Exam 1 Review
A client has developed a pulmonary problem that has resulted in decreased lung compliance. How will this affect respiratory system?
It will increase the client's work of breathing. Rationale: Because the lung is less compliant or "stiffer," it makes it more difficult to expand, increasing the work required to breathe.
Acute respiratory acidosis is defined clinically as:
PaCO2 greater then 50mmHg and pH less than 7.30 Rationale: This is the criteria of respiratory needed to place a pt onto a ventilator with acute respiratory acidosis thats moved towards respiratory failure.
A client who has flu-like symptoms for the last few days presents in the ED with increasing SOB. The client states that the cough has become worse over the last few hours, and coughing up thick stuff. The nurse would ask assessment questions about which manifestations of post-influenza bacterial pneumonia?
- Chills - Chest pain Rationale: - Chills are often a presenting manifestation of pneumonia. - Pleuritic chest pain often occurs with pneumonia.
A client is at high risk for pulmonary embolus. The nurse would monitor this client for the development of which common clinical manifestations?
- Dyspnea - chest pain - Cough Rationale: - Dyspnea is the most common manifestation of pulmonary embolus. - Pleuritic chest pain is a common manifestation of pulmonary embolus. - Cough is a common manifestation of pulmonary embolus.
A client is admitted to the hospital with complaints of severe chest pain and dyspnea. The client has an oral temperature of 38.3 C. Why is it important for the nurse to obtain a nutritional history from this client?
- High carbohydrate diets increase carbon dioxide levels - Poor nutritional status increases susceptibility to infection Rationale: - High-carbohydrate diets increase the carbon dioxide load in the body. - Malnutrition is associated with a weakened immune system, placing the patient at risk for developing infection.
A client is admitted to the emergency department with complaints of SOB, cough, and fever. Which clinical manifestations would the nurse interpret as indicating early respiratory distress?
- Increased respiratory rate - Tachycardia - Agitation - Confusion Rationale: - An increased respiratory rate is the body's way of obtaining more oxygen. - Tachycardia occurs as the body attempts to distribute oxygen. The stress of respiratory distress also increases the heart rate. - Agitation is an early sign that the brain is not receiving sufficient oxygen. - Confusion occurs when the brain is not receiving enough oxygen.
A client who has developed right middle-lobe pneumonia will experience decreased ventilation in the affected lung areas for what reason?
- The pressure gradient is abnormal - Gas follows the path of least resistance - The consolidation in the tissues will increase the pressure Rationale: - The normal pressure gradient has been altered by the presence of inflammation and consolidation. - Ventilation occurs when gas moves from an area of higher pressure to an area of lower pressure, following the path of least resistance. The pressure is higher in the involved areas due to edema and inflammation, so gas will move to areas of lower pressure. - The consolidation in the lung tissues will increase the amount of pressure needed to expand the lung.
A client who left femur was surgically repaired 7 days ago has been on bedrest since surgery. This morning, the nurse is concerned with an acute change in the client's pulmonary status. Which factors of Virchow's triad would the nurse identify in this case, putting the client at risk development of DVT
- Venous Stasis -Venous injury Rationale: - Venous stasis is part of Virchow's triad and occurs with prolonged immobility. In this case, the patient's mobility has been restricted for at least 7 days. - Venous or endothelial injury is part of Virchow's triad and is present in this case due to trauma and surgery
Brain natriuretic peptide (BNP) has been drawn to assess whether a client has heart failure or ARDS. What will the nurse expect the test to reveal if this client has heart failure rather than ARDS?
A value over than 100pg/mL rationale: A BNP in excess of 100 pg/mL suggests that the patient's symptoms are due to heart failure rather than ARDS
A client is hospitalized with chronic respiratory insufficiency. The nurse is developing a plan to address the problem of impaired oxygenation and ventilation. Which desired client outcome most accurately measures progress in addressing this problem?
ABG within acceptable limits for client Rationale: ABG within normal limits for the patient is a realistic outcome for patients with chronic respiratory insufficiency.
A client is scheduled for chest tube removal today. How should the nurse plan to address pain control for this procedure?
Administer a PRN IV analgesic so that the drug's peak effect coincides with tube removal Rationale: Administering IV analgesia and then giving it time to take effect will reduce the pain associated with this procedure.
Supportive equipment when a person has an artificial airway in place includes which of the following? (Select all that apply.) A. At least one oxygen source B. Suctioning equipment C. Manual resuscitation bag and mask D. A backup ventilator in the room E. Oral pharyngeal airway or bite block
Ans: B,C,E, Rationale: A. Two oxygen sources should be available, one for the ventilator and one for a manual resuscitation bag to provide 100% oxygen. B. Suctioning equipment and at least one suction source C. A manual resuscitation bag to provide adequate backup in case of ventilator failure and for open system suctioning D. False E. Oral pharyngeal airway or bite block if the oral route is used to prevent closure of the airway if the patient should bite down on the tube, also facilitates access to the oropharynx for suctioning.
The term pulmonary shunt refers to what condition? A. Movement of air directly from one alveolus to another B. Normal pulmonary capillary perfusion, reduced alveolar ventilation C. An opening between the pulmonary artery and the heart D. Normal alveolar ventilation, reduced pulmonary capillary perfusion
B. Normal pulmonary capillary perfusion, reduced alveolar ventilation. Rationale: Pulmonary capillary blood that circulates through a nonfunctioning alveolar unit cannot pick up ocygen from that alveolus. Although some shunting is normal, if many alveolar unites become nonfunctioning, a significant decreases in oxygen saturation will occur, causing hypoxemia.
A client who has COPD is in a state of chronic respiratory insufficiency. Which assessment finding would the nurse attribute to that condition?
BP 145/88 Rationale: Respiratory insufficiency requires compensation of other systems and reflects a chronic state of stress. Hypertension (BP of 145/88) would be a compensatory mechanism.
A client who has a right upper lobe pneumothorax has had a chest tube for 2 days. While assessing the chest drainage system, the nurse notes continuous vigorous bubbling in the water-seal chamber. What should the nurse do?
Check all connections for a leak Rationale: Continuous bubbling in the water-seal chamber indicates either a very large pleural fistula or a leak in the chest tube system. Such leaks are most common at connection points, so checking all connections is the most appropriate action at this time.
A client has been in the ICU and intubated for 1 week. EtCO2 is attached to the client's mechanical ventilator circuit to assess for which development?
Early changes in ventilation Rationale: Low EtCO2 is associated with hyperventilation, whereas increased EtCO2 is associated with hypoventilation.
A client who was severely injured in a motor vehicle crash 7 days ago has developed ARDS. The nurse has explained the concept of nonhydrostatic pulmonary edema to the client's family. What statement by a family member would indicate understanding of this concept?
Her disease has injured the membranes in her lung so that fluid is leaking into her lungs from the tiny blood vessels. Rationale: Nonhydrostatic pulmonary edema allows fluid to move from the vascular space into the lung due to injury/disruption of the capillary and alveolar membranes.
In an emergency situation, what is the most common entry route for airway access?
Oral intubation rationale: Current guidelines recommend the use of orotracheal as opposed to nasotracheal route. Although the nasotracheal tube may be more comfortable for the pt, it carries greater risk of sinusitis and other infections. Other porblems associated with the smaller tibe needed to intubate nasally include increased airway resistance, increased chance of tube kinking and more difficulty suctioning effectively.
A client with pneumonia develops what is believed to be an absolute pulmonary shunt. Oxygen therapy as been initiated per venti-mask. The nurse would expect what effect on the client's hypoxemia?
It will worsen Rationale: An absolute shunt is the combination of blood that does not take part in gas exchange and the normal flow of blood past unventilated alveoli. Because the alveoli are nonfunctioning, an absolute shunt is refractory to oxygen therapy. Because the patient is continuing to use oxygen, hypoxemia will worsen.
The term acute ventilatory failure refers to the inability of the lungs to do what?
Maintain adequate alveolar ventilation Rationale: AVF is the most common indication for ventilator support and occurs when the lungs are unable to maintain adequate alveolar ventilation. One exception is pts with COPD
A client is diagnosed with DKA after being admitted to the hospital with a serum glucose of 650mg/dL and positive serum ketones. Blood gases are: pH 7.25, PaCO2 36mmHg, HCO3 14 mEq/L. This pH is most likely a result of which acid-base disturbance?
Metabolic Acidosis Rationale: The pH below 7.35 and the HCO3 below 22 mEq/L indicate metabolic acidosis.
A client has the following ABG results: pH 7.50, PaCO2 30 mmHg, HCO3 20 mEq/L, PaO2 88mmHg, SaO2 98%. How would the nurse interpret these results?
Partially compensated respiratory alkalosis Rationale: The elevated pH (alkaline) and low PaCO2 indicate metabolic alkalosis. The decreased (acid) HCO3 represents partial compensation, as the pH is not in normal range.
A low V/Q exists when what occurs?
Perfusion is in excess of ventilation rationale: The cause of a low V/Q may be an obstructing mucous plug in the distal airway, causing a reduction in alveolar ventilation. Conditions where this occurs are asthma, pneumonia, and COPD
A client comes to the emergency department complaining of SOB and chest pain. The ABG results are: pH 7.45, PaCo2 35 mmHg, PaO2 60mmHg, HCO3 24mEq/L. What should be the nurse's first intervention?
Place the client on oxygen Rationale: Normal PaO2 is 80-100 mmHg. This patient's value is only 60 mmHg, so supplemental oxygen should be initiated.
A client is admitted to the hospital with severe dyspnea and a productive cough. History reveals that the client has smoked one to two packages of cigarettes daily for the last 45 years and was diagnosed with COPD 10 years ago. A diagnosis of right lower lobe pneumonia is established. Based on this data, the nurse would plan care for a client who has which type of acute lung disorder.
Restrictive disease Rationale: Although this patient does have some COPD, the acute disorder is pneumonia, which is a restrictive disease.
In the adult, an inflated ET tube cuff is necessary for positive pressure mechanical ventilation primarily because it does what?
Seals off the lower airway from the upper airway. Rationale: When it is inflated, the tube seals the space between the tube and the trachea so air is directed through the tube into the lower airway, ensuring a predictable tidal volume or pressure is being delivered.
Pulmonary function test are performed on a client diagnosed with right middle-lobe pneumonia. The client's tidal volume and vital capacity are both below normal. The nurse would plan care based on which interpretation of these results?
The client has respiratory muscle fatigue Rationale: Tidal volume and vital capacity monitor respiratory muscle strength. When these values decrease, it is indicative of respiratory muscle fatigue.