Gas exchange PrepU
A 41-year-old male client has presented to the emergency department with an acute onset of increased respiratory rate and difficulty breathing. STAT chest X-ray indicates diffuse bilateral infiltrates of his lung tissue and ECG displays no cardiac dysfunction. What is this client's most likely diagnosis? Cor pulmonale Acute lung injury Pulmonary hypertension Sarcoidosis
Correct response: Acute lung injury Explanation: Rapid onset of respiratory distress accompanied by diffuse bilateral infiltrates of lung tissue and an absence of cardiac changes are associated with acute lung injury/acute respiratory distress syndrome. These particular signs and symptoms are not as closely associated with cor pulmonale, pulmonary hypertension, or sarcoidosis.
Which of the following is a potential complication of a low pressure in the endotracheal cuff? Aspiration pneumonia Tracheal bleeding Tracheal ischemia Pressure necrosis
Correct response: Aspiration pneumonia Explanation: Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.
While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? Skin around tube is pink. Bloody drainage is observed in the collection chamber. Absence of bloody drainage in the anterior/upper tube The tissues give a crackling sensation when palpated.
Correct response: The tissues give a crackling sensation when palpated. Explanation: Subcutaneous emphysema is the result of air leaking between the subcutaneous layers. It is not a serious complication but is notable and reportable. Pink skin and blood in the collection chamber are normal findings. When two tubes are inserted, the posterior or lower tube drains fluid, whereas the anterior or upper tube is for air removal.
The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication? Atelectasis Acute respiratory distress syndrome Metabolic alkalosis Respiratory acidosis
Correct response: Acute respiratory distress syndrome Explanation: Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Options A, C, and D are incorrect.
The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following? Acute respiratory distress syndrome Lung cancer Bronchitis Tracheobronchitis
Correct response: Acute respiratory distress syndrome Explanation: Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis.
A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? Instruct the client to breathe into a paper bag. Administer oxygen by nasal cannula as ordered. Auscultate breath sounds bilaterally every 4 hours. Encourage the client to deep-breathe and cough every 2 hours.
Correct response: Administer oxygen by nasal cannula as ordered. Explanation: When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client re-inhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation.
A client sustained a puncture injury to the chest resulting in development of a tension pneumothorax. What is the pathogenesis behind a tension pneumothorax? Expired air exits the bleeding wound at a faster rate than inhalation. Air is permitted to enter but not leave the pleural space, causing lung collapse. The opposite lung hyperinflates to compensate for the collapsed lung. Blebs on the lung surface rupture due to increased intrapleural pressure.
Correct response: Air is permitted to enter but not leave the pleural space, causing lung collapse. Explanation: Tension pneumothorax occurs when the intrapleural pressure exceeds atmospheric pressure. It is a life-threatening condition and occurs when injury to the chest or respiratory structures permits air to enter but not leave the pleural space. Spontaneous pneumothorax occurs when an air-filled bleb, or blister, on the lung surface ruptures. Rupture of these blebs allows atmospheric air from the airways to enter the pleural cavity. This results in a rapid increase in pressure in the chest with a compression atelectasis of the unaffected lung.
A client has a sucking stab wound to the chest. Which action should the nurse take first? Draw blood for a hematocrit and hemoglobin level. Apply a dressing over the wound and tape it on three sides. Prepare a chest tube insertion tray. Prepare to start an I.V. line.
Correct response: Apply a dressing over the wound and tape it on three sides. Explanation: The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.
Which is a potential complication of a low pressure in the endotracheal tube cuff? Tracheal bleeding Aspiration pneumonia Tracheal ischemia Pressure necrosis
Correct response: Aspiration pneumonia Explanation: Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis.
The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to: Notify the physician. Assess pulse and blood pressure. Administer prescribed pain medication. Lay the client's head to a flat position.
Correct response: Assess pulse and blood pressure. Explanation: The client has bled 120 mL of bloody drainage in the chest drainage system within 15 minutes. It is most important for the nurse to assess for signs and symptoms of hemorrhage, which may be indicated by a rapid pulse and decreasing blood pressure. The nurse may then lay the client in a flat position and notify the physician.
A client has sudden severe dyspnea, fear, asymmetrical chest movement and decreased lung sounds on the right side. Which intervention is most appropriate? Administer morphine sulfate (morphine) to reduce pain and increase contractility. Assist to high-Fowler's position and prepare for chest tube insertion. Position head of bed at 45 degrees and prepare for intubation to improve respiratory status. Position limbs above heart for venous return and give dobutamine IV.
Correct response: Assist to high-Fowler's position and prepare for chest tube insertion. Explanation: Spontaneous pneumothorax can occur in healthy people and tends to occur most often in tall boys and young men between the ages of 10 and 30 years. It is treated with insertion of chest tubes to reinflate the affected lung.
For a client with an endotracheal (ET) tube, which nursing action is the most important? Auscultating the lungs for bilateral breath sounds Turning the client from side to side every 2 hours Monitoring serial blood gas values every 4 hours Providing frequent oral hygiene
Correct response: Auscultating the lungs for bilateral breath sounds Explanation: For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.
Atelectasis is the term used to designate an incomplete expansion of a portion of the lung. Depending on the size of the collapsed area and the type of atelectasis occurring, the nurse may see a shift of the mediastinum and trachea. Which way does the mediastinum and trachea shift in compression atelectasis? Toward the affected lung Toward the mediastinum Away from the affected lung Away from the trachea
Correct response: Away from the affected lung Explanation: If the collapsed area is large, the mediastinum and trachea shift to the affected side. In compression atelectasis, the mediastinum shifts away from the affected lung.
The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse? Heart rate, 112 bpm Moderate amounts of colorless sputum Pain of 5 on a 1-to-10 scale Chest tube drainage, 190 mL/hr
Correct response: Chest tube drainage, 190 mL/hr Explanation: The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse must notify the primary provider if drainage is ≥150 mL/hr. The other findings are normal following a thoracotomy and no intervention would be required.
A client has developed chronic hypoxia and has developed pulmonary hypertension (HTN). The nurse recognizes that the most likely cause of pulmonary hypertension would be: Constant dilation of the pulmonary vessels in response to hypoxia Constriction of the pulmonary vessels in response to hypoxemia Hardening of the pulmonary vessels due to increased fat deposits Decreased vascular resistance in the pulmonary vessels
Correct response: Constriction of the pulmonary vessels in response to hypoxemia Explanation: Pulmonary HTN occurs as a result of chronic hypoxia. In response to hypoxia, the pulmonary vessels constrict. The pulmonary vessels differ from the systemic circulation vessels, which dilate in response to hypoxia and hypercapnia. Smooth muscle hypertrophy and proliferation of the vessel intima occur in pulmonary HTN.
A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? Surgery to remove the tonsils and adenoids Medications to assist the patient with sleep at night Continuous positive airway pressure (CPAP) Bi-level positive airway pressure (BiPAP)
Correct response: Continuous positive airway pressure (CPAP) Explanation: CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea.
The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined? Call respiratory therapy and wait until they arrive to determine what is happening. Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. Stop the ventilator by pressing the off button, wait 15 seconds, and then turn it on again to see if the alarm stops. Suction the patient since the patient may be obstructed by secretions.
Correct response: Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. Explanation: If the cause of an alarm cannot be determined, the nurse should disconnect the patient from the ventilator and manually ventilate the patient, because leaving the patient on the mechanical ventilator may be dangerous.
What is the reason for chest tubes after thoracic surgery? Draining secretions, air, and blood from the thoracic cavity is necessary. Chest tubes allow air into the pleural space. Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.
Correct response: Draining secretions, air, and blood from the thoracic cavity is necessary. Explanation: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand.
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? Impaired gas exchange Anxiety Decreased cardiac output Ineffective tissue perfusion (cardiopulmonary)
Correct response: Impaired gas exchange Explanation: For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.
A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client? Impaired gas exchange related to ventilator setting adjustments Risk for trauma related to endotracheal intubation and cuff pressure Risk for infection related to endotracheal intubation and suctioning Impaired physical mobility related to being on a ventilator
Correct response: Impaired gas exchange related to ventilator setting adjustments Explanation: All the nursing diagnoses are appropriate for this client. Per Maslow's hierarchy of needs, airway, breathing, and circulation are the highest priorities within physiological needs. The client has an oxygen saturation of 91%, which is below normal. This places impaired gas exchange as the highest prioritized nursing diagnosis.
The nurse is caring for a patient at risk for atelectasis and chooses to implement a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis? Incentive spirometry Intermittent positive pressure-breathing (IPPB) Positive end-expiratory pressure (PEEP) Bronchoscopy
Correct response: Incentive spirometry Explanation: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In patients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as PEEP, continuous or intermittent positive pressure-breathing (IPPB), or bronchoscopy may be used.
A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: Risk for falls. Ineffective breathing pattern. Impaired tissue integrity. Ineffective airway clearance.
Correct response: Ineffective airway clearance. Explanation: Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? Intubate the client and control breathing with mechanical ventilation Increase oxygen administration Administer a large dose of furosemide (Lasix) IVP stat Schedule the client for pulmonary surgery
Correct response: Intubate the client and control breathing with mechanical ventilation Explanation: A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.
A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? Kinking of the ventilator tubing A disconnected ventilator circuit An ET cuff leak A change in the oxygen concentration without resetting the oxygen level alarm
Correct response: Kinking of the ventilator tubing Explanation: Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator circuit or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.
A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure? Partial pressure of arterial oxygen (PaO2) Partial pressure of arterial carbon dioxide (PaCO2) pH Bicarbonate (HCO3-)
Correct response: Partial pressure of arterial oxygen (PaO2) Explanation: In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed.
A client arrives in the ED after an automobile accident. Which clinical manifestations lead the nurse to suspect a pneumothorax? Select all that apply. Respiratory rate 34. Asymmetrical chest movements, especially on inspiration Diminished breath sounds over painful chest area Pulse oximetry 98% ABG pH level of 7.38
Correct response: Respiratory rate 34. Asymmetrical chest movements, especially on inspiration Diminished breath sounds over painful chest area Explanation: Manifestations of pneumothorax include increased respiratory rate, dyspnea, asymmetrical movements of chest wall (especially during inspiration), hyperresonant sound on percussion, and decreased or absent breath sounds over area of pneumothorax. The pulse oximetry reading is normal. ABG pH level of 7.38 is a normal finding.
A client arrives in the ED after an automobile accident. Which clinical manifestations lead the nurse to suspect a pneumothorax? Select all that apply. Respiratory rate 34. Asymmetrical chest movements, especially on inspiration Diminished breath sounds over painful chest area Pulse oximetry 98% ABG pH level of 7.38
Correct response: Respiratory rate 34. Asymmetrical chest movements, especially on inspiration Diminished breath sounds over painful chest area Explanation: Manifestations of pneumothorax include increased respiratory rate, dyspnea, asymmetrical movements of chest wall (especially during inspiration), hyperresonant sound on percussion, and decreased or absent breath sounds over area of pneumothorax. The pulse oximetry reading is normal. ABG pH level of 7.38 is a normal finding.
A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped? Respiratory rate of 16 breaths/minute Oxygen saturation of 93% Runs of ventricular tachycardia Blood pressure remains stable
Correct response: Runs of ventricular tachycardia Explanation: Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. The client's blood pressure remains stable, so the weaning can continue.
A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time? The patient will be extubated and another endotracheal tube will be inserted. The patient will be extubated and a nasotracheal tube will be inserted. The patient will have an insertion of a tracheostomy tube. The patient will begin the weaning process.
Correct response: The patient will have an insertion of a tracheostomy tube. Explanation: Endotracheal intubation may be used for no longer than 14 to 21 days, by which time a tracheostomy must be considered to decrease irritation of and trauma to the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing (Wiegand, 2011).
While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? The system is functioning normally. The patient has a pneumothorax. The system has an air leak. The chest tube is obstructed.
Correct response: The system has an air leak. Explanation: Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. Patients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? The system is functioning normally. The client has a pneumothorax. The system has an air leak. The chest tube is obstructed.
Correct response: The system has an air leak. Explanation: Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.
A client is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action first? Notify the respiratory therapist. Manually ventilate the client. Troubleshoot to identify the malfunction. Reposition the endotracheal tube.
Correct response: Troubleshoot to identify the malfunction. Explanation: The nurse should first immediately attempt to identify and correct the problem; if the problem cannot be identified and/or corrected, the client must be manually ventilated with an Ambu bag. The respiratory therapist may be notified, but this is not the first action by the nurse. The nurse should not reposition the endotracheal tube as a first response to an alarm.
The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS? Unresponsive arterial hypoxemia Diminished alveolar dilation Tachypnea Increased PaO2
Correct response: Unresponsive arterial hypoxemia Explanation: Acute respiratory distress syndrome (ARDS) can be thought of as a spectrum of disease, from its milder form (acute lung injury) to its most severe form of fulminate, life-threatening ARDS. This clinical syndrome is characterized by a severe inflammatory process causing diffuse alveolar damage that results in sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP, and the absence of an elevated left atrial pressure.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? Negative-pressure Volume-controlled Time-cycled Pressure-cycled
Correct response: Volume-controlled Explanation: With volume-controlled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.
A client is brought to the emergency department and immediately diagnosed with a tension pneumothorax. The priority intervention would be: insertion of a large-bore needle or chest tube. chest x-ray. arterial blood gas analysis. administration of oxygen by face mask.
Correct response: insertion of a large-bore needle or chest tube. Explanation: Emergency treatment of tension pneumothorax involves the prompt insertion of a large-bore needle or chest tube into the affected side of the chest along with one-way valve drainage or continuous chest suction to aid in lung reexpansion. Other listed options may be implemented after the emergency measure.
A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as pleural effusion. pneumothorax. hemothorax. consolidation.
Correct response: pleural effusion. Explanation: Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process.
A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as: pressure support ventilation (PSV). synchronized intermittent mandatory ventilation (SIMV). assist-control (AC) ventilation. continuous positive airway pressure (CPAP).
Correct response: synchronized intermittent mandatory ventilation (SIMV). Explanation: In SIMV mode, the ventilator delivers a preset number of breaths at a preset tidal volume. The client can breathe on his own in between the breaths delivered by the ventilator. In PSV, a pressure plateau is added to the ventilator to prevent the airway pressure from falling beneath a preset level. In AC ventilation, the ventilator delivers a preset number of breaths at a preset tidal volume and any breaths that the client takes on his own are assisted by the ventilator so they reach the preset tidal volume. In CPAP, the ventilator provides only positive airway pressure; it doesn't provide any breaths to the client.