Oxygenation

4.The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a. Adherence to proper hand hygiene b. Administering anti-ulcer medication c. Elevating the head of the bed d. Providing oral care per protocol e. Suctioning the client on a regular schedule

ANS: A, B, C, D The ventilator bundle is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.

6.The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a. Chest wall stiffness b. Decreased muscle strength c. Inability to cooperate d. Less lung elasticity e. Poor vision and hearing

ANS: A, B, D Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity.

5.A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a. Allow visitors at the clients bedside. b. Ensure the client can communicate if awake. c. Keep the television tuned to a favorite channel. d. Provide back and hand massages when turning. e. Turn the client every 2 hours or more.

ANS: A, B, D, E There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the clients skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.

A family member of a patient who has acute respiratory distress syndrome (ARDS) asks the nurse how long it will take for the patient to get better. The nurse reviews the medical record and notes that the patient has been receiving mechanical ventilation for 2 weeks. What does the nurse tell the family member? A. "Multi-system organ changes occur at 2 weeks." B. "Lung changes have occurred that are irreversible." C. "Patients who are ventilator-dependent usually die." D. "Recovery may be complete, but it will take months."

ANS: B Pulmonary fibrosis with progression occurs after 10 days of onset of ARDS. Patients who survive to this point will have permanent lung changes and may remain ventilator-dependent indefinitely. While many die, telling the family member this initially will destroy any hope for a good outcome; this must be discussed with the provider, the nurse, and possibly the palliative care team. Multisystem organ changes are more likely but have not necessarily occurred. Recovery is rarely complete at this stage.

17.A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management? a. Poor visual acuity b. Strict vegetarian c. Refusal to stop smoking d. Wants weight loss surgery

ANS: B Warfarin works by inhibiting the synthesis of vitamin K dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have trouble maintaining this diet. The nurse should explore this possibility with the client. The other options are not related.

16.A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication? a. Hamburger and French fries b. Large chefs salad and muffin c. No selection; spouse brings pizza d. Tuna salad sandwich and chips

ANS: B Warfarin works by inhibiting the synthesis of vitamin K dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. The chefs salad most likely has too many leafy green vegetables, which contain high amounts of vitamin K. The other selections, while not particularly healthy, will not interfere with the medications mechanism of action.

The nurse coming on shift prepares to perform an initial assessment of a sedated ventilated patient. Which are priorities for the nurse to carry out? Select all that apply. A. Ask visitors to leave. B. Listen for bilateral breath sounds. C. Confirm alarms and ventilator settings. D. Assess the patient's color and respirations. E. Ensure that the tube cuff is inflated and is in the proper position. F. Provide routine tracheotomy and endotracheotomy and mouth care.

ANS: B, C, D, E The first priority when caring for a critically ill patient receiving mechanical ventilation is to assess airway and breathing. Alarm settings should be confirmed each shift, more frequently if necessary. Confirming that the patient cannot speak ensures that air is going through the endotracheal tube and not around it. Auscultating for equal bilateral breath sounds assists in confirming that the tube is above the carina. Having visitors remain with the patient may promote comfort and prevent confusion. Routine tracheostomy care is performed according to schedule, not necessarily as part of an initial assessment.

4. An adolescent is being placed on a calcium channel blocker. What should the nurse inform the adolescent with regard to this medication? (Select all that apply.) a. The medication may cause fatigue. b. The medication may increase heart rate. c. The medication may cause constipation. d. The medication may cause cold extremities. e. The medication may cause peripheral edema. f. This is the only question i could find in hock 27 that was relevant. fmlll

ANS: B, C, E Calcium channel blockers may cause an increase in heart rate, constipation, and peripheral edema. Beta-blockers can cause fatigue and cold extremities, but calcium channel blockers do not cause these potential side effects.

A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? a. Ensure the client has adequate sedation. b. Find another provider to intubate. c. Interrupt the procedure to give oxygen. d. Monitor the clients oxygen saturation. e. Tell the patient "the pain is almost over"

ANS: C Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation during the procedure and monitor the clients oxygen saturation, but these do not take priority. Finding another provider is not appropriate at this time.

All of these nursing actions are included in the plan of care for a patient who has just been extubated. Which action should the nurse delegate to unlicensed assistive personnel (UAP)? A. Adjust the nasal oxygen flow rate. B. Monitor vital signs every 5 minutes. C. Keep the head of the bed elevated. D. Teach about incentive spirometer use.

ANS: C Positioning of patients is included in UAP education and scope of practice and can be delegated. Patient teaching is an activity performed by the professional nurse. Although taking vital signs is an activity of the UAP, monitoring a potentially unstable patient is done by the professional nurse. Adjusting oxygen flow rates requires complex decision making and should be done by the RN.

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? a. Assess the client for sedation needs. b. Get family permission for restraints. c. Provide frequent oral care per protocol. d. Use nonverbal pain assessment tools

ANS: C The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse.

A patient sitting upright and receiving high-flow oxygen with a non-rebreather mask appears anxious and has a respiratory rate of 30 breaths/min, a heart rate of 110 beats/min, and an oxygen saturation of 88%. The patient is using accessory muscles to breathe and appears fatigued. The nurse notifies the provider and prepares to receive an order for which intervention? A. Insertion of an oral airway B. Chest x-ray and arterial blood gases C. Intubation and mechanical ventilation D. Lowering the head of the bed to 30 degrees

ANS: C The patient is hypoxic despite receiving oxygen and is showing signs of increasing distress and fatigue; intubation and mechanical ventilation are necessary to treat respiratory failure in this patient. A chest x-ray and arterial blood gases may be performed once the patient is stabilized as part of the ongoing assessment. An oral airway is used when the patient cannot maintain a patent airway. The head of the bed should be elevated to at least 30 degrees or higher if the patient prefers.

15.A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Apply oxygen at 100%. b. Assess the respiratory rate. c. Ensure a patent airway. d. Start two large-bore IV lines.

ANS: C The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs.

Which antidote is used for blocking fibrinolytic therapy? A. Alteplase B. Vitamin K 1 C. Protamine sulfate D. Aminocaproic acid

ANS: D Fibrinolytic therapy is used to break up an existing clot, but these agents may cause excessive bleeding; it may be necessary to block the activity of fibrinolytic agents by using its antidote to prevent further excessive bleeding. Aminocaproic acid is the antidote for fibrinolytic therapy. Alteplase is a fibrinolytic drug that increases the risk of bleeding. Vitamin K 1 is an antidote for warfarin, an oral anticoagulant used for the long-term prevention of venous thrombi. Protamine sulfate is used to block the activity of heparin.

A patient who has been on a ventilator for the past week has become increasingly hypoxemic and has not been responding well to the increasing oxygen settings. The nurse suspects the patient is in which phase of acute respiratory distress syndrome (ARDS)? A. Fibrosis B. Exudative C. Resolution D. Fibroproliferative

ANS: D In the fibroproliferative phase increased lung damage leads to pulmonary hypertension and fibrosis. The body attempts to repair the damage, and increasing lung involvement reduces gas exchange and oxygenation. In the exudative phase patients experience dyspnea and tachypnea and require oxygen via mask or nasal cannula. The resolution phase usually occurs after 14 days. Resolution of the injury can occur; if not, the patient either dies or has chronic disease. Fibrosis may or may not occur.

The nurse is caring for a patient who is on mechanical ventilation and the ventilator alarm sounded. For which high pressure alarm would it be appropriate for the nurse to insert an oral airway? A. The patient has a decreased airway size. B. The patient has increased mucus secretions. C. The patient experiences decreased compliance of the lungs. D. The patient is coughing and biting on the oral endotracheal tube.

ANS: D Inserting an oral airway helps prevent the patient from coughing and biting on the oral endotracheal tube. The high pressure alarm may sound due to decreased airway size, increased mucus secretions, or decreased compliance of the lungs, but none of these problems can be solved by the insertion of an oral airway. When the patient has increased mucus secretions, suction should be provided. When decreased compliance of the lungs is experienced, the nurse should evaluate the underlying cause and try to alleviate the problem.

A patient receiving 100% oxygen for treatment of pneumonitis after inhaling an irritant has worsening hypoxemia confirmed with arterial blood gases and has increasing dyspnea and work of breathing. A chest x-ray reveals a ground-glass appearance in both lungs. Which condition does the nurse suspect this patient has developed? A. Pneumonia B. Oil or fat embolism C. Tension pneumothorax D. Acute respiratory distress syndrome

ANS: D Patients who have these symptoms most likely have acute respiratory distress syndrome (ARDS). The ground-glass appearance on the x-ray confirms this diagnosis. Patients with pulmonary embolism may have normal chest x-rays or may have infiltrates localized to the area around the embolism. Patients with pneumonia typically have infiltration or consolidation of one or more lobes. A tension pneumothorax is visible on x-ray with one-sided lung involvement.

22.A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best? a. It is chronic hypoxemia that accompanies restrictive airway disease. b. It is hypoxemia from lung damage due to mechanical ventilation. c. It is hypoxemia that continues even after the client is weaned from oxygen. d. It is hypoxemia that persists even with 100% oxygen administration.

ANS: D Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.

14.A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best? a. It will increase the motility of the gastrointestinal tract. b. It will keep the gastrointestinal tract functioning normally. c. It will prepare the gastrointestinal tract for enteral feedings. d. It will prevent ulcers from the stress of mechanical ventilation.

ANS: D Stress ulcers occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Zantac is a histamine blocking agent.

11.A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? a. The client is able to initiate spontaneous breaths. b. The inspired oxygen has adequate humidification. c. The upper peak airway pressure limit alarm is off. d. The upper peak airway pressure limit alarm is on.

ANS: D The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury.

21.A client is brought to the emergency department after sustaining injuries in a severe car crash. The clients chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority? a. Administer oxygen and reassess. b. Auscultate the clients lung sounds. c. Facilitate a portable chest x-ray. d. Prepare to assist with intubation.

ANS: D This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.

A patient requiring mechanical ventilation for treatment of pneumonia becomes agitated, restless, and shows symptoms of respiratory distress. The mechanical ventilator high-pressure alarm has been activated. What is the nurse's priority intervention? A. Medicate the patient with a sedating agent. B. Increase oxygen delivery to 100% through the ventilator. C. Check the mechanical ventilator for possible causes of the alarm. D. Disconnect the ventilator and provide ventilation with a self-inflating bag.

ANS: D When a patient shows signs of respiratory distress while being mechanically ventilated, the nurse should focus on the patient, not the mechanical ventilator. The first best action is to disconnect the ventilator and use a self-inflating bag to ventilate the patient while problem-solving the cause of the alarm. Although it may be necessary to administer sedation to the patient, but the nurse must attempt to stabilize the patient first. The nurse should not increase oxygen through the ventilator until the cause of the alarm is determined.

The nurse is teaching the family of a patient who is receiving mechanical ventilation. Which statement reflects appropriate information that the nurse should communicate? A. "Paralysis and sedatives help decrease the demand for oxygen." B. "Suctioning is important to remove organisms from the lower airway." C. "We are encouraging oral and IV fluids to keep your loved one hydrated." D. "Sedation is needed so your loved one does not rip the breathing tube out."

ANS: A Paralytics and sedation decrease oxygen demand. Sedation is needed more for its effects on oxygenation than to prevent the patient from ripping out the endotracheal tube. Suctioning is performed to maintain airway patency. Minimizing fluids while administering diuretics leads to better outcomes.

1.A 242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.) ___ mL

ANS: 660 mL A low tidal volume of 6 mL/kg is used to prevent lung injury. 242 pounds = 110 kg. 110 kg 6 mL/kg = 660 mL.

The nurse is extubating a patient who has been receiving mechanical ventilation for several days. Which action is correct immediately after removal of the endotracheal (ET) tube? A. Monitoring vital signs B. Suctioning the oropharynx C. Asking the patient to cough D. Hyperoxygenating the patient

ANS: C The patient should be asked to cough immediately after removal of the ET tube to help clear secretions. The nurse should hyperoxygenate the patient and suction the oropharynx prior to removal of the ET tube. After the ET tube is safely removed, the nurse should monitor vital signs every 5 minutes initially.

20.A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a. Alteplase (Activase) b. Enoxaparin (Lovenox) c. Unfractionated heparin d. Warfarin sodium (Coumadin)

ANS: A Activase is a clot-busting agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.

19.A client in the emergency department has several broken ribs. What care measure will best promote comfort? a. Allowing the client to choose the position in bed b. Humidifying the supplemental oxygen c. Offering frequent, small drinks of water d. Providing warmed blankets

ANS: A Allow the client with respiratory problems to assume a position of comfort if it does not interfere with care. Often the client will choose a more upright position, which also improves oxygenation. The other options are less effective comfort measures.

A patient has intensive care unit (ICU) psychosis. What procedure is the most probable cause? A. Mechanical ventilation B. Cardiac catheterization C. Electrophysiological study D. Intravascular ultrasonography

ANS: A Intensive care unit (ICU) psychosis is observed most frequently in patients undergoing mechanical ventilation. Cardiac catheterization is an invasive test used in the diagnosis of heart diseases. An electrophysiological study (EPS) is an invasive procedure during which programed electrical stimulation of the heart is used to cause and evaluate lethal dysrhythmias and conduction abnormalities. Intravascular ultrasonography (IVUS) is a technique which introduces a flexible catheter with a miniature transducer at the distal tip to view the coronary arteries. All these are diagnostic procedures and are not related to ICU psychosis.

The student nurse, under the supervision of a registered nurse, is caring for a patient with chronic obstructive pulmonary disease (COPD) who is on mechanical ventilation. Which statement of the student nurse needs correction? A. "I will provide the patient with a carbohydrate-rich diet." B. "I will administer proton-pump inhibitors to the patient." C. "I will provide the patient with formulas having high fat content." D. "I will regularly monitor the calcium and magnesium levels of the patient."

ANS: A Patients with COPD require a reduction of dietary carbohydrates. During metabolism, carbohydrates are broken down to glucose, which then produces energy, carbon dioxide, and water. Excess carbohydrate loads increase carbon dioxide production that the patient cannot exhale, resulting in hypercarbic respiratory failure. Administering proton-pump inhibitors is beneficial to the patient to prevent stress ulcers because the patient may be unable to consume if there are mouth ulcerations. This affects the patient's nutritional status. Providing the patient with formulas that have high fat content will combat imbalances in nutrition. Monitoring electrolytes is useful in detecting any electrolyte imbalances.

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Assess for other manifestations of hypoxia. b. Change the sensor on the pulse oximeter. c. Obtain a new oximeter from central supply. d. Tell the client to take slow, deep breaths.

ANS: A Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.

12.A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a. Assess the cause of the agitation. b. Reassure the client that he or she is safe. c. Restrain the clients hands. d. Sedate the client immediately.

ANS: A The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain and confusion can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary, but not as a first step.

18.A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse? a. Assessing the clients platelet count b. Choosing an 18-gauge, 2-inch needle c. Not aspirating prior to injection d. Swabbing the injection site with alcohol

ANS: B Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions are appropriate.

13.A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority? a. Assessing that the ventilator settings are correct b. Ensuring there is a bag-valve-mask in the room c. Obtaining personal protective equipment d. Planning to suction the client upon arrival to the room

ANS: B Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse should know and check the settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or may not need suctioning on arrival.

A patient who is receiving packed red blood cells to treat anemia has a respiratory rate of 25 breaths/min, intercostal retractions with breathing, and clear breath sounds. Which action should the nurse take? A. Assess the patient's anxiety level. B. Notify the provider of the respiratory distress. C. Request an order for an anxiolytic medication. D. Continue to monitor the patient every 15 minutes.

ANS: B Patients receiving transfusions are at risk for transfusion-related acute lung injury (TRALI). Early signs are hyperpnea and increased work of breathing; this should be reported immediately so that treatment can be initiated. These symptoms may be signs of increased anxiety, but the nurse should report the findings to the provider since rapid treatment of TRALI is essential to prevent serious effects. Until the patient is evaluated for the presence of TRALI, an anxiolytic medication is not indicated.

Which condition manifests as delirium in patients on mechanical ventilation in the intensive care unit (ICU)? A. ICU paranoia B. ICU dementia C. ICU psychosis D. ICU depression

ANS: C The use of mechanical ventilation for a patient in the intensive care unit (ICU) can cause anxiety and delirium, a condition known as "ICU psychosis." Paranoia involves a patient being overly suspicious, not delirious. Dementia may manifest as delirium, but it is the result of cognitive disorders and aging, not anxiety. Depression may occur in a patient on mechanical ventilation in the ICU, but it is not characterized by delirium.

An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority? a. Determine if the tube is kinked. b. Ensure all connections are patent. c. Listen to the clients lung sounds. d. Suction the endotracheal tube.

ANS: C When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems. The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.

The nurse expects which changes in a patient with acute respiratory distress syndrome (ARDS)? Select all that apply. a. Increase in lung volume b. Expansion of lung channels c. Reduction in surfactant activity d. Damage to type II pneumocytes e. Edema around terminal airways

ANS: C, D, E ARDS occurs as a result of an acute lung injury. The injury typically happens in the alveolar-capillary membrane. As a result of the injury, surfactant is diluted by extra fluid in the lungs. Type II pneumocytes are damaged, and edema forms around terminal airways. Surfactant activity is reduced due to the damage of type II pneumocytes. The collapsed alveoli cannot exchange gases, and edema forms around terminal airways. In ARDS, lung volume is decreased and lung channels are compressed.

The nurse is caring for a patient with impending respiratory failure who refuses intubation and mechanical ventilation. Which method provides an alternative to mechanical ventilation? A. Oropharyngeal airway B. Positive end-expiratory pressure (PEEP) C. Nonrebreathing mask with 100% oxygen D. Bilevel positive airway pressure (BiPAP)

ANS: D BiPAP ventilation is a noninvasive method that may provide short-term ventilation without intubation. An oropharyngeal airway is used to prevent the tongue from occluding the airway or the patient from biting the endotracheal tube. A nonrebreathing mask will assist with oxygenation; however, muscle fatigue and hypoventilation may occur as causes of respiratory failure. The need for PEEP indicates a severe gas-exchange problem; this modality is "dialed in" on the mechanical ventilator.

The nurse assists with the intubation of an 80-kg patient who will receive mechanical ventilation with positive end-expiratory pressure (PEEP) ventilation. When monitoring the patient, the nurse ensures that which settings are maintained? A. FiO 2 as high as possible B. Tidal volume of 400 mL C. Oxygen flow rate of 20 L/min D. PEEP pressure between 5 and 15 cm H 2O

Patients receiving PEEP ventilation should have pressure settings between 5 and 15 cm H 2O. Because prolonged use of high FiO 2 can damage lungs, the FiO 2 should be lowered to the lowest possible amount. The oxygen flow rate should be 40 L/min. The patient's tidal volume should be 7 to 10 mL/kg; for this patient, the range would be 560 to 800 mL.