PTT is necessary because it helps detect side effects and prevent complications. Protamine sulfate is used as an antidote in emergency situations caused by heparin overdose because it reverses the anticoagulation effect by binding to heparin. While using warfarin, patients may experience adverse effects of the drug; vitamin K is used as an antidote because of its coagulating effect. Regular monitoring of INR is recommended when a patient is on warfarin therapy.

Which condition is consistent with an x-ray report of three adjacent ribs each fractured in three different places? Flail chest Pulmonary contusion Tension pneumothorax Tracheobronchial trauma

Flail chest Rationale Flail chest appears in CT as the fracture of at least three neighboring ribs in two or more places. The chest x-ray of a patient with a pulmonary contusion reveals hazy opacity in the lobes or parenchyma. A tension pneumothorax is indicated by the asymmetry of the thorax in the x-ray. In tracheobronchial trauma, the chest x-ray shows a tracheobronchial tear.

A patient with pneumonitis caused by inhaling an irritant is receiving 100% oxygen for treatment of worsening hypoxemia. The patient has increasing dyspnea and work of breathing. A chest x-ray reveals a ground-glass appearance in both lungs. Which condition would the nurse suspect this patient has developed? Aspiration pneumonia Oil or fat embolism Tension pneumothorax Acute respiratory distress syndrome (ARDS)

ARDS Rationale Patients who have these symptoms most likely have ARDS. The ground-glass appearance on the x-ray confirms this diagnosis. Patients with pulmonary embolism may have normal chest x-rays or may have infiltrates localized to the area around the embolism. Patients with pneumonia typically have infiltration or consolidation of one or more lobes. A tension pneumothorax is visible on x-ray with one-sided lung involvement.

The patient who has a venous thromboembolism in the upper arm is to begin receiving prescribed oral warfarin. The nurse is aware that the patient is currently receiving an IV heparin infusion. Which action would the nurse take? Administer both of the medications as prescribed. Decrease the heparin infusion rate by 50%. Clarify the warfarin and heparin prescriptions with the health care provider. Hold the dose of warfarin until the heparin prescription is discontinued.

Administer both as prescribed Rationale Although both heparin and warfarin are anticoagulants, they have different mechanisms and onsets of action. Because warfarin has a slow onset, it must be started while the patient is still receiving heparin to maintain a safe level of anticoagulation for effective treatment of the venous thromboembolism. It is not necessary to clarify the prescription as the patient must take warfarin while on the heparin because warfarin has a slow onset. Warfarin should not be held as it can be given while the heparin is being administered. The heparin dosing is based on serial measures of the partial thromboplastin time (PTT); the nurse should not change the rate of heparin infusion based on the warfarin being prescribed.

Which step would the nurse consider first in the emergency approach to a patient with chest injuries? Airway Breathing Circulation Disability

Airway Rationale The first step in the ABC emergency approach to all chest injuries is to clear the patient's airway, followed by addressing breathing and circulation. Assessment of disability follows the other steps.

Which drug would the nurse expect to be prescribed for a patient experiencing massive pulmonary embolism who has shock symptoms?

Alteplase Fibrinolytic agents, such as alteplase, are used in the treatment of pulmonary embolism, specifically when the patient has shock and hemodynamic collapse.

A patient develops distended neck veins, severe dyspnea, cyanosis, and syncope. The patient is hypoxic and hypotensive and has an abnormal electrocardiogram. The Rapid Response Team arrives. Which medication would the nurse anticipate will be prescribed immediately? Alteplase Warfarin Clopidogrel Low-molecular-weight heparin

Alteplase Rationale This patient is displaying symptoms of a pulmonary embolism (PE). Patients who are hemodynamically unstable will need fibrinolytic drugs to break up the clot causing the PE. Heparin is used when the patient is stable to prevent the clot from getting larger. Clopidogrel is used to prevent PE in nonhospitalized patients. Warfarin is used after the patient is stable as it generally takes 72 hours to produce anticoagulation.

Which drug is an antidote to fibrinolytic therapy?

Aminocaproic acid -to prevent excess bleeding

The nurse is extubating a patient who has been receiving mechanical ventilation for several days. Which action would the nurse plan to take directly after removal of the endotracheal (ET) tube? A. Monitoring vital signs B. Suctioning the oropharynx C. Asking the patient to cough D. Hyperoxygenating the patient

Asking the patient to cough Rationale: The patient should be asked to cough immediately after removal of the ET tube to help clear secretions. The nurse should hyperoxygenate the patient and suction the oropharynx prior to removal of the ET tube. After the ET tube is safely removed, the nurse should monitor vital signs every 5 minutes initially.

A patient in the ICU on mechanical ventilation appears increasingly restless and picks at the bedcovers. Which action would the nurse take? A. Increase the sedation. B. Assess for adequate oxygenation. C. Request that the family members leave. D. Explain the breathing tube to the patient.

Assess for adequate oxygenation Increase the sedation. Assess for adequate oxygenation. Request that the family members leave. Explain the breathing tube to the patient.

A postoperative patient is obese and reports smoking a pack of cigarettes a day. Which intervention would the nurse include in this patient's plan of care to help prevent venous thromboembolism? A. Teach the patient about smoking-cessation techniques. B. Assist with passive and active range-of-motion exercises. C. Elevate the patient's legs by placing pillows under the knees. D. Encourage the patient to take deep breaths and cough frequently.

Assist with passive and active range of motion exercises Rationale This patient is at risk for deep vein thrombosis (DVT) in the legs, which can cause pulmonary complications when a blood clot breaks loose and lodges in the lungs. Passive and active range-of-motion exercises can help prevent DVTs. Placing a pillow under the knees increases the risk for DVT because it puts pressure on the popliteal space. Coughing can help clear airways in patients who are not at risk for DVT, but coughing involves the Valsalva maneuver, which can increase the risk for clots. Smoking-cessation techniques are an important part of long-term management but will not help in the immediate time period to prevent clots.

A 5-foot 2-inch tall, 38-year-old patient who weighs 110 lb (50 kg) is being mechanically ventilated at a tidal volume of 400 mL and a respiratory rate of 16 breaths/min. The most recent arterial blood gas (ABG) results are: pH = 7.32; partial pressure of arterial oxygen (Pao 2) = 85 mm Hg; and partial pressure of arterial carbon dioxide (PaCo 2) = 55 mm Hg. Which action would the nurse take? A. Continue to monitor the patient's currently stable status. B. Request an order to begin weaning the patient from the ventilator. C. Notify the health care health care provider about the need for sodium bicarbonate. D. Auscultate breath sounds to check endotracheal tube placement.

Auscultate breath sounds to check endotracheal tube placement Rationale 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 kilograms. This patient weighs 110 lb (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 Pao 2, and elevated PaCo 2. 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, the patient 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.

Which risk factor increases a patient's risk for a venous thromboembolism that may progress to a pulmonary embolism? Select all that apply. One, some, or all responses may be correct. A. Nonsmoker B. 72 years of age C. Presence of a central venous catheter D. Admission weight of 290 lb (131.8 kg) E. Ability to ambulate with assistance of one person

B, C, D Rationale Several factors place a patient at an increased risk for developing a pulmonary embolism from a thromboembolism. Risk factors that should be assessed include prolonged immobility, central venous catheter, surgery, obesity, advanced age, history of thromboembolism, smoking history, pregnancy, estrogen therapy, heart failure, stroke, and cancer.

Which action is a priority for a nurse coming on shift to care for a ventilated patient who is sedated? Select all that apply. One, some, or all responses may be correct. A. Ask family members to leave. B. Listen for bilateral breath sounds. C. Confirm alarms and ventilator settings. D. Assess the patient's color and respirations. E. Ensure that the tube cuff is inflated and is in the proper position. F. Provide routine tracheotomy and endotracheotomy care and mouth care.

B, C, D, E Rationale The first priority when caring for a critically ill patient receiving mechanical ventilation is to assess airway and breathing. Alarm settings should be confirmed each shift and 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 family visitors remain with the patient may promote comfort and prevent confusion. Routine tracheostomy care is performed according to schedule and PRN, not necessarily as part of an initial assessment.

which mode of ventilation would the nurse expect to be prescribed for a patient who has sleep apnea?

Bilevel positive airway ventilation (BiPAP)

Which finding indicates that the endotracheal tube remains correctly placed in the patient's trachea and is not in the esophagus? A. Breath sounds are present equally over bilateral lung fields. B. Oxygen saturation by pulse oximetry is greater than 85%. C. A suction catheter is easily passed through the endotracheal tube. D. No air is heard in the stomach when auscultated with a stethoscope.

Breath sounds are present equally over bilateral lung fields Rationale Bilateral positive breath sounds indicate the endotracheal tube is in the proper placement. If breath sounds are heard on the right but not the left, the breathing tube may be in the right mainstem bronchus and may need to be retracted until breath sounds are heard equally. The gold standard for endotracheal tube placement verification is a chest x-ray. If the endotracheal tube was in the esophagus or stomach, breath sounds would be heard over the stomach rather than the bilateral lung fields. Other indications of proper tube placement include positive end-tidal carbon dioxide (CO 2) readings and condensation in the tube. The fact that air cannot be heard in the stomach or that a suction catheter is easily passed are not conclusive assessments of a correctly placed endotracheal tube. Although an increase in oxygen saturation after intubation and ventilation indicates that the patient has improved oxygenation, the saturation value alone does not assure correct tube location.

Which change would the nurse anticipate in a patient with worsening acute respiratory distress syndrome (ARDS)? Select all that apply. One, some, or all responses may be correct. A. Increase in lung volume B. Expansion of lung channels C. Reduction in surfactant activity D. Damage to type II pneumocytes E. Edema around terminal airways

C, D, E Rationale ARDS occurs as a result of an acute lung injury. The injury typically happens in the alveolar-capillary membrane. As a result of the injury, surfactant is diluted by extra fluid in the lungs. Type II pneumocytes are damaged, and edema forms around terminal airways. Surfactant activity is reduced because of the damage of type II pneumocytes. The collapsed alveoli cannot exchange gases, and edema forms around terminal airways. In ARDS, lung volume is decreased, and lung channels are compressed.

A patient has deep vein thrombosis. The nurse is teaching the patient's caregiver about measures for preventing pulmonary embolism. Which statement made by the caregiver indicates effective learning? Select all that apply. One, some, or all responses may be correct. A. "Help the patient to cross the legs." B. "Gently massage the patient's leg muscles." C. "Change the patient's position every 2 hours." D. "Avoid placing a pillow under the patient's knee." E. "Elevate the affected limb above the heart level."

C, D, E Rationale Changing the patient's position every 2 hours may reduce the pressure in specific areas and promote blood circulation. Placing a pillow under the knees can cause pressure under the popliteal space. Elevation of the affected limb 20 degrees or more above the level of the heart improves the venous return. Crossing legs should be avoided to prevent pressure on the blood vessels in the affected limbs, which may result in clot formation. The caregiver should refrain from massaging the leg muscles to prevent dislodging of the clot and causing pulmonary embolism.

Which component of a patient's plan of care is based on the ventilator bundle approach to prevent ventilator-associated pneumonia (VAP)? Select all that apply. One, some, or all responses may be correct. A. Placing a nasogastric tube B. Administering antibiotic prophylaxis C. Removing subglottic secretions continuously D. Placing the patient in a negative airflow room E. Handwashing before and after contact with the patient F. Elevating the head of the bed at least 30 degrees when possible

C, E, F Rationale 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 but would be used if a patient had an airborne communicable disease.

Which finding is characteristic of hypoxic respiratory failure? Select all that apply. One, some, or all responses may be correct. A. Confusion B. Diarrhea C. Irritability D. Restlessness E. Tachycardia

Confusion, Irritability, Restlessness When a patient's oxygen level is low, the patient may be restless, irritable, or confused because decreased oxygen levels affect cerebral blood flow. The heart rate usually increases to compensate for low perfusion in hypoxemia. Diarrhea is not a manifestation of hypoxemia.

Which finding is consistent with a pulmonary embolism (PE)? Select all that apply. One, some, or all responses may be correct. A. Crackles B. Diaphoresis C. Bradycardia D. Low-grade fever E. Severe headache

Crackles, Diaphoresis, Low-grade fever A PE is a collection of particulate matter that enters venous circulation and lodges in the pulmonary vessels. Crackles, diaphoresis, and low-grade fever are some of the signs of PE. Crackles are heard because the embolism blocks pulmonary vessels and fluid accumulates. Diaphoresis occurs because of the pooling of fluid. Tachycardia occurs during a PE; the patient experiences an elevated heart rate as the heart works harder to circulate blood throughout the body. A severe headache is not a sign of PE.

A patient who has been on a ventilator for the past week has become increasingly hypoxemic despite increased oxygen settings. Which phase of acute respiratory distress syndrome (ARDS) would the nurse suspect the patient is experiencing? A. Increased compliance B. Exudative C. Resolution D. Fibrosing alveolitis

Fibrosing alveolitis In the fibrosing alveolitis phase, increasing lung involvement reduces gas exchange and oxygenation. ARDS decreases rather than increases lung compliance. In the exudative phase patients experience dyspnea and tachypnea and require oxygen via mask or nasal cannula. The resolution phase usually occurs after 14 days. Resolution of the injury can occur; if not, the patient either dies or has chronic disease.

A patient is receiving mechanical ventilation with a fraction of inspired oxygen (Fio 2) of 85%. The health care provider has prescribed the positive end-expiratory pressure (PEEP) to be increased from 10 cm of H 2O to 15 cm of H 2O. If the increase in PEEP is successful, which change will the nurse anticipate being made to the ventilator settings? Increase the tidal volume. Decrease the tidal volume. Increase the oxygen flow rate. Decrease the oxygen flow rate.

Decrease the oxygen flow rate Rationale PEEP is added when patients cannot maintain adequate gas exchange even with high-flow oxygen. The effect of preventing atelectasis should increase arterial blood oxygenation and allow the oxygen flow rate to be decreased. Adding PEEP does not have a direct effect on tidal volume, which is determined by the patient's weight and lung capacity.

A patient requiring mechanical ventilation for treatment of pneumonia becomes agitated, restless, and shows symptoms of respiratory distress. The mechanical ventilator high-pressure alarm has been activated. Which action would the nurse take? A. Medicate the patient with a sedating agent. B. Increase oxygen delivery to 100% through the ventilator. C. Check the mechanical ventilator data for possible causes of the alarm. D. Disconnect the ventilator, and provide ventilation with a self-inflating bag.

Disconnect ventilator, and provide ventilation with a self inflating bag Rationale When a patient shows signs of respiratory distress while being mechanically ventilated, the nurse should focus on the patient, not the mechanical ventilator. The first best action is to disconnect the ventilator and use a self-inflating bag to ventilate the patient while problem solving the cause of the alarm. Although it may be necessary to administer sedation to the patient, the nurse must attempt to stabilize the patient first. The nurse should not increase oxygen through the ventilator until the cause of the alarm is determined.

A patient recovering from a pulmonary embolism is receiving low-molecular-weight heparin and warfarin. The patient's international normalized ratio (INR) was 2.1 yesterday and is 2.4 today. After reporting today's laboratory value to the health care provider, the nurse would anticipate which prescription? A. Discontinue the heparin, and continue the warfarin. B. Discontinue the warfarin, and administer phytonadione. C. Discontinue the heparin, and administer protamine sulfate. D. Continue the heparin and warfarin, and repeat the INR in 1 day.

Discontinue heparin, and continue the warfarin Rationale The patient will typically take both drugs until the INR is more than 2.0 for 24 hours and then will stop taking the heparin. Patients may take warfarin for 3 to 6 weeks or indefinitely. There is no need to administer protamine sulfate or phytonadione, which are antidotes for heparin and warfarin, because the INR is within desired limits to prevent clotting.

A patient being treated for a pulmonary embolism is receiving heparin, oxygen, and IV fluids. The nurse notes a persistent blood pressure of 88/58 mm Hg and a urine output of 20 mL/hr. Which medication would the nurse anticipate will be prescribed? Vitamin K Dobutamine Protamine sulfate Aminocaproic acid

Dobutamine Rationale Patients who have persistent hypotension with a pulmonary embolism may be given an inotropic agent such as dobutamine to improve cardiac output. Vitamin K is the antidote for warfarin, protamine sulfate is the antidote for heparin, and aminocaproic acid is the antidote for fibrinolytic therapy.

A patient reports a sudden onset of shortness of breath; a sharp, stabbing chest pain; and a feeling of apprehension. The nurse auscultates crackles in both lungs and assesses tachypnea and an oxygen saturation of 88%. After notifying the Rapid Response Team, the nurse would take which action next? A. Prepare to give IV heparin and obtain venous access. B. Reassure the patient, and continue to assess for other symptoms. C. Elevate the head of the bed, and assemble oxygen delivery equipment. D. Prepare the patient for a chest x-ray, and apply telemetry monitoring equipment.

Elevate the head of the bed, and assemble oxygen delivery equipment Rationale Shortness of breath; a sharp, stabbing chest pain; and a feeling of apprehension are symptoms of pulmonary embolism. The nurse's initial intervention after activating the Rapid Response Team will be to elevate the head of the bed and prepare to give oxygen. Heparin, venous access, chest x-ray, and telemetry require prescriptions. Reassurance and assessment of symptoms are ongoing.

A patient receiving mechanical ventilation and anticoagulant medication after experiencing a pulmonary embolism appears tense and is unable to sleep or rest. Which action should the nurse take? A. Request a prescription for pain medication, and remind the patient to report discomfort. B. Ask the health care provider if conscious sedation may be administered to help the patient rest. C. Explain all interventions to the patient, and provide reassurance that care is appropriate. D. Tell the patient's family that the patient is unstable, and suggest that they remain close by.

Explain all interventions to the patient, and provide reassurance that care is appropriate Rationale 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. The patient's anxiety is not related to pain. A sedative may be prescribed if other comfort measures are not effective; however, conscious sedation is a specific level of analgesia recommended during uncomfortable or painful procedures or when a mechanically ventilated patient is unable to be oxygenated adequately. Family presence may provide comfort; however, telling the patient's family that the patient is unstable will increase the level of anxiety for everyone involved.

Which term describes bleeding into the chest cavity? Stridor Hemothorax Thoracotomy Pneumothorax

Hemothorax Rationale Hemothorax is bleeding into the chest cavity. Stridor is a high-pitched, crowing noise during inspiration caused by laryngospasm or edema around the glottis. Thoracotomy is a surgical incision into the chest wall. Pneumothorax is air in the pleural space causing a loss of negative pressure in chest cavity, a rise in chest pressure, and a reduction in vital capacity, which can lead to lung collapse.

Which assessment finding would the nurse expect in a patient with a tension pneumothorax? Dry, nonproductive cough Crackles in the lung bases Reduced breath sounds bilaterally Hyperresonant sounds on percussion

Hyperresonant sounds on percussion Rationale A common assessment finding in a patient with a tension pneumothorax is hyperresonant sounds on percussion. This occurs because of the trapped air in the pleural space. A dry cough, crackles over the affected area, and reduced breath sounds bilaterally are findings associated with a pulmonary contusion.

A patient with a pulmonary embolism is experiencing anxiety and asks the nurse for a sedative. Which risk would be increased by administering a sedative? A. Increased clotting B. Hypoventilation C. Hyperventilation D. Abnormal bleeding

Hypoventilation Rationale Although a sedative can help manage a patient's anxiety, a health care provider is unlikely to prescribe it to a patient with a pulmonary embolism because sedatives carry the risk for hypoventilation as a side effect. Sedative agents do not carry a risk for increasing clots. Anticoagulants, not sedatives, may cause abnormal bleeding. Sedative agents slow, not quicken, breathing, so they are unlikely to cause hyperventilation.

Which patient condition indicates a need for immediate intubation? A. Oxygen (O 2) saturation of 90% B. Difficulty swallowing oral secretions C. Thick, purulent secretions and crackles D. Hypoventilation and decreased breath sounds

Hypoventilation and decreased breath sounds Rationale 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 O 2 saturation of less than 90% and other symptoms of hypoxemia or hypercarbia if oxygen supplementation is not effective.

Which patient problem would be the focus of initial nursing interventions for a patient admitted with a pulmonary embolism (PE)? A. Risk for impaired skin integrity B. Insufficient knowledge related to the cause of PE C. Hypoxemia related to ventilation-perfusion mismatch D. Inadequate nutrition related to food-drug interactions

Hypoxemia related to ventilation -perfusion mismatch Rationale Restoring adequate oxygenation and tissue perfusion takes priority when a patient presents with a PE. Although nutrition must be addressed, priorities include airway, breathing, and circulation. Interventions for skin integrity will be addressed after the patient's oxygenation is stabilized. Education as to the cause of PE must be postponed until oxygenation and hemodynamic stability occur.

Which condition manifests as delirium in patients on mechanical ventilation?

ICU psychosis -use of mechanical ventilation for a patient in the ICU can cause anxiety and delirium

A patient with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation. Which outcome would be supported by the plan to turn the patient every 2 hours? A. Reduce lung fibrosis B. Increase gas exchange C. Enhance blood clotting D. Improve lung compliance

Increase gas exchange Rationale Positioning may be important in promoting gas exchange in patients with ARDS, but the exact position is controversial. Manually turning the patient every 2 hours has been shown to improve perfusion. Turning the patient does not affect lung compliance or reduce lung fibrosis. Turning helps prevent thrombophlebitis, or clots, from developing.

A 154-lb (70-kg) patient receiving manual ventilation is becoming agitated and restless. The nurse determines that the endotracheal tube is in place and notes an oxygen saturation of 97%. Ventilator settings include a pressure of 12 cm H 2O, a tidal volume of 600 mL, and a flow rate of 30 L/min. Which action would the nurse take? A. Reassure the patient that this is typical of "ICU psychosis." B. Contact the health care provider to discuss increasing the tidal volume. C. Increase the oxygen flow rate, and reassess the patient. D. Notify the health care provider that this patient is ready to be weaned from the ventilator.

Increase oxygen, and reassess the patient Rationale 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 who is a lifetime smoker and obese and has a previous history of thromboembolism is preparing to have major surgery that will require prolonged immobility. Past treatments with anticoagulant medications caused serious bleeding. Which management strategy would the nurse expect the health team to recommend for this patient? A. Embolectomy B. Fibrinolytic therapy C. Anticoagulant therapy D. Inferior vena cava filtration

Inferior vena cava filtration Rationale High-risk patients with a previous history of thromboembolism and bleeding with anticoagulant therapy can have a vena cava filtration device placed to prevent clots from reaching the lungs. Anticoagulant therapy is contraindicated in this patient because of the previous history of bleeding. Embolectomy is a surgical procedure to remove clots when a massive clot or multiple clots are present, causing shock. Fibrinolytic therapy also carries a risk for bleeding.

A patient sitting upright and receiving high-flow oxygen with a nonrebreather mask appears anxious and has a respiratory rate of 30 breaths/min, a heart rate of 110 beats/min, and an oxygen saturation of 88%. The patient is using accessory muscles to breathe and appears fatigued. For which procedure would the nurse prepare to assist? A. Insertion of an oral or nasal airway B. Chest x-ray and arterial blood gases C. Intubation and mechanical ventilation D. Thoracostomy and chest tube insertion

Intubation and mechanical ventilation Rationale The patient is hypoxic despite receiving oxygen and is showing signs of increasing distress and fatigue; intubation and mechanical ventilation are necessary to treat respiratory failure in this patient. A chest x-ray and arterial blood gases may be performed after the patient is stabilized as part of the ongoing assessment. An oral airway is used when the patient cannot maintain a patent airway. A thoracostomy and chest tube insertion would be performed for signs of a pneumothorax.

Which action describes paradoxical chest wall movement? Bilateral separation of the ribs from their cartilage Deviation of the trachea away from the side of the injury Forceful entry of air into the chest cavity causing lung collapse Inward movement of the thorax during inspiration

Inward movement of the thorax during inspiration Rationale 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.

A patient is refusing to wear pneumatic compression stockings while in bed, stating he does not like how they feel and they keep him awake. Which response would the nurse provide? A. "Let me talk to the health care provider about discontinuing them." B. "Would you like me to give you medication to help you sleep?" C. "It is important to wear them in bed so you don't develop a blood clot in your legs." D. "I'll give you a break from them for an hour, but then I'll need to put them back on."

It's important to wear them in bed so you don't develop a blood clot in your legs Rationale The continuous use of antiembolism and pneumatic compression stockings is an essential intervention in the prevention of venous thromboembolism. Providing education to patients may help with their refusal to wear compression stockings. It may be necessary to request a prescription for a sleep aid, but this is not the best response.

When caring for a patient who is receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action would the nurse take first? Assess the set tidal volume. Call the respiratory therapist. Check the ventilator alarm settings. Listen to the patient's breath sounds.

Listen to the patient's breath sounds Rationale A typical reason for the high-pressure alarm to sound is the need for suctioning or tension pneumothorax. The nurse should begin the assessment with the patient, not with the ventilator. Although an excessively high tidal volume could contribute to sounding of the high-pressure alarm, assessment always begins with the patient. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention.

Which activity would the nurse recommend that the patient avoid for several hours after extubation? A. Using supplemental oxygen B. Lying supine to rest C. Using the spirometer D. Taking deep breaths

Lying supine to rest Rationale The patient should sit in a semi-Fowler position rather than lying down for resting after extubation because it reduces the risk for fluid accumulation and aspiration immediately after extubation. The patient who has recently been extubated is likely to require supplemental oxygen. Using the spirometer every 2 hours promotes gas exchange and is advisable. Taking deep breaths every half-hour improves gas exchange.

Which procedure is associated with a patient developing ICU psychosis?

Mechanical ventilation

Which Fowler position is recommended for a patient with a pulmonary contusion? Low Fowler High Fowler Standard Fowler Moderate Fowler

Moderate Fowler Rationale The patient with a pulmonary contusion is placed in a moderate-Fowler position to maintain ventilation and oxygenation. Low-, high-, and standard-Fowler positions do not ensure proper respiration and are not suitable.

A postoperative patient exhibits a sudden onset of shortness of breath accompanied by syncope when getting up to a chair. The nurse assists the patient into the bed and performs an assessment that reveals a heart rate of 110 beats/min and a blood pressure of 88/56 mm Hg. The patient appears cyanotic and has distended neck veins. Which action would the nurse take first?

Notify the Rapid Response Team Rationale A patient at risk for pulmonary embolism (PE) with the symptom cluster described should be assumed to have a PE, and the Rapid Response Team should be called. Once this is done, the nurse should continue assessing the patient and administer oxygen.

Which factor increases a patient's risk for a venous thromboembolism (VTE)? Select all that apply. One, some, or all responses may be correct. A. Obesity B. Malnutrition C. Advancing age D. Vitamin deficiency E. Prolonged immobility

Obesity, Advancing age, Prolonged immobility Rationale In VTE, blood tends to clot in the veins. Obesity contributes to the deposition of cholesterol in the veins, leading to clot formation. The elasticity of veins decreases with age, which leads to clot formation. Prolonged immobility increases the risk for VTE because of venous pooling. Malnutrition and vitamin deficiency are not risk factors for VTE; they are not associated with functions related to blood vessels and blood clotting mechanisms.

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. Which action would the nurse take? A. Notify the Rapid Response Team. B. Request an order for a chest x-ray. C. Obtain an order for arterial blood gases. D. Apply high-flow oxygen with a Venturi mask.

Obtain an order for ABG Rationale 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 or 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.

A patient receiving mechanical ventilation has had the positive end-expiratory pressure (PEEP) decreased from 10 cm H 2O to 5 cm H 2O. Which change in the patient's status would prompt the nurse to notify the health care provider? Breath sounds are distant over both lung bases. The patient is requiring more frequent suctioning. Oxygen saturation decreases from 95% to 80%. The patient is coughing up more sputum.

Oxygen saturation decreases from 95% to 80% Rationale PEEP is used to improve oxygenation and reduce atelectasis. A drop in oxygen saturation when PEEP is reduced should be reported to the health care provider because oxygenation may not be effective. The decrease in breath sounds may be related to the reduction in PEEP, but it is less urgent than the change in oxygenation. Increased secretions and coughing are not abnormal when PEEP is reduced during mechanical ventilation.

A patient with acute respiratory distress syndrome (ARDS) is being mechanically ventilated. The health care provider has prescribed10 cm H 2O of positive end-expiratory pressure (PEEP). Which data would inform the nurse that the PEEP was effective? Urine output increases to 45 mL/hr. Heart rate increases from 96 beats/min to 110 beats/min. c Blood pressure decreases from 120/80 mm Hg to 92/65 mm Hg.

Oxygen saturation increases from 85% to 92%. Rationale The patient with ARDS often requires intubation and mechanical ventilation with PEEP. PEEP improves oxygenation by enhancing gas exchange and preventing atelectasis. An improvement in oxygen saturation would be used to evaluate the effectiveness of adding PEEP to the patient's mechanical ventilation mode. Improving the patient's oxygenation status would help to stabilize the vital signs, not cause tachycardia or hypotension. Adjusting the patient's PEEP would not alter the urine output.

The nurse assists with the intubation of an 176-lb (80-kg) patient who will receive mechanical ventilation on assist/control mode with positive end-expiratory pressure (PEEP). Which ventilator setting would the nurse expect to be maintained over the next shift? Fraction of inspired oxygen (Fio 2) as high as possible Tidal volume of 400 mL Oxygen flow rate of 20 L/min PEEP between 5 and 15 cm H 2O

PEEP between 5 and 15 cm H 2O Rationale Patients receiving PEEP ventilation should have pressure settings between 5 and 15 cm H 2O. Because prolonged use of high Fio2 can damage lungs, the Fio 2 should be lowered to the lowest possible amount. The oxygen flow rate should be 40 L/min. The patient's tidal volume should be 6 to 8 mL/kg; for this patient, the range would be 480 to 640 mL.

Which information would the nurse communicate to the family of a patient who is receiving mechanical ventilation? A. "Paralytic and sedative medications help decrease the demand for oxygen." B. "Suctioning is important to remove organisms from the lower airway." C. "We are encouraging oral and IV fluids to keep your loved one hydrated." D. "Sedation is needed so your loved one does not remove the breathing tube."

Paralytic and sedative meds help decrease the demand for oxygen Rationale Paralytics and sedation decrease oxygen demand. Sedation is needed more for its effects on oxygenation than to prevent the patient from removing the endotracheal tube. Suctioning is performed to maintain airway patency. Oral fluids would increase the risk for aspiration and pneumonia while an artificial airway and mechanical ventilation are in use. p. 596

A patient has developed a pulmonary embolism. Which laboratory test would the nurse anticipate being prescribed before beginning heparin therapy?

Partial thromboplastin time (PTT) A baseline PTT should be obtained before the administration of heparin

Which critically ill patient is at high risk for developing acute respiratory distress syndrome (ARDS)? A. Patient with atrial fibrillation B. Patient with acute kidney failure C. Patient with aspiration pneumonia D, Patient with diabetic ketoacidosis (DKA)

Patient with aspiration pneumonia Aspiration of acidic gastric contents is a risk for ARDS. Patients with DKA may develop metabolic acidosis, but not ARDS, which develops in lung injury. Atrial fibrillation does not cause lung injury unless embolization occurs. Acute kidney failure results in metabolic acidosis, not in acute lung injury.

Which comfort measure would the nurse plan to use for a patient who has orthopnea? A. Place in upright position B. Encourage frequent ambulation C. Suggest an order for bronchodilator D. Provide low-flow oxygen by nasal cannula

Place the patient in an upright position to facilitate breathing Patients who have orthopnea have increased dyspnea when lying down and should be placed in an upright position to facilitate breathing. Dyspnea that occurs with exercise may be managed by a gradual increase in activity. The patient with orthopnea is not necessarily hypoxic and does not need oxygen unless oxygen saturation or blood gas measures indicate hypoxia. Patients who have wheezing may need bronchodilator therapy.

A patient formerly on synchronous intermittent mandatory ventilation is placed on a T-piece to begin weaning from mechanical ventilation. Seven minutes later, the patient's oxygen saturation decreases from 90% to 70%, and the patient becomes tachycardic, diaphoretic, and anxious. Which action would the nurse take? A. Call the Rapid Response Team. B. Instruct the patient to breathe deeply and try to relax. C. Give sedation medication to help the patient continue the weaning. D. Place the patient back on the recent mechanical ventilator settings.

Place the pt back on the recent mechanical ventilator setting Rationale The patient is showing signs of distress with the weaning process; the nurse should place the patient back on the ventilator or facilitate the process for having mechanical ventilator support reinitiated. The anxiety is a response to hypoxemia; a patient who has reached this level of distress is unlikely to be able to breathe more deeply or relax in response to instructions. A Rapid Response Team call is not indicated because weaning is a controlled process and the health care team works closely together to monitor the patient's tolerance of weaning and reinitiating mechanical ventilation. Giving sedation agents will decrease the patient's drive to breathe.

A patient who has been admitted for a pulmonary embolism is receiving a heparin infusion. Which laboratory result would the nurse monitor to detect a possible complication of heparin therapy?

Platelet count

A patient has been receiving heparin subcutaneously for 4 days. For which laboratory value would the nurse contact the health care provider? A. Hemoglobin of 14.2 g/dL B. Platelet count of 50,000/mm 3 C. International normalized ratio (INR) of 1.1 D. Activated partial thromboplastin time of 35 seconds

Platelet count of 50,000/mm3 Rationale The normal range for platelets is 200,000/mm 3 to 400,000/mm 3. Platelets are needed for blood clotting. This patient's platelet count is extremely low, and he or she is at risk for bleeding. The low platelet count may be an indication of an adverse reaction to heparin known as heparin-induced thrombocytopenia (HIT). The heparin must be discontinued, and the patient may need to receive platelet therapy before life-threatening hemorrhage occurs. The hemoglobin, INR, and activated partial thromboplastin time values are is normal.

Which term describes air in the pleural space? Stridor Hemothorax Thoracotomy Pneumothorax

Pneumothorax Rationale Pneumothorax is air in the pleural space causing a loss of negative pressure in chest cavity, a rise in chest pressure, and a reduction in vital capacity, which can lead to a lung collapse. Stridor is a high-pitched, crowing noise during inspiration caused by laryngospasm or edema around the glottis. Hemothorax is bleeding into the chest cavity. Thoracotomy is a surgical incision into the chest wall.

A patient who has recently been extubated is hoarse and has a cough. Which action would the nurse take? Suction the patient to remove secretions and encourage deep breathing. Notify the Rapid Response Team that the patient may need to be reintubated. Notify the health care provider, and request a prescription to administer racemic epinephrine. Position the patient in a semi-Fowler position, and continue to monitor.

Position the patient in a semi-Fowler position, and continue to monitor. Rationale Coughing and difficulty clearing secretions are early signs of possible obstruction; the nurse should monitor the patient closely and position the patient in a semi-Fowler position. Stridor is a late sign and signifies an emergency requiring racemic epinephrine and possible reintubation. Suctioning the patient may increase irritation and cause increased swelling of the airway.

Several hours after extubation, the patient reports a sore throat and cough, and the nurse notes a hoarse voice. Which action would the nurse take? A. Notify the Rapid Response Team. B. Prepare for reintubation at the bedside. C. Encourage use of an incentive spirometer. D. Request a prescription for nebulized racemic epinephrine.

Prepare for reintubation at the bedside Rationale The patient is experiencing signs of throat irritation, which are common after extubation. Incentive spirometry is used to prevent atelectasis and 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. Reintubation would be used if the patient could not maintain ventilation.

Which patient needs immediate attention by the nurse? 57-year-old who was recently extubated and is reporting a sore throat 54-year-old who is mechanically ventilated and has tracheal deviation 60-year-old who is receiving oxygen (O 2) by facemask and whose respiratory rate is 24 breaths/min 40-year-old who is receiving continuous positive airway pressure (CPAP) and has intermittent wheezing

Rationale The 54-year-old patient is showing signs of a tension pneumothorax that could lead to decreased cardiac output and shock if not addressed promptly. The 40-year-old patient has intermittent adventitious breath sounds but is not in immediate danger. The 57-year-old patient has mild discomfort but is not in danger of a life-threatening situation. The 60-year-old patient has mild tachypnea but is not in immediate distress or danger.

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. Which action would the nurse take? A. Request a prescription for an antianxiety medication. B. Reassure the patient that the treatment is working. C. Suggest that the patient take deep breaths to relax. D. Increase the oxygen flow to improve oxygen saturation.

Reassure the patient that the treatment is working Rationale The patient with a pulmonary embolism is receiving appropriate treatment and has stable vital signs, so the nurse should stay with the patient and provide assurance that the measures are working. Anxiety is a common response to pulmonary embolism, even when the patient is stable. The patient has adequate oxygen saturation, so increasing the oxygen flow is not indicated. If reassurance is not effective, an antianxiety medication may be necessary at a later time. The patient may not be able to take deep breaths, so this is not recommended as a relaxation technique.

A patient is receiving mechanical ventilation after developing acute respiratory distress syndrome (ARDS) from aspiration pneumonia. The patient's spouse asks the nurse how long it will take the patient to recover. Which response would the nurse provide? A. "Patients eventually recover but require medications indefinitely." B. "Recovery time depends on the severity and progression of symptoms." C. "With appropriate medications and treatments, most patients recover fully." D. "Patients with ARDS have permanent lung damage and require long-term care."

Recovery time depends on the severity and progression of symptoms Rationale The most accurate answer is to tell the family member that the severity and progression of symptoms can indicate recovery chances and length of time to recovery. Not all patients will eventually recover or need medication indefinitely, nor do all patients recover fully, even with aggressive medical and nursing treatment. Permanent lung damage is not always the result of ARDS. Permanent damage is typically seen in those who progress to stage 4 disease.

Which intervention would the nurse plan for reducing anxiety in a patient with a pulmonary embolism (PE)? A. Offer the patient a mild sedative. B. Allow a family member to remain in the room. C. Remain with the patient, and provide oxygen. D. Have the patient breathe into a brown paper bag.

Remain with pt and provide oxygen Rationale The underlying cause for anxiety with a PE is hypoxemia, which will be alleviated by oxygen; remaining with the patient in distress is appropriate. Rebreathing from a brown bag is an intervention that increases partial pressure of arterial carbon dioxide (Paco 2) during hyperventilation, as in a panic attack; it will not provide needed oxygen. Sedation or allowing a family member to stay may calm the patient but will not improve oxygenation.

A patient who is being mechanically ventilated shows increased respiratory distress, including intercostal retractions, anxiety, and restlessness, with an oxygen saturation of 86%. Which action would the nurse perform first? A. Increase the oxygen flow rate and fraction of inspired oxygen (Fio 2) levels. B. Remove the ventilator, and provide manual ventilation. C. Suction the patient via the endotracheal tube. D. Notify the health care provider, and request an order for blood gas evaluation.

Remove the ventilator, and provide manual ventilation Rationale Patients who develop respiratory distress while being mechanically ventilated should be manually ventilated to allow quick assessment of whether the problem is with the ventilator or the patient. Increasing oxygen flow rate and Fio 2 levels, obtaining an order for blood gases, or suctioning may be indicated based on the assessment while manually ventilating the patient.

A patient with pneumonia has a productive cough, dyspnea with ambulation, and increased work of breathing with use of accessory muscles. The patient's oxygen saturation is 92%, and arterial blood gas monitoring reveals a partial pressure of arterial oxygen (PaO 2) of 88 mm Hg. Which condition would the nurse report to the health care provider? Ventilatory failure Respiratory failure Respiratory distress Oxygenation failure

Respiratory distress Rationale This patient has increased work of breathing and dyspnea characteristic of respiratory distress but is still compensating to maintain oxygenation as evidenced by an oxygen saturation of 92% and a PaO 2 of 88 mm Hg. Ventilatory failure is a rise in PaCO 2 (hypercapnia) that occurs when the respiratory load can no longer be supported by the strength or activity of the system. The PaO 2 in respiratory failure would be less than 60 mm Hg. Oxygen failure (hypoxemic respiratory failure) means that you don't have enough oxygen in your blood, but your levels of carbon dioxide are close to normal.

Which action for the care of a patient who has just been extubated would the nurse delegate to assistive personnel (AP)? Adjust the nasal oxygen flow rate. Take vital signs every 5 minutes. Assess the patient's ability to swallow liquids. Teach about incentive spirometer use.

Take vital signs every 5 minutes

Which adverse effect is associated with the use of positive end-expiratory pressure (PEEP)? A. Lung infection B. Ventilatory failure C. Pulmonary embolism D. Tension pneumothorax

Tension pneumothorax PEEP is used to prevent the alveoli from collapsing at the end of expiration. The most serious side effect of PEEP is tension pneumothorax, in which the alveoli rupture and air accumulates in the pleura. Infection is not associated with application of PEEP. PEEP is used for prevention of ventilatory failure. PEEP does not affect the clotting mechanism of the body; pulmonary embolism is not associated with PEEP.

A patient who is on mechanical ventilation is setting off the high-pressure alarm. For which situation would the nurse insert an oral airway? A. The patient has a decreased airway size. B. The patient has increased oral mucus secretions. C. The patient experiences decreased compliance of the lungs. D. The patient is biting on the endotracheal tube.

The patient is biting on the endotracheal tube Rationale Inserting an oral airway helps prevent the patient from biting on the oral endotracheal tube. The high-pressure alarm may sound because of decreased airway size, increased mucus secretions, or decreased compliance of the lungs, but none of these problems can be solved by the insertion of an oral airway. 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 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? A. The patient has bloody sputum and expiratory wheezes. B. The chest caves in on inspiration and "puffs out" on expiration. C. The trachea is deviated to the right side, and cyanosis is present. D. The left lung field is dull to percussion with crackles on auscultation.

The trachea is deviated to the right side, and cyanosis is present Rationale Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention (JVD), cyanosis, and hyperresonance to percussion over the affected area. Flail chest is manifested by paradoxical chest movement, which consists of "sucking inward" of the loose chest area during inspiration and puffing out of the same area during expiration. Open pneumothorax presents with decreased breath sounds, hyperresonance, and poor respiratory excursion on the affected side. Pulmonary contusion presents with hemoptysis, dullness to percussion, and crackles or wheezes.

The nurse is explaining thrombolytic therapy to a patient. Which information would the nurse include? A. "You will receive a dose of enoxaparin IM for 3 days." B. "Therapy with warfarin is effective when your international normalized ratio (INR) is between 2 and 3." C. "If bleeding develops, we will give you platelets to reverse the anticoagulant." D. "As soon as the health care provider prescribes warfarin, we will stop the IV heparin."

Therapy with warfarin is effective when your INR is between 2 and 3 Rationale The INR, a measurement of anticoagulation with warfarin, is in the therapeutic range between 2 and 3. Enoxaparin is a low-molecular-weight heparin that is usually given by the subcutaneous route. Heparin and warfarin are overlapped until the INR is in the therapeutic range; then the heparin can be discontinued. Fresh-frozen plasma is used as an antidote for anticoagulant therapy, not platelets.

A patient who had knee surgery 2 days ago now has extreme shortness of breath, agitation, and apprehension. A heart rate of 119 beats/min and a respiratory rate of 24 breaths/min with an oxygen saturation of 84% are also noted. Which condition would the nurse suspect?

Venous thromboemboli are a potential complication after orthopedic surgery. Shortness of breath, agitation, apprehension, tachycardia, and a decreased oxygen saturation are findings consistent with a pulmonary embolism. Anaphylaxis and bronchospasm are characterized by wheezing. Pneumothorax is characterized by absent breath sounds on the affected side.

A patient who is intubated and on mechanical ventilation develops respiratory distress. Which action would the nurse take first? A. Arrange to have arterial blood gases drawn. B. Activate the hospital's Rapid Response Team. C. Notify the health care provider, and monitor the patient's saturated arterial oxygen (Sao 2). D. Ventilate the patient using a bag-valve-mask device.

Ventilate the patient using a bag valve mask device Rationale 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. Arterial blood gases may provide useful information later but will not help with determining the immediate actions.

A patient is being mechanically ventilated via synchronized intermittent mandatory ventilation with a set rate of 10 breaths/min. The patient is sedated and not breathing spontaneously. The most recent arterial blood gas (ABG) results are: pH = 7.32; partial pressure of arterial oxygen (PaO 2) = 85 mm Hg; and partial pressure of arterial carbon dioxide (PaCO 2) = 55 mm Hg. What is the nurse's interpretation of these results? Ventilation is adequate to maintain oxygenation. Ventilation is excessive; respiratory alkalosis is present. Ventilation is inadequate; respiratory acidosis is present. Ventilation status cannot be determined from the information presented.

Ventilation is inadequate; respiratory acidosis is present. Rationale The PaCO 2 indicates the patient is not effectively ventilating and more frequent or larger breaths are necessary. The settings of the ventilator are causing hypoventilation and respiratory acidosis. If the ventilation was adequate, the PaCO 2 would be within normal limits. If the ventilation was excessive, the PaCO 2 would be below normal. The PaCO 2 is sufficient information to determine ventilation.

A patient with an acute exacerbation of asthma exhibits wheezing, dyspnea, and intercostal retractions. An arterial blood gas shows partial pressure of arterial oxygen (PaO 2) of 55 mm Hg, a partial pressure of arterial carbon dioxide (PaCO 2) of 50 mm Hg, and a pH of 7.25. Which condition is this patient experiencing? A. Ventilatory failure B. Oxygenation failure C. Acute respiratory distress syndrome D. Ventilatory and oxygenation failure

Ventilatory and oxygenation failure Rationale Patients with chronic obstructive diseases such as asthma may develop oxygenation failure because of diseased airways and subsequent increased work of breathing that progresses to ventilatory failure. This patient is demonstrating hypercapnia and hypoxia and acidosis. Ventilatory failure causes hypercapnia. Oxygenation failure causes hypoxemia. Acute respiratory distress syndrome is a cause of oxygenation failure.

Which drug is an antidote for warfarin?

Vit K

A patient who has a pulmonary embolism is very anxious. In which situation would the nurse expect the health care provider to prescribe sedation for the patient?

When the pt is mechanically ventilated Rationale A health care provider may prescribe sedation to a patient with pulmonary embolism who is mechanically ventilated. Even if the patient reports pain, is unable to sleep, or will not cooperate for diagnostic testing, sedation may result in hypoventilation, so it is contraindicated for this patient.

volutrauma

when excess volume of ventilation is delivered to only one lung

Which blood gas result would the nurse anticipate early in the course of pulmonary embolism (PE)? pH 7.24, partial pressure of arterial carbon dioxide (PaCo 2) 55 mm Hg, bicarbonate (HCO 3 -) 26 mEq/L, partial pressure of arterial oxygen (Pao 2) 56 mm Hg pH 7.46, PaCo 2 30 mm Hg, HCO 3 - 26 mEq/L, Pao 2 68 mm Hg pH 7.35, PaCo 2 45 mm Hg, HCO 3 - 24 mEq/L, Pao 2 80 mm Hg pH 7.47, PaCo 2 35 mm Hg, HCO - 30 mEq/L, Pao 2 75 mm Hg

pH 7.46, PaCo 2 30 mm Hg, HCO 3 - 26 mEq/L, Pao 2 68 mm Hg Rationale Hyperventilation triggered by hypoxia and pain first leads to respiratory alkalosis, indicated by a low PaCo 2 of 30 and a high pH of 7.46. No compensation is present because the HCO 3- of 26 is normal and hypoxemia is present, consistent with PE. A pH of 7.24 is acidotic, a Pao 2 of 56 reflects hypoxemia, and no compensation is present with a normal HCO 3- of 26; this blood would be found in a person in acute respiratory failure because of hypoventilation and hypoxemia. A pH between 7.35 and 7.45, PaCo 2 of 35 to 45, HCO 3- of 22 to 26, and Pao 2 greater than 75 all reflect a normal blood gas. A pH of 7.47 and an HCO 3- of 30 are alkalotic, indicating metabolic alkalosis; a PaCo 2 of 35 is normal (indicating lack of compensation), and a Pao 2 of 75 is normal.

Oropharyngeal airway

used to prevent the tongue from occluding the airway or the patient from biting the endotracheal tube

Assist-control

ventilation continues to deliver a preset tidal volume, even when the pt's spontaneous breathing rate increases