Exam 1 Ventilation and Septic Shock

The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?"Given the client's condition, which statement is most correct? a) "The client is in shock because the blood volume has decreased in the system." b) "The client is in shock because all peripheral blood vessels have massively dilated." c) "The client is in shock because your loved one is not responding and brain dead." d) "The client is in shock because the heart is unable to circulate the body fluids."

"The client is in shock because the blood volume has decreased in the system."

Which of the following is a correct endotracheal tube cuff pressure? a) 17 mm Hg b) 21 mm Hg c) 13 mm Hg d) 25 mm Hg

17 mm Hg Explanation: Cuff pressures should be checked with a calibrated aneroid manometer device every 6 to 8 hours to maintain cuff pressures between 15 and 20 mm Hg.

A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse a) Sets a schedule to suction the tracheostomy every hour b) Encourages the client to cough every 30 minutes and prn c) Assesses the client's tracheostomy and lung sounds every 15 minutes d) Decreases the amount of humidity set to flow through the tracheostomy tube

Assesses the client's tracheostomy and lung sounds every 15 minutes Correct Explanation: Tracheal suctioning is performed when secretions are obvious or adventitious breath sounds are heard. The client is producing thick yellow mucus frequently, so the nurse needs to make frequent assessments about the need for suctioning. Suctioning every hour could be too frequent or not frequent enough. It also does not address the client's needs. The client needs high humidity to liquify the mucus, which is described as thick. The client has a decresed effectiveness of coughing with a tracheostomy tube. Again, this is not a viable option.

Which of the following ventilator modes provides full ventilatory support by delivering a present tidal volume and respiratory rate? a) Pressure support b) Assist control c) SIMV d) IMV

Assist control Explanation: Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. IMV provides a combination of mechanically assisted breaths and spontaneous breaths. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths.

Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate? a) Assist-control b) SIMV c) IMV d) Pressure support

Assist-control Explanation: Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. Intermittent mandatory ventilation (IMV) provides a combination of mechanically assisted breaths and spontaneous breaths. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths.

Which of the following is an adverse reaction that would require termination of the weaning process from the ventilator? a) Heart rate less than 100 b) Vital capacity of 12 mL/kg c) PaOgreater than 60 mmHg with a FiO less than 40% d) Blood pressure increase of 20 mm Hg

Blood pressure increase of 20 mm Hg Explanation: Criteria for termination of the weaning process includes: heart rate increase of 20 beats per minute, and systolic blood pressure increase of 20 mm Hg. A normal vital capacity is 10 to 15 mL/kg.

When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the nurse will anticipate administration of large volumes of crystalloids when the a. cardiac output is increased and the central venous pressure (CVP) is low. b. pulmonary artery wedge pressure (PAWP) is increased, and the urine output is low. c. heart rate is decreased, and the systemic vascular resistance is low. d. cardiac output is decreased and the PAWP is high.

Correct Answer: A Rationale: A high cardiac output and low CVP suggest septic shock, and massive fluid replacement is indicated. Increased PAWP indicates that the patient has excessive fluid volume (and suggests cardiogenic shock), and diuresis is indicated. Bradycardia and a low systemic vascular resistance (SVR) suggest neurogenic shock, and fluids should be infused cautiously.

An assessment finding indicating to the nurse that a 70-kg patient in septic shock is progressing to MODS includes a. respiratory rate of 10 breaths/min. b. fixed urine specific gravity at 1.010. c. MAP of 55 mm Hg. d. 360-ml urine output in 8 hours.

Correct Answer: B Rationale: A fixed urine specific gravity points to an inability of the kidney to concentrate urine caused by acute tubular necrosis. With MODS, the patient's respiratory rate would initially increase. The MAP of 55 shows continued shock, but not necessarily progression to MODS. A 360-ml urine output over 8 hours indicates adequate renal perfusion.

A patient who has just been admitted with septic shock has a BP of 70/46, pulse 136, respirations 32, temperature 104.0° F, and blood glucose 246 mg/dl. Which order will the nurse accomplish first? a. Start insulin drip to maintain blood glucose at 110 to 150 mg/dl. b. Give normal saline IV at 500 ml/hr. c. Titrate norepinephrine (Levophed) to keep MAP at 65 to 70 mm Hg. d. Infuse drotrecogin- (Xigris) 24 mcg/kg.

Correct Answer: B Rationale: Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions are also appropriate and should be initiated quickly as well.

A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)? a. Administer all medications through the patient's indwelling central line. b. Place the patient in a private room. c. Restrict the patient to foods that have been well-cooked or processed. d. Insert a nasogastric (NG) tube for enteral feeding.

Correct Answer: B Rationale: The patient who has received chemotherapy is immune compromised, and placing the patient in a private room will decrease the exposure to other patients and reduce infection/sepsis risk. Administration of medications through the central line increases the risk for infection and sepsis. There is no indication that the patient is neutropenic, and restricting the patient to cooked and processed foods is likely to decrease oral intake further and cause further malnutrition, a risk factor for sepsis and shock. Insertion of an NG tube is invasive and will not decrease the patient's nausea and vomiting.

When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse? a. BP 88/56 mm Hg b. Apical pulse 110 beats/min c. Urine output 15 ml for 2 hours d. Arterial oxygen saturation 90%

Correct Answer: C Rationale: The best data for assessing the adequacy of cardiac output are those that provide information about end-organ perfusion such as urine output by the kidneys. The low urine output is an indicator that renal tissue perfusion is inadequate and the patient is in the progressive stage of shock. The low BP, increase in pulse, and low-normal O2 saturation are more typical of compensated septic shock.

A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of a. nitroglycerine (Tridil). b. dobutamine (Dobutrex). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride).

Correct Answer: C Rationale: When fluid resuscitation is unsuccessful, administration of vasopressor drugs is used to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Dobutamine will increase stroke volume, but it would also further decrease SVR. Nitroprusside is an arterial vasodilator and would further decrease SVR.

The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy? a. The patient is restless and anxious. b. The patient has a heart rate of 134. c. The patient has hypotonic bowel sounds. d. The patient has a temperature of 94.1° F.

Correct Answer: D Rationale: Hypothermia is an indication that the patient is in the progressive stage of shock. The other data are consistent with compensated shock.

A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is

Dextran Explanation: Dextran may interfere with platelet aggregation in clients who are in hypovolemic shock as a result of a hemorrhage. The other options are appropriate solutions to administer in this situation.

A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to: a) Inhale and exhale rapidly with the spirometer. b) Expect coughing when using the spirometer properly. c) Use the spirometer twice every hour. d) Maintain a supine position to use the spirometer.

Expect coughing when using the spirometer properly. Explanation: When using an incentive spirometer, the client should be sitting or in the semi-Fowler's position. The client is to inhale, hold the breath for about 3 seconds, and then exhale slowly. Coughing occurs with the use of the incentive spirometer and is encouraged. The client should use the spirometer 10 times every hour while awake.

The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? Please choose from one of the following options. Antibiotics to treat the underlying infection. Corticosteroids to reduce inflammation. IV fluids to increase intravascular volume. Vasopressors to increase blood pressure.

IV fluids to increase intravascular volume.

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? a) Impaired physical mobility related to being on a ventilator b) Risk for infection related to endotracheal intubation and suctioning c) Impaired gas exchange related to ventilator setting adjustments d) Risk for trauma related to endotracheal intubation and cuff pressure

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

Which of the following ventilator modes provides a combination of mechanically assisted breaths and spontaneous breaths? a) Assist control b) Intermittent mandatory ventilation (IMV) c) Synchronized intermittent mandatory ventilation (SIMV) d) Pressure support

Intermittent mandatory ventilation (IMV) Explanation: IMV provides a combination of mechanically assisted breaths and spontaneous breaths. Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the patient-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing.

The nurse is preparing to perform tracheostomy care on a patient with a newly inserted tracheostomy tube. Which of the following actions, if preformed by the nurse, indicates the need for further review of the procedure? a) Dries and reinserts the inner cannula or replaces it with a new disposable inner cannula b) Puts on clean gloves; removes and discards the soiled dressing in a biohazard container c) Cleans the wound and the plate with a sterile cotton tip moistened with hydrogen peroxide d) Places clean tracheostomy ties, and removes soiled ties after the new ties are in place

Places clean tracheostomy ties, and removes soiled ties after the new ties are in place

The client is postoperative for a total laryngectomy and has recovered from anesthesia. The client's respirations are 32 breaths/minute, blood pressure is 102/58, and pulse rate is 104 beats/minute. Pulse oximetry is 90%. The client is receiving humidified oxygen. To aid in the client's respiratory status, the nurse places the client in which of the following positions.

The client is in respiratory distress. The best position for the client who has a tracheostomy and recovered from anesthesia is semi-Fowler's.

Ventilation and Septic Shock PrepU

Ventilation and Septic Shock PrepU

Which of the following would be a pulse pressure indicative of shock? a) 120/90 b) 90/70 c) 130/90 d) 100/60

b) 90/70

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for a) Higher than normal endotracheal cuff pressure b) A kink in the ventilator tubing c) Malfunction of the alarm button d) A cut or slice in the tubing from the ventilator

b) A kink in the ventilator tubing

Which positioning strategy should be used for the patient diagnosed with hypovolemic shock? a) Supine b) Modified Trendelenburg c) Semi-Fowler's d) Prone

b) Modified Trendelenburg c)

The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to a) Sit in an upright position only. b) Purse the lips when exhaling air from the lungs. c) Hold the breath for 5 seconds and then exhale. d) Initially inhale through the mouth.

b) Purse the lips when exhaling air from the lungs.

Which of the following statements would not be considered an appropriate intervention for a patient with an ET tube? a) Humidified oxygen should always be introduced through the tube b) Routine cuff deflation is recommended c) Cuff pressures should be checked every 6 to 8 hours d) Cuff is deflated prior to tube removal

b) Routine cuff deflation is recommended

The nurse anticipates that the immunosuppressed patient is at greatest risk for which type of shock? a) Cardiogenic b) Septic c) Anaphylactic d) Neurogenic

b) Septic

A 57-year-old client has been brought to your ED via squad. He is unresponsive, and his wife reports his symptoms of elevated temperature and flushed skin. Physical assessment reveals a rapid, bounding pulse. The high school where the client is employed has had a significant increase in cases of staphylococcal and streptococcal infections among student athletes. His labs show an elevated WBC; cultures are forthcoming. You suspect which of the following may be the cause of the client's present condition? a) Neurogenic shock b) Septic shock c) Cardiogenic shock d) Anaphylactic shock

b) Septic shock

A client has been placed on a ventilator, and the spouse is visiting for the first time. The spouse begins to cry. The best statement by the nurse is a) "If this upsets you, it may be better to not visit." b) "He is going to get better" c) "Tell me what you are feeling." d) "I know what you are going through."

c) "Tell me what you are feeling."

The nurse is caring for a patient in the ICU who required emergent endotracheal (ET) intubation with mechanical ventilation. The nurse receives an order to obtain arterial blood gases (ABGs) following the procedure. The nurse recognizes that ABGs should be obtained at which timeframe following the initiation of mechanical ventilation? a) 10 minutes b) 25 minutes c) 20 minutes d) 15 minutes

c) 20 minutes

Which of the following is a potential complication of a low pressure in the ET cuff? a) Tracheal ischemia b) Tracheal bleeding c) Aspiration pneumonia d) Pressure necrosis

c) Aspiration pneumonia

The nurse is caring for a patient in the ICU who is receiving mechanical ventilation. Which of the following nursing measures are implemented in an effort to reduce the patient's risk of developing ventilator-associated pneumonia (VAP)? a) Turning and repositioning the patient every 4 hours b) Ensuring that the patient remains sedated while intubated c) Cleaning the patient's mouth with chlorhexidine daily d) Maintaining the patient in a high Fowler's position

c) Cleaning the patient's mouth with chlorhexidine daily

Stress ulcers occur frequently in acutely ill patient. Which of the following medications would be used to prevent ulcer formation? Select all that apply. a) Furosemide (Lasix) b) Desmopressin (DDAVP) c) Famotidine (Pepcid) d) Lansoprazole (Prevacid) e) Ranitidine (Zantac)

c) Famotidine (Pepcid) d) Lansoprazole (Prevacid) e) Ranitidine (Zantac)

A patient is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which of the following actions first? a) Notify the respiratory therapist. b) Reposition the endotracheal (ET) tube. c) Troubleshoot to identify the malfunction. d) Manually ventilate the patient.

c) Troubleshoot to identify the malfunction

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 20 to 25 seconds b) 0 to 5 seconds c) 30 to 35 seconds d) 10 to 15 seconds

d) 10 to 15 seconds

Which of the following ranges of water pressure identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration? a) 30 to 35 mm Hg b) 0 to 5 mm Hg c) 10 to 15 mm Hg d) 15 to 20 mm Hg

d) 15 to 20 mm Hg

Which of the following would indicate a decrease in pressure with mechanical ventilation? a) Decrease in lung compliance b) Plugged airway tube c) Kinked tubing d) Increase in compliance

d) Increase in compliance

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for: a) A scheduled time for deflation of the tracheal cuff b) Cool air humidified through the tube c) Tracheal cuff pressure set at 30 mm Hg d) Symmetry of the client's chest expansion

d) Symmetry of the client's chest expansion

The nurse is obtaining physician orders which include a pulse pressure. The nurse is most correct to report which of the following? a) The difference between an upper extremity and lower extremity blood pressure b) The difference between an apical and radial pulse c) The difference between the arterial and venous blood pressure d) The difference between the systolic and diastolic pressure

d) The difference between the systolic and diastolic pressure

Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration? a) Time cycled b) Negative pressure c) Pressure cycled d) Volume cycled

d) Volume cycled

The healthcare provider is caring for a patient with a diagnosis of hemorrhagic pancreatitis. The patient's central venous pressure (CVP) reading is 2 22 cm 2 O H ​2 ​​ OH, start subscript, 2, end subscript, O, blood pressure is 9 0 / 5 0 90/50mmHg90, slash, 50, space, m, m, H, g, lung sounds are clear, and jugular veins are flat. Which of these actions is most appropriate for the nurse to take? Please choose from one of the following options. Slow the IV infusion rate Administer dopamine No interventions are needed at this time Increase the IV infusion rate

ncrease the IV infusion rate