Chapter 14 Questions

A patient on the ventilator has a PaO2 of 95 and an FIO2 of 50%. Calculate the P/F ratio. 40 190 475 526

190

Diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetrical chest movement are indicative of which of the following disorders? a. Tension pneumothorax b. Pneumonia c. Pulmonary fibrosis d. Atelectasis

ANS: A Diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetrical chest movement are indicative of tension pneumothorax.

A patient was admitted to the critical care unit after a left pneumonectomy. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. The patient becomes agitated, has decreased level of consciousness, and has an inability to maintain saturation. The nurse expects the next action will include a. placing the patient on a mechanical ventilator. b. change in antibiotics to control infection. c. suctioning and repositioning. d. administering a sedative to control anxiety.

ANS: A Nursing interventions include optimizing oxygenation and ventilation, preventing the spread of infection, providing comfort and emotional support, and maintaining surveillance for complications.

Which of the following nursing interventions should be used to optimize oxygenation and ventilation in the patient with acute respiratory failure? a. Provide adequate rest and recovery time between procedures. b. Position the patient with the good lung up. c. Suction the patient every hour. d. Avoid hyperventilating the patient. .

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. Hyperventilate the patient before suctioning; suction patients as needed

A patient with chronic obstructive pulmonary disease requires intubation. After the physician intubates the patient, the nurse auscultates for breath sounds. Breath sounds are questionable in this patient. Which action would best assist in determining endotracheal tube placement in this patient? a. Stat chest radiographic examination b. End-tidal CO2 monitor c. V/Q scan d. Pulmonary artery catheter insertion

ANS: B Although a stat chest radiography examination would be helpful, it has a long turnaround time, and the patient's respiratory status can deteriorate quickly. An end-tidal CO2 monitor gives an immediate response, and the tube can then be reinserted without delay if incorrectly placed. The other tests are not for endotracheal tube placement.

A patient was admitted to the critical care unit after a left pneumonectomy. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. The single most important measure to prevent the spread of infection between staff and patients is a. respiratory isolation. b. hand washing. c. use of PPE. d. antibiotics.

ANS: B Proper hand hygiene is the single most important measure available to prevent the spread of bacteria from person to person.

Which of the following chest radiography findings is consistent with a left pneumothorax? a. Flattening of the diaphragm b. Shifting of the mediastinum to the right c. Presence of a gastric air bubble d. Increased radiolucency of the left lung field

ANS: B Shifting of the mediastinal structures away from the area of involvement is a sign of a pneumothorax.

While conducting a physical assessment, you note that the patient's breathing is rapid and shallow. This type of breathing pattern is known as a. hyperventilation. b. tachypnea. c. obstructive breathing. d. bradypnea.

ANS: B Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation. Hyperventilation is manifested by an increase in both the rate and depth of ventilation. Obstructive breathing is characterized by progressively more shallow breathing until the client actively and forcefully exhales. Bradypnea is a slow respiratory rate characterized as less than 12 breaths/min in an adult.

The major hemodynamic consequence of a massive pulmonary embolus is 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 of the following findings confirms the diagnosis of a PE? 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 embolus 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 pneumothorax greater than 15% requires a. systemic antibiotics to treat the inflammatory response. b. an occlusive dressing to equalize lung pressures. c. interventions to evacuate the air from the pleural space and facilitate re-expansion of the collapsed lung. d. mechanical ventilation to assist with re-expansion of the collapsed lung.

ANS: C A pneumothorax greater than 15% requires intervention to evacuate the air from the pleural space and facilitate re-expansion of the collapsed lung. Interventions include aspiration of the air with a needle and placement of a small-bore (12-20 Fr) or large-bore (24-40 Fr) chest tube.

A patient is admitted with acute respiratory failure attributable to pneumonia. Smoking history reveals that the patient smoked two packs of cigarettes a day for 25 years, stopping 10 years ago. ABG values on the current ventilator settings are pH, 7.37; PaCO2, 50 mm Hg; and HCO3−, 27 mEq/L. Chest radiograph reveals a large right pleural effusion. Intrapulmonary shunting value of 35% indicates a. normal gas exchange of venous blood. b. an abnormal finding indicative of a shunt-producing disorder. c. a serious and potentially life-threatening condition. d. metabolic alkalosis.

ANS: C A shunt greater than 10% is considered abnormal and indicative of a shunt-producing disorder. A shunt greater than 30% is a serious and potentially life-threatening condition that requires pulmonary intervention

A patient was admitted to the critical care unit after a left pneumonectomy. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. Which test would the nurse expect the health care provider 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.

The two most common causes of hospital-acquired pneumonia in the United States are a. Staphylococcus aureus and Pseudomonas aeruginosa b. Escherichia coli and Haemophilus influenzae c. methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa d. Klebsiella spp. and Enterobacter spp.

ANS: C Pathogens that can cause health care-associated pneumonia are similar to those causing both community- and hospital-acquired pneumonia (HAP) with Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) being the most common in the United States. Pathogens that can cause HAP include Escherichia coli, Haemophilus influenzae, methicillin-sensitive Staphylococcus aureus, Streptococcus pneumoniae, P. aeruginosa, Acinetobacter baumannii, MRSA, Klebsiella spp., and Enterobacter spp.

Depending on the patient's risk for the recurrence of PE, a patient may be placed on warfarin for a. 1 to 3 months. b. 3 to 6 months. c. 3 to 12 months. d. 12 to 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 is admitted to the critical care unit with acute respiratory failure. Upon auscultation, the health care provider hears creaking, leathery, coarse breath sounds in the lower anterolateral chest area during inspiration and expiration. The nurse suspects that the patient has a(n) a. emphysema. b. atelectasis. c. pulmonary fibrosis. d. pleural friction rub.

ANS: D A pleural friction rub is the result of irritated pleural surfaces rubbing together and is characterized by a leathery, dry, loud, coarse sound. A pleural friction rub is seen with pleural effusions or pleurisy and is not indicative of emphysema.

On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3, 24 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. What treatment would the physician or nurse practitioner likely order for this patient? a. Increase O2 to 6 L/min. b. Prepare for emergency intubation. c. Administer 1 ampule of sodium bicarbonate. d. Repeat ABG testing in 4 hours.

ANS: D Increasing the FiO2 on this patient could decrease the respiratory rate and increase the severity of the patient's CO2 retention. The patient's arterial blood gas (ABG) values do not warrant intubation at this time. Additional sodium bicarbonate is not indicated because this patient has a fully compensated pH. A repeat ABG may be ordered to assess the patient's ongoing respiratory status. Other factors must be considered when reviewing a patient's ABGs, including oxygen saturation, oxygen content, base excess and deficit, and anion gap analysis.

Patients with left-sided pneumonia may benefit from placing them in which of the following positions? 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.

Which of the following lung sounds would be most likely heard in a client experiencing an asthma attack? a. Coarse rales b. Pleural friction rub c. Fine crackles d. Expiratory wheezes

ANS: D Wheezes are high-pitched, squeaking, whistling sounds produced by airflow through narrowed small airways. They are heard mainly on expiration but may also be heard throughout the ventilatory cycle. Depending on their severity, wheezes can be further classified as mild, moderate, or severe. Rales are crackling sounds produced by fluid in the small airways or alveoli or by the snapping open of collapsed airways during inspiration. A pleural friction rub is a dry, coarse sound produced by irritated pleural surfaces rubbing together and is caused by inflammation of the pleura.

Why would the nurse perform an inspection of the oral cavity during a complete pulmonary assessment? a. To provide evidence of hypoxia b. To provide evidence of dyspnea c. To provide evidence of dehydration d. To provide evidence of nutritional status

ANS: A Severe hypoxia will be manifested by central cyanosis, which is evident in the oral and circumoral areas. Although dehydration and nutritional status can both be partially assessed by oral cavity inspection; this information is not as vital as determining hypoxia. Dyspnea means difficulty breathing.

A patient's assessment data present as follows: pH, 7.10; PaCO2, 60 mm Hg; PaO2, 40 mm Hg; HCO3, 24 mEq/L; RR, 34 breaths/min; HR, 128 beats/min; and BP, 180/92 mm Hg. This condition is best described as a. uncompensated respiratory acidosis. b. uncompensated metabolic acidosis. c. compensated metabolic acidosis. d. compensated respiratory acidosis.

ANS: A The pH is below normal range (7.35-7.45), so this is uncompensated acidosis. The PaCO2 is markedly elevated, and the HCO3 is normal. This indicates uncompensated respiratory acidosis. Uncompensated respiratory acidosis values include a pH below 7.35, PACO2 above 45 mm Hg, and HCO3 of 22 to 26 mEq/L. Uncompensated metabolic acidosis values include a pH below 7.35, PACO2 of 35 to 45 mm Hg, and HCO3 above 22 mEq/L. Compensated metabolic acidosis values include a pH of 7.35 to 7.39, PACO2 below 35 mm Hg, and HCO3− below 22 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.35, PACO2 above 45 mm Hg, and HCO3 above 26 mEq/L.

The most common presenting signs and symptoms associated with PEs are 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 client just involved in a motor vehicle accident has sustained blunt chest trauma as part of his injuries. The nurse assessment reveals absent breath sounds in the left lung field. A left-sided pneumothorax is suspected and is further validated when assessment of the trachea reveals a. a shift to the right. b. a shift to the left. c. no deviation. d. subcutaneous emphysema.

ANS: A With a pneumothorax, the trachea shifts to the opposite side of the problem; with atelectasis, the trachea shifts to the same side as the problem. Subcutaneous emphysema is more commonly related to a pneumomediastinum and is not specifically related to the trachea but to air trapped in the mediastinum and general neck area.

Weaning methods that are used in combination with each other include (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.

Psychologic factors that may contribute to long-term mechanical ventilation dependence include (Select all that apply.) a. fear. b. delirium. c. lack of confidence in the ability to breathe. d. depression. e. trust in the staff so the patient displays a lack of effort.

ANS: A, B, C, D Psychologic 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).

Which of the following regarding the client history will assist the nurse in developing the plan of management? (Select all that apply.) a. Provides direction for the rest of the assessment b. Exposes key clinical manifestations c. Aids in developing the plan of care d. The degree of the client's distress determines the extent of the interview e. Determines length of stay in the hospital setting

ANS: A, B, C, D The initial presentation of the patient determines the rapidity and direction of the interview. For a patient in acute distress, the history should be curtailed to just a few questions about the patient's chief complaint and precipitating events.

A patient with acute respiratory failure may require a bronchodilator if which of the following occurs? 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. Mucolytics and expectorants are no longer used because they have been found to be of no benefit in this patient population.

For which of the following conditions is a bronchoscopy indicated? a. Pulmonary edema b. Ineffective clearance of secretions c. Upper gastrointestinal bleed d. Instillation of surfactant

ANS: B Bronchoscopy visualizes the bronchial tree. If secretions are present, they can be removed by suctioning and sent for culture to help adjust antibiotic therapy.

The adventitious breath sounds that sound like popping in the small airways or alveoli are a. sonorous wheezes. b. crackles. c. sibilant wheezes. d. pleural friction rubs.

ANS: B Crackles or rales are short, discrete, popping or crackling sounds produced by fluid in the small airways or alveoli.

Which of the following patients would be considered hypoxemic? a. A 70-year-old man with a PaO2 of 72 b. A 50-year-old woman with a PaO2 of 65 c. An 84-year-old man with a PaO2 of 96 d. A 68-year-old woman with a PaO2 of 80

ANS: B Normal PaO2 is 80 to 100 mm Hg in persons younger than 60 years. The formula for determining PaO2 for a person older than 60 years of age is 80 mm Hg minus 1 mm Hg for every year of age above 60 years of age, for example, 70 years old = 80 mm Hg - 10 mm Hg = 70 mm Hg; 84 years old = 80 mm Hg - 20 mm Hg = 60 mm Hg; and 68 years old = 80 mm Hg - 8 mm Hg = 72 mm Hg.

A patient presents with the following values: pH, 7.20; paO2, 106 mm Hg; paCO2, 35 mm Hg; and HCO3−, 11 mEq/L. These values are most consistent with a. uncompensated respiratory acidosis. b. uncompensated metabolic acidosis. c. uncompensated metabolic alkalosis. d. uncompensated respiratory alkalosis.

ANS: B The pH indicates acidosis, and the HCO3− is markedly decreased, indicating a metabolic disorder. Uncompensated metabolic acidosis values include a pH below 7.35, PACO2 of 35 to 45 mm Hg, and HCO3− above 22 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PACO2 above 45 mm Hg, and HCO3− of 22 to 26 mEq/L. Uncompensated respiratory alkalosis values include a pH above 7.45, PACO2 below 35 mm Hg, and HCO3− of 22 to 26 mEq/L. Uncompensated metabolic alkalosis values include a pH above 7.45, PACO2 of 35 to 45 mm Hg, and HCO3− above 26 mEq/L.

A patient is admitted to the critical care unit with acute respiratory failure secondary to COPD. The patient has a 15-year history of emphysema and bronchitis. On inspection, the nurse observes that the patient is experiencing air trapping. While auscultating the chest, the nurse notes the presence of coarse, rumbling, low-pitched sounds in the right middle and lower lobes. On percussion of the lung fields, a patient with emphysema will predictably exhibit which tone? a. Resonance b. Hyperresonance c. Tympany d. Dullness

ANS: B The percussion tone of hyperresonance is heard with emphysema related to overinflation of the lung. Resonance can be found in normal lungs or with the diagnosis of bronchitis. Tympany occurs with the diagnosis of large pneumothorax and emphysematous blebs. Dullness occurs with the diagnosis of atelectasis, pleural effusion, pulmonary edema, pneumonia, and a lung mass.

A patient is admitted to the critical care unit with acute respiratory failure secondary to COPD. The patient has a 15-year history of emphysema and bronchitis. On inspection, the nurse notes that the patient is experiencing air trapping. While auscultating his chest, you note the presence of coarse, rumbling, low-pitched sounds in the right middle and lower lobes. Which of the following best describes the patient's breathing pattern? a. Deep sighing breaths without pauses b. Rapid, shallow breaths c. Normal breathing pattern interspersed with forced expirations d. Irregular breathing pattern with both deep and shallow breaths

ANS: C Air trapping is described as a normal breathing pattern interspersed with forced expirations. As the patient breathes, air becomes trapped in the lungs, and ventilations become progressively shallower until the patient actively and forcefully exhales.

Determination of oxygenation status by oxygen saturation alone is inadequate. What other value must be known? a. pH b. PaCO2 c. HCO3- d. Hemoglobin (Hgb)

ANS: D Proper evaluation of the oxygen saturation level is vital. For example, an Sao2 of 97% means that 97% of the available hemoglobin is bound with oxygen. The word available is essential to evaluating the Sao2 level because the hemoglobin level is not always within normal limits and oxygen can bind only with what is available.

A patient is admitted to the critical care unit with acute respiratory failure secondary to chronic obstructive pulmonary disease. The patient has a 15-year history of emphysema and bronchitis. On inspection, the nurse observes that the patient is experiencing air trapping. While auscultating the chest, the nurse notes the presence of coarse, rumbling, low-pitched sounds in the right middle and lower lobes. On further inspection of the patient, the nurse observes that his fingers appear discolored. This is a result of a. clubbing. b. central cyanosis. c. peripheral cyanosis. d. chronic tuberculosis.

ANS: C Discoloration of the fingers is an indication of peripheral cyanosis. Central cyanosis occurs when the unsaturated hemoglobin of arterial blood exceeds 5 g/dL and is considered a life-threatening situation. Clubbing refers to an abnormality of the fingers caused by chronically low blood levels of oxygen often related to a heart or lung disease.

On assessment of a client, you note fremitus over the trachea but not in the lung periphery. You know that this most likely represents a. bilateral pleural effusion. b. bronchial obstruction. c. a normal finding. d. apical pneumothorax.

ANS: C Fremitus is described as normal, decreased, or increased. With normal fremitus, vibrations can be felt over the trachea but are barely palpable over the periphery. With decreased fremitus, there is interference with the transmission of vibrations. Examples of disorders that decrease fremitus include pleural effusion, pneumothorax, bronchial obstruction, pleural thickening, and emphysema.

Which of the following causes 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. Drug overdose

ANS: C Hypoxemia is the result of impaired gas exchange and is the hallmark of acute respiratory failure. Hypercapnia may be present, depending on the underlying cause of the problem. The main causes of hypoxemia are alveolar hypoventilation, ventilation/perfusion (V/Q) mismatching, and intrapulmonary shunting. Intrapulmonary shunting occurs when blood passes through a portion of a lung that is not ventilated. Drug overdose is an extrapulmonary cause that affects the brain.

Diaphragmatic excursion is a measurement of the difference in the level of the diaphragm on inspiration and expiration determined by percussion. It is increased in a. atelectasis and emphysema. b. hepatomegaly and ascites. c. atelectasis and paralysis. d. pneumonia and pneumothorax.

ANS: C Normal diaphragmatic excursion is 3 to 5 cm and is part of the percussion component of the physical examination. An assessment finding other than normal would indicate the need for further evaluation such as chest radiographic examination.

A patient presents with chest trauma from an MVA. Upon assessment, the nurse documents that the patient is complaining of dyspnea, shortness of breath, tachypnea, and tracheal deviation to the right. In addition, the client's tongue is blue-gray. Based on the following data, what the nurse would expect to find? a. PaO2 of 88 and PCO2 of 55 b. Absent breath sounds in all right lung fields c. Absent breath sounds in all left lung fields d. Diminished breath sounds in all fields

ANS: C The clinical picture described is most consistent with left pneumothorax. This would cause the trachea to deviate to the right, away from the increasing pressure of the left. A pneumothorax this severe would completely collapse the right lung, thus causing absent breath sounds in that lung.

A patient is admitted to the unit in respiratory distress secondary to pneumonia. The nurse knows that obtaining a history is very important. What is the appropriate intervention at this time for obtaining this data? a. Collect an overview of past medical history, present history, and current health status. b. Do not obtain any history at this time. c. Curtail the history to just a few questions about the client's chief complaint and precipitating events. d. Complete the history and then provide measures to assist the client to breathe easier.

ANS: C The initial presentation of the client determines the rapidity and direction for the interview. For a client in acute distress, the history should be curtailed to just a few questions about the client's chief complaint and the precipitating events.

On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3, 34 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. These gases show a. uncompensated metabolic alkalosis. b. uncompensated respiratory acidosis. c. compensated respiratory acidosis. d. compensated respiratory alkalosis. .

ANS: C The pH is closer to the acidic level, so the primary disorder is acidosis. Compensated respiratory acidosis values include a pH of 7.35 to 7.39, PACO2 greater than 45 mm Hg, and HCO3 greater than 26 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PACO2 above 45 mm Hg, and HCO3− of 22 to 26 mEq/L. Compensated respiratory alkalosis values include a pH of 7.41 to 7.45, PACO2 below 35 mm Hg, and HCO3 below 22 mEq/L. Uncompensated metabolic alkalosis values include a pH above 7.45, PACO2 of 35 to 45 mm Hg, and HCO3− above 26 mEq/L

A patient is intubated, and sputum for culture and sensitivity is ordered. Which of the following is important for obtaining the best specimen? a. After the specimen is in the container, dilute thick secretions with sterile water. b. Apply suction when the catheter is advanced to obtain secretions from within the endotracheal tube. c. Do not apply suction while the catheter is being withdrawn because this can contaminate the sample with sputum left in the endotracheal tube. d. Do not clear the endotracheal tube of all local secretions before obtaining the specimen.

ANS: C To prevent contamination of secretions in the upper portion of the endotracheal tube, do not apply suction while the catheter is being withdrawn. Clear the endotracheal or tracheostomy tube for all local secretions, avoiding deep airway penetration. This will prevent contamination with upper airway flora. Do not dilute thick secretions with sterile water. This will compromise the specimen.

A patient has been admitted to the critical care unit 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 health care provider orders a repeat ABG. The nurse anticipates the following results 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.

Auscultation of the anterior chest should be performed using which of the following sequences? 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

ANS: D Auscultation should be done in a systematic sequence: side to side, top to bottom, posteriorly, laterally, and anteriorly.

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

ANS: D Examples of disorders that increase tactile fremitus include pneumonia, lung cancer, and pulmonary fibrosis. Emphysema, pleural effusion, and pneumothorax are disorders that decrease fremitus

Which of the following describes the major difference between tachypnea and hyperventilation? a. Tachypnea has increased rate; hyperventilation has decreased rate. b. Tachypnea has decreased rate; hyperventilation has increased rate. c. Tachypnea has increased depth; hyperventilation has decreased depth. d. Tachypnea has decreased depth; hyperventilation has increased depth.

ANS: D Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation. Hyperventilation is manifested by an increase in both the rate and depth of ventilation.

In normal respiration, inspiration is longer than expiration. In which disorders will inspiration be equal to expiration? (Select all that apply.) Pneumothorax Pneumonia with consolidation Pulmonary fibrosis Atelectasis Effusion

Pneumonia with consolidation Pulmonary fibrosis

A postoperative patient has a respiratory rate of 10 breaths/min with an SpO2 of 95%. Arterial blood gas (ABG) values are PaO2 85, pH 7.32, PaCO2 51, and HCO3 24. The patient is experiencing: respiratory alkalosis. respiratory acidosis. metabolic alkalosis. metabolic acidosis.

respiratory acidosis

Which ABG is considered compensated? pH 7.22, PaCO255, HCO325 pH 7.33, PaCO2 62, HCO335 pH 7.35, PaCO2 48, HCO328 pH 7.50, PaCO2 42, HCO333

pH 7.35, PaCO2 48, HCO328

Severe coughing and shortness of breath during a thoracentesis are indicative of which of the following complications? a. Re-expansion pulmonary edema b. Pleural infection c. Pneumothorax d. Hemothorax

ANS: A Re-expansion pulmonary edema can occur when a large amount of effusion fluid (~1000-1500 mL) is removed from the pleural space. Removal of the fluid increases the negative intrapleural pressure, which can lead to edema when the lung does not re-expand to fill the space. The patient experiences severe coughing and shortness of breath. The onset of these symptoms is an indication to discontinue the thoracentesis.

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

ANS: A This test is ordered for the evaluation of pulmonary emboli. Electrocardiography or cardiac enzymes are ordered to evaluate for myocardial infarction; arterial blood gas analysis, chest radiography, and pulmonary function tests are ordered to evaluate for emphysema. Chest radiography and hemodynamic monitoring are ordered for evaluation of acute respiratory distress syndrome.

A patient presents moderately short of breath and dyspneic. A chest radiographic examination reveals a large right pleural effusion with significant atelectasis. The physician or nurse practitioner would be most likely to order which of the following procedures? a. Thoracentesis b. Bronchoscopy c. Ventilation/perfusion (V/Q) scan d. Repeat chest radiograph

ANS: A Thoracentesis is a procedure that can be performed at the bedside for the removal of fluid or air from the pleural space. It is used most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema. No evidence is present that would necessitate a V/Q scan. A bronchoscopy cannot assist in fluid removal. A problem with this chest radiograph is not indicated.

Voice sounds such as bronchophony, egophony, and whispering pectoriloquy are increased in a. pneumonia with consolidation. b. pneumothorax. c. asthma. d. bronchiectasis.

ANS: A Voice sounds are increased in pneumonia with consolidation because there is increased vibration through material. Bronchophony and whispering pectoriloquy are heard as clear transmission of sounds on auscultation; egophony is heard as an "a" sound when the client is saying "e."

Risk factors that need to be considered with a thoracentesis include (Select all that apply.) a. coagulation defects. b. intra-aortic balloon pump. c. pleural effusion. d. uncooperative patient. e. empyema.

ANS: A, B, D No absolute contraindications to thoracentesis exist, although some risks may contraindicate the procedure in all but emergency situations. These risk factors include unstable hemodynamics, coagulation defects, mechanical ventilation, the presence of an intra-aortic balloon pump, and patients who are uncooperative. It is used most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema.

Which of the following diagnostic criteria is indicative of ARDS? a. Radiologic evidence of bibasilar atelectasis b. PaO2/FiO2 ratio less than or equal to 200 mm Hg c. Pulmonary artery wedge pressure greater than 18 mm Hg d. Increased static and dynamic compliance .

ANS: B The Berlin Definition of ARDS is as follows: timing—within 1 week of known clinical insult or new or worsening respiratory symptoms; chest imaging—bilateral opacities not fully explained by effusions, lobar or lung collapse, or nodules; origin of edema—respiratory failure not fully explained by cardiac failure or fluid overload; need objective assessment to exclude hydrostatic edema if no risk factor present; oxygenation—mild (200 mg Hg less than PaO2/FiO2 less than or equal to 300 mm Hg with positive end-respiratory airway pressure (PEEP) or constant positive airway pressure greater than or equal to 5 cm H2O), moderate (100 mg Hg less than PaO2/FiO2 less than or equal to 200 mm Hg with PEEP greater than or equal to 5 cm H2O), or severe (PaO2/FiO2 less than or equal to 100 mm Hg with PEEP greater than or equal to 5 cm H2O). The mortality rate for ARDS is estimated to be 34% to 58%

A patient's pulse oximeter alarm goes off. The monitor reads 82%. What is the first action the nurse should perform? a. Prepare to intubate. b. Assess the patient's condition. c. Turn off the alarm and reapply the oximeter sensor. d. Increase O2 level to 4L/NC.

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 would turn off the alarm and reapply the oximeter sensor. The pulse oximeter cannot differentiate between normal and abnormal hemoglobin. Elevated levels of abnormal hemoglobin falsely elevate the Spo2. The ability of a pulse oximeter to detect hypoventilation is accurate only when the patient is breathing room air. Because most critically ill patients require some form of oxygen therapy, pulse oximetry is not a reliable method of detecting hypercapnia and should not be used for this purpose.

A patient in metabolic acidosis has the following laboratory results: Na+ 146; Cl2- 106; HCO3 15. What kind of acidosis would this be? Non-anion gap metabolic acidosis High anion gap metabolic acidosis Low anion gap metabolic acidosis Normal anion gap metabolic acidosis

High anion gap metabolic acidosis

Normal anteroposterior (AP) diameter ranges from 1:2 to 5:7. An increase in AP diameter of the chest that is characterized by displacement of the sternum forward and the ribs outward is indicative of a. a funnel chest. b. a pigeon breast. c. a barrel chest. d. Harrison's groove.

ANS: C Normal ratio of anteroposterior diameter to lateral diameter ranges from 1:2 to 5:7. A barrel chest is characterized by displacement of the sternum forward and the ribs outward and is suggestive of chronic obstructive pulmonary disease. Funnel chest, pectus excavatum, creates a pit-shaped depression. Pigeon chest, pectus carinatum, causes an increase in anteroposterior diameter. Both are related to restrictive pulmonary disease. Harrison's groove, a rib deformity, is a result of rickets.

Which of the following therapeutic measures would be the most effective in treating hypoxemia in the presence of intrapulmonary shunting associated with ARDS? 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.

In a patient who is hemodynamically stable, which procedure can be used to estimate the PaCO2 levels? a. PaO2/FIO2 ratio b. A-a gradient c. Residual volume (RV) d. End-tidal CO2

ANS: D Capnography is the measurement of exhaled carbon dioxide (CO2) gas; it is also known as end-tidal CO2 monitoring. Normally, alveolar and arterial CO2 concentrations are equal in the presence of normal V/Q relationships. In a patient who is hemodynamically stable, the end-tidal CO2 (Petco2) can be used to estimate the PaCO2. Normally, the PaO2/FiO2 ratio is greater than 286; the lower the value, the worse the lung function. The a?2-a gradient (P[a ?2- a]O2) is normally less than 20 mm Hg on room air for patients younger than 61 years. This estimate of intrapulmonary shunting is the least reliable clinically, but it is used often in clinical decision making. Residual volume is the amount of air left in the lung after maximal exhalation. A normal value is 1200 to 1300 mL.

Aspiration can best be prevented by 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 a 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 a. physiologic shunting. b. dead space ventilation. c. hypercapnia with a PaCO2 of 35 mm Hg. 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. If the patient is also experiencing hypercapnia, the PaCO2 will be greater than 45 mm Hg. In patients with chronically elevated PaCO2 levels, these criteria must be broadened to include a pH less than 7.35.

On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3−, 24 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. Which of the following diagnoses would be most consistent with the above arterial blood gas values? a. Acute pulmonary embolism b. Acute myocardial infarction c. Congestive heart failure d. Chronic obstructive pulmonary disease

ANS: D The fact that the HCO3− level has increased enough to compensate for the increased pCO2 level indicates that this is not an acute condition because the kidneys can take several days to adjust. The other choices would present with a lower HCO3− level. The values indicate respiratory acidosis, and one of the potential causes is chronic obstructive pulmonary disease. Potential causes for respiratory alkalosis are pulmonary embolism, acute myocardial infarction, and congestive heart failure.

A patient was admitted to the critical care unit after a left pneumonectomy. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. The first action that should be taken after the patient's aspiration event is a. lavaging his airway with normal saline. b. placing him on his back in a semi-Fowler position. c. administering manual ventilations with a resuscitation bag. d. suctioning his 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.

A nurse notes that a patient's trachea is deviated to the left side. What condition could cause this to occur? (Select all that apply.) Atelectasis in the left lung Pneumothorax in the right lung Bilateral pneumonia Pleural effusion on the left side Bronchiectasis in the left lung

Atelectasis in the left lung Pneumothorax in the right lung Bronchiectasis in the left lung

A nurse is performing an assessment on a patient's lungs. While performing percussion on the left lung, the nurse notes a low-pitched resonant sound. This is compatible with what disease process? Asthma Bronchitis Emphysema Pneumothorax

Bronchitis

You have been asked to use suction and a sputum trap to obtain a sputum sample for Ms. Q through her tracheostomy. Which statement regarding this procedure is correct? Using the side of the tracheostomy tube as a guide, slide the suction catheter as far as it will go without forcing it. Apply suction to the catheter until secretions return to the sputum trap, continuing to apply suction as you withdraw the catheter Do not attempt to flush the catheter with sterile water. Maintain the specimen at room temperature until transported to the laboratory.

Do not attempt to flush the catheter with sterile water.

You have been caring for Ms. T since her admission this morning with acute asthma. She has become very anxious and short of breath. It is important to have an accurate measurement of her SpO2, but her agitation has caused her to wring her hands and swing her feet in agitation. Which site might provide the most accurate reflection of her oxygen saturation? Ear Toe Ankle Wrist

Ear

The nurse is providing pre-procedural teaching for a patient who is going to have a fiber-optic bronchoscopy. Which statement indicates that more teaching is needed? I will receive medication that will make it okay for me to eat before the procedure. I will receive medication that will make me sleepy and keep my heart rate from dropping. I will need to be on a cardiac monitor before, during, and after the procedure. I will have lab work drawn before the procedure to make sure I am not at risk for bleeding.

I will receive medication that will make it okay for me to eat before the procedure.

A patient has bronchial breath sounds over the peripheral lung fields. What condition could cause this? (Select all that apply.) Asthma Lung mass with exudate Bronchitis Pulmonary edema Bronchospasms

Lung mass with exudate Pulmonary edema

Mr. F is a 42-year-old man with a history of bipolar disease. He also has diabetes and is known for not following his medical regimen. He is admitted with a diagnosis of diabetic ketoacidosis, and you are awaiting treatment orders. You would expect which of the following arterial blood gas results for this patient? PaO2 90 mm Hg, pH 7.42, PaCO2 48 mm Hg, HCO3- 35 mEq/L PaO2 90 mm Hg, pH 7.37, PaCO2 60 mm Hg, HCO3- 39 mEq/L PaO2 90 mm Hg, pH 7.25, PaCO2 55 mm Hg, HCO3- 22 mEq/L PaO2 90 mm Hg, pH 7.25, PaCO2 40 mm Hg, HCO3- 17 mEq/L

PaO2 90 mm Hg, pH 7.25, PaCO2 40 mm Hg, HCO3- 17 mEq/L

You are asked to prepare Mr. W for a thoracentesis to relieve his left pleural effusion. He is very short of breath. Which position would be most appropriate for him during the procedure? Lying on his right side with his back flush to the edge of the bed Sitting on the side of the bed with his arms supported on the bedside table Lying prone with the head of the bed in Trendelenburg to facilitate drainage of fluids Lying supine with both arms place beneath the head

Sitting on the side of the bed with his arms supported on the bedside table

A patient has a history of respiratory problems. The nurse is assessing the patient's chest and notes that the sternum and lower ribs are displaced posteriorly, creating a pit-shaped depression in the chest. The nurse recognizes this as: barrel chest. kyphosis. pectus excavatum. pectus carinatum

pectus excavatum.