Chapter 32 - Care of Critically Ill Patients with Respiratory Problems

A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best?

"It is hypoxemia that persists even with 100% oxygen administration." Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome.

A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best?

"It will prevent ulcers from the stress of mechanical ventilation." Stress ulcers occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them.

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?

"The blood clot interferes with perfusion in the lungs." A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated.

A client states, "At night, I usually need to sleep propped up on two pillows in the chair, but now it seems I need three pillows." What is the nurse's best response?

"You need to stay in the hospital for further evaluation." Orthopnea is the sensation of dyspnea or breathlessness in the supine position. Clients feel that they cannot catch their breath in the supine position and must rest or sleep in a semi-sitting position by placing pillows behind their backs or by using a reclining chair.

The nurse is prioritizing care for a client on a ventilator. What are essential nursing interventions for this client? (Select all that apply.)

- Assess the reasons for alarms. - Compare the ventilator settings with ordered settings - Assess the water level in the humidifier. The nurse should assess the client when an alarm sounds and should intervene accordingly. The nurse should also check the settings to make sure they are correct and should evaluate the water level to make sure the humidifier does not go dry.

Which clients are at highest risk for pulmonary embolism (PE)? (Select all that apply)

- Older adult with a 20-pack-year history of smoking - Client who has been on bedrest for 3 weeks - Obese client who has elevated platelets - Older adult who has just had abdominal surgery Older adults, especially those with chronic lung problems, are at higher risk for pulmonary embolism. Prolonged bedrest is also a risk factor, as are abdominal surgery and smoking. Because platelets are involved in the clotting process, elevated platelets may contribute to increased clotting.

A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.)

-Acknowledge the frightening nature of the illness. -Delegate a back rub to the unlicensed assistive personnel (UAP). -Give simple explanations of what is happening. -Stay with the client and speak in a quiet, calm voice. Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegate comfort measures, give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also reassuring.

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)

-Adherence to proper hand hygiene -Administering anti-ulcer medication -Elevating the head of the bed -Providing oral care per protocol The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures.

A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.)

-Allow visitors at the client's bedside. -Ensure the client can communicate if awake. -Provide back and hand massages when turning. -Turn the client every 2 hours or more. There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the client's skin, and routinely turning and repositioning the client are some of them.

The nurse is caring for a client on a ventilator when the high-pressure alarm sounds. What actions are most appropriate? (Select all that apply.)

-Assess the tubing for kinks. -Determine the need for suctioning. -Auscultate the client's lungs. Reasons for a high-pressure alarm include water or a kink impeding airflow or mucus in the airway. The nurse first should assess the client and determine whether he or she needs to be suctioned; then the nurse should auscultate the lungs. The nurse also should assess the tubing for kinks.

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.)

-Chest wall stiffness -Decreased muscle strength -Less lung elasticity Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue.

A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)

-Client with a new spinal cord injury on a rotating bed -Older client who is 1-day post hip replacement surgery -Young obese client with a fractured femur Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma.

When working with women who are taking hormonal birth control, what health promotion measures should the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)

-Exercise on a regular basis. -Maintain a healthy weight. -Stop smoking cigarettes. Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a healthy weight, exercising on a regular basis, and not smoking.

A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)? (Select all that apply.)

-Oxygen administered at 100%, PaO2 60 -Increased dyspnea -Anxiety A client who is developing ARDS presents with a decrease in oxygen despite an increase in the fraction of inspired oxygen. Increased dyspnea goes along with the increased hypoxemia, as does anxiety.

A 242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.) ___ mL

ANS: 660 mL A low tidal volume of 6 mL/kg is used to prevent lung injury. 242 pounds = 110 kg. 110 kg × 6 mL/kg = 660 mL.

A client is ordered heparin 5000 units at 7 AM. The heparin is provided in a vial labeled 20,000 units per mL. How much does the nurse administer? ______ mL

ANS: 0.25 5000 units/20,000 units ´ 1 mL = 0.25 mL

A nurse is making initial rounds on assigned clients at the beginning of the shift. One client is receiving a heparin infusion at 5 mL/hr. The nurse notes that 25,000 units of heparin are mixed in 250 mL of solution. How many units per hour is the client receiving? __________ units/hr

ANS: 500 25,000 units/250 mL = X units/hr/(5 mL/hr) 250X = 125,000 X = 500 units/hr

The nurse assesses a client admitted for chest trauma who reports dyspnea. The nurse finds tracheal deviation and a pulse oximetry reading of 86%. What is the nurse's priority intervention?

Administer oxygen and prepare for chest tube insertion. Blunt chest trauma can cause an air leak into the thoracic cavity, collapsing the lung on the side with the air leak (pneumothorax). More air enters the pleural space with each breath, increasing intrathoracic pressure on the affected side, moving the trachea to the unaffected side, and leading to decreased cardiac output. This condition (tension pneumothorax) is life threatening without intervention. The client will need oxygen administration right away and a chest tube inserted.

A client in the emergency department has several broken ribs. What care measure will best promote comfort?

Allowing the client to choose the position in bed Allow the client with respiratory problems to assume a position of comfort if it does not interfere with care. Often the client will choose a more upright position, which also improves oxygenation.

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?

Alteplase (Activase) Activase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially.

What is the best way for the nurse to communicate with a client who is intubated and is receiving mechanical ventilation?

Ask the client to point to words on a board. The nurse should have the client point to words on a board to communicate needs. The endotracheal tube is positioned and placement is maintained with tape or some other type of appliance.

A client is admitted owing to difficulty breathing. The nurse assesses the client's color, lung sounds, and pulse oximetry reading. The pulse oximetry is 90%. What is the nurse's next action?

Assess an arterial blood gas. When clients with respiratory problems are assessed, an arterial blood gas is needed for the most accurate assessment of oxygenation.

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?

Assess for other manifestations of hypoxia. Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment.

The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation and positive end-expiratory pressure (PEEP). The alarm sounds, indicating decreased pressure in the system. What is the nurse's best action?

Assess lung sounds. One of the biggest risks in the client with ARDS on mechanical ventilation with PEEP is tension pneumothorax. The nurse needs to assess lung sounds hourly. The alarms on a ventilator should never be turned off. If the client needed to be suctioned, the high-pressure alarm would sound

The nurse auscultates the lungs of a client on mechanical ventilation and hears vesicular breath sounds throughout the right side but decreased sounds on the left side of the chest. What is the nurse's best action?

Assess placement of the endotracheal (ET) tube. The endotracheal tube is more likely to slip into the right mainstem bronchus, leading to the breath sounds described. The nurse should assess placement of the ET tube by assessing where the markings are, making sure it is taped, and confirming equal breath sounds bilaterally.

The nurse notes that each time the mechanical ventilator delivers a breath to a client with acute respiratory distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the nurse's best intervention?

Assess the airway. An increase in peak inspiratory pressure (PIP) in the ARDS client is indicative of decreased lung compliance, making it more difficult to ventilate diseased lungs. The nurse first should assess the airway to make sure no sputum is present in the airway and that no kinks are noted in the tubing.

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?

Assess the cause of the agitation. The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain and confusion can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause.

The pressure reading during inspiration on the ventilator of a client receiving mechanical ventilation is fluctuating widely. What is the nurse's first action?

Assess the client's oxygenation. A widely fluctuating pressure reading is one indication of inadequate airflow and oxygenation. The nurse's priority is to check the client's oxygenation status.

The client receiving mechanical ventilation has become more restless over the course of the shift. Which is the nurse's first action?

Assess the client's oxygenation. Increasing restlessness in a client being mechanically ventilated may mean that the client is not receiving sufficient oxygen. It can also be a manifestation of pain. When in doubt, determining the adequacy of ventilation has the highest priority.

A client with dyspnea is becoming very anxious. An arterial blood gas (ABG) shows a PaO2 of 93 mm Hg. How does the nurse best intervene?

Assist with relaxation techniques. The nurse should assess the client's oxygenation; however, this client's arterial blood gas documents that the client's hypoxia has resolved.

The nurse is caring for a client who is receiving mechanical ventilation accompanied by positive end-expiratory pressure (PEEP). What assessment findings require immediate intervention?

Blood pressure drop from 110/90 mm Hg to 80/50 mm/Hg Increased intrathoracic pressure can inhibit blood return to the heart and cause decreased cardiac output. This manifests with a drop in blood pressure.

The nurse auscultates the following lung sound in a client with a respiratory disorder. What is the nurse's best action? (Click the media button to hear the audio clip.)

Call for the Rapid Response Team. The sound heard is stridor. Stridor on inspiration is caused by laryngospasm or edema and heralds impending airway occlusion. The client's airway is in jeopardy and immediate intervention is necessary.

The nurse is caring for a client who is intubated with an endotracheal tube and on a mechanical ventilator. The client is able to make sounds. What is the nurse's first action?

Check cuff inflation on the endotracheal tube. If the client has the cuff on the endotracheal tube inflated, the cuff should prevent air from going around the cuff and through the vocal cords. If the client can talk with the cuff inflated, the cuff probably has a leak, causing it to become deflated and allowing air to pass through. The risk is that the client will not receive the prescribed tidal volume.

A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse?

Choosing an 18-gauge, 2-inch needle Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions are appropriate.

The nurse is caring for a client who has been intubated and placed on a ventilator for treatment of acute respiratory distress syndrome (ARDS). Aside from assessing oxygenation, what is the nurse's priority action?

Consult with the registered dietitian. The client who is intubated needs nutrition delivered via enteral tube feeding. If nutrition is ignored, the client's respiratory status can deteriorate, because respiratory muscle function can deteriorate.

A client with severe respiratory insufficiency becomes short of breath during activities of daily living. Which nursing intervention is best?

Decrease involvement in care until the episode is past. Clients with shortness of breath and decreased oxygen saturation must be monitored closely. Minimal involvement in activities is required if the client is severely short of breath. The nurse should continue to assess the client and can increase involvement in activities if shortness of breath subsides.

The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus. The client's international normalized ratio (INR) is 2.0. What is the nurse's best action?

Discontinue the heparin. The client who is being treated for pulmonary embolism usually continues on heparin and warfarin until the INR reaches a therapeutic level between 2 and 3. Heparin can then be discontinued because warfarin is therapeutic.

The nurse is caring for a postoperative client who suddenly reports difficulty breathing and sharp chest pain. After notifying the Rapid Response Team, what is the nurse's priority action?

Elevate the head of the bed and apply oxygen. The client's immediate need is to have oxygen applied. The nurse should then assess the client's pulse oximetry.

A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?

Ensure a patent airway. The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a patent airway.

A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?

Ensuring there is a bag-valve-mask in the room Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse should know and check the settings.

A nurse is caring for a client on the medical stepdown unit. The following data are related to this client: Shortness of breath for 20 minutes Feels frightened "Can't catch my breath" pH: 7.12 PaCO2: 28 mm Hg PaO2: 58 mm Hg SaO2: 88% Pulse: 120 beats/min Respiratory rate: 34 breaths/min Blood pressure 158/92 mm Hg Lungs have crackles What action by the nurse is most appropriate?

Facilitate a STAT pulmonary angiography. This client has manifestations of pulmonary embolism (PE); however, many conditions can cause the client's presentation. The gold standard for diagnosing a PE is pulmonary angiography. The nurse should facilitate this test as soon as possible.

Which assessment finding of a client requires the nurse's immediate action?

Having the endotracheal (ET) tube taped to the lower jaw The endotracheal tube can be taped to the upper lip but should never be taped to the lower jaw because the lower jaw moves too much.

A client is admitted to the emergency department several hours after a motor vehicle crash. The car's driver-side airbag was activated during the accident. Which assessment requires the nurse's immediate intervention?

Hemoptysis The nurse should be concerned about possible pulmonary contusion. Interstitial hemorrhage accompanies pulmonary contusion. Bleeding may not be evident at the initial injury, but the client develops hemoptysis and decreased breath sounds up to several hours after injury as bleeding into the alveoli or airways occurs.

Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)? (Select all that apply.)

Hemoptysis Sharp chest pain Hypotension Hemoptysis, sharp chest pain, and hypotension all may be caused by pulmonary embolism and the pulmonary hypertension that results.

A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?

Increase the heparin rate. For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working. A normal PTT is 25 to 35 seconds, so this client's PTT value is too low. The heparin rate needs to be increased.

The pilot balloon on the endotracheal tube of a client being mechanically ventilated is deflated. What is the nurse's priority action?

Inflate the cuff using minimal leak technique. The pilot balloon indicates whether the endotracheal tube cuff is inflated or deflated. A deflated balloon means that the cuff is also deflated and a seal is no longer present around the tube to prevent air from escaping. Thus, some of the air being moved into the client's airway by the ventilator is escaping through the client's trachea before it reaches the lower airways and alveoli.

A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?

Interrupt the procedure to give oxygen. Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should interrupt the intubation attempt and give the client oxygen.

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?

Large chef's salad and muffin Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. The chef's salad most likely has too many leafy green vegetables, which contain high amounts of vitamin K.

An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority?

Listen to the client's lung sounds. When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed.

The nurse is caring for a client who is taken off a ventilator and placed on continuous positive airway pressure (CPAP). What intervention is most appropriate for this client?

Making sure the client is breathing spontaneously A requirement for using CPAP is that the client will be able to breathe spontaneously.

It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurse's priority action?

Monitor the client's oxygenation. Airway and breathing are the top priority. The nurse would also need to monitor for bleeding when administering fibrinolytic therapy, and would monitor the IV site as well.

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?

Notify the Rapid Response Team. This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment.

The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation. The client's oxygen saturation has dropped from 94% to 86%. What is the priority action by the nurse?

Notify the health care provider and prepare for intubation. This client has a flail chest characterized by paradoxical chest wall motion. With the oxygen saturation dropping, the client is at high risk for respiratory failure and needs to be intubated.

A client with a large pulmonary embolism is receiving alteplase (Activase). The nurse notes frank red blood in the Foley catheter drainage bag. What is the nurse's first action?

Notify the health care provider. Alteplase is a fibrinolytic agent that dissolves formed clots. The drug has an impact on clots outside the pulmonary embolism, and the client is at great risk for hemorrhage and shock.

The nurse is caring for several clients on the respiratory floor. Which client does the nurse assess most carefully for the development of acute respiratory distress syndrome (ARDS)?

Older adult who has aspirated his tube feeding The older adult who has aspirated a tube feeding is at high risk and should be assessed closely for the possibility of ARDS.

A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?

Platelet count: 82,000/L This platelet count is low and could indicate heparin-induced thrombocytopenia. The other values are normal for either gender.

The nurse is caring for a client with a ventilation/perfusion mismatch who is receiving mechanical ventilation. Which intervention is a priority for this client?

Positioning the client with the "good lung dependent" Clients who are being mechanically ventilated are experiencing a problem in that their normal ventilation is not adequate. The recommended position for clients who have one lung more affected by a problem than the other lung is to place the "good lung down," keeping the healthier lung dependent to the less healthy lung. Such positioning allows gravity to keep more blood in the lower lung (healthier lung) and better ventilation in the upper lung, thus helping a ventilation/perfusion mismatch.

A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best?

Prepare preoperative teaching for an inferior vena cava (IVC) filter. Often clients are discharged from the hospital on warfarin (Coumadin) after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have higher blood levels and more side effects

A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority?

Prepare to assist with intubation. This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately.

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)?

Provide frequent oral care per protocol. The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse.

The nurse assesses a client who has a hemothorax and a chest tube inserted on the right side. What finding requires immediate attention?

Puffiness of the skin around the chest tube insertion site and a crackling feeling Puffiness of the skin around the chest tube and a crackling feeling indicate subcutaneous emphysema, or air leaking into the tissue around the insertion site. This must be addressed immediately.

A client admitted with respiratory difficulty and decreased oxygen saturation keeps pulling off the oxygen mask. What action does the nurse take?

Stays with the client and replaces the oxygen mask Restlessness and confusion are clinical manifestations of hypoxemia. It is important that the nurse stay with the client, ensure that the oxygen is maintained, and attempt to calm the client.

A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?

Strict vegetarian Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have trouble maintaining this diet.

A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate?

Teach the client about factor V Leiden testing. Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder should be referred for testing.

A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority?

The upper peak airway pressure limit alarm is on. The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off.

The nurse is caring for a client with a pulmonary embolus who also has right-sided heart failure. Which symptom will the nurse need to intervene for immediately?

Urinary output of 10 mL/hr Urinary output is very low; this could indicate that the client has decreased cardiac output. The nurse will need to intervene and notify the health care provider.

The nurse is caring for a client with a high risk for pulmonary embolism (PE). Which prevention measures does the nurse add to the client's care plan? (Select all that apply.)

Use antiembolism stockings. Turn every 2 hours if client is in bed. Both antiembolism stockings (or sequential pressure devices) and a turning schedule can help prevent venous thromboembolism, which can lead to PE.

The nurse is assessing arterial blood gases (ABGs). The client with which ABG reading requires the nurse's immediate attention?

pH, 7.55; PaCO2, 32 mm Hg; PaO2, 50 mm Hg This client has the most severe hypoxia and respiratory alkalosis, indicated by low partial pressure of arterial carbon dioxide (PaCO2) values on ABG analysis.