Gas Exchange Critical Care
A nurse teaches a client how to perform diaphragmatic breathing. Which instruction should the nurse provide? 1 Take rapid, deep breaths 2 Breathe with hands on the hips 3 Expand the abdomen on inhalation 4 Perform exercises leaning forward while in a sitting position
Expand the abdomen on inhalation Expanding the abdomen on inhalation aids descent of the diaphragm so that more air can enter and fill the lungs. Rapid breathing promotes respiratory alkalosis; diaphragmatic breathing includes slow deep breathing. The hands should be placed lightly on the abdomen to verify abdominal excursion. Diaphragmatic breathing may be performed in any position, but the best is supine; leaning forward may prevent the client from moving the abdomen properly.
The nurse is caring for a school-aged child with cystic fibrosis. Which pathophysiologic factor has the greatest impact on the child's health status and is of priority in the care plan? 1 Extremely thick mucus causes obstructed airways. 2 There is acute inflammation of the lung parenchyma. 3 Endocrine glands secrete increased levels of hormones. 4 Increased irritability of the airways results in obstruction.
Extremely thick mucus causes obstructed airways. Dysfunction of the exocrine glands leads to an excessive accumulation of thick mucus, a slower flow rate of mucus, and incomplete expectoration of mucus, all of which contribute to airway obstruction. Acute inflammation of the lung parenchyma is associated with pneumonia, not cystic fibrosis. The endocrine glands are not affected in cystic fibrosis. Increased irritability of the airways causes obstruction and is associated with asthma, not cystic fibrosis.
What is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation? 1 Duration of cry 2 Respiratory distress 3 Frequency of voiding 4 Decreased temperature
Respiratory distress Respiratory distress is a common response in the preterm infant, related to possible immaturity of the newborn's respiratory tract, manifesting as a small lumen, weakness of the respiratory musculature, paucity of functional alveoli, or insufficient calcification of the bony thorax. The tone of the cry is more pertinent than its duration. Frequency of voiding is not the priority because the newborn's intake is limited during the first 24 hours. The temperature of the preterm infant is expected to decrease due to immature thermoregulation.
A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen? 1 To prevent dyspnea 2 To prevent cyanosis 3 To increase oxygen concentration to heart cells 4 To increase oxygen tension in the circulating blood
To increase oxygen concentration to heart cells Oxygen increases the transalveolar oxygen gradient, which improves the efficiency of the cardiopulmonary system. This enhances the oxygen supply to the heart. Increased oxygen to the heart cells will improve cardiac output, which may or may not prevent dyspnea. Pallor, not cyanosis, usually is associated with myocardial infarction. Although increasing oxygen tension in the circulating blood may be true, it is not specific to heart cells.
The nurse provides teaching about self-care management to a client who recently was diagnosed with emphysema. The nurse concludes that further teaching is needed when the client makes which statement? 1 "I will try to avoid smoking." 2 "I will maintain complete bed rest." 3 "I'll control the temperature in my home." 4 "I'll need to clean my mouth several times a day."
"I will maintain complete bed rest." Although energy should be conserved, it is not necessary to restrict all activity; the client needs further teaching. Smoking should be avoided because it is a respiratory tract irritant and it interferes with gas exchange in the alveoli. Extremes in environmental temperature and humidity place stress on the respiratory system, interfering with gaseous exchange. Meticulous oral care is advisable because of the presence of excessive mucus; also, it reduces the amount of microorganisms that can enter the tracheobronchial tree, which can precipitate infection.
A nurse instructs a client to breathe deeply to open collapsed alveoli. What should the nurse include in the explanation of the relationship between alveoli and improved oxygenation? 1 "The alveoli need oxygen to live." 2 "The alveoli have no direct effect on oxygenation." 3 "Collapsed alveoli increase oxygen demands." 4 "Oxygen is exchanged for carbon dioxide in the alveolar membrane."
"Oxygen is exchanged for carbon dioxide in the alveolar membrane. The exchange of oxygen and carbon dioxide occurs in the alveolar membrane. Therefore, if the alveoli collapse, this exchange cannot occur. Explaining this process in simple terms to a client may increase compliance with recommended breathing exercises aimed at improving oxygenation. Alveoli do have a direct effect on oxygenation. The statements that alveoli need oxygen to live and that collapsed alveoli increase oxygen demands are nonspecific regarding the pathophysiology of the alveolar membrane.
A client is to undergo amniocentesis at 38 weeks' gestation to determine fetal lung maturity. What lecithin/sphingomyelin ratio (L/S ratio) is adequate for the nurse to conclude that the fetus's lungs are mature enough to sustain extrauterine life? 1 2:1 2 1:1 3 1:4 4 3:4
2:1 The lecithin concentration increases abruptly at 35 weeks, reaching a level that is twice the amount of sphingomyelin, which decreases concurrently. At 30 to 32 weeks' gestation, the amounts of lecithin and sphingomyelin are equal, indicating lung immaturity. A ratio of 1:4 does not reflect fetal lung maturity; nor does a ratio of 3:4.
A client is receiving morphine sulfate for severe metastatic bone pain. What will the nurse do to assess for complications from a common serious side effect of morphine? 1 Monitor for diarrhea 2 Observe for an opioid addiction 3 Assess for altered breathing patterns 4 Check for a decreased urinary output
Assess for altered breathing patterns Morphine sulfate is a central nervous system depressant that commonly decreases the respiratory rate, which can lead to respiratory arrest. Morphine, an opioid, will cause constipation, not diarrhea. Addiction is not a concern for a terminally ill client. Although morphine sulfate may cause urinary retention, it is not a common side effect and is not life threatening.
Which complications does the nurse anticipate in the client who has blue-colored nail beds? 1 Thrombocytopenia 2 Polycythemia vera 3 Methemoglobinemia 4 Cardiopulmonary disease
Cardiopulmonary disease A bluish-color to the nail beds is due to an increase in deoxygenated blood that may be due to cardiopulmonary disease. When there is bleeding from the vessels into the tissues, small blue-colored spots are formed (petechiae), which may be due to thrombocytopenia (decreased numbers of platelets). Polycythemia vera is characterized by brown spots on the skin caused by increased melanin production. Methemoglobinemia is a complication in which the mucous membranes appear blue in color due to increased deoxygenated blood in the body.
A client is admitted to the hospital with gastrointestinal bleeding, and a nasogastric tube is inserted. The healthcare provider prescribes the nasogastric tube to be irrigated with normal saline whenever necessary to maintain patency. What should the nurse do first when it is determined that the nasogastric tube is not patent? 1 Instill normal saline. 2 Assess breath sounds. 3 Auscultate for bowel sounds. 4 Check the tube for placement.
Check the tube for placement. Checking the tube for placement reduces the risk of introducing the irrigant into the lungs. Instilling normal saline increases the risk of introducing irrigant into the lungs if the tube is not in the stomach. Assessing for breath sounds is not related to the steps associated with instilling a nasogastric tube with an irrigant. Auscultating for bowel sounds is not related to the steps associated with instilling a nasogastric tube with an irrigant.
A client's breath has a sweet, fruity odor. Which condition is likely affecting this client? 1 Gum disease 2 Uremic acidosis 3 Diabetic acidosis 4 Infection inside a cast
Diabetic acidosis A client with diabetic acidosis has a sweet, fruity odor to the breath. Gum disease is marked by halitosis. A stale urine smell indicates uremic acidosis. An infection inside a cast is accompanied by a musty odor of the casted body part.
A client has a history of falling while playing football and now reports pain in the nose and difficulty breathing. What condition may the client have? 1 Crepitus 2 Sinusitis 3 Fracture of the nose 4 Upper respiratory tract infection
Fracture of the nose Fractures of the nose often result from injuries received during falls, sports activities, car crashes, or physical assaults. Nose fractures may lead to difficulty in breathing. Crepitus is crackling of the skin on palpitation. Sinusitis is an inflammation of the tissues lining the sinuses. In an upper respiratory tract infection, a stuffy nose and itching results in difficulty breathing. However, pain may not be present.
A client is admitted to the intensive care unit with acute pulmonary edema. Which diuretic does the nurse anticipate will be prescribed? 1 Furosemide 2 Chlorothiazide 3 Spironolactone 4 Acetazolamide
Furosemide Furosemide acts on the loop of Henle by increasing the excretion of chloride and sodium, is available for intravenous administration, and is more effective than chlorothiazide, spironolactone, and acetazolamide. Although used in the treatment of edema and hypertension, chlorothiazide is not as efficacious as furosemide. Spironolactone is a potassium-sparing diuretic; it is less efficacious than thiazide diuretics. Acetazolamide is used in the treatment of glaucoma to lower intraocular pressure.
A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern? 1 Loss of skin integrity caused by the burns 2 Potential infection as a result of the burn injury 3 Inadequate gas exchange caused by smoke inhalation 4 Decreased fluid volume because of the depth of the burns
Inadequate gas exchange caused by smoke inhalation Maintaining a patent airway is the priority; because of the proximity of the chest and face to the nose and mouth, inhalation burns also may have occurred. Although loss of skin integrity caused by the burns is important, it is not the priority at this time. Although potential for infection as a result of the burn injury is important, it is not the priority. Although fluid needs are important, the gas exchange is priority.
A client who has acquired human immunodeficiency syndrome (HIV) develops bacterial pneumonia. On admission to the emergency department, the client's PaO 2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is determined to be 65 mm Hg. What should the nurse do first? 1 Prepare to intubate the client. 2 Increase the oxygen flow rate per facility protocol. 3 Decrease the tension of oxygen in the plasma. 4 Have the arterial blood gases redone to verify accuracy.
Increase the oxygen flow rate per facility protocol. This decrease in PaO 2 indicates respiratory failure; it warrants immediate medical evaluation. Most facilities have a protocol to increase the oxygen flow rate to keep oxygen saturation greater than 92%. The client PaO 2 of 65 mm Hg is not severe enough to intubate the client without first increasing flow rate to determine if the client improves. Decreasing the tension of oxygen in the plasma is inappropriate and will compound the problem. The PaO 2 is a measure of the pressure (tension) of oxygen in the plasma; this level is decreased in individuals who have perfusion difficulties, such as those with pneumonia. Having the arterial blood gases redone to verify accuracy is negligent and dangerous; a falling PaO 2 level is a serious indication of worsening pulmonary status and must be addressed immediately. Drawing another blood sample and waiting for results will take too long.
A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do? 1 Perform the procedure once in the morning and once at night. 2 Move the trunk to an upright position and then exhale while bending over. 3 Inhale completely and then blow out as hard and as fast as possible through the mouthpiece. 4 Place the mouthpiece between the lips and in front of the teeth before starting the procedure.
Inhale completely and then blow out as hard and as fast as possible through the mouthpiece. A peak flow meter measures the peak expiratory flow rate, the maximum flow of air that can be forcefully exhaled in one second; this monitors the pulmonary status of a client with asthma. The peak flow measurement should be done daily in the morning before the administration of medication or when experiencing dyspnea. The client should be standing. Placing the mouthpiece between the lips and in front of the teeth before starting the procedure will interfere with an accurate test; the mouthpiece should be in the mouth between the teeth with the lips creating a seal around the mouthpiece.
A nurse is caring for a client who just had surgery for a parotid tumor. Which nursing intervention is the priority in the immediate postoperative period? 1 Offering psychological support 2 Monitoring the client's fluid balance 3 Keeping the client's respiratory passages patent 4 Providing a pad and pencil for writing messages
Keeping the client's respiratory passages patent A patent airway is always the priority; therefore, removal of secretions is imperative. Offering psychological support is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Monitoring the client's fluid balance is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor. Providing for a means of communication is an important postoperative intervention, but it is not the priority immediately after removal of a parotid tumor.
An older client with a history of congestive heart failure expresses concern about potential exposure to tuberculosis. The client states that a roommate at the extended care facility where the client resides sleeps a lot, coughs a great deal, and sometimes spits up blood. What is the primary reason that the nurse pursues more information about the roommate? 1 Death from tuberculosis is on the increase 2 The roommate is causing the client to be anxious 3 Older adults with chronic illness are affected adversely by tuberculosis 4 The roommate most likely is preventing the client from getting proper sleep
Older adults with chronic illness are affected adversely by tuberculosis The client's cardiac condition and age make the client vulnerable to communicable diseases. In the United States, death from tuberculosis is declining because of improved drug therapy. (Canada: According to the Public Health Agency of Canada, 1,607 new active and re-treatment (latent) TB cases were reported to the Canadian Tuberculosis Reporting System in 2011, but TB is no longer common in the overall Canadian population.) The nurse's primary concern is to prevent the spread of infection. The issues of client anxiety and potential sleep disturbance should be addressed later; they are not the greatest concern at this time.
The nurse is providing postoperative care to a client who had an abdominal cholecystectomy and choledochostomy who has a T-tube and a nasogastric tube in place. The client refuses deep breathing and coughing exercises. Which conclusion by the nurse is the most probable reason for the noncompliance? 1 T-tube movement increases. 2 Pain at the incision site increases. 3 The nasogastric tube gets irritating. 4 The bandage on the abdomen is constricting.
Pain at the incision site increases. The incision is just below the diaphragm; deep breathing causes tension and pain when the thorax expands, and coughing increases intraabdominal pressure, which stresses the surgical area. The T-tube will not move because it is sutured in place. Clients with nasogastric tubes generally resort to breathing through the mouth, limiting nasal irritation. Dressings do not encircle the abdomen; they should not be tight enough to restrict respirations.
A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. What is the priority nursing intervention? 1 Increasing physical activities 2 Performing postural drainage 3 Maintaining dietary restrictions 4 Administering prescribed pancreatic enzymes
Performing postural drainage Postural drainage, including percussion and vibration, aids removal of respiratory secretions that provide a medium for further bacterial growth. Children with CF must cope with impaired gas exchange that results in intolerance to activity. Increasing activity at this time may be too taxing. There must be a balance between activity and rest within the child's limitations. There are no dietary restrictions. Children with CF should have a balanced nutritional intake that is high in calories. Although important, administration of prescribed pancreatic enzymes is not the priority.
A 3-year-old boy in respiratory distress is treated in the emergency department. A diagnosis of acute spasmodic laryngitis (spasmodic croup) is made. At the time of discharge, the mother asks how to handle another attack at home. What should the nurse recommend? 1 Placing him near a cool-mist humidifier 2 Bringing him to the emergency department 3 Giving him an over-the-counter cough syrup 4 Offering him warm tea sweetened with honey
Placing him near a cool-mist humidifier
A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain? 1 Retrospective 24-hour calorie count 2 Elimination pattern during the last 30 days 3 Complete gynecological and sexual history 4 Presence of a cough and pulmonary secretions
Presence of a cough and pulmonary secretions The presence of a cough and pulmonary secretions, in addition to a history of rheumatic fever, requires an assessment for other cardiopulmonary problems and fluid overload. Anorexia and weight gain do not indicate a nutritional problem but a fluid balance problem. Loss of appetite in conjunction with shortness of breath and the history of rheumatic fever makes gastrointestinal (elimination) symptoms secondary in importance. There is no reason to investigate the gynecological and sexual history in relation to the current problem.
A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments? 1 Level of consciousness and pupil size 2 Characteristics of pain and blood pressure 3 Quality of respirations and presence of pulses 4 Observation of abdominal contusions and other wounds
Quality of respirations and presence of pulses Assessing breathing and circulation are the priorities in trauma management; basic life functions must be maintained or reestablished (ABC's: Airway, Breathing, Circulation). Level of consciousness and pupil size are assessments associated with head injury; in this situation these follow determination of respiratory and circulatory status, which are the priorities. Although blood pressure is an important assessment associated with adequacy of circulation, it is obtained after assessments associated with patency of airway and breathing; a client's pain is addressed after airway, breathing, and circulation needs are assessed and interventions implemented to support life. Assessment for abdominal injury and other wounds follows determination of respiratory and circulatory status, which are the priorities.
A client sustains a crushing injury of the spinal cord above the level of origin of the phrenic nerve. As a result of this injury, the nurse expects what client response? 1 Ventricular fibrillation 2 Dysfunction of the vagus nerve 3 Retention of sensation but paralysis of the lower extremities 4 Respiratory paralysis and cessation of diaphragmatic contractions
Respiratory paralysis and cessation of diaphragmatic contractions The phrenic nerve innervates the diaphragm. Therefore a crushing spinal cord injury above the cervical plexuses, the level of phrenic nerve origin, results in respiratory paralysis. Cardiac activity will not be affected; the heart is regulated by the autonomic nervous system fibers originating in the medulla. Activities regulated by the vagus nerve will be unaffected; it originates in the medulla, which is superior to the cervical region; the phrenic nerves originate from the cervical plexuses. In a crushing spinal cord injury, both motor and sensory conduction are affected.
An infant with cardiopulmonary disease who displays signs and symptoms of bronchiolitis and pneumonia was admitted to the hospital. What condition is the infant likely to have? 1 Poliomyelitis 2 Pneumococcal infection 3 Meningococcal infection 4 Respiratory syncytial virus infection
Respiratory syncytial virus infection Respiratory syncytial virus infections are the most common cause for hospitalization of infants younger than 1 year of age; this disease especially affects premature infants and infants with cardiopulmonary disease. Poliomyelitis is caused by the poliovirus. Streptococcus pneumonia infections cause meningitis, sepsis, pneumonia, and otitis media. Neisseria meningitidis causes meningitis.
A toddler with cystic fibrosis has been hospitalized with bacterial pneumonia. The nurse determines that the child has no known allergies. What does the nurse conclude is the reason that the healthcare provider selected a specific antibiotic? 1 Tolerance of the child 2 Sensitivity of the bacteria 3 Selectivity of the bacteria 4 Preference of the healthcare provider
Sensitivity of the bacteria When the causative organism is isolated, it is tested for antimicrobial susceptibility (sensitivity) to various antimicrobial agents. When a microorganism is sensitive to a medication, the medication is capable of destroying the microorganism. The tolerance of the child of the particular antibiotic is unknown because up to this time the child has not exhibited any allergies. Bacteria are not selective. Although the healthcare provider may have a preference for a particular antibiotic, it first must be determined whether the bacteria are sensitive to it.
What are the clinical manifestations during the fulminant stage in a client with inhalation anthrax? Select all that apply. 1 Septic shock 2 Harsh cough 3 Mild chest pain 4 Pleural effusion 5 Body temperature of 104 °F
Septic shock Pleural effusion Body temperature of 104 °F Inhalation anthrax is a bacterial infection caused by Bacillus anthracis. Manifestations such as septic shock, pleural effusion, and body temperature above 103°F indicate the fulminant stage of inhalation anthrax. The prodromal stage is the early stage of inhalation anthrax; clinical manifestations include a harsh cough and mild chest pain.
A nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. What is the most important intervention for the nurse to include in this plan? 1 Ensuring sufficient rest 2 Changing lifestyle routines 3 Breathing clean outdoor air 4 Taking medications as prescribed
Taking medications as prescribed Tubercle bacilli are particularly resistant to treatment and can remain dormant for long periods. Drugs must be taken consistently, or more drug-resistant forms may recolonize and flourish. Although a balance between activity and rest is desirable, it is not the priority. A change in lifestyle is not necessary. Although clean, fresh air is desirable, it is not the priority.
A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and should begin with which aspect of care? 1 The disease process and breathing exercises 2 How to control or prevent respiratory infections 3 Using aerosol therapy, especially nebulizers 4 Priorities in carrying out everyday activities
The disease process and breathing exercises Clients need to understand the disease process and how interventions, such as breathing exercises, can improve ventilation. Learning to control or prevent respiratory infections is important, but it should be taught later. Although it is helpful to know about aerosol therapy and nebulizers, knowing how to use aerosol therapy, especially nebulizers, should be taught later. Although it is important to teach the client how to set priorities in carrying out everyday activities, this should be taught later.
The parents of a toddler with newly diagnosed cystic fibrosis (CF) tell a nurse that even though they were told it is an inherited disorder, there is no history of CF in the family. How can the nurse clarify the way in which the disease was inherited? 1 It is a mutated gene. 2 It involves an X-linked gene. 3 The inheritance is autosomal recessive. 4 The inheritance is autosomal dominant.
The inheritance is autosomal recessive. Both parents are carriers; the gene for CF is recessive, not dominant, and the parents do not have the disease. The gene for CF is not a mutant gene, nor is it located on the X or Y chromosome.