RESP 4th - HiAqNursing

A patient's PaO2 level is 76 mm Hg. The nurse would be least concerned regarding this finding in which patient? 1. The patient is 83 years old. 2. The patient is recovering from anesthesia. 3. The patient is a smoker. 4. The patient is intubated.

Correct Answer: 1 Rationale 1: Age affects normal ABG values. The older adult has a 25 to 30% decrease in PaO2 between the ages of 30 and 80 years. Rationale 2: Low oxygen levels in a patient who is recovering from anesthesia would alert the nurse to a possible problem. Rationale 3: Smoking can decrease oxygenation, but the nurse would be concerned if the level was this low. Rationale 4: The patient who is intubated should have a PaO2 higher than 76 mm Hg. The nurse would be concerned about an obstruction in the tube or developing pathology.

A patient who is endotracheally intubated and on mechanical ventilation has a decreasing oxygen saturation level with an increasing heart rate. What is the nurse's priority action? 1. Ensure the airway is clear. 2. Auscultate lung sounds. 3. Reposition the patient. 4. Reposition the endotracheal tube.

Correct Answer: 1 Rationale 1: Airway clearance is a top-priority nursing goal in management of the patient with an artificial airway. If airway patency is not maintained, the patient's breathing and cardiovascular status eventually will fail as a result of hypoxia or hypercapnia. Rationale 2: Auscultation of lung sounds is an important intervention for this patient, but is not the first priority. Rationale 3: Repositioning the patient may improve alertness and therefore oxygenation if the patient is on an assist ventilator mode. However, repositioning is not the first nursing priority. Rationale 4: Repositioning the airway may be indicated, but the nurse must take another action to determine if that is the correct intervention.

The emergency department has treated two patients in the last day with symptoms that may be SARS. The nurse manager is updating staff on the pathophysiology of this disease. Which information would the nurse include? 1. It is thought that SARS is a nonhuman virus that has crossed species. 2. SARS is more common in patients also infected with HIV. 3. SARS is a form of influenza virus, so additional cases are probable. 4. SARS is related to RSV, so young children will be the most likely patients.

Correct Answer: 1 Rationale 1: Although the origin of SARS-CoV is unknown, it is suspected to be a nonhuman virus that jumped to humans. Rationale 2: SARS is not associated with HIV. Rationale 3: SARS is not a form on influenza virus. Rationale 4: SARS is not related to RSV.

The nurse is preparing to care for a patient returning from elective surgery who will require mechanical ventilation for a few more hours. The nurse would initiate which ventilator setting orders without question? 1. SIMV with a rate of 12, tidal volume 750 mL, FIO2 0.60 2. Assist-control with a rate of 16, tidal volume 1,000 mL, FIO2 0.40 3. Assist-control with a rate of 20, tidal volume 1,200 mL, FIO2 0.60 4. SIMV with a rate of 4, tidal volume 1,200 mL, FIO2 0.60

Correct Answer: 1 Rationale 1: It is most likely that the ventilator settings would include the SIMV mode, which is often used for weaning patients from ventilators. A tidal volume of 750 is appropriate for an adult and FIO2 of 0.60 is reasonable. Rationale 2: Assist control mode would not be a likely choice since it is anticipated that this patient will only require mechanical ventilation for a few more hours. Tidal volume of 1,000 mL is too high. Rationale 3: Assist control mode would not be a likely choice for a patient only expected to need mechanical ventilation for a few more hours. Rationale 4: It is most likely that the ventilator settings would include the SIMV mode, which is often used for weaning patients from ventilators. The SIMV mode with a tidal volume of 1,200 mL is too high.

A patient is diagnosed with iron deficiency anemia. The nurse plans interventions for a patient with which most likely complication? 1. Impaired oxygen delivery 2. Bleeding 3. Multisystem organ failure 4. Reduced lung function

Correct Answer: 1 Rationale 1: Oxygen delivery can be significantly reduced in a patient with a decrease in hemoglobin level, which would occur in a patient with iron deficiency anemia. Rationale 2: Iron deficiency anemia should not increase the patient's risk of bleeding. Rationale 3: This patient has some risk for organ failure, but this is not the most likely complication. Rationale 4: Anemia should not affect this patient's ability to breath.

The nurse, caring for a patient with hypovolemic shock is primarily concerned that which change could occur in this patient's pulmonary gas exchange? 1. Insufficient distribution of oxygen 2. Buildup of electrolytes in the blood 3. Over-oxygenation 4. Oxygen delivery shift to osmosis

Correct Answer: 1 Rationale 1: Since adequate blood flow must exist to distribute the oxygenated blood to the left side of the heart and the systemic circulation, the patient with hypovolemic shock is not going to have sufficient blood flow, which can lead to an insufficient distribution of oxygen to the tissues. Rationale 2: A buildup of electrolytes in the blood is not of primary concern in this patient's oxygenation. Rationale 3: Hypovolemic shock will not result in over-oxygenation. Rationale 4: Oxygen delivery is through diffusion and not osmosis. Hypovolemic shock does not cause an alteration to a different process.

A patient has a hemoglobin level of 8.6 mg/dL. The nurse is concerned that which oxygenation component will be affected in this patient? 1. Oxygen delivery 2. Diffusion of oxygen 3. Pulmonary gas exchange 4. Oxygen consumption

Correct Answer: 1 Rationale 1: The concept of oxygenation involves three physiologic components for the intake, delivery, and use of oxygen for energy: pulmonary gas exchange, oxygen delivery, and oxygen consumption. Adequacy of oxygenation depends on the integration of these physiologic components. Oxygen delivery is the process of transportation of oxygen to cells and is dependent on cardiac output, hemoglobin saturation with oxygen, and the partial pressure of oxygen in arterial blood. Rationale 2: Diffusion is part of pulmonary gas exchange. The actual process of diffusion will not be affected by low hemoglobin. Rationale 3: The concept of oxygenation involves three physiologic components for the intake, delivery, and use of oxygen for energy: pulmonary gas exchange, oxygen delivery, and oxygen consumption. Adequacy of oxygenation depends on the integration of these physiologic components. Pulmonary gas exchange involves the intake of oxygen from the external environment into the internal environment. Rationale 4: The concept of oxygenation involves three physiologic components for the intake, delivery, and use of oxygen for energy: pulmonary gas exchange, oxygen delivery, and oxygen consumption. Adequacy of oxygenation depends on the integration of these physiologic components. Oxygen consumption involves the use of oxygen at the cellular level to generate energy for cells to use to perform their specific functions.

A postoperative patient's nasogastric drainage has been 500 mL in the last 8 hours. The nurse would assess this patient for findings associated with which acid-base imbalance? 1. Metabolic alkalosis 2. Metabolic acidosis 3. Respiratory acidosis 4. Respiratory alkalosis

Correct Answer: 1 Rationale 1: The loss of gastric fluid from nasogastric suction can result in metabolic alkalosis. Rationale 2: Loss of body fluids from lower abdominal drains would result in loss of bicarbonate and produce metabolic acidosis. Rationale 3: The respiratory system is not involved in the development of this acid-base imbalance. Rationale 4: The respiratory system is not involved in this acid-base imbalance.

A nurse reviewing arterial blood gas results identifies the oxygen saturation level as low. The nurse interprets this information to reflect changes in which process? 1. Ratio of oxygenated hemoglobin to total hemoglobin 2. Percentage of cardiac output 3. Content of oxygen in arterial blood 4. Autoregulation

Correct Answer: 1 Rationale 1: The measurement of SaO2 or oxygen saturation by arterial blood gas analysis is a measurement of the ratio of oxygenated hemoglobin to total hemoglobin. Rationale 2: Oxygen saturation level does not provide evidence about percentage of cardiac output. Rationale 3: The content of oxygen in arterial blood is expressed as CaO2. Rationale 4: Oxygen saturation level within the arterial blood gas analysis is not evidence of autoregulation.

The nurse is caring for a patient who has recently undergone major abdominal surgery. The patient is exhibiting shallow breathing and is hesitant to cough and deep breathe. Which nursing diagnosis (NDX) should the nurse choose for this patient? 1. Ineffective Breathing Pattern 2. Ineffective Airway Clearance 3. Potential for Pneumonia 4. Impaired Gas Exchange

Correct Answer: 1 Rationale 1: The patient has documented shallow breathing, indicative of an ineffective breathing pattern. Rationale 2: Since there is no evidence of inability to clear secretions, this is not the best NDX choice for this patient. Rationale 3: Potential for pneumonia is not a nursing diagnosis. Rationale 4: In order to support the NDX Impaired Gas Exchange, the patient must exhibit cyanosis or have arterial blood gas evidence of poor oxygenation or carbon dioxide retention.

The patient complains that he awakens "two or three" times every night because he is so short of breath. The nurse would ask additional assessment questions about which condition? 1. Paroxysmal nocturnal dyspnea 2. Pneumonia 3. Stroke 4. Kidney infection

Correct Answer: 1 Rationale 1: The patient is describing episodes of paroxysmal nocturnal dyspnea, which is related to left ventricular failure. The prolonged supine position allows dependent fluid from the lower extremities to recirculate causing volume overload and sudden severe dyspnea. Rationale 2: Pneumonia results in consolidation of lung tissue. It is not associated with sudden dyspnea during the night. Rationale 3: There is no indication that a neurological problem is causing this patient's symptoms. Rationale 4: There is no indication that this patient is experiencing shortness of breath at night due to a kidney infection. Kidney infection might result in need to urinate frequently during the night.

A patient who will require long-term mechanical ventilation has had a tracheostomy for 2 weeks. The nurse is concerned that stoma erosion is occurring. Which nursing assessment would support the nurse's concern? 1. Secretions are present at the stoma opening. 2. Granulation tissue is noted at the stoma site. 3. The patient has developed a dry cough. 4. The skin at the stoma opening is flaky.

Correct Answer: 1 Rationale 1: The presence of excessive secretions at the stoma opening indicates that the stoma size in increasing. Rationale 2: Granulation tissue is more likely to result in obstruction or stricture. Rationale 3: Dry cough does not indicate stoma erosion. Rationale 4: Flakiness indicates dryness. In stoma erosion the skin is excoriated from constant moisture.

The nurse is planning to use a respiratory spirometer to measure the amount of air that moves in and out of a patient's lungs with each normal breath. How will the nurse document the results of this test? 1. Tidal volume 2. Vital capacity 3. Forced expiratory volume 4. Minute ventilation

Correct Answer: 1 Rationale 1: Tidal volume is the amount of air that moves in and out of the lungs with each normal breath. Rationale 2: Vital capacity is the maximum amount of air expired after a maximal inspiration. Rationale 3: Forced expiratory volume testing generally is not conducted as a bedside trending parameter. Rationale 4: Minute ventilation is the total volume of expired air in 1 minute and is not a direct measurement but a simple calculation.

A patient recovering from thoracic surgery is demonstrating evidence of Impaired Gas exchange with a dropping oxygen saturation level. Which nursing intervention is most suited to addressing this nursing diagnosis? 1. Teach the patient to use the incentive spirometer every 1 to 2 hours. 2. Suction as necessary. 3. Splint the chest when coughing. 4. Encourage fluids up to 2.5 liters per day.

Correct Answer: 1 Rationale 1: Using the incentive spirometer correctly every 1 to 2 hours will help to improve gas exchange. Rationale 2: Suctioning is related more to Ineffective Airway Clearance. Rationale 3: Using a splint with coughing will help reduce pain so that the airway can be cleared. This intervention is most related to Ineffective Airway Clearance. Rationale 4: Increasing fluids will help to thin secretions so that they are more easily mobilized. This intervention is most related to Ineffective Airway Clearance.

The nurse manager teaches newly hired nurses about findings associated with barotrauma. The manager would include that this complication is most common in which type of mechanical ventilation? 1. Volume 2. Time 3. Pressure 4. Flow

Correct Answer: 1 Rationale 1: Volume-cycled ventilation delivers a preset volume of gas to the lungs. Volume ventilation has the potential to generate high pressures, especially in less compliant lungs in order to deliver the set volume, which increases the risk of barotrauma. Rationale 2: Time-cycled ventilators also limit the maximum amount of pressure that can be delivered, which offers protection against barotrauma. Rationale 3: Pressure-cycled ventilation is increasingly used as a method to protect the injured lung from further damage from high pressures. Rationale 4: Flow-cycled ventilators augment the patient's inspiratory effort as long as the patient continues to inhale at a certain flow rate. The risk of barotrauma is not as significant as with another type of ventilator.

A patient with severe chronic respiratory illness suddenly develops a high fever. The nurse would plan care for this patient based upon which understanding of the fever's impact on the oxyhemoglobin dissociation curve? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The curve will shift to the right. 2. Additional oxygen will be released to the tissues. 3. Life-threatening tissue hypoxia may occur. 4. The change will be similar to what occurs with alkalosis. 5. Hemoglobin will bind more readily to oxygen.

Correct Answer: 1,2,3 Rationale 1: Increased temperature causes increased oxygen demand which shifts the curve to the right. Rationale 2: Increasing body temperature increases oxygen demand, so additional oxygen will be released to the tissue to meet this demand. Rationale 3: Severe and rapid shifts in the curve can result in life-threatening tissue hypoxia. Rationale 4: Alkalosis causes an opposite response in the oxyhemoglobin dissociation curve and inhibits oxygen release at the tissue level. Rationale 5: Hemoglobin binds more readily to oxygen in the lungs when the patient is hypothermic.

A nurse is monitoring trends of a patient's SvO2 as a measure of oxygen delivery to tissues. The nurse would be concerned about the accuracy of this trending if which patient condition develops? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The patient's heart rate drops. 2. The patient develops a high fever. 3. The patient develops gastrointestinal bleeding. 4. The patient's SaO2 improves with antibiotic therapy. 5. The patient is receiving multivitamins in intravenous infusions.

Correct Answer: 1,2,3,4 Rationale 1: Dropping heart rate would change cardiac output. SvO2 is influenced by cardiac output. Rationale 2: High fever will increase oxygen consumption, which affects SvO2. Rationale 3: If the patients hemoglobin level changes it will change SvO2. Rationale 4: Improvement of SaO2 will change SvO2. Rationale 5: The presence of vitamins in intravenous infusions will not change SvO2.

A nurse is preparing a patient for pulmonary functioning testing (PFT). Which nursing statements will help to reinforce teaching about the purposes of these tests? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. These tests can help in the diagnosis of any pulmonary diseases you may have. 2. We can monitor how well therapies are working by comparing the results of your tests. 3. Insurance companies require these tests be done before you can be discharged from the hospital. 4. By testing you frequently we can identify changes occurring in your pulmonary health before they become severe. 5. The tests give us numbers so we can make accurate assessments of your pulmonary health.

Correct Answer: 1,2,4,5 Rationale 1: PFT are helpful in diagnosing pulmonary diseases. Rationale 2: These tests are often used for monitoring the effects of therapies. Rationale 3: The results of the tests may be used to satisfy discharge screens but saying they are required by insurance companies is not accurate. Rationale 4: Identifying changes in pulmonary status is a valid rationale for these tests. Rationale 5: Because the results of these tests are reported in numbers, the trending of results is easy and useful.

AN adult patient has suffered a respiratory arrest and requires endotracheal intubation. The nurse should obtain which equipment for this procedure? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Topical anesthetic 2. Magill forceps 3. Cuffless endotracheal tube 4. Oxygen cannula 5. Water-soluble lubricant

Correct Answer: 1,2,5 Rationale 1: A topical anesthetic may be administered to decrease gagging. Rationale 2: Magill forceps may be used to help guide the tube through the larynx. Rationale 3: Since this patient is an adult a soft-cuffed ET tube will be used. Rationale 4: Although an oxygen source would be appropriate for providing manual bagging of the patient, a nasal cannula is useless for this patient. Rationale 5: Water-soluble lubricant can be used to help advance the endotracheal tube.

The nurse is preparing to participate in evaluation of the severity of a patient's community acquired pneumonia using the CURB-65 criteria. Which information will the nurse collect for this evaluation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The patient's respiratory rates for the last several hours 2. BUN results 3. If the patient has a history of smoking 4. The patient's gender. 5. The patient's age

Correct Answer: 1,2,5 Rationale 1: CURB-65 evaluates the patient's respiratory rate. Rate of 30 or over is scored as a 1. Rationale 2: CURB-65 evaluates that patient's BUN level. BUN greater than 19.6 mg/dL is scored as a 1. Rationale 3: Tobacco use history is not considered in CURB-65 scoring. Rationale 4: Gender is not considered in CURB-65 scoring. Rationale 5: The patient's age is considered in CURB-65 scoring. If the patient is 65 or older, a score of 1 is assigned.

A patient in respiratory failure has a heart rate of 124, respirations of 24, blood pressure of 168/98, blood pH of 7.28 and oxygen saturation of 84%. The patient is can be aroused, but returns to sleep quickly. Noninvasive intermittent positive pressure (NIPPV) is initiated. On reassessment, which findings would the nurse evaluate as indicating that this therapy is having the desired outcomes? Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Respiratory rate is 22. 2. The patient is not using accessory muscles. 3. The patient is somnolent. 4. Blood pH is 7.26. 5. O2 saturation is 90%.

Correct Answer: 1,2,5 Rationale 1: The respiratory rate is trending downward which is an indicator that NIPPV is being effective. Rationale 2: Decreased use of accessory muscles indicates the patient is not working as hard to breath. This is a positive effect of NIPPV. Rationale 3: NIPPV should help reduce carbon dioxide retention which would manifest as the patient being easier to arouse. Rationale 4: A blood pH of 7.26 would indicate worsening acidosis, possibly caused by retaining carbon dioxide. Rationale 5: Improved oxygenation would indicate the therapy is working.

A patient's PaO2 is 88 mm Hg while on FiO2 of 0.50. What can the nurse conclude about this patient's intrapulmonary shunt? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The shunt is estimated to be 176. 2. The shunt is estimated to be 568. 3. The shunt is below the minimum acceptable level. 4. This data has little use in determining oxygenation status of the patient who is retaining CO2. 5. No determination of intrapulmonary shunt can be made from this data.

Correct Answer: 1,3 Rationale 1: Calculating the P/F ratio is the simplest way to estimate intrapulmonary shunt. In this case the value is 176. Rationale 2: This is not a valid estimation of intrapulmonary shunt. Rationale 3: The minimum acceptable level is higher than this estimation of intrapulmonary shunt. Rationale 4: As long as the PaCO2 is stable this estimation is valid and is applicable to oxygenation status. Rationale 5: Intrapulmonary shunt can be estimated by comparing this data.

A patient who is receiving chemotherapy is anemic and has low CaO2 levels. Which nursing interventions offer the best support for this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Monitor the administration of blood products. 2. Administer diuretics as ordered. 3. Keep the patient's oxygen cannula in place. 4. Keep the patient on bedrest 5. Monitor the patient's pulmonary artery wedge pressure (PAWP).

Correct Answer: 1,3 Rationale 1: One of the methods for increasing the amount of oxygen in arterial blood is to increase the amount of hemoglobin in the blood. If the patient is severely anemic, blood transfusion is an option. Rationale 2: Diuretics will not increase CaO2 but might increase hematocrit. Rationale 3: Supplementing oxygen to increase SaO2 and PaO2 will help increase CaO2. Rationale 4: Keeping the patient on bedrest would decrease the effects of low CaO2 by decreasing metabolic demand, but will not increase CaO2. Rationale 5: Monitoring the PAWP will not improve oxygenation of arterial blood.

Arterial blood gases were drawn when a patient was discovered in cardiopulmonary arrest. Which results would the nurse evaluate as indicating global lactic acidosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. pH 7.21 2. HCO3 24 mEq/L 3. Base excess -12 mmol/L 4. PaO2 82 mm Hg 5. PaCO2 37 mmHg

Correct Answer: 1,3 Rationale 1: The patient in global lactic acidosis will have an acidotic pH (less than 7.35). Rationale 2: HCO3 of 24 mEq/L is normal. In global lactic acidosis the HCO3 would be low. Rationale 3: A base deficit will be seen in global lactic acidosis. Rationale 4: This is a normal PaO2 and is not an expected finding in the global hypoxia that results in global lactic acidosis. Rationale 5: This is a normal PaCO2.

A patient is being admitted to the intensive care unit after being resuscitated in the emergency department. The patient is being mechanically ventilated. Which information provided by the transferring nurse would the nurse evaluate as increasing this patient's risk of developing ventilator associated pneumonia (VAP)? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. "The patient is intubated nasally." 2. "The patient arrested after having a myocardial infarction." 3. "The patient required placement of a nasogastric tube to relieve persistent gastric distention." 4. "The patient's home medications include a proton pump inhibitor." 5. "The patient has a history of COPD."

Correct Answer: 1,3,4,5 Rationale 1: The presence of an endotracheal tube is a risk factor for VAP. Rationale 2: There is no particular increase in risk because the etiology of the arrest was a myocardial infarction. Rationale 3: Placement of a nasogastric tube increases risk for gastroesophageal reflux. Rationale 4: Medications to prevent stress ulcer formation create an alkaline pH in which bacteria multiply. Rationale 5: COPD increases risk for VAP.

A patient is going to be assessed for oxygen consumption level. Which parameter will the nurse identify for this assessment? 1. Serum potassium level 2. Hemoglobin level 3. Creatinine level 4. Serum lactate level

Correct Answer: 4 Rationale 1: Serum potassium is not used in determining oxygen consumption. Rationale 2: Hemoglobin is not used in determining oxygen consumption. Rationale 3: Creatinine is not used in determining oxygen consumption. Rationale 4: Current methods of assessing oxygen consumption are limited to indirect measurement techniques including measurement of serum lactate levels, base deficit, and mixed venous oxygen saturation monitoring; therefore, the serum lactate level will be used to assess the patient's oxygen consumption level.

The health care team has planned to begin weaning a patient from the mechanical ventilator in the morning. The nurse should alert the team to which situations that could decrease the chance of successful weaning? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The patient has developed a fever. 2. The patient was suctioned twice during the night for a small amount of thin secretions. 3. ABGs reveal a pH of 7.34. 4. The patient is constipated. 5. The patient's serum sodium level is 138 mEq/L.

Correct Answer: 1,4 Rationale 1: Fever increases metabolic rate and decreases the chance of successful weaning. Rationale 2: It is normal for the patient to require suctioning. Twice during the night is not excessive and the secretions are thin. This finding should not impede weaning. Rationale 3: pH between 7.30 and 7.45 offer the best chance of successful weaning. Rationale 4: Bowel problems such a diarrhea or constipation can decrease successful weaning. Rationale 5: Normal electrolyte measurements, such as this normal sodium level, increase the chance that weaning will be successful.

A patient injured in an explosion has a flail chest and crushing injuries to his left arm and leg. He is unconscious and is losing blood rapidly. Laboratory testing reveals impaired oxygenation. Nursing interventions should be implemented to improve which components of oxygenation disrupted by this injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Ventilation 2. Thickness of the alveolar-capillary membrane 3. Oxygen affinity 4. Hemoglobin concentration 5. Blood flow to the lungs

Correct Answer: 1,4,5 Rationale 1: Since the patient has a flail chest, ventilation, or the movement of air between the atmosphere and the lungs, will be impaired. Rationale 2: These injuries should not have a significant initial impact on thickness of the alveolar-capillary membrane. Should the flail chest result in pneumothorax or hemothorax, the effective surface area of the lungs will be decreased, but the thickness of the membrane will not be affected initially. Rationale 3: Nothing in this scenario will affect hemoglobin affinity for oxygen. Rationale 4: As the patient continues to bleed, the amount of available hemoglobin will continue to reduce. Rationale 5: Since the patient has massive blood loss, the body has shunted blood to core organs in an attempt to maintain blood flow. This compensation is short lived as bleeding continues.

A patient tells the nurse that when he is exposed to cigarette smoke he begins to get short of breath, starts coughing, and gets a "high pitched noise" in his lungs when he breathes. The nurse would ask additional assessment questions about which pulmonary disorder? 1. COPD 2. Asthma 3. Emphysema 4. Pneumonia

Correct Answer: 2 Rationale 1: COPD also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms. Rationale 2: The classic triad of asthma symptoms includes paroxysmal episodes of dyspnea, wheeze, and cough triggered by a stimulus. The stimulus, or trigger, for the patient is cigarette smoke. This patient most likely is describing the symptoms of asthma. Rationale 3: Emphysema also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms. Rationale 4: Pneumonia will not "suddenly appear" after exposure to cigarette smoke to cause the onset of the patient's symptoms.

The nurse is auscultating a patient's lung fields and hears a coarse sound like bubbling water. The sounds are heard best on expiration and in the center of the patient's chest. How should the nurse document these sounds? 1. Crackles 2. Rhonchi 3. Wheeze 4. Stridor

Correct Answer: 2 Rationale 1: Crackles are discrete, delicate popping sounds heard best on inspiration. Rationale 2: Rhonchi are course bubbly sounds that frequently occur during expiration and are heard over the larger airways. Rationale 3: Wheezes are musical sounds that may be high-pitched or low-pitched. They are heard both on inspiration and expiration and are of long duration. Rationale 4: Stridor is a type of wheeze. It is high-pitched, inspiratory, and heard best over the neck.

The patient has been diagnosed with early stage pneumonia. The nurse would anticipate which laboratory results? 1. Increased PaO2 and increased PaCO2 2. Decreased PaO2 and normal PaCO2 3. Normal PaO2 and elevated PaCO2 4. Decreased PaO2 and increased PaCO2

Correct Answer: 2 Rationale 1: Presence of pneumonia will not result in an increase in oxygen. Rationale 2: In the early stages of pneumonia the alveolar surface area is reduced and the alveolar-capillary membrane begins to thicken causing diffusion abnormalities. Oxygen and carbon dioxide do not diffuse at the same rate. Carbon dioxide diffuses 20 times faster than oxygen; therefore, hypoxemia may be present with a normal PaCO2. Only when the condition progresses untreated will the PaCO2 rise. Rationale 3: PaCO2 will rise only after the disease has progressed. Rationale 4: Oxygen will decrease, but PaCO2 will not rise initially.

The nurse is admitting a patient who sustained a traumatic brain injury and who is now deeply sedated. The nurse would anticipate managing which mode of ventilation during this patient's initial care? 1. Pressure support ventilation 2. Assist-control ventilation 3. Pressure support ventilation (PSV) 4. Synchronized intermittent mandatory ventilation (SIMV)

Correct Answer: 2 Rationale 1: Pressure support ventilation requires that the patient have spontaneous respiratory effort. That will not be the case with a deeply sedated patient. Rationale 2: With assist-control ventilation, every breath is a machine breath. At the appropriate settings, this is desirable for a deeply sedated head-injured patient who is unlikely to initiate spontaneous breaths. Rationale 3: PSV is an adjunctive weaning mode which requires spontaneous breathing attempts which would not be present in a deeply sedated patient. Rationale 4: SIMV relies on the patient spontaneously breathing through the circuit to do much of the work of breathing. This will not happen in a deeply sedated patient.

A patient presents to the emergency department after falling from a ladder at home. He has multiple contusions and abrasion on his right side and is holding his right arm tightly across his chest. On inspection the nurse notes that the patient's trachea is slight displaced toward the left. Which nursing intervention is priority? 1. Have the patient release his arm and sit up straight for reassessment. 2. Notify the emergency room physician immediately. 3. Auscultate the patient's lung fields. 4. Position the patient flat in bed without a pillow.

Correct Answer: 2 Rationale 1: Reassessment is not the priority in this situation. Rationale 2: Deviation of the trachea away from the injured side indicates pressure on the affected side which may be from a developing pneumothorax or hemothorax. If so the patient may require immediate placement of a chest tube. Delay could be detrimental to the patient's condition. Rationale 3: The nurse will auscultate the lungs, but another intervention is the priority. Rationale 4: This position is not indicated for this patient. Positioning is not the immediate priority.

A patient's mixed venous oxygen saturation level is 56%. What evaluation would the nurse make of this reading? 1. The cells are taking more oxygen to meet needs. 2. The cells are not receiving enough oxygen. 3. The cells are releasing more carbon dioxide. 4. There isn't enough oxyhemoglobin to meet the patient's needs.

Correct Answer: 2 Rationale 1: The level of 56% does not mean that the cells are taking more oxygen to meet needs. Rationale 2: Venous blood from all body systems is considered "mixed" when it has reached the pulmonary artery. Normal mixed venous oxygen saturation is 60%-80%. If the oxygen delivery to tissues is adequate for tissue demands, oxygen saturation of the blood in the pulmonary artery will be 60%-80%. A low mixed venous oxygen saturation level means that less oxygen is returning to the right heart and the cells are not getting enough oxygen to meet their needs. Rationale 3: The level of 56% does not mean that the cells are releasing more carbon dioxide. Rationale 4: There is not enough information to determine the cause of this reading.

A patient's ventilator settings are going to be modified to include positive end expiratory pressure (PEEP). What nursing action is most important? 1. Suction the patient before and after the change. 2. Monitor vital signs frequently. 3. Notify the physician of abrupt increases in oxygenation. 4. Monitor breath sounds at least every 15 minutes

Correct Answer: 2 Rationale 1: The nurse is expected to suction the patient as needed. However, this does not imply that it should be done before and after instituting PEEP. Rationale 2: It is most important for the nurse to monitor vital signs frequently because the addition of PEEP increases intrathoracic pressure, which decreases venous return and, therefore, compromises cardiac output. Rationale 3: The nurse would not notify the physician of an abrupt increase in oxygenation. This would be a desirable outcome. Rationale 4: Although the nurse would certainly auscultate breath sounds on a routine basis, it would not typically be expected every 15 minutes and would not be particularly associated with instituting PEEP.

The nurse is caring for a patient with obstructive pulmonary disease who had tachycardia, tachypnea, and restlessness. The patient has become very lethargic, but has a normal respiratory rate. The nurse should evaluate this change as indicating which condition? 1. The patient is now able to rest and sleep. 2. The patient's condition has significantly deteriorated. 3. The patient's condition shows some slight improvement. 4. The patient's condition has stabilized significantly.

Correct Answer: 2 Rationale 1: These findings do not indicate that the patient is resting and now able to sleep. Rationale 2: The patient's condition has deteriorated as evidenced by lethargy and decreased respiratory rate. The elevated carbon dioxide levels have affected the central nervous system causing lethargy, which may progress to coma. The patient has become exhausted and is unable to maintain the compensatory mechanisms needed to maintain acid-base balance. Rationale 3: These findings do not indicate that the patient's condition is improving. Rationale 4: These findings do not indicate significant stabilization of the patient's condition.

The nurse monitors all mechanically ventilated patients for the development of oxygen toxicity. Which patient would the nurse determine to be at highest risk? 1. The patient has required FiO2 of 0.7 for the first 2 hours after being intubated. 2. A patient has required FiO2 of 1.0 for the last 8 hours. 3. The patient's ventilator was set at FiO2 of 0.4 for the last 2 days. 4. The patient has required FiO2 of 0.8 for 24 hours after intubation.

Correct Answer: 2 Rationale 1: While this FiO2 is high the length of time it was used is short so the risk of oxygen toxicity is not high. Rationale 2: The use of FiO2 of 1.0 can cause pulmonary changes within 6 hours. Rationale 3: This FiO2 does not represent a high risk for oxygen toxicity. Rationale 4: This is a high FiO2 but the duration is rather short. This patient is not at highest risk for oxygen toxicity.

A nurse is participating on a committee charged with the task of choosing capnography equipment for a new emergency department. The nurse should present which information regarding these choices? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Sidestream analyzers provide direct real-time measurements of ETCO2. 2. Mainstream analyzers require the patient to be intubated. 3. Colorimetric capnography is useful for determining accurate placement of endotracheal tubes. 4. Mainstream analyzers provide continuous ETCO2 measurements. 5. Colorimetric measurement provides a wide range of color results that are compared to a standard chart.

Correct Answer: 2,3,4 Rationale 1: The major disadvantage of sidestream analyzers is that values are indirect estimated measurements. Rationale 2: A major disadvantage to the mainstream technique is that it requires the patient to be intubated. Rationale 3: Colorimetric capnography can be used in the ED or in the field to determine accurate placement of endotracheal tubes. Rationale 4: Mainstream analyzers are placed in-line as part of the airway circuit and continuously measure the ETCO2. The measurement is real-time. Rationale 5: Colorimetric measurement responds to the patient's exhaled CO2 with three color ranges.

A patient who is mechanically ventilated requires a high level of PEEP. The nurse would monitor for which findings indicating possible barotrauma? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Sudden increase in systolic blood pressure. 2. Absent breath sounds. 3. Subcutaneous emphysema across the anterior chest. 4. Patient is somnolent. 5. Sudden deterioration of ABGs.

Correct Answer: 2,3,5 Rationale 1: Deterioration of blood pressure that occurs suddenly may indicate barotrauma. Rationale 2: Sudden absence of breath sounds may indicate barotrauma. Rationale 3: Development of subcutaneous emphysema on the anterior neck or chest may be related to barotrauma. Rationale 4: Sudden onset of agitation is a more likely manifestation of barotrauma. Rationale 5: Barotrauma will result in sudden deterioration of ABGs.

A patient has a diagnosis of Ineffective Airway Clearance as evidenced by the inability to clear thick secretions effectively. Which nursing interventions are appropriate to address this nursing diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Encourage bedrest to conserve energy. 2. Administer pain medications as needed. 3. Position the patient on the unaffected side. 4. Encourage the patient to provide as much self-care as possible. 5. Encourage slow, deep breaths

Correct Answer: 2,4 Rationale 1: Bedrest will impair the patient's ability to mobilize secretions. Activity as tolerated will help mobilize secretions. Rationale 2: The nurse should treat the patient's pain but avoid oversedation. Rationale 3: Positioning the patient on the unaffected side is an intervention to improve gas exchange. Ineffective airway clearance generally involved both lungs and the trachea. Rationale 4: Providing care for self encourages the patient to move within the environment even if it is limited to the bed or bedside. Movement encourages mobilization of secretions. Rationale 5: Slow, deep breaths will support a healthier breathing pattern, but is not necessarily indicated for impaired gas exchange.

A patient with pneumonia is restless and confused with increased blood pressure and respiratory rate. PaO2 is less than 60 mm Hg with a normal PaCO2. What conclusion can the nurse draw regarding this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. The patient has ventilation failure. 2. Without treatment the patient's oxygen saturation is likely to drop rapidly. 3. The patient has decreased airflow. 4. The patient is at risk for respiratory muscle fatigue. 5. Acute respiratory failure is present.

Correct Answer: 2,4 Rationale 1: Ventilation failure is reflected by an increased PaCO2. Rationale 2: Once the PaO2 drops below 60 mm Hg oxygen's affinity to hemoglobin drops. Rationale 3: When the patient has ventilatory failure (decreased airflow) carbon dioxide levels increase. This patient has a normal PaCO2. Rationale 4: As respiratory rate increases the risk of respiratory muscle fatigue also increases. Rationale 5: Currently the patient does not have acute respiratory failure because the PaCO2 is normal.

The nurse is assessing a patient with an endotracheal tube and notes decreased breath sounds on the left with normal sounds on the right. Which condition may cause this? Select all that apply. 1. Pressure from a right pneumothorax 2. Misplacement of the endotracheal tube 3. High pulmonary pressures 4. Partial obstruction of the endotracheal tube 5. A large infiltrate in the left lung

Correct Answer: 2,5 Rationale 1: A right pneumothorax would present with decreased sounds on the right. Rationale 2: The right bronchus is larger than the left bronchus and is at almost a straight angle with the trachea. This anatomical difference makes it easy for the tip of the endotracheal tube to slip into the right bronchus, depriving the left lung from air. This results in decreased breath sounds on the left. Rationale 3: High pulmonary pressures would affect both sides equally. Rationale 4: A partially obstructed endotracheal tube would affect both sides equally. Rationale 5: A large infiltrate in the left lung will decrease air movement through the tissues. This change in air movement will decrease breath sounds on the affected side.

A patient was extubated in the postanesthesia recovery room prior to transfer to the intensive care unit (ICU). Upon admission to the ICU the patient is sedated, but will arouse when stimulated. Blood pressure is 106/68 mm/Hg, heart rate is 68 and regular, temperature is 97.8 F, and respirations are 12 bpm. The nurse would monitor this patient for which changes in arterial blood gases? 1. Increase in pH and decrease in PaCO2 2. Increase in pH and increase in HCO3 3. Decrease in pH and increase in PaCO2 4. Decrease in pH and decrease in HCO3

Correct Answer: 3 Rationale 1: An increase in pH and decrease in PaCO2 indicates respiratory alkalosis is occurring. This is not the expected change with this patient. Rationale 2: These ABG results indicate metabolic alkalosis. This is not the expected change with this patient. Rationale 3: The patient is at risk for respiratory acidosis, which is associated with these ABG changes, as a result of decreased, shallow respirations that can cause alveolar hypoventilation. Carbon dioxide is not being blown off and carbonic acid levels can rise. Rationale 4: These ABG results indicate metabolic acidosis. This is not the expected change in this patient.

The arterial blood gases of a patient with a large mass in the right lung show increasing hypoxemia and the patient will be intubated for placement on a mechanical ventilator. In which position should the nurse place this patient until intubation is begun? 1. Flat in bed lying on the left side 2. Flat in bed lying on the right side 3. Lying on the left side with the head of the bed elevated to 30 degrees 4. Lying on the right side with the head of the bed elevated 30 degrees

Correct Answer: 3 Rationale 1: Being placed flat in bed will not improve ventilation perfusion. The patient should benefit from being on the left side. Rationale 2: This position will not take advantage of gravity or of the body's natural ventilation tendencies. Rationale 3: Positioning the patient at 30 degrees and left side down will lower the diaphragm allowing more expansion and redirect blood flow to the healthy lung because of gravity. Air is naturally drawn toward the diaphragm and because blood is gravity dependent the ventilation-perfusion ratio will be improved. Rationale 4: If the right lung is not capable of normal ventilation, redirecting blood flow would result in a mismatch.

A patient, diagnosed with diabetic ketoacidosis, presents with Kussmaul respirations at a rate of 28. A newly licensed nurse asks the patient to try to slow his breathing. What instruction should the preceptor provide? 1. "Keep trying to slow the patient's respirations because breathing so fast is hard on his heart." 2. "If he keeps breathing like that he will develop respiratory acidosis." 3. "Let the patient set his respiratory rate as rapid breathing helps to compensate for his acidosis." 4. "The patient is breathing deeply to help offset diabetes-induced hypoxemia."

Correct Answer: 3 Rationale 1: Breathing rapidly does increase strain on the heart, but the rapid respirations in this situation are helpful to the patient and should not be discouraged. Rationale 2: Breathing rapidly and deeply as in Kussmaul's respirations will not result in respiratory acidosis. Rationale 3: A patient with diabetic ketoacidosis has a primary metabolic acidosis. As a compensatory mechanism to regain acid-base homeostasis, alveolar hyperventilation occurs in an attempt to blow off carbon dioxide and drive the pH upward toward alkaline. The respiratory buffer system is a rapid-response compensatory mechanism for metabolic acid-base disturbances. Rationale 4: The patient does not have diabetes-induced hypoxemia.

The nurse is caring for a patient with a chest tube and a three-chamber disposable drainage system. The physician orders an AP chest x-ray to be done in the x-ray department. How would the nurse transport the patient? 1. Do a portable film in the patient's room. 2. Clamp the chest tube after full exhalation and call the department so they can be ready when you arrive. 3. Disconnect the drainage system from the wall suction and transport. 4. Clamp the chest tube after full inspiration and call the department so they can be ready when you arrive.

Correct Answer: 3 Rationale 1: Changing of a physician's order is not within the scope of practice of the nurse. Rationale 2: Clamping a chest tube for any length of time will obstruct the exit of air, causing pressure to build up in the pleural space, resulting in a tension pneumothorax. Rationale 3: The nurse would disconnect the drainage system from wall suction and transport with the drainage system in an upright position, placed below the level of the heart. The suction chamber does not require attachment to an external suction source, although it does make the system more effective. As long as the water seal chamber is intact, air is not permitted to reenter the chest cavity. Rationale 4: Clamping a chest tube for any length of time will obstruct the exit of air, causing pressure to build up in the pleural space, resulting in a tension pneumothorax.

The nurse is planning essential activities for a critically ill patient. In order to provide the least impact on oxygen consumption, the nurse would be certain the patient rests before and after which activity? 1. Abdominal wound dressing change 2. Bed bath 3. Daily weight using bed sling scale 4. Turning and repositioning

Correct Answer: 3 Rationale 1: Changing the abdominal wound dressing will increase the patient's oxygen consumption by 10%. This is not the activity with the greatest impact on oxygen status. Rationale 2: A bed bath will increase the patient's oxygen consumption by 20%. This is not the activity with the greatest impact on oxygen status. Rationale 3: A daily weight with a bed sling scale will increase a patient's oxygen consumption by 40% and is the activity that the nurse should do separately and then permit the patient to rest. Rationale 4: Turning and repositioning will increase the patient's oxygen consumption by 30%. This is not the activity with the greatest impact on oxygen status.

A patient is being admitted for treatment of pneumothorax. The nurse would anticipate providing care for a patient with which pathophysiology? 1. Prolonged expiratory time 2. Increased lung compliance 3. Reduced tidal volume 4. Hyper-inflated lungs

Correct Answer: 3 Rationale 1: Expiratory time is dependent upon airflow with remains normal in the patient with a restrictive lung disorder such as pneumothorax. Rationale 2: With restrictive lung disorders such as pneumothorax the air cannot move into the alveoli because of decreased lung compliance. Rationale 3: Restrictive disorders such as pneumothorax are problems of volume rather than airflow. The patient's tidal volume will be reduced. Rationale 4: Restrictive lung disorders such as pneumothorax result in decrease in the air capacity of the lungs.

The nurse assessing a patient with multiple injuries is concerned about the patient's ability to maintain adequate oxygenation. Which explanation would the nurse provide for this increased concern? 1. The patient's bowel sounds are hypoactive. 2. The patient has a hemoglobin level of 14 mg/dL. 3. The patient suffered a cervical neck injury and slight concussion. 4. The patient had an arm injury from flying glass.

Correct Answer: 3 Rationale 1: Hypoactive bowel sounds would not necessarily indicate an injury that would impact the patient's ability to maintain adequate oxygenation. Rationale 2: A hemoglobin level of 14 mg/dL would be sufficient for oxygenation to the tissues and would not cause the nurse concern. Rationale 3: Since the respiratory system requires constant input from the nervous system, the assessment findings of a cervical neck injury and slight concussion would be the ones that concern the nurse about the patient's ability to maintain adequate oxygenation. Rationale 4: An arm injury due to flying glass would likely have little impact on the patient's ability to maintain oxygenation.

A patient's PaO2 level is 48 mm Hg. The nurse would plan care to prevent development of which condition? 1. Hypoxemia 2. Intrapulmonary shunt 3. Hypoxia 4. Hyperventilation

Correct Answer: 3 Rationale 1: Hypoxemia, an inadequate amount of oxygen in the blood, is frequently quantified as a PaO2 of less than 60 mm Hg. This condition already exists. Rationale 2: There is not enough information to identify whether the current condition is related to intrapulmonary shunt. Rationale 3: If this condition is allowed to progress, hypoxia may result. The nurse's interventions are directed at reversing this progression. Rationale 4: There is not enough information to determine if the patient is hyperventilating.

A patient who has been extubated postoperatively is retaining carbon dioxide. In order to avoid reintubating this patient the nurse would expect to manage which intervention? 1. Insertion of an oral airway 2. Insertion of a nasal airway 3. Use of noninvasive intermittent positive pressure ventilation (NIPPV) 4. Use of continuous positive airway ventilation (CPAP)

Correct Answer: 3 Rationale 1: Inserting an oral airway may be indicated, but it will not reduce the retention of carbon dioxide if used alone. Rationale 2: A nasal airway may be indicated, but will not reverse carbon dioxide retention alone. Rationale 3: In the ICU setting, noninvasive intermittent positive pressure ventilation is used for patients in acute respiratory distress as a treatment option to avoid intubation. Noninvasive positive pressure ventilation has been used successfully for patients with hypercapnic failure. Rationale 4: Continuous positive airway pressure ventilation is most commonly used to treat obstructive sleep apnea. It does not provide assisted ventilation on inspiration as does NIPPV.

A patient is being started on oxygen therapy for an oxygen saturation level of 84% on room air. The nurse expects that this therapy will be effective if oxygen enters the blood through which physiological process? 1. Osmosis 2. Fluid shift 3. Diffusion 4. Concentration gradient

Correct Answer: 3 Rationale 1: Osmosis is a passive exchange and is not the primary mechanism by which oxygen crosses the alveolar-capillary membrane. Rationale 2: Fluid shifts are not involved in the physiologic process in which oxygen crosses the alveolar-capillary membrane. Rationale 3: Oxygen crosses alveolar-capillary membranes by diffusion, combines with hemoglobin, and is transported via the pulmonary vein to the left side of the heart. After the heart pumps oxygenated blood into the vascular system where it is transported to cells, oxygenated blood then leaves the capillaries by diffusion and enters cells. Rationale 4: Movement of oxygen across the alveolar-capillary membrane is not dependent upon a concentration gradient. It does depend upon the presence of a pressure gradient.

A patient tells the nurse that he feels more energetic when he wears oxygen. What would the nurse consider prior to responding to this statement? 1. The patient's ability to extract oxygen is increased by wearing oxygen. 2. Increasing oxygen availability has shifted the oxyhemoglobin dissociation curve to the left. 3. Increasing availability of oxygen has produced more adenosine triphosphate. 4. Increased oxygen increases energy by breaking down carbohydrates.

Correct Answer: 3 Rationale 1: Oxygen extraction is the ability to take oxygen into the cells. The process of extraction is not improved by increased delivery. Rationale 2: Shifting the oxyhemoglobin dissociation curve to the left will increase the body's hemoglobin carrying capacity of oxygen, but will also decrease the release of oxygen to the tissues. Rationale 3: Oxygen consumption is the process by which cells use oxygen to generate energy. Oxygen enables the energy contained in food to be broken down into elements that are converted into energy in the form of adenosine triphosphate. The primary value of oxygen is its ability to develop adenosine triphosphate, which would explain why the patient feels more energetic when he wears oxygen. Rationale 4: The breakdown of carbohydrates is done without oxygen.

The nurse is caring for a patient with ARDS. Which finding would indicate that the disease is progressing? 1. Increased lung compliance 2. Decrease in heart rate 3. Hypoxemia refractory to oxygen therapy 4. Respiratory acidosis

Correct Answer: 3 Rationale 1: Pulmonary function tests would indicate decreased lung compliance because of the restrictive component of the disease. Rationale 2: The heart rate increases as the work of breathing increases. Rationale 3: In progressive ARDS there is a pattern of increasing hypoxemia that is refractory to increasing concentrations of oxygen because of collapsed alveoli, decreased lung compliance, and significant shunting. Rationale 4: In the early onset of ARDS, respiratory alkalosis, and not acidosis, predominates as a result of compensatory mechanisms.

The nurse is caring for a patient diagnosed with uncontrolled asthma. The nurse implements interventions to help control the effects of asthma on which element of the patient's pulmonary gas exchange? 1. Removal 2. Diffusion 3. Ventilation 4. Perfusion

Correct Answer: 3 Rationale 1: Removal is not an element of pulmonary gas exchange. Rationale 2: Diffusion impairments are seen in pneumonia, lung cancer, and conditions that cause pulmonary edema. Rationale 3: Restrictive pulmonary disorders, such as uncontrolled asthma, will impair ventilation, the actual movement of air between the atmosphere and lungs. Rationale 4: Perfusion impairments are seen in anemia, carbon dioxide poisoning, hemorrhage, and pulmonary embolism.

Which nursing intervention will help to decrease the risk of tracheal and laryngeal injuries in an intubated patient? 1. Use an endotracheal tube equipped for continuous removal of subglottic secretions. 2. Deflate the cuff for 5 minutes every 8 hours. 3. Use the minimal occluding pressure technique to maintain cuff pressure at 20 to 25 mm Hg. 4. Test cuff pressure by assessing firmness of the inflation balloon.

Correct Answer: 3 Rationale 1: Removal of subglottic secretions will help prevent ventilator associated pneumonia but will not protect the integrity of the tracheal and laryngeal tissues. Rationale 2: Deflating the cuff will allow pooled secretions to enter the lower airways and increases risk for ventilator associated pneumonia. There is no evidence that decreasing cuff pressure this infrequently will protect tracheal or laryngeal tissues. Rationale 3: The minimal occluding pressure technique can be used and cuff pressures should be maintained in the 20 to 25 mm Hg range. Rationale 4: Firmness of the inflation balloon is a subjective measure of cuff pressure. The pressure should be checked at least once per shift via a cuff manometer.

The nurse is assessing the nutritional intake of a patient diagnosed with chronic carbon dioxide retention. Which patient report indicates the patient requires additional information about dietary choices? 1. "I try to eat salad with lunch every day." 2. "I drink a cup of coffee in the morning with breakfast." 3. "I usually eat a sandwich and pasta salad for lunch." 4. "I have been trying to increase the protein in my diet."

Correct Answer: 3 Rationale 1: Salad is a low fat, high fiber option that would benefit this patient's nutrition. Rationale 2: There is no indication that coffee is not appropriate for this patient. Rationale 3: The patient who retains carbon dioxide should avoid high carbohydrate meals. Carbohydrates increase the overall carbon dioxide load in the body. Rationale 4: A protein-calorie deficit weakens muscles, including respiratory muscles. The patient's attempts to increase protein in the diet should be reinforced.

A patient is being manually weaned from mechanical ventilation. What nursing intervention is indicated? 1. Suction the patient once the ventilator is removed. 2. Have intubation equipment at the bedside. 3. Project a calm and confident manner. 4. Change the ventilator settings so the patient can breathe spontaneously between set breaths.

Correct Answer: 3 Rationale 1: Suctioning removes oxygen as well as removing secretions. If suctioning is needed it should be done prior to the weaning period. Rationale 2: The patient remains intubated during this weaning so having intubation equipment at the bedside is not necessary. Rationale 3: The nurse's calm and confident presence is reassuring to the patient during this stressful time. Rationale 4: Manual weaning involves removing the patient from the ventilator so settings are not changed.

A patient is diagnosed with cystic fibrosis. The nurse will anticipate providing care for a patient with which change in lung function? 1. Decreased total lung capacity 2. Progressive respiratory alkalosis 3. Increased PaCO2 4. Increased forced expiratory volume (FEV)

Correct Answer: 3 Rationale 1: The air trapping associated with obstructive lung disorders such as cystic fibrosis results in increase in total lung capacity. Rationale 2: Obstructive pulmonary disorders such as cystic fibrosis tends to produce progressive respiratory acidosis. Rationale 3: In obstructive lung disorders such as cystic fibrosis PaCO2 levels increase as a result of air trapping. Rationale 4: Obstructive disorders such as cystic fibrosis cause inability to exhale trapped air. This results in a decreased FEV.

The nurse is caring for a patient who sustained a fractured femur from a motor vehicle accident 1 day ago. The patient is anxious, restless, appears short of breath, and requests pain medication for chest discomfort. Which nursing intervention is priority? 1. Administer pain medication as ordered. 2. Increase intravenous fluids. 3. Evaluate the patient's oxygen saturation. 4. Help the patient assume a more comfortable position.

Correct Answer: 3 Rationale 1: The patient's pain should be treated but this is not the priority intervention. Rationale 2: Intravenous fluids may be increased, but this is not the priority intervention. Rationale 3: The patient may be experiencing a fat embolism from the previous long bone fracture. The nurse should do a thorough assessment noting lung sounds, conjunctivae and pulse oximetry before calling the physician. Anticipate orders for supplemental oxygen, arterial blood gases, serum laboratory values, chest x-rays, electrocardiogram, a V/Q scan, and angiography. Rationale 4: Positioning is not the priority intervention.

A nurse who is evaluating a patient's arterial blood gases has determined that the patient's pH is acidic. What is the next question the nurse would ask in this interpretation? 1. Is the patient symptomatic of an acidic condition? 2. Which individual ABG component matches the pH acid-base state? 3. Is the PaCO2 within normal range? 4. Is HCO3 within normal range?

Correct Answer: 3 Rationale 1: The patient's symptoms are not considered at this point in the evaluation. Rationale 2: The nurse has not yet assessed the components, so this question is premature. Rationale 3: After determining the pH status, the next step is evaluation of PaCO2. Rationale 4: The HCO3 is not assessed at this point.

The nurse is caring for a patient with pneumonia that has impaired diffusion of oxygen. Assessment findings related to this impairment are similar to those the nurse would see in patients with which other disease states? 1. Spinal cord injuries 2. Flail chest 3. Atelectasis 4. Carbon monoxide poisoning

Correct Answer: 3 Rationale 1: The underlying pathophysiology of respiratory system changes in spinal cord injuries is associated with inability to ventilate. Rationale 2: The underlying pathophysiology of respiratory system changes in flail chest is associated with inability to ventilate. Rationale 3: Atelectasis results in decreased lung surface area and decreased ability to diffuse oxygen. Rationale 4: Carbon dioxide poisoning affects the affinity of oxygen to hemoglobin, therefore affecting perfusion.

The nurse responds to a ventilator pressure alarm by going to the patient's room. What should be the nurse's first action? 1. Turn off the ventilator alarm to help calm the patient. 2. Administer intravenous sedation according to prn prescription. 3. Assess for the cause of the alarm. 4. Manually bag the patient until the cause of the alarm is detected.

Correct Answer: 3 Rationale 1: The ventilator alarm should not be turned off. Most systems have a mechanism by which the alarm can be temporarily muted. Attending to the alarm is not the nurse's priority action. Rationale 2: The nurse cannot ascertain the need for sedation without additional action. Rationale 3: The nurse's first action should always be to assess the patient. Rationale 4: Manual bagging would be used after the patient is assessed and if the nurse could not quickly discover the reason for the alarm. This step is not indicated at this time.

A patient had chest tube insertion for a pneumothorax. External suction was discontinued yesterday. This morning the nurse assesses cessation of tidling in the water-seal chamber. What nursing action is indicated? 1. Collaborate with the health care provide regarding need to reinstitute the external suction. 2. Check the connections between the chest tube and the drainage system. 3. No action is necessary as this is an expected occurrence. 4. Have the patient cough forcefully.

Correct Answer: 3 Rationale 1: There is no need for external suction. Rationale 2: The nurse should always check these connections, but there is no special need for that action related to this assessment. Rationale 3: The cessation of tidling in this patient likely indicates successful reinflation of the lung which is the desired outcome. Rationale 4: This assessment does not indicate that coughing is necessary.

A patient with COPD says, "I have to rest a lot. It just wears me out trying to breath." The nurse interprets this statement to mean the patient has difficulty with which respiratory process? 1. Perfusion 2. Diffusion 3. Ventilation 4. Consumption

Correct Answer: 3 Rationale 1: There is nothing in this statement that indicates the patient is not perfusing the lungs adequately. Rationale 2: Oxygen is moved across the alveoli and into pulmonary capillaries by diffusion. This process does not require work on the part of the patient. Rationale 3: Ventilation is movement of air between the atmosphere and the lungs. It involves the actual work of breathing. In a patient with COPD the movement of air into and out of the lungs is impaired. Rationale 4: Oxygen consumption involves the use of oxygen at the cellular level and does not require work on the patient's part.

A patient's arterial blood gases (ABGs) are as follows: pH 7.30, PaCO2 30 mm Hg, HCO3 14 mEq/L, and PaO2 50. The nurse evaluates these ABGs as representing which acid-base imbalance? 1. Uncompensated respiratory alkalosis with moderate hypoxemia 2. Compensated metabolic acidosis with severe hypoxemia 3. Partially compensated metabolic acidosis with moderate hypoxemia 4. Partially compensated respiratory alkalosis with mild hypoxemia

Correct Answer: 3 Rationale 1: These ABGs do not represent an uncompensated state. Rationale 2: These ABGs do not represent a fully compensated state because the pH is not normal. Rationale 3: The patient has a partially compensated metabolic acidosis with moderate hypoxemia because the pH is still within the acid range. The HCO3 is the primary acidic metabolic component causing the acidic pH. In an attempt to correct the metabolic acidosis, the CO2 is being blown off as indicated by the alkaline PaCO2. The PaO2 falls within the moderate range of hypoxemia (60 to 40 mm Hg). Rationale 4: These ABGs do not indicate respiratory alkalosis.

A 40-year-old postoperative patient has a hemoglobin level of 8 g/dL and a SaO2 of 95 percent. Considering all aspects, what conclusion would the nurse make about this patient's condition? 1. The patient is stable and at no special risk. 2. Oxygenation is adequate for a postoperative patient. 3. This patient has a potential risk of hypoxia. 4. The patient's SaO2 is higher than expected for the patient's age.

Correct Answer: 3 Rationale 1: This patient's test results do indicate a risk potential. Rationale 2: It is not possible to accurately assess this patient's true oxygenation status from the test results provided. Rationale 3: The patient has a potential risk for hypoxia because SaO2 is the measure of percentage of oxygen combined with hemoglobin compared to the total amount it could carry. Although the patient's SaO2 is within normal range, the hemoglobin is only 8 g/dL, indicating that all 8 grams are adequately being saturated. Should the patient's oxygen demand increase, as it frequently will in a postoperative patient, the potential for hypoxia may exist because of the lower hemoglobin and inability to carry more oxygen to meet the demand. Rationale 4: The SaO2 is within normal limits for the patient's age; however, its accuracy is at doubt.

The nurse is assessing an 80-year-old patient who has no underlying respiratory pathology but whose carbon dioxide level is slightly elevated. The nurse would contribute this increase to which changes associated with normal aging? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Increase in alveolar-capillary membrane thins 2. Increase in total lung surface area 3. Increase in size of the airways 4. Increase in air trapping 5. Overgrowth of alveoli

Correct Answer: 3,4 Rationale 1: The alveolar-capillary membrane thickens with aging, which may result in hypoxemia and/or hypercapnia if the older patient becomes ill. Rationale 2: As a person ages there is a normal decrease in the total lung surface area. Rationale 3: Aging results in an increase in size of the airways, which increases dead space ventilation. This can lead to carbon dioxide retention. Rationale 4: Older patients may have increased air trapping due to normal loss of terminal airway supportive structures. Rationale 5: As a person ages, alveoli are destroyed. Overgrowth does not occur.

The patient's Wells Score indicate intermediate risk for the development of pulmonary embolism. Which nursing interventions would help reduce this risk? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Monitor daily D-dimer levels. 2. Strictly measure all intake and output. 3. Encourage ambulation. 4. Instruct the patient on use of antiembolism stockings. 5. Prevention of leg injury

Correct Answer: 3,4,5 Rationale 1: D-dimer elevation indicates presence of thrombolytic activity, but will not help to prevent occurrence of thrombus. Rationale 2: Measuring intake and output will not prevent development of thrombus. Rationale 3: Ambulation will help to support circulation and prevent clot development. Rationale 4: Proper use of antiembolism stocking is helpful in decreasing development of thrombus. Rationale 5: One of the risk factors for development of deep vein thrombosis in the leg is injury. This injury can occur from trauma from striking the bed or other objects in the room. The nurse should intervene to prevent this trauma.

A patient with pulmonary edema has a respiratory rate of 28 per minute. The nurse plans care for this patient based on which change in the lungs? 1. Decreased work of breathing 2. Reduced muscle activity 3. Dehydration of lung tissues 4. Decreased compliance

Correct Answer: 4 Rationale 1: A respiratory rate of 28 is evidence of increased work of breathing. Rationale 2: It requires more muscle activity to breath at a rate of 28. Rationale 3: Pulmonary edema results from retention of fluid in the lung tissues. Rationale 4: Decreased compliance increases the work of breathing and causes a decreased tidal volume. The breathing rate increases to compensate for the decreased tidal volume. Examples of pulmonary disorders causing decreased lung compliance include pulmonary edema.

A patient is diagnosed with diabetic ketoacidosis. The nurse plans to provide care to a patient whose energy is being produced through which process? 1. Affinity 2. Aerobic metabolism 3. Extraction 4. Anaerobic metabolism

Correct Answer: 4 Rationale 1: Affinity refers to the hemoglobin's ability to release oxygen to the tissues. Rationale 2: Aerobic metabolism would not cause diabetic ketoacidosis. Rationale 3: Extraction refers to the body cell's ability to extract oxygen from hemoglobin. Rationale 4: Carbohydrates are the only food substrates that can be broken down to generate adenosine triphosphate without the use of oxygen. Anaerobic metabolism produces the by-products pyruvate and lactate, causes lactate to accumulate in the body, and leads to lactic acidosis.

A patient diagnosed with ARDS is being mechanically ventilated with 12 cm of PEEP. On assessment, the nurse notes deterioration of vital signs and absent breath sounds in the right lung field. The nurse intervenes immediately due to the presence of which most likely complication? 1. Obstructed endotracheal tube 2. Increased severity of ARDS 3. Decreased cardiac output 4. Pneumothorax

Correct Answer: 4 Rationale 1: An obstructed endotracheal tube would affect both lung fields. Rationale 2: If the disease process was worsening it would be likely that both lung fields would be involved. Rationale 3: Decreased cardiac output would affect vital signs but not breath sounds. Rationale 4: A complication of PEEP may be a pneumothorax as a result of overdistention of the alveoli. Pneumothorax could be manifested by deterioration of vital signs and loss of air movement in the affected lung.

A patient aspirated while eating and suffered a respiratory arrest. A code blue was called, the obstruction was removed, but the patient required endotracheal intubation. Postintubation the nurse hears breath sounds bilaterally, but the carbon dioxide monitor indicates a higher than expected level. Which patient history could account for this discrepancy? 1. The patient's original admittance diagnosis was dehydration. 2. The patient's wife reports, "We were talking and laughing when he choked." 3. The patient has history of calcium deficiency requiring dietary supplementation. 4. The patient's wife says, "He had some heartburn earlier, so the nurse had given him a lemon-lime soda to drink with his supper."

Correct Answer: 4 Rationale 1: Dehydration would not result in high carbon dioxide levels. Rationale 2: Laughing and talking while eating could explain why the obstruction occurred, but would not explain why the discrepancy between auscultation and carbon dioxide monitor. Rationale 3: Calcium deficiency is not related to the discrepancy in this scenario. Rationale 4: Drinking a carbonated beverage just before intubation can cause a false positive carbon dioxide monitor report.

A patient has been uncooperative with pulmonary hygiene following thoracic surgery because "it hurts more than I can bear." Which intervention should the nurse employ? 1. Instruct the patient to cough 3 to 4 times with each exhalation. 2. Assist the patient to a sitting position to lean over the bedside table while coughing. 3. Provide the patient with a pillow to splint the incision while coughing. 4. Guide the patient to cough with the glottis open.

Correct Answer: 4 Rationale 1: The "cascade" cough is a series of 3 to 4 coughs on one exhalation. This type of cough could cause the patient more discomfort. Rationale 2: Positioning the patient over the bedside table might cause injury during coughing. Rationale 3: A pillow is too soft to effectively splint the incision for best pain relief. Rationale 4: Pulmonary hygiene is an integral part of post-thoracic surgery care. Patients must be able to take a deep breath and generate an exhalation sufficiently strong to clear secretions. There are two types of coughs however the "huff" cough or coughing with the glottis open is a gentle maneuver, and is effective. This is the type of cough the nurse should assist the patient with performing.

An older adult presents to the emergency department with cough, fever, and elevated temperature. A diagnosis of pneumonia is made, antibiotics are prescribed, and the patient will be admitted to the acute care unit. When should the nurse start the prescribed intravenous antibiotic? 1. Whenever the drug is received from the pharmacy 2. After the preliminary results of the sputum specimen are obtained 3. Within 30 minutes of the order being received 4. Within 4 hours of diagnosis

Correct Answer: 4 Rationale 1: There is a standard by which this drug should be started. If the drug is delayed from the pharmacy this standard might not be met. The nurse should advise pharmacy of the patient's diagnosis and need to start the antibiotic quickly. Rationale 2: The nurse should not wait for sputum specimen results. Rationale 3: There is no standard by which the antibiotic must be started within 30 minutes of the order being received. Rationale 4: Standards indicate that antibiotic therapy for pneumonia should be started within 4 hours of diagnosis or while the patient is in the setting where the diagnosis is made.

The nurse notes these ventilator setting change orders. What nursing intervention is indicated? 1. Carry out the orders as written. 2. Verify the respiratory rate. 3. Verify the mode. 4. Verify the tidal volume.

Correct Answer: 4 Rationale 1: These orders are not safe and should not be carried out without question. Rationale 2: Ventilator rate of 12 is appropriate for ventilator assist control mode. Rationale 3: Assist-control mode allows the patient to maintain some control over rate of breathing and is an appropriate mode in many cases. Rationale 4: The nurse should contact the physician to request a reduction in tidal volume. Normal tidal volume should range from 7 to 9 mL/kg (approximately 600 to 800 mL in an adult). Therefore, the ordered tidal volume is very high, which could result in barotrauma. The possibility exists of an entry error in the order.

A patient in the emergency department (ED) becomes suddenly unresponsive. CPR is initiated. Arterial blood gas results reveal pH 7.225, PaCO2 55, HCO3 15, PaO2 45, SaO2 76 percent. The nurse would prepare for which priority intervention? 1. Call for a rapid response team. 2. Auscultate the patient's lungs. 3. Place the patient on a 50 percent humidified mask. 4. Administer endotracheal intubation.

Correct Answer: 4 Rationale 1: This situation is not uncommon in the ED and personnel should be prepared to intervene without the support of a rapid response team. Rationale 2: Auscultation of the lungs is not the priority. Rationale 3: A humidified mask will not be effective for the patient who is not ventilating well. Rationale 4: The patient is unresponsive. Based on the blood gas results, it is obvious that the patient is suffering from acute ventilatory failure and is in urgent need of intubation and mechanical ventilation.

A patient is undergoing testing to differentiate her airway disorder as being restrictive or obstructive. The nurse would evaluate a normal result on which test to indicate a restrictive disorder is present? 1. Vital capacity 2. Tidal volume 3. Minute ventilation 4. Forced expiratory volume

Correct Answer: 4 Rationale 1: Vital capacity is the maximum amount of air expired after a maximal inspiration. Vital capacity decreases in the presence of restrictive pulmonary diseases. Rationale 2: Tidal volume is the amount of air that moves in and out of the lungs with each normal breath. Tidal volume decreases when lung diseases exist. Results do not differentiate between restrictive and obstructive disorders. Rationale 3: Minute ventilation measures total lung ventilation changes. It may be abnormal in either restrictive or obstructive diseases. Rationale 4: Forced expiratory volume measures how rapidly a person can forcefully exhale air after a maximal inhalation, measuring volume over time. Patients who have a restrictive airway problem are able to push air forcefully out of their lungs at a normal rate.

The nurse working in an intensive care unit is alert to the development of ALI/ARDS. The nurse would monitor which patients most closely for this complication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. A patient who sustained a severe chest contusion. 2. A patient hospitalized for treatment of drug overdose. 3. A patient who sustained severe head trauma. 4. A patient hospitalized for treatment of pneumonia. 5. A patient diagnosed with sepsis.

Correct Answer: 4,5 Rationale 1: Chest contusion can result in ALI/ARDS, but this is not the patient of most concern. Rationale 2: Drug overdose can result in ALI/ARDS, but this is not the patient of most concern. Rationale 3: Head trauma can result in ALI/ARDS, but this is not the patient of most concern. Rationale 4: Pneumonia is one of the most common predisposing disorders in the development of ALI/ARDS. Rationale 5: Sepsis is one of the most common predisposing disorders in the development of ALI/ARDS.

The nurse caring for a patient who is ventilated via the assist-control mode monitors for which complication specifically related to this intervention? 1. Pneumonia 2. Anxiety 3. Pneumothorax 4. Respiratory alkalosis

orrect Answer: 4 Rationale 1: Ventilator associated pneumonia is a risk for all modes of mechanical ventilation. Rationale 2: Anxiety may be present with all modes of mechanical ventilation and is not specific to the mode used with this patient. Rationale 3: Pneumothorax is a risk of all mechanical ventilation modes if the tidal volume is not appropriate for the patient. Rationale 4: With assist-control, every breath is a ventilator breath. Therefore, if a patient attempts to initiate spontaneous breaths, each attempt will result in a breath of full tidal volume. The ultimate effect, if untreated, is hyperventilation. Hyperventilation causes the patient to blow off carbon dioxide, leading to the development of respiratory alkalosis.