Urden Ch 14
A patient was admitted following an aspiration event on the medical-surgical floor. The patient is receiving 40% oxygen via a simple face mask. The patient has become increasingly agitated and confused. The patient's oxygen saturation has dropped from 92% to 84%. The nurse notifies the practitioner about the change in the patient's condition. What interventions should the nurse anticipate? a. Intubation and mechanical ventilation b. Change in antibiotics orders c. Suction and reposition the patient d. Orders for a sedative
ANS: A Given the significant drop in oxygen saturation, increasing agitation and confusion, the nurse should anticipate the patient will need to be intubated and mechanically ventilated. Administrating antibiotics, suctioning and repositioning, and administering a sedative would not address the development of severe hypoxemia.
Which nursing intervention should be used to optimize oxygenation and ventilation in the patient with acute lung failure? a. Provide adequate rest time between procedures. b. Position the patient with the good lung up. c. Suction the patient every hour. d. Avoid preoxygenating the patient before suctioning.
ANS: A Providing adequate rest and recovery time between various procedures prevents desaturation and optimizes oxygenation. In acute lung failure, the goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Preoxygenate the patient before suctioning and suction the patient only as needed.
A patient who is 2 days postoperative from a hip replacement suddenly develops hypoxemia. The nurse suspects that the patient has developed a pulmonary embolism (PE) when the patient exhibits which signs and symptoms? a. Tachycardia and tachypnea b. Hemoptysis and evidence of deep vein thromboses c. Apprehension and dyspnea d. Right ventricular failure and fever
ANS: A The patient with a pulmonary embolism may have any number of presenting signs and symptoms, with the most common being tachycardia and tachypnea. Additional signs and symptoms that may be present include dyspnea, apprehension, increased pulmonic component of the second heart sound (P1), fever, crackles, pleuritic chest pain, cough, evidence of deep vein thrombosis, and hemoptysis. Syncope and hemodynamic instability can occur as a result of right ventricular failure.
A patient has developed ventilator-associated pneumonia (VAP). The nurse knows that the two pathogens most frequently associated with this condition are which? a. Staphylococcus aureus and Pseudomonas aeruginosa b. Escherichia coli and Haemophilus influenzae c. Acinetobacter baumannii and Haemophilus influenzae d. Klebsiella spp. and Enterobacter spp.
ANS: A Two of the pathogens most frequently associated with VAP are S. aureus and P. aeruginosa.
Which weaning methods are used in combination with each other? (Select all that apply.) a. SIMV with CPAP b. SIMV with PSV c. CPAP with PSV d. T-piece and PSV e. PEEP with CPAP
ANS: A, B, C, D A variety of weaning methods are available, but no one method has consistently proven to be superior to the others. These methods include T-tube (T-piece), continuous positive airway pressure (CPAP), pressure support ventilation (PSV), and synchronized intermittent mandatory ventilation (SIMV). One recent multicenter study lends evidence to support the use of PSV for weaning over T-tube or SIMV weaning. Often these weaning methods are used in combination with each other, such as SIMV with PSV, CPAP with PSV, or SIMV with CPAP.
The nurse is caring for a patient who is ventilator-dependent. The patient's plan of care should include interventions to decrease which psychological factors that may be contributing to the patient's condition? (Select all that apply.) a. Fear b. Sensory overload c. Depersonalization d. Depression e. Trust in the staff
ANS: A, B, C, D Psychological factors contributing to long-term mechanical ventilation dependence include a loss of breathing pattern control (anxiety, fear, dyspnea, pain, ventilator asynchrony, lack of confidence in ability to breathe), lack of motivation and confidence (inadequate trust in staff, depersonalization, hopelessness, powerlessness, depression, inadequate communication), and delirium (sensory overload, sensory deprivation, sleep deprivation, pain medications). The plan of care should include interventions to increase the trust in the staff.
An exhausted patient has been admitted with status asthmaticus. The nurse anticipates the medical management plan to include which treatments? (Select all that apply.) a. Oxygen therapy b. Bronchodilators c. Corticosteroids d. Antibiotics e. Intubation and mechanical ventilation
ANS: A, B, C, E Medical management of a patient with status asthmaticus is directed toward supporting oxygenation and ventilation. Bronchodilators, corticosteroids, oxygen therapy, and intubation and mechanical ventilation are the mainstays of therapy. Indications for mechanical ventilation include cardiac or respiratory arrest, disorientation, failure to respond to bronchodilator therapy, and exhaustion. Antibiotics are not part of the plan unless the patient develops an infection.
The practitioner indicates in her notes that the patient has mild adult respiratory distress syndrome (ARDS). The patient is requiring mechanical ventilation and has a PEEP of 5 cm H2O. The nurse would anticipate the patient having which finding? a. Radiologic evidence of bibasilar atelectasis b. PaO2/FiO2 ratio of 220 mm Hg c. Pulmonary artery occlusion pressure greater than 18 mm Hg d. Oxygen saturation of 92%
ANS: B According to the definition, ARDS is characterized by: • Lung injury of acute onset, within 1 week of an apparent clinical insult and with progression of respiratory symptoms • Bilateral opacities on chest imaging (chest radiograph or CT) not explained by other lung pathology (e.g. effusion, lobar/lung collapse, or nodules) • Respiratory failure not explained by heart failure or volume overload • Decreased PaO2/FiO2 ratio (mild: 201 to 300 mmHg, moderate: 101 to 200 mmHg, severe ARDS: ≤ 100 mmHg) • Note that the Berlin definition requires a minimum positive end expiratory pressure (PEEP) of 5 cm H2O for consideration of the PaO2/FiO2 ratio.
For which situation does a patient with acute lung failure require a bronchodilator? a. Excessive secretions b. Bronchospasms c. Thick secretions d. Fighting the ventilator
ANS: B Bronchodilators aid in smooth muscle relaxation and are of particular benefit to patients with airflow limitations. Bronchospasms are a form of airflow limitation. The patient with excessive secretions requires suctioning. The patient with thick secretions requires increased hydration. The patient fighting the ventilator needs further assessment and possibly an anxiolytic or sedative.
A patient was admitted with acute lung failure secondary to pneumonia. What is the single most important measure to prevent the spread of infection between staff and patients? a. Place the patient in respiratory isolation. b. Ensure everyone is using proper hand hygiene. c. Use personal protective equipment when touching the patient. d. Initiate prompt administration of antibiotics.
ANS: B Proper hand hygiene is the single most important measure available to prevent the spread of bacteria from person to person.
The nurse is caring for a patient with pneumonia. The nurse is alerted when pulse oximeter alarm goes off. The monitor reads 82%. Which action should the nurse should perform first? a. Notify the practitioner and get ready to intubate the patient. b. Assess the patient's condition. c. Turn off the alarm and reapply the oximeter sensor. d. Increase the amount of oxygen being administered to the patient.
ANS: B The first nursing action would be to assess the patient to see if there is a change in his or her condition. If the patient is stable, then the nurse should turn off the alarm and reapply the oximeter sensor as indicated. If the patient is unstable, the practitioner should be notified. The amount of oxygen should not be increased without a practitioner's order.
The nurse is caring for a patient with massive pulmonary embolus. Which pathophysiologic hemodynamic consequence should the nurse anticipate the patient may develop? a. Increased systemic vascular resistance leading to left heart failure b. Pulmonary hypertension leading to right heart failure c. Portal vein blockage leading to ascites d. Embolism to the internal carotids leading to a stroke
ANS: B The major hemodynamic consequence of a pulmonary embolus 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.
Which patient would be at risk for developing hypoxemic normocapnic respiratory failure (type I)? a. A young adult patient with a recent cervical spinal injury b. An older adult patient with a stroke with swallowing difficulties c. An adult patient with Guillain-Barré syndrome d. A young adult patient admitted with chest trauma and fractured ribs
ANS: B While all these patients are at risk for acute lung failure, the patient with a stroke and swallowing difficulties is at risk for aspiration pneumonitis which could result in hypoxemic normocapnic respiratory failure. The other patients are at risk for hypoxemic hypercapnic respiratory failure secondary to alveolar hypoventilation. A cervical spinal injury, Guillain-Barré syndrome, and chest trauma can all interfere with the patient's ability to breath.
The nurse is caring for a patient who is ventilator-dependent. The interprofessional team feels the patient's main problem is increased ventilatory workload. The patient's collaborative plan of care should include which interventions to address this issue? (Select all that apply.) a. Decrease the respiratory rate on the ventilator. b. Optimize the ventilator settings and trigger sensitivity. c. Position the patient with the head of the bed elevated at least 30 degrees. d. Insert a nasogastric tube to relieve abdominal distention. e. Replace a small endotracheal tube with a larger tube or a tracheostomy.
ANS: B, C, D, E Physiologic factors that increase ventilatory workload include decreased lung compliance, increased airway resistance, small endotracheal tube size, decreased ventilatory sensitivity, improper positioning, abdominal distention, and dyspnea. All the interventions address the patient's increased ventilatory workload except decreasing the patient's ventilatory rate. Decreasing the rate will make the patient work harder and may potentiate respiratory muscle fatigue.
The patient management plan of a patient with acute lung failure should include which interventions? (Select all that apply.) a. Positioning the patient with the least affected side up b. Providing adequate rest between treatments c. Performing percussion and postural drainage every 4 hours d. Controlling fever e. Pharmaceutical medications to control anxiety
ANS: B, D, E The goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Other interventions include performing procedures only as needed, preoxygenating the patient before suctioning, providing adequate rest and recovery time between various procedures, and minimizing oxygen consumption. Interventions to minimize oxygen consumption include limiting the patient's physical activity, administering sedation to control anxiety, and providing measures to control fever.
A patient has been admitted with severe shortness of breath and pleuritic chest pain. The practitioner suspects the patient may have a pulmonary embolism (PE). Which finding would confirm this diagnosis? a. Low-probability V/Q scan b. Negative pulmonary angiogram c. High-probability V/Q scan d. Absence of vascular markings on the chest radiograph
ANS: C A definitive diagnosis of a pulmonary embolism requires confirmation by a high-probability V/Q scan, an abnormal pulmonary angiogram or computed tomography scan, or strong clinical suspicion coupled with abnormal findings on lower extremity deep venous thrombosis studies.
A patient was admitted in acute lung failure. The patient is receiving 40% oxygen via a simple face mask. The morning chest radiography study reveals right lower lobe pneumonia. Which test would the nurse expect the practitioner to order to identify the infectious pathogen? a. CBC with differential b. Wound culture of surgical site c. Sputum gram stain and culture d. Urine specimen
ANS: C A sputum gram stain and culture are done to facilitate the identification of the infectious pathogen. In 50% of cases, though, a causative agent is not identified. A diagnostic bronchoscopy may be needed, particularly if the diagnosis is unclear or current therapy is not working. In addition, a complete blood count with differential, chemistry panel, blood cultures, and arterial blood gas analysis is obtained.
A patient at risk for the recurrence of a pulmonary embolism (PE) is being discharged home. The patient asks "How long do I have to remain on warfarin?" Which response from the nurse is the most accurate? a. "You only have to take warfarin for 1 month and then you can stop." b. "You could be on warfarin for up to 6 months depending on your lab work." c. "Depending on your risk, it could be anywhere from 3 to 12 months." d. "Most patients have to stay on warfarin for at least 36 months."
ANS: C The patient should remain on warfarin for 3 to 12 months depending on his or her risk for thromboembolic disease.
A patient with acute respiratory distress syndrome (ARDS) continues to have ongoing problems with hypoxemia. Which therapeutic measure should the nurse anticipate the practitioner will order next? a. Sedating the patient to blunt noxious stimuli b. Increasing the FiO2 on the ventilator c. Administering positive-end expiratory pressure (PEEP) d. Restricting fluids to 500 mL per shift
ANS: C The purpose of using positive-end expiratory pressure (PEEP) in a patient with acute respiratory distress syndrome is to improve oxygenation while reducing FiO2 to less toxic levels. PEEP has several positive effects on the lungs, including opening collapsed alveoli, stabilizing flooded alveoli, and increasing functional residual capacity. Thus, PEEP decreases intrapulmonary shunting and increases compliance.
A patient with severe unilateral pneumonia has been admitted with severe hypoxemia. The nurse suspects the underlying cause of the hypoxemia is which pathophysiologic process? a. Alveolar hypoventilation b. Dead space ventilation c. Intrapulmonary shunting d. Physiologic shunting
ANS: C The underlying cause of this patient's hypoxemia is probably intrapulmonary shunting. As blood passes through the affected lung, minimal gas exchange is taking place. Intrapulmonary shunting occurs when blood passes through a portion of a lung that is not ventilated. Physiologic shunting is normal and not a cause of hypoxemia.
A patient has been admitted with the diagnosis of acute respiratory distress syndrome (ARDS). Arterial blood gasses (ABGs) revealed an elevated pH and decreased PaCO2. The patient is becoming fatigued, and the practitioner orders a repeat ABG. Which set of results would be indicative of the patient's current condition? a. Elevated pH and decreased PaCO2 b. Elevated pH and elevated PaCO2 c. Decreased pH and decreased PaCO2 d. Decreased pH and elevated PaCO2
ANS: D Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen administration (refractory hypoxemia). 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.
While caring for a patient with severe left-sided pneumonia, the nurse observes that the patient's oxygen saturation varies depending on the patient's position. Given this information the patient would probably benefit from being placed in which position? a. Reverse Trendelenburg b. Supine c. On the left side d. On the right side
ANS: D Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Because gravity normally facilitates preferential ventilation and perfusion to the dependent areas of the lungs, the best gas exchange would take place in the dependent areas of the lungs. Thus, the goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position.
The nurse is developing a patient management plan for an older adult patient who has had a stroke. The patient is unable to adequately swallow and is receiving tube feedings. Which nursing intervention should be incorporated into the plan of care? a. Observing the amount given in the tube feeding b. Assessing the patient's level of consciousness c. Encouraging the patient to cough and to breathe deeply d. Positioning the patient in a semirecumbent position
ANS: D Semirecumbency has been shown to decrease the risk of aspiration and inhibit the development of hospital-associated pneumonia.
Supplemental oxygen administration is usually effective in treating hypoxemia related to which situation? a. Physiologic shunting b. Dead space ventilation c. Alveolar hyperventilation d. Ventilation/perfusion mismatching
ANS: D Supplemental oxygen administration is effective in treating hypoxemia related to alveolar hypoventilation and ventilation/perfusion mismatching. When intrapulmonary shunting exists, supplemental oxygen alone is ineffective. In this situation, positive pressure is necessary to open collapsed alveoli and facilitate their participation in gas exchange. Positive pressure is delivered via invasive and noninvasive mechanical ventilation.
A patient was admitted after a left pneumonectomy. The patient is receiving 40% oxygen via a simple face mask. The morning chest radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. What action should the nurse take next? a. Lavage the airway with normal saline b. Place the patient supine in a semi-Fowler position c. Manually ventilate the patient d. Suction the airway
ANS: D When aspiration is witnessed, emergency treatment should be instituted to secure the airway and minimize pulmonary damage. The patient's head should be turned to the side, and the oral cavity and upper airway should be suctioned immediately to remove the gastric contents.
