Module 2 Quiz
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? A. pH 7.28, PaO2 50 mm Hg B. pH 7.46, PaO2 80 mm Hg C. pH 7.36, PaCO2 32 mm Hg D. pH 7.35, PaCO2 48 mm Hg
A. pH 7.28, PaO2 50 mm Hg ARF is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.
The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? A. Promote more efficient and controlled ventilation and to decrease the work of breathing B. Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing C. Promote the strengthening of the client's diaphragm D. Promote the client's ability to take in oxygen
B. Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.
Arterial blood gas analysis would reveal which value related to acute respiratory failure? A. PaO2 80 mm Hg B. pH 7.28 C. PaCO2 32 mm Hg D. pH 7.35
B. pH 7.28 Acute respiratory failure is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH less than 7.35.
While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? A. Skin around tube is pink. B. Bloody drainage is observed in the collection chamber. C. Absence of bloody drainage in the anterior/upper tube D. The tissues give a crackling sensation when palpated.
D. The tissues give a crackling sensation when palpated. 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.
Acute respiratory failure (ARF) occurs when oxygen tension (PaO2) falls to less than __________ mm Hg (hypoxemia) and carbon dioxide tension (PaCO2) rises to greater than __________ mm Hg (hypercapnia). A. 60; 50 B. 60; 40 C. 75; 50 D. 75; 40
A. 60; 50 Acute respiratory failure (ARF) is classified as hypoxemic (decrease in arterial oxygen tension [PaO2] to less than 60 mm Hg on room air) and hypercapnic (increase in arterial carbon dioxide tension [PaCO2] to greater than 50 mm Hg with an arterial pH of less than 7.35).
A mediastinal shift occurs in which type of chest disorder? A. Tension pneumothorax B. Traumatic pneumothorax C. Simple pneumothorax D. Cardiac tamponade
A. Tension pneumothorax A tension pneumothorax causes the lung to collapse and the heart, the great vessels, and the trachea to shift toward the unaffected side of the chest (mediastinal shift). A traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or enters the pleural space through a wound in the chest wall. A simple pneumothorax most commonly occurs as air enters the pleural space through the rupture of a bleb or a bronchopleural fistula. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac.
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? A. Tension pneumothorax B. Cardiac tamponade C. Flail chest D. Pulmonary contusion
A. Tension pneumothorax Clamping can result in a tension pneumothorax. The other options would not occur if the chest tube was clamped during transportation.
A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates? A. Pneumothorax B. Flail chest C. ARDS D. Tension pneumothorax
B. Flail chest During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.
A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for: A. chronic obstructive pulmonary disease (COPD). B. bronchial asthma. C. acute respiratory distress syndrome (ARDS). D. renal failure.
C. acute respiratory distress syndrome (ARDS). A client who receives massive fluid resuscitation or blood transfusions or who aspirates stomach contents is at highest risk for ARDS, which is associated with catastrophic events, such as multiple trauma, bacteremia, pneumonia, near drowning, and smoke inhalation. COPD refers to a group of chronic diseases, including bronchial asthma, characterized by recurring airflow obstruction in the lungs. Although renal failure may occur in a client with multiple trauma (depending on the organs involved), this client's history points to an assault on the respiratory system secondary to aspiration of stomach contents and massive fluid resuscitation.
A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism? A. Nonproductive cough and abdominal pain B. Hypertension and lack of fever C. Bradypnea and bradycardia D. Chest pain and dyspnea
D. Chest pain and dyspnea As an embolus occludes a pulmonary artery, it blocks the supply of oxygenated blood to the heart, causing chest pain. It also blocks blood flow to the lungs, causing dyspnea. The client with pulmonary embolism typically has a cough that produces blood-tinged sputum (rather than a nonproductive cough) and chest pain (rather than abdominal pain). Hypertension, absence of fever, bradypnea, and bradycardia aren't associated with pulmonary embolism.
Which of the following is a potential complication of a low pressure in the endotracheal cuff? A. Aspiration pneumonia B. Tracheal bleeding C. Tracheal ischemia D. Pressure necrosis
A. Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.
The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS? A. Rapid onset of severe dyspnea B. Inspiratory crackles C. Bilateral wheezing D. Cyanosis
A. Rapid onset of severe dyspnea The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.
For a client with pleural effusion, what does chest percussion over the involved area reveal? A. Absent breath sounds B. Dullness over the involved area C. Friction rub D. Fluid presence
B. Dullness over the involved area Chest percussion reveals dullness over the involved area. The nurse may note diminished or absent breath sounds over the involved area when auscultating the lungs and may also hear a friction rub. Chest radiography and computed tomography show fluid in the involved area.
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? A. Acute respiratory distress syndrome B. Lung cancer C. Bronchitis D. Tracheobronchitis
A. Acute respiratory distress syndrome 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.
What is the reason for chest tubes after thoracic surgery? A. Draining secretions, air, and blood from the thoracic cavity is necessary. B. Chest tubes allow air into the pleural space. C. Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. D. Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.
A. Draining secretions, air, and blood from the thoracic cavity is necessary. 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? A. Impaired gas exchange B. Anxiety C. Decreased cardiac output D. Ineffective tissue perfusion (cardiopulmonary)
A. Impaired gas exchange 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 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? A. Intubate the client and control breathing with mechanical ventilation B. Increase oxygen administration C. Administer a large dose of furosemide (Lasix) IVP stat D. Schedule the client for pulmonary surgery
A. Intubate the client and control breathing with mechanical ventilation 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.
The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber? A. Notify the physician. B. Place the head of the patient's bed flat. C. Milk the chest tube. D. Disconnect the system and get another.
A. Notify the physician. Observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. In addition, assess the chest tube system for correctable external leaks. Notify the primary provider immediately of excessive bubbling in the water seal chamber not due to external leaks.
A client admitted to the hospital following a motor vehicle crash has suffered a flail chest. The nurse assesses the client for what most common clinical manifestation of flail chest? A. Paradoxical chest movement B. Cyanosis C. Hypertension D. Wheezing
A. Paradoxical chest movement During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. Upon expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the client's ability to exhale. The mediastinum then shifts back to the affected side. This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.
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? A. Partial pressure of arterial oxygen (PaO2) B. Partial pressure of arterial carbon dioxide (PaCO2) C. pH D. Bicarbonate (HCO3-)
A. Partial pressure of arterial oxygen (PaO2) 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.
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? A. Unresponsive arterial hypoxemia B. Diminished alveolar dilation C. Tachypnea D. Increased PaO2
A. Unresponsive arterial hypoxemia 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.
On auscultation, which finding suggests a right pneumothorax? A. Bilateral inspiratory and expiratory crackles B. Absence of breath sounds in the right thorax C. Inspiratory wheezes in the right thorax D. Bilateral pleural friction rub
B. Absence of breath sounds in the right thorax In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.
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? A. Instruct the client to breathe into a paper bag. B. Administer oxygen by nasal cannula as ordered. C. Auscultate breath sounds bilaterally every 4 hours. D. Encourage the client to deep-breathe and cough every 2 hours.
B. Administer oxygen by nasal cannula as ordered. 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 is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest? A. Respiratory acidosis B. Paradoxical chest movement C. Chest pain on inspiration D. Clubbing of fingers and toes
B. Paradoxical chest movement Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chest wall movement. Respiratory acidosis and chest pain are symptoms that can occur with flail chest but is not as significant in the diagnosis as paradoxical chest movement. Clubbing of fingers and toes are sign of prolonged tissue hypoxia.
A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure? A. Insidious onset of lung impairment in a client who had normal lung function B. Sudden onset of lung impairment in a client who had normal lung function C. Insidious onset of lung impairment in a client who had compromised lung function D. Sudden onset of lung impairment in a client who had compromised lung function
B. Sudden onset of lung impairment in a client who had normal lung function In acute respiratory failure, the ventilation or perfusion mechanisms in the lung are impaired. Acute respiratory failure occurs suddenly in a client who previously had normal lung function.
A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which client need would the nurse identify as a priority? A. Acute pain B. Infection risk C. Impaired gas exchange D. Ineffective airway clearance
C. Impaired gas exchange The diaphragm separates the thoracic and abdominal cavities. On inspiration, the diaphragm contracts and moves downward, creating a partial vacuum. Without this vacuum, air is not as efficiently drawn into the thoracic cavity. Hypoxia or hypoxemia may occur from the poor availability of oxygen. Although the nursing diagnosis of acute pain is probable, gas exchange is a higher priority. Ineffective airway clearance is not the greatest concern because the problem is with ventilation. Infection risk is present but is not the highest-priority client need.
The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse? A. "The tube will allow air to be restored to the lung." B. "The tube will drain secretions from the lung." C. The tube will provide a route for medication instillation to the lung." D. "The tube will drain air from the space around the lung."
D. "The tube will drain air from the space around the lung." Negative pressure must be maintained in the pleural cavity for the lungs to be inflated. An injury that allows air into the pleural space will result in a collapse of the lung. The chest tube can be used to drain fluid and blood from the pleural cavity and to instill medication, such as talc, to the cavity.
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? A. Hypotension, hyperoxemia, and hypercapnia B. Hyperventilation, hypertension, and hypocapnia C. Hyperoxemia, hypocapnia, and hyperventilation D. Hypercapnia, hypoventilation, and hypoxemia
D. Hypercapnia, hypoventilation, and hypoxemia The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? A. Pulmonary embolism B. Myocardial infarction (MI) C. Heart failure D. Pneumothorax
D. Pneumothorax Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.
You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? A. See if the chest tube is clogged. B. See if the wall suction unit has malfunctioned. C. See if a kink has developed in the tubing. D. See if there are leaks in the system.
D. See if there are leaks in the system. Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks. Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease if the chest tube is clogged or a kink develops in the tubing. If the suction unit malfunctions, the suction control chamber, not the water-seal chamber, will be affected.
The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment? A. Cough B. Hemoptysis C. Syncope D. Tachypnea
D. Tachypnea Symptoms of PE depend on the size of the thrombus and the area of the pulmonary artery occluded by the thrombus; they may be nonspecific. Dyspnea is the most frequent symptom; the duration and intensity of the dyspnea depend on the extent of embolization. Chest pain is common and is usually sudden and pleuritic in origin. It may be substernal and may mimic angina pectoris or a myocardial infarction. Other symptoms include anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope. The most frequent sign is tachypnea (very rapid respiratory rate).