Ch 19
The nurse is discussing the pharmacologic treatment of a pulmonary embolism (PE) with a nursing student. Which statement made by the nursing student indicates that the education was effective? "Heparin is administered to break down the existing clots." "Heparin is titrated to achieve a prothrombin time of two to three times the control value." "Heparin should be continued until the warfarin is started." "rt-PA can be used to treat patients with massive pulmonary embolism and hemodynamic instability."
"rt-PA can be used to treat patients with massive pulmonary embolism and hemodynamic instability." Recombinant tissue-type plasminogen activator (rt-PA) is a fibrinolytic reserved for severe pulmonary embolism (PE). Heparin is administered to prevent further clots from forming and has no effect on the existing clot. The heparin should be adjusted to maintain the activated partial thromboplastin time (aPTT) in the range of two to three times of upper normal. Warfarin should be started at the same time, and when the international normalized ratio (INR) reaches 3.0, the heparin should be discontinued. The INR should be maintained between 2.0 and 3.0
Which patient would most benefit from noninvasive positive pressure ventilation (NIPPV) to promote oxygenation? A patient whose cardiac output and blood pressure are unstable A patient whose respiratory failure is due to a head injury with loss of consciousness A patient with a diagnosis of cystic fibrosis and who is currently producing copious secretions A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis
A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis NIPPV such as continuous positive airway pressure (CPAP) is most effective in treating patients with respiratory failure resulting from chest wall and neuromuscular disease. It is not recommended in patients who are experiencing hemodynamic instability, decreased level of consciousness, or excessive secretions.
A patient is admitted with shortness of breath. Temperature is 39.5° C, blood pressure is 160/82 mm Hg, heart rate is 115 beats/min, and respiratory rate is 26 breaths/min. Chest radiography confirms the presence of right upper lobe pneumonia. Arterial blood gases reveal the following:pH 7.27PaCO2 64 mm HgHCO3 33 mEq/LPaO2 50 mm HgThese findings are indicative of which disorder? Obstructive lung disease Acute lung failure Restrictive lung disease Acute respiratory distress syndrome
Acute lung failure Diagnosing and following the course of respiratory failure is best accomplished by arterial blood gas (ABG) analysis. ABG analysis confirms the level of PaCO2, PaO2, and blood pH. Acute lung failure is generally accepted as being present when the PaO2 is less than 60 mm Hg. If the patient is also experiencing hypercapnia, the PaCO2 will be greater than 45 mm Hg. In patients with chronically elevated PaCO2 levels, these criteria must be broadened to include a pH less than 7.35.
A patient is in acute respiratory distress syndrome (ARDS) as a result of sepsis. Which measure would be implemented to maintain cardiac output? Administer crystalloid fluids. Position the patient in the Trendelenburg position. Place the patient on fluid restriction and administer diuretics. Perform chest physiotherapy and assist with staged coughing.
Administer crystalloid fluids. Low cardiac output may necessitate crystalloid fluids in addition to lowering positive end-expiratory pressure (PEEP) or administering inotropes. The Trendelenburg position (not recommended to treat hypotension) and chest physiotherapy are unlikely to relieve decreased cardiac output, and fluid restriction and diuresis would be inappropriate interventions.
A mechanically ventilated patient has a fever, P/F ratio of 230, and a pulmonary artery occlusive pressure of 15 mm Hg. The patient is coughing and triggering the high-pressure alarm on the ventilator. The radiologist has notified the nurse that the patient's feeding tube is in the right lung, and the patient has developed bilateral infiltrates on the radiograph. The nurse is concerned that the patient is developing what problem? Acute pulmonary embolism Adult respiratory distress syndrome Pneumothorax Inadequate nutrition
Adult respiratory distress syndrome The patient is showing signs of acute respiratory distress syndrome brought on by the direct lung injury from the misplaced feeding tube. There is no evidence of a pulmonary embolism. A pneumothorax would have shown up on the radiograph as a unilateral problem, not a diffuse infiltrate. Nutrition is not the immediate concern at this moment.
The nurse is admitting a 45-yr-old patient with asthma in acute respiratory distress. The nurse auscultates the patient's lungs and notes cessation of the inspiratory wheezing. The patient has not yet received any medication. What should this finding suggest to the nurse? Spontaneous resolution of the acute asthma attack An acute development of bilateral pleural effusions Airway constriction requiring immediate interventions Overworked intercostal muscles resulting in poor air exchange
Airway constriction requiring immediate interventions When a patient in respiratory distress has inspiratory wheezing and then it ceases, it is an indication of airway obstruction. This finding requires emergency action to restore airway patency. Cessation of inspiratory wheezing does not indicate spontaneous resolution of the acute asthma attack, bilateral pleural effusion development, or overworked intercostal muscles in this asthmatic patient that is in acute respiratory distress.
Mr. Z is admitted with acute lung failure. Which statement describes appropriate action for optimizing his oxygenation and ventilation? Place Mr. Z in a supine position. Allow Mr. Z to rest in between nursing interventions. Perform vigorous postural drainage and chest percussion to facilitate secretion clearance. Make sure Mr. Z coughs every 2 hours even if he has no secretions.
Allow Mr. Z to rest in between nursing interventions. Allowing adequate rest between nursing interventions will minimize oxygen consumption. The supine position is not advantageous because of the risk of aspiration. Postural drainage and chest percussion have been found to be of little benefit, and coughing, unless secretions need to be expelled, should be avoided because it causes collapse of the smaller airways.
A patient has been in the progressive care unit for 3 days with a diagnosis of pneumonia. The patient is being treated with antibiotics, 50% oxygen, and vigorous pulmonary toilet. Which diagnostic testing result would indicate early progression of the patient's condition to acute respiratory distress syndrome? PaO2/FiO2 ratio of 325 Arterial PaO2 of 58 mm Hg Arterial PaCO2 of 58 mm Hg Arterial blood pH of 7.29
Arterial PaO2 of 58 mm Hg Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen administration (refractory hypoxemia). The drop in PaO2 is attributable to intrapulmonary shunting secondary to compression, collapse, and flooding of the alveoli and small airways. Initially, the PaCO2 is low as a result of hyperventilation, but eventually the PaCO2 increases as the patient fatigues. The pH is high initially but decreases as respiratory acidosis develops. A ratio of partial pressure of oxygen (PaO2) to fraction of inspired oxygen (FiO2) less than or equal to 300 mm Hg is indicative of acute lung injury.
A patient with pneumonia has been in the unit for 3 days. The medical plan includes antibiotics and oxygen therapy. Which finding would indicate the patient is developing acute respiratory distress syndrome (ARDS)? Sputum cultures are positive for Streptococcus pneumoniae. Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen. Chest radiography shows evidence of pulmonary hypertension. High probability ventilation-perfusion scan.
Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen. Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen administration (refractory hypoxemia). Positive sputum cultures are indicative of pneumonia. Pulmonary hypertension is not indicative of acute respiratory distress syndrome (ARDS). A high probability ventilation-perfusion scan is indicative of a pulmonary embolism. Initially, the PaCO2 is low as a result of hyperventilation, but eventually, the PaCO2 increases as the patient fatigues. The pH is high initially but decreases as respiratory acidosis develops. Initially, the chest radiography findings may be normal because changes in the lungs do not become evident for up to 24 hours. As the pulmonary edema becomes apparent, diffuse, patchy interstitial and alveolar infiltrates appear. This progresses to multifocal consolidation of the lungs, which appears as a "whiteout" on the chest radiographs.
When caring for older adult patients with respiratory failure, the nurse will add which intervention to individualize care? Position the patient in the supine position primarily. Assess frequently for signs and symptoms of delirium. Provide early endotracheal intubation to reduce complications. Delay activity and ambulation to provide additional healing time.
Assess frequently for signs and symptoms of delirium. Older adult patients are more predisposed to factors such as delirium, health care associated infections, and polypharmacy. Individualizing the older patient's care plan to address these factors will improve care. Older adult patients are not required to remain in a supine position only and should increase activity as soon as stability is determined. Endotracheal intubation is not provided early, and noninvasive positive pressure ventilation may be considered as an alternative. The nurse should consider that the aging process leads to decreased lung elastic recoil, weakened lung muscles and reduced gas exchange, which may make the patient difficult to wean from the ventilator.
The nurse is providing care for an older adult patient who is experiencing low partial pressure of oxygen in arterial blood (PaO2) as a result of worsening left-sided pneumonia. Which intervention should the nurse use to help the patient mobilize his secretions? Augmented coughing or huff coughing Positioning the patient side-lying on his left side Frequent and aggressive nasopharyngeal suctioning Application of noninvasive positive pressure ventilation (NIPPV)
Augmented coughing or huff coughing Augmented coughing and huff coughing techniques may aid the patient in the mobilization of secretions. If positioned side-lying, the patient should be positioned on his right side (good lung down) for improved perfusion and ventilation. Suctioning may be indicated but should always be performed cautiously because of the risk of hypoxia. NIPPV is inappropriate in the treatment of patients with excessive secretions.
When caring for a patient, the nurse assesses tachypnea, a cough, and restlessness. The lung sounds have fine, scattered crackles, and the chest x-ray shows new bilateral interstitial and alveolar infiltrates. The nurse is aware that the patient may have an acute lung injury (ALI). In what order does the nurse expect the physiologic changes of acute respiratory distress syndrome (ARDS)to occur if it happens with this patient? (Answer with a letter followed by a comma and a space (e.g. A, B, C, D).) a. Atelectasisb. Interstitial edemac. Refractory hypoxemiad. Surfactant dysfunctione. Increased inflammatory responsef. Decreased gas exchange surface area
B, D, A, C, E, F In the injury or exudative phase of ARDS (1-7 days after acute lung injury), there is interstitial edema and surfactant dysfunction that lead to atelectasis. Widespread atelectasis decreases lung compliance, hyaline membranes form, and refractory hypoxemia occurs. In the reparative or proliferative phase (1-2 weeks after acute lung injury), there is an increased inflammatory response which worsens hypoxia. In the fibrotic phase (2-3 weeks after acute lung injury), the lung tissue is remodeled by collagen and fibrous tissue, which decreases the available surface area for gas exchange.
The nurse is caring for a 37-yr-old female patient with multiple musculoskeletal injuries who has developed acute respiratory distress syndrome (ARDS). Which intervention should the nurse initiate to prevent stress ulcers? Observe stools for frank bleeding and occult blood. Maintain head of the bed elevation at 30 to 45 degrees. Begin enteral feedings as soon as bowel sounds are present. Administer prescribed lorazepam (Ativan) to reduce anxiety.
Begin enteral feedings as soon as bowel sounds are present. Stress ulcers prevention includes early initiation of enteral nutrition to protect the gastrointestinal (GI) tract from mucosal damage. Antiulcer agents such as histamine (H2)-receptor antagonists, proton pump inhibitors, and mucosal protecting agents are also indicated to prevent stress ulcers. Monitoring for GI bleeding does not prevent stress ulcers. Ventilator-associated pneumonia related to aspiration is prevented by elevation of the head of bed to 30 to 45 degrees Stress ulcers are not caused by anxiety. Stress ulcers are related to GI ischemia from hypotension, shock, and acidosis.
A patient has been admitted following a motor vehicle collision in which the patient sustained multiple abrasions and bruising across the chest. Suddenly, the patient complains of difficulty breathing, the O2 saturation has dropped dramatically, there are decreased breath sounds on the left, and it appears that there is some tracheal deviation. What would be your next logical action? Notify the patient's practitioner and prepare for a stat V/Q scan. Start the patient on O2 at 4 L/min nasal cannula and prepare an aminophylline drip. Call the rapid response team and prepare for emergency insertion of a chest tube. Notify the patient's practitioner of these changes.
Call the rapid response team and prepare for emergency insertion of a chest tube. The signs and symptoms are classic indications of development of a pneumothorax. The characteristics that particularly differentiate this diagnosis are the bruising on the chest after motor vehicle accident (MVA) and the deviated trachea.
The sputum culture obtained on admission shows Streptococcus pneumoniae in a patient with a history of coronary artery disease and alcoholism. The nurse suspects the patient has developed which problem? Hospital-acquired pneumonia (HAP) Community-acquired pneumonia (CAP) Health care associated pneumonia Ventilator-associated pneumonia (VAP)
Community-acquired pneumonia (CAP) The patient has community-acquired pneumonia (CAP). The culture was obtained on admission, S. pneumoniae is a commonly acquired pathogen, and the patient has comorbidities that could lead to CAP. The patient was not in the hospital longer than 48 hours or on the ventilator, and there is no mention of the radiography report describing the location of the pneumonia
Which statement is true regarding status asthmaticus? Initial arterial blood gas levels indicate severe hypoxemia and respiratory acidosis. Low-flow oxygen therapy should be used cautiously in patients with asthma. Small, frequent doses of bronchodilators should be started immediately. Corticosteroids, although useful in the treatment of status asthmaticus, usually require 6 to 8 hours to take effect.
Corticosteroids, although useful in the treatment of status asthmaticus, usually require 6 to 8 hours to take effect. The onset of action of corticosteroids is 6 to 8 hours. A patient in status asthmaticus often initially presents with alkalosis caused by tachypnea and hyperventilation, but as fatigue sets in, hypoventilation and hypercapnia result in acidosis. These patients often require high-flow oxygen therapy and high-dose bronchodilators.
The patient has pulmonary fibrosis and experiences hypoxemia during exercise but not at rest. To plan patient care, the nurse should know the patient is experiencing which physiologic mechanism of respiratory failure? Diffusion limitation Intrapulmonary shunt Alveolar hypoventilation Ventilation-perfusion mismatch
Diffusion limitation The patient with pulmonary fibrosis has a thickened alveolar-capillary interface that slows gas transport, and hypoxemia is more likely during exercise than at rest. Intrapulmonary shunt occurs when alveoli fill with fluid (e.g., acute respiratory distress syndrome, pneumonia). Alveolar hypoventilation occurs when there is a generalized decrease in ventilation (e.g., restrictive lung disease, central nervous system diseases, neuromuscular diseases). Ventilation-perfusion mismatch occurs when the amount of air does not match the amount of blood that the lung receives (e.g., chronic obstructive pulmonary disease, pulmonary embolus).
The nurse is caring for a 27-yr-old man with multiple fractured ribs from a motor vehicle crash. Which clinical manifestation, if experienced by the patient, is an early indication that the patient is developing respiratory failure? Tachycardia and pursed lip breathing Kussmaul respirations and hypotension Frequent position changes and agitation Cyanosis and increased capillary refill time
Frequent position changes and agitation A change in mental status is an early indication of respiratory failure. The brain is sensitive to variations in oxygenation, arterial carbon dioxide levels, and acid-base balance. Restlessness, confusion, agitation, and combative behavior suggest inadequate oxygen delivery to the brain.
The nurse is caring for a patient who is admitted with a barbiturate overdose. The patient is comatose with a blood pressure of 90/60 mm Hg, apical pulse of 110 beats/min, and respiratory rate of 8 breaths/min. Based on the initial assessment findings, the nurse recognizes that the patient is at risk for which type of respiratory failure? Hypoxemic respiratory failure related to shunting of blood Hypoxemic respiratory failure related to diffusion limitation Hypercapnic respiratory failure related to alveolar hypoventilation Hypercapnic respiratory failure related to increased airway resistance
Hypercapnic respiratory failure related to alveolar hypoventilation The patient's respiratory rate is decreased as a result of barbiturate overdose, which caused respiratory depression. The patient is at risk for hypercapnic respiratory failure due to an obtunded airway causing decreased respiratory rate and thus decreased CO2 elimination. Barbiturate overdose does not lead to shunting of blood, diffusion limitations, or increased airway resistance.
A 56-yr-old man with acute respiratory distress syndrome (ARDS) is on positive pressure ventilation (PPV). The patient's cardiac index is 1.4 L/min and pulmonary artery wedge pressure is 8 mm Hg. What order by the physician is important for the nurse to question? Initiate a dobutamine infusion at 3 mcg/kg/min. Administer 1 unit of packed red blood cells over the next 2 hours. Change the maintenance intravenous (IV) rate from 75 to 125 mL/hr. Increase positive end-expiratory pressure (PEEP) from 10 to 15 cm H2O.
Increase positive end-expiratory pressure (PEEP) from 10 to 15 cm H2O. Patients on PPV and PEEP frequently experience decreased cardiac output (CO) and cardiac index (CI). High levels of PEEP increase intrathoracic pressure and cause decreased venous return which results in decreased CO. Interventions to improve CO include lowering the PEEP, administering crystalloid fluids or colloid solutions, and use of inotropic drugs (e.g., dobutamine, dopamine). Packed red blood cells may also be administered to improve CO and oxygenation if the hemoglobin is less than 9 or 10 mg/dL.
Arterial blood gas results are reported to the nurse for a 68-yr-old patient admitted with pneumonia: pH 7.31, PaCO2 49 mm Hg, HCO3 26 mEq/L, and PaO2 52 mm Hg. What order should the nurse complete first? Administer albuterol inhaler prn. Increase fluid intake to 2500 mL per 24 hours. Initiate oxygen at 2 liters/minute by nasal cannula. Perform chest physical therapy four times per day.
Initiate oxygen at 2 liters/minute by nasal cannula. The arterial blood gas results indicate the patient is in uncompensated respiratory acidosis with moderate hypoxemia. Oxygen therapy is indicated to correct hypoxemia secondary to V/Q mismatch. Supplemental oxygen should be initiated at 1 to 3 L/min by nasal cannula, or 24% to 32% by simple face mask or Venturi mask to improve the PaO2. Albuterol would be administered next if needed for bronchodilation. Hydration is indicated for thick secretions, and chest physical therapy is indicated for patients with 30 mL or more of sputum production per day.
The nurse in the cardiac care unit is caring for a patient who has developed acute respiratory failure. Which medication is used to decrease patient pulmonary congestion and agitation? Morphine Albuterol Azithromycin Methylprednisolone
Morphine For a patient with acute respiratory failure related to the heart, morphine is used to decrease pulmonary congestion as well as anxiety, agitation, and pain. Albuterol is used to reduce bronchospasm. Azithromycin is used for pulmonary infections. Methylprednisolone is used to reduce airway inflammation and edema.
When caring for a patient with acute respiratory distress syndrome (ARDS), which finding indicates therapy is appropriate? pH is 7.32. PaO2 is greater than or equal to 60 mm Hg. PEEP increased to 20 cm H2O caused BP to fall to 80/40. No change in PaO2 when patient is turned from supine to prone position
PaO2 is greater than or equal to 60 mm Hg. The overall goal in caring for the patient with ARDS is for the PaO2 to be greater than or equal to 60 mm Hg with adequate lung ventilation to maintain a normal pH of 7.35 to 7.45. PEEP is usually increased for ARDS patients, but a dramatic reduction in BP indicates a complication of decreased cardiac output. A positive occurrence is a marked improvement in PaO2 from perfusion better matching ventilation when the anterior air-filled, nonatelectatic alveoli become dependent in the prone position.
Which mode of ventilation uses low tidal volume in conjunction with normal respiratory rates to limit the effects of barotrauma in patients with adult respiratory distress syndrome (ARDS)? Assist control (A/C) ventilation Permissive hypercapnia Pressure control ventilation (PCV) Continuous positive airway pressure (CPAP)
Permissive hypercapnia Permissive hypercapnia is the mode with normal rates (not increased) and small tidal volumes to allow the CO2 levels to increase. Assist control (A/C) ventilation has a preset tidal volume that the patient gets from the ventilator whether he or she breathes extra or allows the machine to deliver all breaths. Pressure control ventilation (PCV) sets an inspiratory pressure rather than a tidal volume. Continuous positive airway pressure (CPAP) delivers oxygen and a pressure above baseline to keep the alveoli inflated and prevent atelectasis.
A 72-yr-old woman with aspiration pneumonia develops severe respiratory distress. Her PaO2 is 42 mmHg and FIO2 is 80%. Which intervention should the nurse complete first? Stat portable chest radiography Administer lorazepam (Ativan) 1 mg IV push Place the patient in a prone position on a rotational bed Position the patient with arms supported away from the chest
Position the patient with arms supported away from the chest The nurse will first position the patient to facilitate ventilation. Additional oxygen support may be necessary. Refractory hypoxemia indicates the patient is not demonstrating acute lung injury but has now developed acute respiratory distress syndrome (ARDS). If the PaO2 is 42 mm Hg on 80% FIO2 (fraction of inspired oxygen; room air is 21% FIO2), then the PaO2/FIO2 ratio is 52.5, indicating ARDS (PaO2/FIO2 ratio<200). Stat portable chest radiography may show worsening infiltrates or "white lung." A rotational bed placing the patient in prone position would be a strategy to use for select patients with ARDS. This patient's age, diagnosis, and comorbidities may indicate appropriateness for this treatment. Administration of lorazepam (Ativan) 1 mg may be harmful to this patient's oxygenation status. Further assessment would be needed to determine safety.
Which clinical manifestation is associated with the exudative phase of acute respiratory distress syndrome (ARDS)? Increased work of breathing Increasing agitation Fine crackles Respiratory alkalosis
Respiratory alkalosis Respiratory alkalosis is one finding associated with the exudative phase of acute respiratory distress syndrome (ARDS). Increasing agitation, fine crackles, and increased work of breathing are associated with the fibroproliferative phase of ARDS.
The nurse is admitting a patient with severe community-acquired pneumonia. Select all interventions that are appropriate for this patient. Select all that apply. Start intravenous (IV) antibiotics. Place the patient on the monitor and obtain vital signs. Obtain sputum cultures and laboratory work. Inquire about allergies and current medications. Start a peripheral IV.
Start intravenous (IV) antibiotics. Place the patient on the monitor and obtain vital signs. Obtain sputum cultures and laboratory work. Inquire about allergies and current medications. Start a peripheral IV.
The nurse is caring for a patient who has experienced a pulmonary embolism (PE). Which statement is an important physiologic concept for the nurse to remember about this condition? The major hemodynamic compromise after PE is pulmonary hypertension. Hypercoagulability is the most significant predisposing factor for PE. Pulmonary system effects include bronchoconstriction and decreased alveolar dead space. Pulmonary vasodilation occurs as a result of mediators released at the injury site.
The major hemodynamic compromise after PE is pulmonary hypertension. Of the three predisposing factors (ie, hypercoagulability, injury to vascular endothelium, and venous stasis), endothelial injury appears to be the most significant. The effects on the pulmonary system are increased alveolar dead space, bronchoconstriction, and compensatory shunting. The major hemodynamic consequence of a pulmonary embolism (PE) is the development of pulmonary hypertension, which is part of the effect of a mechanical obstruction when more than 50% of the vascular bed is occluded. In addition, the mediators released at the injury site and the development of hypoxia cause pulmonary vasoconstriction, which further exacerbates pulmonary hypertension.
