ARDS & Respiratory Review Questions
A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg; PaCO2, 28 mm Hg; HCO -, 24 mEq/L. Based upon the client's PaO , 32 which of the following conclusions would be accu- rate? 1. The client is severely hypoxic. 2. The oxygen level is low but poses no risk for the client. 3. The client's PaO2 level is within normal range. 4. The client requires oxygen therapy with very low oxygen concentrations.
ANSWER: 1. Normal PaO2 level ranges from 80 to 100 mm Hg. When the PaO2 value falls to 50 mm Hg, the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The PaO2 is not within normal range. The client will require oxygenation at a concentration that main- tains the PaO2 at 55 to 60 mm Hg or more.
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements continue to show poor oxygenation. Which action does the nurse anticipate that the health care provider will prescribe? 1. Perform endotracheal intubation and initiate mechanical ventilation. 2. Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth. 3. Administer furosemide (Lasix) 100 mg IV push immediately (STAT). 4. Call a code for respiratory arrest.
Ans: 1 A nonrebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing. Focus: Prioritization.
On auscultation, which finding suggests a right pneumothorax? A. Bilateral inspiratory and expiratory crackles B. Absence of breaths sound in the right thorax C. Inspiratory wheezes in the right thorax D. Bilateral pleural friction rub.
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A client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of: 1. Right pneumothorax 2. Pulmonary embolism 3. Displaced endotracheal tube 4. Acute respiratory distress syndrome
ANSWER: 1 Rationale: Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased air- way pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi. Test-Taking Strategy: Use the process of elimination. Focus on the symptoms presented in the question and note the rela- tionship between right upper lobe and right pneumothorax in option 1. Review the manifestations associated with pneumo- thorax if you had difficulty with this question.
A client with acute respiratory distress syn- drome (ARDS) has fine crackles at lung bases and the respirations are shallow at a rate of 28 breaths/minute. The client is restless and anxious. In addition to moni- toring the arterial blood gas results, the nurse should do which of the following? Select all that apply. 1. Monitor serum creatinine and blood urea nitrogen levels. 2. Administer a sedative. 3. Keep the head of the bed flat. 4. Administer humidified oxygen. 5. Auscultate the lungs.
ANSWER: 1, 4, 5 Acute respiratory distress syndrome (ARDS) may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries. Treatment of hypoxemia can be com- plicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidified oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases, so the nurse should continue to assess breath sounds. Sedatives should be used with caution in clients with ARDS. The nurse should try other measures to relieve the client's restlessness and anxiety. The head of the bed should be elevated to 30 degrees to promote chest expansion and prevent atelectasis.
A client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for: 1. Sudden, sharp chest pain. 2. Wheezing breath sounds over affected side. 3. Hemoptysis. 4. Cyanosis.
ANSWER: 1. Pneumothorax signs and symptoms include sudden, sharp chest pain; tachypnea; and tachycar- dia. Other signs and symptoms include diminished or absent breath sounds over the affected lung, anxi- ety, and restlessness. Breath sounds are diminished or absent over the affected side. Hemoptysis and cyanosis are not typically present with a moderate pneumothorax.
A client has a chest tube attached to a water- seal drainage system and the nurse notes that the fluid in the chest tube and in the water-seal column has stopped fluctuating. The nurse should deter- mine that: 1. The lung has fully expanded. 2. The lung has collapsed. 3. The chest tube is in the pleural space. 4. The mediastinal space has decreased.
ANSWER: 1. Cessation of fluid fluctuation in the tubing can mean one of several things: the lung has fully expanded and negative intrapleural pressure has been re-established; the chest tube is occluded; or the chest tube is not in the pleural space. Fluid fluc- tuation occurs because, during inspiration, intrapleu- ral pressure exceeds the negative pressure generated in the water-seal system. Therefore, drainage moves toward the client. During expiration, the pleural pressure exceeds that generated in the water-seal system, and fluid moves away from the client. When the lung is collapsed or the chest tube is in the pleu- ral space, fluid fluctuation is likely to be noted. The chest tube is not inserted in the mediastinal space.
A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should: 106. When caring for a client with a chest tube and water-seal drainage system, the nurse should: 1. Check the tubing to ensure that the client is not lying on it or kinking it. 2. Increase the suction. 3. Lower the drainage bottles 2 to 3 feet below the level of the client's chest. 4. Ensure that the chest tube has two clamps on it to prevent air leaks.
ANSWER: 1. In this case, there may be some obstruc- tion to the flow of air and fluid out of the pleural space, causing air and fluid to collect and build up pressure. This prevents the remaining lung from re- expanding and can cause a mediastinal shift to the opposite side. The nurse's first response is to assess the tubing for kinks or obstruction. Increasing the suction is not done without a physician's order. The normal position of the drainage bottles is 2 to 3 feet below chest level. Clamping the tubes obstructs the flow of air and fluid out of the pleural space and should not be done.
Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)? 1. Septic shock. 2. Chronic obstructive pulmonary disease. 3. Asthma. 4. Heart failure.
ANSWER: 1. The two risk factors most commonly asso- ciated with the development of ARDS are gram- negative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessinga client for onset of ARDS if the client has experi- enced direct lung trauma or a systemic inflammatory response syndrome (which can be caused by any physiologic insult that leads to widespread inflamma- tion). Chronic obstructive pulmonary disease, asthma, and heart failure are not direct causes of ARDS.
An emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a barrel chest 4. A sucking sound at the site of injury
ANSWER: 2 Rationale: This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are short- ness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.Test-Taking Strategy: Use the process of elimination and note the strategic word blunt in the question. This will assist in eliminating option 4, sucking chest wound injury. Know- ing that in a respiratory injury increased respirations will occur will assist you in eliminating option 1. Option 3 can be eliminated because a barrel chest is a characteristic finding in a client with chronic obstructive pulmonary disease. Review the signs of pneumothorax if you had difficulty with this question.
The nurse interprets which of the following as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? 1. Elevated carbon dioxide level. 2. Hypoxia not responsive to oxygen therapy. 3. Metabolic acidosis. 4. Severe, unexplained electrolyte imbalance.
ANSWER: 2. A hallmark of early ARDS is refractory hypoxemia. The client's PaO2 level continues to fall, despite higher concentrations of administered oxy- gen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbal- ances are not indicators of ARDS.
he nurse observes a constant gentle bubbling in the water-seal column of a water-seal chest drain- age system. This observation should prompt the nurse to do which of the following? 1. Continue monitoring as usual; this is expected. 2. Check the connectors between the chest and drainage tubes and where the drainage tube enters the collection bottle. 3. Decrease the suction to -15 cm H2O and continue observing the system for changes in bubbling during the next several hours. 4. Drain half of the water from the water-seal chamber.
ANSWER: 2. There should never be constant bubbling in the water-seal bottle; normally the bubbling is inter- mittent. Constant bubbling in the water-seal bottle indicates an air leak, which means that less nega- tive pressure is being exerted on the pleural space. Decreasing the suction or draining part of the water in the water-seal chamber will not reduce the leak.
A nurse is suctioning fluids from a client through an endotracheal tube. During the suctioning pro- cedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention? 1. Continue to suction. 2. Notify the physician immediately. 3. Stop the procedure and reoxygenate the client. 4. Ensure that the suction is limited to 15 seconds.
ANSWER: 3 Rationale: During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irre- gularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregulari- ties, the procedure is stopped and the client is reoxygenated. Test-Taking Strategy: Use the process of elimination, recall- ing that suctioning can cause cardiac irregularities. Noting the strategic words heart rate is decreasing should direct you to option 3. If you had difficulty with this question, review the complications and interventions associated with suction- ing procedures.
The low-pressure alarm sounds on a ventilator. A nurse assesses the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initial action? 1. Administers oxygen 2. Checks the client's vital signs 3. Ventilates the client manually 4. Starts cardiopulmonary resuscitation
ANSWER: 3 Rationale: If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is discon- nected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin cardiopulmonary resuscitation. Checking vital signs is not the initial action. Although oxygen is helpful, it will not provide ventilation to the client. Test-Taking Strategy: Read the question carefully, and note that the subject relates to adequate ventilation of the client. Also note that the nurse is unsuccessful in determining the cause of the alarm. This will direct you to option 3. If you are unfamiliar with the management of ventilators and alarms, review this content.
Which of the following interventions should the nurse anticipate in a client who has been diag- nosed with acute respiratory distress syndrome (ARDS)? 1. Tracheostomy. 2. Use of a nasal cannula. 3. Mechanical ventilation. 4. Insertion of a chest tube.
ANSWER: 3. Endotracheal intubation and mechanical ventilation are required in ARDS to maintain ade- quate respiratory support. Endotracheal intubation, not a tracheostomy, is usually the initial method of maintaining an airway. The client requires mechani- cal ventilation; nasal oxygen will not provide ade- quate oxygenation. Chest tubes are used to remove air or fluid from intrapleural spaces.
Which of the following should be readily available at the bedside of a client with a chest tube in place? 1. A tracheostomy tray. 2. Another sterile chest tube. 3. A bottle of sterile water. 4. A spirometer.
ANSWER: 3. A bottle of sterile water should be readily available and in view when a client has a chest tube so that the tube can be immediately submersed in the water if the chest tube system becomes discon- nected. The chest tube should be reconnected to the water-seal system as soon as a sterile functioning system can be re-established. There is no need for a tracheostomy tray, another chest tube, or a spirom- eter to be placed at the bedside for emergency use.
A nurse should interpret which of the following as an early sign of a tension pneumothorax in a client with chest trauma? 1. Diminished bilateral breath sounds. 2. Muffled heart sounds. 3. Respiratory distress. 4. Tracheal deviation.
ANSWER: 3. Respiratory distress or arrest is a univer- sal finding of a tension pneumothorax. Unilateral, diminished, or absent breath sounds is a common finding. Tracheal deviation is an inconsistent and late finding. Muffled heart sounds are suggestive of pericardial tamponade.
Which of the following interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)? 1. Teaching cigarette smoking cessation. 2. Maintaining adequate serum potassium levels. 3. Monitoring clients for signs of hypercapnia. 4. Replacing fluids adequately during hypovolemic states.
ANSWER: 4 One of the major risk factors for develop- ment of ARDS is hypovolemic shock. Adequate fluid replacement is essential to minimize the risk of ARDS in these clients. Teaching smoking cessation does not prevent ARDS. An abnormal serum potas- sium level and hypercapnia are not risk factors for ARDS.
A nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate
ANSWER: 4 Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. Test-Taking Strategy: Use the process of elimination, noting the strategic word earliest. Eliminate option 3 first because intercostal retraction is a later sign of respiratory distress. Of the remaining options, recall that adventitious breath sounds (options 1 and 2) would occur later than an increased respi- ratory rate. Review the early signs of acute respiratory distress syndrome if you had difficulty with this question.
Which one of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client? 1. Assessing the client's skin color. 2. Monitoring the respiratory rate. 3. Verifying the amount of cuff inflation. 4. Auscultating breath sounds bilaterally.
ANSWER: 4. Auscultation for bilateral breath sounds is the most appropriate method for determining cuff placement. The nurse should also look for the sym- metrical rise and fall of the chest and should note the location of the exit mark on the tube. Assess- ments of skin color, respiratory rate, and the amount of cuff inflation cannot validate the placement of the endotracheal tube.
A client's chest tube is to be removed by the physician. Which of the following items should the nurse have ready to be placed directly over the wound when the chest tube is removed? 1. Butterfly dressing. 2. Montgomery strap. 3. Fine-mesh gauze dressing. 4. Petroleum gauze dressing.
ANSWER: 4. Immediately after chest tube removal, a petroleum gauze is placed over the wound and covered with a dry sterile dressing. This serves as an airtight seal to prevent air leakage or air movement in either direction. Bandages are not applied directly over wounds. Montgomery straps are used in place of adhesive tape when a dressing requires very frequent changes and the constant removal of adhesive tape would damage the skin. Montgomery straps are not placed over open wounds. Mesh gauze would allow air movement.
Which of the following findings would suggest pneumothorax in a trauma victim? 1. Pronounced crackles. 2. Inspiratory wheezing. 3. Dullness on percussion. 4. Absent breath sounds.
ANSWER: 4. Pneumothorax means that the lung has collapsed and is not functioning. The nurse will hear no sounds of air movement on auscultation. Movement of air through mucus produces crackles. Wheezing occurs when airways become obstructed. Dullness on percussion indicates increased density of lung tissue, usually caused by accumulation of fluid.
The physician has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube: 1. For administration of oxygen. 2. To promote formation of lung scar tissue. 3. To insert antibiotics into the pleural space. 4. To remove air and fluid.
ANSWER: 4. A chest tube is inserted to re-expand the lung and remove air and fluid. Oxygen is not admin- istered through a chest tube. Chest tubes are not inserted to promote scar tissue formation. Antibiot- ics are not used to treat a pneumothorax.
When caring for a client with a chest tube and water-seal drainage system, the nurse should: 1. verify that the air vent on the water-seal drainage system is capped when the suction is off. 2. Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs. 3. Ensure that the chest tube is clamped when moving the client out of the bed. 4. Make sure that the drainage apparatus is always below the client's chest level.
ANSWER: 4. The drainage apparatus is always kept below the client's chest level to prevent back flowof fluid into the pleural space. The air vent must always be open in the closed chest drainage system to allow air from the client to escape. Stripping a chest tube causes excessive negative intrapleural pressure and is not recommended. Clamping a chest tube when moving a client is not recommended.
Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress? 1. Administering oxygen every 2 hours. 2. Turning the client every 4 hours. 3. Administering sedatives to promote rest. 4. Suctioning if cough is ineffective.
ANSWER: 4. The nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned every 2 hours to help move secretions; every 4 hours is not often enough. Administering sedatives is contraindi- cated in acute respiratory distress because sedatives can depress respirations.
A nurse is suctioning fluids from a client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: 1. 1 minute 2. 5 seconds 3. 10 seconds 4. 30 seconds
ANSWER:3 Rationale: Hypoxemia can be caused by prolonged suction- ing, which stimulates the pacemaker cells in the heart. A vaso- vagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.Test-Taking Strategy: Use the process of elimination. Recall that during suctioning, the client's airway is blocked; there- fore you should be able to eliminate options 1 and 4 easily. From the remaining options, eliminate option 2 because of the short time frame. Five seconds does not seem reasonable to achieve removal of secretions. Review the procedure for suctioning if you had difficulty with this question.
The high-pressure alarm on a patient's ventilator goes off. When the nurse enters the room to assess the patient, who has acute respiratory distress syndrome (ARDS), the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first? 1. Reassure the patient that the ventilator will do the work of breathing for him. 2. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. 3. Increase the fraction of inspired oxygen (Fio2) on the ventilator to 100% in preparation for endotracheal suctioning. 4. Insert an oral airway to prevent the patient from biting on the endotracheal tube.
Ans: 2 Manual ventilation of the patient will allow the nurse to deliver an Fio2 of 100% to the patient while attempting to determine the cause of the high-pressure alarm. The patient may need reassurance, suctioning, or insertion of an oral airway, but the first step should be assessing the reason for the high-pressure alarm and resolving the hypoxemia.
The nurse is assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? 1. Assessing the patient's respiratory status every 4 hours 2. Taking vital signs and pulse oximetry readings every 4 hours 3. Checking the ventilator settings to make sure they are as prescribed 4. Observing whether the patient's tube needs suctioning every 2 hours
Ans: 2 The UAP's educational preparation includes measuring vital signs, and an experienced UAP would have been taught and know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN.
The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? 1. Chest tube drainage of 10 to 15 mL/hr 2. Continuous bubbling in the water-seal chamber 3. Reports of pain at the chest tube site 4. Chest tube dressing dated yesterday
Ans: 2 Continuous bubbling indicates an air leak that must be identified. With the health care provider's (HCP's) order, an RN can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion, which will require the RN to notify the HCP. If the air bubbling does not stop when the RN applies the padded clamp, the air leak is between the clamp and the drainage system, and the RN must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. The patient's reports of pain need to be assessed and treated. This is important but is not as urgent as investigating a chest tube leak.
The nurse is the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with acute respiratory distress syndrome (ARDS) who has just been intubated in preparation for mechanical ventilation. The preceptor observes the RN performing all of these actions. For which action must the preceptor intervene immediately? 1. Assesses for bilateral breath sounds and symmetrical chest movement 2. Uses an end-tidal carbon dioxide detector to confirm endotracheal tube (ET) position 3. Marks the tube 1 cm from where it touches the incisor tooth or nares 4. Orders chest radiography to verify that tube placement is correct
Ans: 3 The ET should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after ET placement. The priority at this time is to verify that the tube has been correctly placed. Use of an end-tidal carbon dioxide detector is the gold standard for evaluating and confirming ET position in patients who have adequate tissue perfusion.
The nurse is supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause the nurse to intervene? 1. Suctioning the tracheostomy tube before performing tracheostomy care 2. Removing old dressings and cleaning off excess secretions 3. Removing the inner cannula and cleaning using standard precautions 4. Replacing the inner cannula and cleaning the stoma site
Ans: 3 When tracheostomy care is performed, a sterile field is set up, and sterile technique is used. Standard precautions such as washing hands must also be maintained but are not enough when performing tracheostomy care. The presence of a tracheostomy tube provides direct access to the lungs for organisms, so sterile technique is used to prevent infection. All of the other steps are correct and appropriate.
After the respiratory therapist performs suctioning on a patient who is intubated, the unlicensed assistive personnel (UAP) measures vital signs for the patient. Which vital sign value should the UAP be instructed to report to the RN immediately? 1. Heart rate of 98 beats/min 2. Respiratory rate of 24 breaths/min 3. Blood pressure of 168/90 mm Hg 4. Tympanic temperature of 101.4°F (38.6°C)
Ans: 4 Infections are always a threat for the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower parts of the respiratory system. The other vital signs are important and should be followed up on but are not of as urgent concern.
After extubation of a patient, which finding would the nurse report to the health care provider immediately? 1. Respiratory rate of 25 breaths/min 2. Patient has difficulty speaking3. Oxygen saturation of 93%4. Crowing noise during inspiration
Ans: 4 Stridor is a high-pitched, crowing noise during inspiration caused by laryngospasm or edema around the glottis. It is a symptom that the patient may need to be reintubated. When stridor or other symptoms of obstruction occur after extubation, respond by immediately calling the Rapid Response Team before the airway becomes completely obstructed. It is common for patients to be hoarse and have a sore throat for a few days after extubation. A respiratory rate of 25 breaths/min should be rechecked but is not an immediate danger, and an oxygen saturation of 93% is low normal.
When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? 1. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. 2. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. 3. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. 4. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (Fio2) and call the health care provider to discuss the patient's status.
Ans: 4 The patient's history and symptoms suggest the development of acute respiratory distress syndrome (ARDS), which will require intubation and mechanical ventilation to maintain oxygenation and gas exchange. The HCP must be notified so that appropriate interventions can be taken. Application of a nonrebreather mask can improve oxygenation up to 95 to 100%. The maximum oxygen delivery with a nasal cannula is an Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.
The RN caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate? A. Do nothing, because this is an expected finding B. Immediately clamp the chest tube and notify the physician C. Check for an air leak because the bubbling should be intermittent D. Increase the suction pressure so that the bubbling becomes vigorous
Answer: A. Do nothing, because this is an expected finding Continuous gentle bubbling should be noted in the suction control chamber. Option b is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option c is incorrect. Bubbling should be continuous and not intermittent. Option d is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.
The RN is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? A. Stridor B. Occasional pink-tinged sputum C. A few basilar lung crackles on the right D. Respiratory rate 24 breaths/min
Answer: A. Stridor The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Options B, C, and D are not signs that require immediate notification of the physician.
The RN has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? A. Inform the physician B. Continue to monitor the client C. Reinforce the occlusive dressing D. Encourage the client to deep breathe
Answer: B. Continue to monitor the client The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspirationand falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has reexpanded. Options A, C, and D are incorrect.
A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? A. Pallor B. Low arterial PaO2 C. Elevated arterial PaO2 D. Decreased respiratory rate
Answer: B. Low arterial PaO2 The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.
A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations? A. Simple mask B. Non-rebreather mask C. Face tent D. Nasal cannula
Answer: B. Non-rebreather mask A non-rebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.
The RN caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: A. Call the physician B. Place the tube in bottle of sterile water C. Immediately replace the chest tube system D. Place a sterile dressing over the disconnection site
Answer: B. Place the tube in bottle of sterile water If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.
A male patient's X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from: A. Cardiogenic pulmonary edema B. Respiratory alkalosis C. Increased pulmonary capillary permeability D. Renal failure
Answer: C. Increased pulmonary capillary permeability ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it does not cause ARDS. Renal failure does not cause ARDS, either.
Which phrase is used to describe the volume of air inspired and expired with a normal breath? A. Total lung capacity B. Forced vital capacity C. Tidal volume D. Residual volume
Answer: C. Tidal volume Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is the vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration.
Which of the following should the nurse assess in a patient with pneumothorax? A. Tracheal alignment. B. Expansion of the chest. C. Breath sounds. D. All of the above.
Answer: D. All of the above. D: All of the options listed should be assessed by the nurse in a patient with pneumothorax. A: Tracheal alignment should be assessed in a patient with pneumothorax. B: Expansion of the chest should be assessed in a patient with pneumothorax. C: Breath sounds should be assessed in a patient with pneumothorax.
The RN assessing a patient for tracheal displacement should know that the trachea will deviate toward the: A. Contralateral side in a simple pneumothorax B. Affected side in a hemothorax C. Affected side in a tension pneumothorax D. Contralateral side in hemothorax
Answer: D. Contralateral side in hemothorax The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax, accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation, the trachea will not shift. Tracheal deviation toward the contralateral side in simple pneumothorax is seen when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.
The following are types of pneumothorax except: A. Trauma. B. Simple. C. Tension. D. Direct.
Answer: D. Direct. D: There is no direct type of pneumothorax. A: Trauma pneumothorax is a type of pneumothorax. B: Simple pneumothorax is a type of pneumothorax. C: Tension pneumothorax is a type of pneumothorax.
A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to: A. Exhale slowly B. Stay very still C. Inhale and exhale quickly D. Perform the Valsalva maneuver
Answer: D. Perform the Valsalva maneuver When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. Options A, B, and C are incorrect client instructions.
An initial characteristic symptom of a simple pneumothorax is: A. ARDS. B. Severe respiratory distress. C. Sudden onset of chest pain. D. Tachypnea and chest discomfort.
Answer: D. Tachypnea and chest discomfort. D: The patient experiences chest discomfort and tachypnea initially. A: The patient does not experience ARDS initially in a simple pneumothorax. B: The patient does not experience severe respiratory disease initially in a simple pneumothorax. C: The patient does not experience sudden onset of chest pain initially in a simple pneumothorax.
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? A. pH, 5.0; PaCO2 30 mm Hg B. pH, 7.40; PaCO2 35 mm Hg C. pH, 7.35; PaCO2 40 mm Hg D. pH, 7.25; PaCO2 50 mm Hg
Answer: D. pH, 7.25; PaCO2 50 mm Hg In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 5.0 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. Options B and C represent normal ABG values, reflecting normal gas exchange in the lungs.