Chapter 19

What condition develops when air enters the pleural space from the lung on inhalation and cannot exit on exhalation? a. Tension pneumothorax b. Sucking chest wound c. Open pneumothorax d. Pulmonary interstitial empyema

ANS: A A tension pneumothorax develops when air enters the pleural space from either the lung or the chest wall on inhalation and cannot escape on exhalation. Open pneumothorax is a laceration in the parietal pleura that allows atmospheric air to enter the pleural space; it occurs as a result of penetrating chest trauma. Pulmonary interstitial emphysema is air in the pulmonary interstitial space.

A patient was admitted following an aspiration event on the medical-surgical floor. The patient is receiving 40% oxygen via a simple facemask. The patient has become increasingly agitated and confused. The patient's oxygen saturation has dropped from 92% to 84%. The nurse notifies the practitioner about the change in the patient's condition. What interventions should the nurse anticipate? a. Intubation and mechanical ventilation b. Change in antibiotics orders c. Suction and reposition the patient d. Orders for a sedative

ANS: A Given the significant drop in oxygen saturation, increasing agitation and confusion, the nurse should anticipate the patient will need to be intubated and mechanically ventilated. Administering antibiotics, suctioning and repositioning, and administering a sedative would not address the development of severe hypoxemia.

What two pathogens are most frequently associated with ventilator-associated pneumonia? a. Staphylococcus aureus and Pseudomonas aeruginosa b. Escherichia coli and Haemophilus influenzae c. Acinetobacter baumannii and Haemophilus influenzae d. Klebsiella spp. and Enterobacter spp.

ANS: A Pathogens that can cause hospital-associated pneumonia (HAP) include Escherichia coli, H. influenzae, methicillin-sensitive S. aureus, S. pneumoniae, P. aeruginosa, Acinetobacter baumannii, methicillin-resistant S. aureus (MRSA), Klebsiella spp., and Enterobacter spp. Two of the pathogens most frequently associated with ventilator-associated pneumonia (VAP) are S. aureus and P. aeruginosa.

Which nursing intervention should be used to optimize oxygenation and ventilation in the patient with acute lung 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.

For which situation does a patient with acute lung failure require a bronchodilator? 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.

A patient was admitted with acute lung failure secondary to pneumonia. What is the single most important measure to prevent the spread of infection between staff and patients? a. Place the patient in respiratory isolation. b. Ensure everyone is using proper hand hygiene. c. Use personal protective equipment. d. Initiate prompt administration of antibiotics.

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

What is the major hemodynamic consequence of a massive pulmonary embolus? 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 finding confirms the diagnosis of a pulmonary embolism (PE)? a. Low-probability ventilation-perfusion (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 embolism requires confirmation by a high-probability ventilation-perfusion (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.

What is the medical treatment for a pneumothorax greater than 15%? 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 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 to 20 Fr) or large-bore (24 to 40 Fr) chest tube.

A patient was admitted in acute lung failure. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. Which test would the nurse expect the practitioner 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 (CBC) with differential, chemistry panel, blood cultures, and arterial blood gas analysis is obtained.

Which cause 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. Physiologic shunting

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. Physiologic shunting is normal and not a cause of hypoxemia.

Depending on the patient's risk for the recurrence of pulmonary embolism (PE), how long may a patient remain on warfarin once they are discharged from the hospital? 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.

Which therapeutic measure would be the most effective in treating hypoxemia in the presence of intrapulmonary shunting associated with acute respiratory distress syndrome (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.

Patients with left-sided pneumonia may benefit from placing them in which position? 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.

Supplemental oxygen administration is usually effective in treating hypoxemia related which situation? a. Physiologic shunting b. Dead space ventilation c. Alveolar hyperventilation 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.

A patient was admitted 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. What action should the nurse take next? a. Lavage the airway with normal saline. b. Place the patient supine in a semi-Fowler position. c. Manually ventilate the patient. d. Suction the 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.

What are the most common presenting signs and symptoms associated with a pulmonary embolism (PE)? 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.

Which diagnostic criteria is indicative of mild adult respiratory distress syndrome (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. Increase in 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 trauma victim has sustained right rib fractures and pulmonary contusions. Auscultation reveals decreased breath sounds on the right side. Bulging intercostal muscles are noted on the right side. Heart rate (HR) is 130 beats/min, respiratory rate (RR) is 32 breaths/min, and breathing is labored. In addition to oxygen administration, what procedure should the nurse anticipate? a. Thoracentesis b. Chest tube insertion c. Pericardiocentesis d. Emergent intubation

ANS: B The patient is experiencing a pneumothorax and will need immediate chest tube insertion. Chest tubes are inserted into the pleural space to remove fluid or air, reinstate the negative intrapleural pressure, and re-expand a collapsed lung.

A patient has been admitted 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 practitioner orders a repeat ABG. Which set of results would be indicative of the patient's current condition? 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.

What nursing intervention can facilitate the prevention of aspiration? 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.