MS exam 3

Ventilatory Rate (VR)

# of breaths *delivered* per minute 10 - 14 bpm

What is the goal of mechanical ventilation?

*improve oxygenation & ventilation* & *↓ effort* needed for effective breathing pattern

Fraction of Inspired Oxygen (FiO2)

*level of O2* delivered 21% - 100%

ARF/ALF - Oxygenation Failure

*normal ventilation* BUT impaired *pulmonary perfusion*

Flow rate

*speed*/how fast each breath is delivered 40 L/min

Tidal Volume (TV)

*volume of air* received per breath 7 - 10 ml/kg of body weight 500 - 800ml

Intrapulmonary causes of ventilatory failure

- *Airway disease* (COPD, asthma) - *V/Q mismatch* (Pneumothorax, ARDS, pulmonary edema, fibrosis)

PE diagnostic tools

- *V/Q Scan* - *CT* - Pulmonary *Angiography* - D-dimer - EKG - Venous *doppler* - CXR - ABGs

ARF/ALF Symptoms

- *hypoxemia* - hypercapnia - respiratory acidosis

Extrapulmonary causes of ventilatory failure

- *neuromuscular injuries* - *spinal* injuries - CNS *depressants* (steroids, opioids, sedatives) - *obesity* - *sleep apnea*

ARF/ALF - Ventilatory Failure

- *normal lungs* BUT impaired *O2 intake* - PaCO2 *>45* in pts with *healthy lungs* - *thoracic pressure changes* to let air in & out of lungs

TEST Interpret the ABGs: pH - 7.55 PaCO2 - 43 HCO3 - 36

uncompensated metabolic alkalosis

Time cycled ventilator

vent delivers a breath *over a preset time* interval/*until a preset time has elapsed*

What is a PFT & its components?

Quantifies respiratory function - Lung volume - Breathing mechanics - Diffusion - ABGs

A pt is admitted with diminished to absent breath sounds on the right side, tracheal deviation to the left side, & asymmetric chest movement. These findings are indicative of which disorder? a. Tension pneumothorax b. Pneumonia c. Pulmonary fibrosis d. Atelectasis

a

Interpret the ABGs: - PaO2 40 - pH, 7.10 - PaCO2 44 - HC03 16 a. Uncompensated metabolic acidosis b. Uncompensated respiratory acidosis c. Compensated metabolic acidosis d. Compensated respiratory acidosis

a

TEST A nurse notes bubbling in the waterseal chamber of a pt with a chest tube connected to the pleurvac. What is the probable cause of this finding? a. Pt has a pneumothorax b. Pt has a pleural effusion c. Pts chest tube is not functioning properly d. Pt has a hemothorax

a

TEST A pt was admitted after an aspiration event & is receiving 40% O2 via simple face mask. His SpO2 is now 84% & he is agitated & confused. What interventions are anticipated? a. Intubation & mechanical ventilation b. Change in antibiotics orders c. Suction & reposition the patient d. Orders for a sedative

a

TEST V/Q scans are ordered to evaluate the possibility of which of the following? a. Pulmonary emboli. b. Acute myocardial infarction. c. Emphysema. d. Acute respiratory distress syndrome.

a

TEST What should the 1st intervention be for a pt with these ABGs - PaO2 77 - pH 7.38 - PaCO2 40 - HCO3 24 a. Give 6L oxygen via nasal cannula b. Encourage pt to take deep breaths c. Auscultate lung sounds

a

The nurse is performing a pulmonary assessment on a pt with a pleural effusion. Which finding is unexpected? a. Increased diaphragmatic excursion b. Decreased tactile fremitus c. Dull percussion tones d. Pleural friction rub

a

The nurse performs inspection of the oral cavity as part of a focused pulmonary assessment to check for evidence of what condition? a. Hypoxia b. Dyspnea c. Dehydration d. Malnutrition

a

Use of oxygen therapy in the pt who is hypercapnic may result in which situation? a. Carbon dioxide retention b. Absorption atelectasis c. Oxygen toxicity d. Pneumothorax

a

A pt has just undergone a bronchoscopy. What complication should they be monitored for? a) Laryngospasm b) Pulmonary embolism 'c) Allergic reaction to the dye d) Headache

a ALSO: - stridor - epistaxis - vomiting - bright red bloody sputum

The nurse notes a pt's breathing is rapid & shallow. What is this type of breathing pattern called? a. Tachypnea b. Hyperventilation c. Obstructive breathing d. Bradypnea

a b- increased ventilation rate & depth

What symptom is the most consistent with these ABGs? - pH 7.32 - PaO2 105 - PaCO2 47 - HC03 16 a. Diarrhea. b. Shortness of breath. c. Central cyanosis. d. Peripheral cyanosis.

a - metabolic acidosis

What level of compensation is reflected based on the ABGs? - pH 7.38 - PaCO2 58 - HCO3 30 a. Full b. Partial c. Uncompensated

a - pH is normal

Which of the following interventions should be included for acute lung failure? SATA a. Position pt with the least affected side up b. Provide adequate rest between treatments c. Performing percussion & postural drainage every 4 hours d. Control fever e. Medications to control anxiety

a, d, b, e

Pressure cycled ventilator

vent delivers a breath *until a preset PRESSURE* is *reached* preset inspiratory pressure is delivered & when established pressure is reached, the inspiratory phase ends

Volume cycled ventilator

vent delivers a breath *until a preset VOLUME* is *delivered* - short term

2 ways of verifying ET tube placement

x-ray & *end-tidal CO2 volume*

TEST What type of breathing is present for a pt with both metabolic acidosis & Kussmaul respirations? a. Audible wheezing or stridor b. Increased rate, large tidal volumes, and no expiratory pause c. Rapid respirations with periods of apnea d. Very slow inhalations and rapid expirations

b

While conducting a physical assessment on a pt with COPD, the nurse notes that their breathing is rapid & shallow. What is this type of breathing pattern called? a. Hyperventilation b. Tachypnea c. Obstructive breathing d. Bradypnea.

b

ARF/ALF Management

- *oxygenate* to correct the *hypoxemia* with low flow or high flow (goal is to keep SaO2 *≥ 90%* - *secretion clearance* (humidify O2, hydrate/fluids, C&DB, ↑ HOB) - *prevent desat* (↓ exercise, prevent fever & anxiety) - *Ventilation* via intubation or CPAP - *Enteral feedings*

Conditions with absent or ↓ breath sounds

- *pneumothorax* - pleural effusion - emphysema

Conditions with deviated trachea

- *pneumothorax* & atelectasis - *pleural effusion* - pneumonia - fibrosis

PE management

- *↑ HOB* - *O2* - IV fluids - *↑ activity level* UNLESS they have DVT

PE symptoms

- Dyspnea & Tachypnea - Tachycardia - *Chest pain* - Restless/Apprehensive - *Hypoxia* - Cough - *Crackles*, *PFR*, *S3 & S4* - *Diaphoresis - *Petechiae*

Causes of Oxygenation failure

- Lung disorders (pneumonia, ARDS, pulmonary edema/CHF, PE) -*Abnormal Hgb binding* (sickle cell) -*R-L shunting* (deoxygenated blood goes to the heart) - Breathing air with ↓ O2 levels (high altitude, smoke)

ARDS management - Oxygenation

- O2 delivered at the *lowest possible level* to prevent toxicity!! - *PRONE* position - Extracorporeal & Intracorporeal (ECMO)

FiO2 level is determined by what 2 things?

- Pt *status/condition* - Pt *ABGs*

PE drugs

- Thrombolytics for *massive* PE - *Anticoagulants/Heparin* - Analgesics

ARDS management - Ventilation

- Tidal volume set at *4-6* - PEEP

Indications for intubation

- airway *protection* (surgery) - Bypass airway obstruction - ↑ gas exchange & oxygenation - facilitate pulmonary hygiene & secretion

Conditions with rhonchi

- asthma (& wheezing) - COPD

Normal breath sounds

- bronchial - vesicular - bronchovesicular

ARF/ALF Drugs

- bronchodilators - steroids - sedation - analgesics

Purpose of suctioning

- maintain patent airway - infection prevention - facilitate C&DB

Conditions with dullness upon percussion

- pleural effusion - pulmonary edema - hemothorax

Conditions with ↓ tactile fremitus upon palpation

- pleural effusion - pneumothorax - emphysema - COPD

Conditions with ↑ tactile fremitus upon palpation

- pneumonia - lung cancer - fibrosis

Conditions with hyperrsonance upon percussion

- pneumothorax - ARDS & emphysema

Conditions with crackles

- pulmonary edema - fibrosis - pneumonia - *ARDS* - *PE*

Main 3 causes of ARDS

- sepsis - severe *pancreatitis* - respiratory *inflammation*

What is considered a normal finding for tactile fremitus upon palpation?

- vibrations over the *trachea* - *NO* vibrations over the *lung periphery*

Indications for suctioning

- visible secretions - *↑ peak airway pressure* - *rhonchi* - *↓ breath sounds* - excessive *coughing*

Type of ventilator is determined by what 2 things?

1. disease *severity* 2. *length of time* needed for *vent support*

TEST Interpret the ABGs: Pa02 - 92 Sa02 - 96 pH - 7.28 PaC02 - 28 HC03 - 16

Adequately oxygenated; Partially compensated metabolic acidosis

How are ventilators classified?

By the mechanism that *ends inspiration* & *starts expiration*

ARF/ALF

Lungs are unable to meet the body's *metabolic oxygen needs* & fails to maintain *adequate gas exchange*

A bronchoscopy is indicated for a what condition? a. Pulmonary edema. b. Ineffective clearance of secretions. c. Upper gastrointestinal bleed. d. Instillation of surfactant.

b

A physical exam shows subcostal & intercostal retractions & pt reports that breathing is difficult & can't get enough air. What term should the nurse use to document this condition? a. Cyanosis b. Dyspnea c. Hyperpnea d. Orthopnea

b

A pt is admitted with acute lung failure secondary to emphysema. Percussion of the lung fields will predictably exhibit which tone? a. Resonance b. Hyperresonance c. Tympany d. Dullness

b

A pts CT shows a large right pleural effusion with significant atelectasis. Which procedure will most likely be performed? a. Bronchoscopy b. Thoracentesis c. Intubation

b

A trauma victim has sustained right rib fractures & pulmonary contusions. There are decreased breath sounds & bulging intercostal muscles on the right side & labored breathing. HR is 130, RR is 32. In addition to oxygen administration, what procedure is anticipate? a. Thoracentesis b. Chest tube insertion c. Pericardiocentesis d. Emergent intubation

b

Interpret the ABGs: - PaO2: 70 - pH: 7.31 - PaCO2: 52 - HC03: 24 a. Uncompensated metabolic alkalosis b. Uncompensated respiratory acidosis c. Compensated respiratory acidosis d. Compensated respiratory alkalosis

b

A patient is admitted with ARF secondary to COPD. Upon inspection, the nurse observes the pt's fingers appear discolored. What does this finding indicate the presence of? a. Clubbing b. Central cyanosis c. Peripheral cyanosis d. Chronic tuberculosis

c

TEST A pt c/o midsternal chest pain, restlessness, & dyspnea. What is the nurses #1 priority to address? a. Anxiety b. Impaired circulation c. Impaired gas exchange d. Pain

c

TEST Which of the following pt situations would the nurse monitor closely for the development of ARDS? a. Post emergency appendectomy b. Postop total knee replacement c. Post near drowning episode d. Pt with chest pain

c

TEST Which pt is at risk for developing ARDS d/t ventilatory failure? a. Pt with pneumonia b. Pt with ARDS c. Pt with spinal cord injury d. Pt with COPD

c

TEST A pt c/o severe SOB after a thoracentesis. What does the nurse suspect is occurring? a. PE b. Pneumonia c. Pneumothorax d. Pleural effusion has reoccurred

c

What condition develops when air enters the pleural space from the lung on inhalation & cannot exit on exhalation? a. Tension pneumothorax b. Sucking chest wound c. Open pneumothorax d. Pulmonary interstitial empyema

c

Which cause of hypoxemia is the result of blood passing through unventilated portions of the lungs? a. Alveolar hypoventilation b. Dead space ventilation c. Intrapulmonary shunting d. Physiologic shunting

c

Which therapeutic measure would be the most effective in treating hypoxemia from intrapulmonary shunting with ARDS? a. Sedating pt to blunt noxious stimuli b. Increasing FiO2 on the ventilator c. Administering positive-end expiratory pressure (PEEP) d. Restricting fluids to 500 mL per shift

c

While palpating a pt's lungs the nurse notes fremitus over their trachea but not the lung periphery. What do these findings indicate? a. Bilateral pleural effusion b. Bronchial obstruction c. A normal finding d. Apical pneumothorax

c

What medication may be included in the preop for a diagnostic bronchoscopy? a. Aspirin for anticoagulation. b. Vecuronium to inhibit breathing. c. Codeine to decrease the cough reflex. d. Cimetidine to decrease hydrochloric acid secretion.

c - ALSO atropine to ↓ vasovagal response & ↓ secretions

A pt presents with chest trauma from an MVA. The pt is complaining of dyspnea, SOB, tachypnea, medistinal shifting & tracheal deviation to the right, & their tongue is blue-gray. What additional assessment finding would the nurse expect? a. Kussmaul breathing pattern b. Absent breath sounds in the right lower lung fields c. Absent breath sounds in the left lung fields d. Diminished breath sounds in the right upper lung fields

c if the trachea & mediastinum are deviated to the right, then the affected side is the LEFT where the absent breath sounds would be

Which physiologic mechanism is a passive event in a spontaneously breathing patient? a. Coughing b. Inhalation c. Exhalation d. Yawning

c inhalation requires diaphragmatic contraction therefore it's an active event

The nurse is planning care for a pt with respiratory acidosis. Which intervention should the nurse include? A) Administer prescribed intravenous fluids carefully B) Administer intravenous sodium bicarbonate C) Maintain adequate hydration D) Reduce environmental stimuli

c - hydration helps facilitate the removal of pulmonary secretions to improve oxygenation :) metabolic acidosis TX: sodium bicarb respiratory alk TX: reduce stimuli

A pt is admitted with acute respiratory failure. Auscultation is creaking, leathery, coarse breath sounds during inspiration & expiration. This finding is indicative of what condition? a. Emphysema b. Atelectasis c. Pulmonary fibrosis d. Pleural effusion

d

A pt is suffering from an emphyema. Which procedure should the nurse expect to be performed? a. Bronchoscopy b. Chest x-ray c. PFT d. Thoracentesis

d

Supplemental oxygen administration is usually effective in treating hypoxemia related which situation? a. Physiologic shunting b. Dead space ventilation c. Alveolar hyperventilation d. Ventilation-perfusion mismatching

d

TEST A nurse is assessing a pt being treated for smoke inhalation. Which early signs indicate possible ARDS onset? a. Cough with blood tinged sputum & respiratory alkalosis b. Steadily increasing BP & elevated PaO2 c. Decreased WBC & RBC d. Diaphoresis & low SaO2 despite oxygen admin

d

TEST A pt is admitted to CCU with blunt chest trauma, left failed chest, several fractures, & other injuries. 12hr after admission, the nurse notes tachypnea, dyspnea, bilateral breath sounds of fine crackles, & x-ray showing ill defined patchy ground-glass area of density on the left side. What is the nurses priority? a. Obtain sputum culture & sensitivity & a gram stain b. Intubate the pt immediately c. Increase admin of crystalloid fluids d. Monitor pulse ox & ABGs closely

d

TEST A pt reports redness, warmth, tenderness, & pain in her right calf. The nurse anticipates an order for which of the following? a. Cold therapy to the affected leg b. Heat therapy to the affected leg c. Monitor Homan's sign d. Venous duplex ultrasound

d

What are the most common presenting signs and symptoms associated with a PE? a. Right ventricular failure & fever b. Hemoptysis & deep vein thromboses c. Apprehension & dyspnea d. Tachycardia & tachypnea

d

What intervention can facilitate the prevention of aspiration? a. Observing the amount given in the tube feeding b. Assessing level of consciousness c. Encouraging pt to cough & deep breathe d. Positioning pt in a semirecumbent position

d

What is the sequence for auscultation of the anterior chest? a. Right side, top to bottom, then left side, top to bottom b. Left side, top to bottom, then right side, top to bottom c. Side to side, bottom to top d. Side to side, top to bottom.

d

Which condition is an example of a disorder with increased tactile fremitus? a. Emphysema b. Pleural effusion c. Pneumothorax d. Pneumonia

d

2 main types of ventilators

positive pressure & negative pressure

Positive End-Expiratory Pressure (PEEP)

positive pressure applied at the *end of each expiration* 5 - 15

Ventilator settings

prescribed by *HCP* & set up by *RT*

3 major cycles of ventilation

pressure, volume, time

Modes of Ventilation

determines *how much* the pt will participate in *their own breathing*

diaphramatic excursion

evaluates diaphragm movement ↑ - pleural effusion ↓ - emphysema

TEST Interpret the ABGs: pH - 7.36 PaCO2 - 60 HCO3 - 35

fully compensated respiratory acidosis

Indirect Injury (ARDS)

injuries in which insult occurs *elsewhere* in the body & mediators are transmitted via bloodstream to the lungs - *sepsis* - *pancreatitis* - shock - HTN - CABG

Direct Injury (ARDS)

injuries where the lung epithelium sustains a direct insult - aspiration - pneumonia - *near drowning* - *toxic inhalation* - transthoracic *radiation* - *O2 toxicity* - pulmonary contusion

positive pressure ventilation

mechanical drive that *forces air into the lungs* through intubation tube & expands the chest

ARF/ALF - Combined Failure

occurs in pts with *ABNORMAL lungs* d/t *poor respiratory movements* (hypoventilation & hypercapnia) & *impaired gas exchange*