Ventilatory Assistance

FiO2 (fraction of inspired oxygen)

0.21 (21% or room air) to 1.00 (100% oxygen) set to maintain a PaO2 greater than 60 or an SpO2 of at least 90% oxygen toxicity a concern in levels over 0.60

PEEP

5 - 20 cm H2O increases oxygenation at end-expiration, holding open the small airways and alveoli to prevent collapse and increase alveolar gas exchange *high level decreases venous return > decreased CO (administer fluids or dobutamine); barotrauma (can lead to pneumothorax), and increased ICP resulting from impedance of venous return from the head.

Continuous Positive Airway Pressure (CPAP)

5-20 cm H20; when 10-5 cm is reached, pt is usually ready to be taken off ventilator patient performs *all WOB* must have reliable respiratory drive and adequate Vt; mode of weaning; pressure provided at end expiration to prevent alveolar collapse and improve oxygenation (identical to PEEP, but PEEP is the term for the setting when another form of vent support is also being used like V-A/C) monitor adequacy of pt's end tidal volume (set alarms to detect if too low); deliver mechanical breaths in event of apnea

The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.) a. Drain condensate from the ventilator tubing away from the patient. b. Elevate the head of the bed 30 to 45 degrees. c. Instill normal saline as part of the suctioning procedure. d. Perform regular oral care with chlorhexidine.

A, B, D Condensate should be drained away from the patient to avoid drainage back into the patients airway. Prevention guidelines recommend elevating the head of bed at 30 to 45 degrees. Regular antiseptic oral care, with an agent such as chlorhexidine, reduces oropharyngeal colonization. Normal saline is not recommended as part of the suctioning procedure, and it may increase the risk for infection.

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse? a. No sedative has been ordered for the patient. b. The patient does not respond to verbal stimulation. c. There is no cough or gag reflex when the patient is suctioned. d. The patient's oxygen saturation remains between 90% to 93%.

ANS: A Because neuromuscular blockade is extremely anxiety provoking, it is essential that patients who are receiving neuromuscular blockade receive concurrent sedation and analgesia. Absence of response to stimuli is expected in patients receiving neuromuscular blockade. The O2 saturation is adequate.

When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider? a. The patient is very somnolent. b. The patient complains of weakness. c. The patient's blood pressure is 164/98. d. The patient's oxygen saturation is 90%.

ANS: A Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest.

The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? a. Decreasing PaO2 levels despite increased FiO2 administration b. Elevated alveolar surfactant levels c. Increased lung compliance with increased FiO2 administration d. Respiratory acidosis associated with hyperventilation

ANS: A Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels are often diminished in ARDS. Compliance decreases in ARDS. In early ARDS, *hyperventilation may occur in response to hypoxemia causing respiratory alkalosis.*

An acute exacerbation of asthma is treated with which of the following? a. Corticosteroids and theophylline by mouth b. Inhaled bronchodilators and intravenous corticosteroids c. Prone positioning or continuous lateral rotation d. Sedation and inhaled bronchodilators

ANS: B *Inhaled bronchodilators and IV corticosteroids* are standard treatment for the exacerbation of asthma; they promote dilation of the bronchioles and decreased inflammation of the airways. Proning and continuous lateral rotation are therapies to treat hypoxemia secondary to acute respiratory distress syndrome. Sedation is not recommended.

The nurse is assessing a patient with acute respiratory distress syndrome. An expected assessment is: a. cardiac output of 10 L/min and low systemic vascular resistance. b. PAOPof10mmHgandPaO2of55. c. PAOP of 20 mm Hg and cardiac output of 3 L/min. d. PAOP of 5 mm Hg and high systemic vascular resistance.

ANS: B A normal PAOP with hypoxemia is an expected assessment finding in ARDS. Cardiac output of 10 L/min and low systemic vascular resistance are expected findings in sepsis. PAOP of 20 mm Hg and cardiac output of 3 L/min are expected findings in heart failure. PAOP of 5 mm Hg and high systemic vascular resistance are expected findings in hypovolemic shock.

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate? a. "PEEP will push more air into the lungs during inhalation." b. "PEEP prevents the lung air sacs from collapsing during exhalation." c. "PEEP will prevent lung damage while the patient is on the ventilator." d. "PEEP allows the breathing machine to deliver 100% O2 to the lungs."

ANS: B By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage (e.g., fibrotic changes that occur with ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.

When fluid is present in the alveoli: a. alveoli collapse and atelectasis occurs. b. diffusion of oxygen and carbon dioxide is impaired. c. hypoventilation occurs. d. the patient is in heart failure.

ANS: B Fluid prevents the diffusion of gases. It does not cause atelectasis or hypoventilation. Fluid can be present in the alveoli secondary to heart failure; however, there are other causes as well, such as acute respiratory distress syndrome.

3. The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration? a. Hyperventilation and respiratory acidosis b. Hypoventilation and respiratory acidosis c. Hypoventilation and respiratory alkalosis d. Respiratory acidosis and normal oxygen levels

ANS: B Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and respiratory acidosis. The overdose depresses the respiratory drive, which results in hypoventilation, not hyperventilation. Hypoxemia is expected secondary to depressed respirations.

The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)? a. Increased oxygen saturation via pulse oximetry b. Increased peak inspiratory pressure on the ventilator c. Normal chest radiograph with enlarged cardiac structures d. PaO2/FiO2 ratio > 300

ANS: B Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation decreases in ARDS. Chest x-ray study will show progressive infiltrates. In ARDS, a *PaO2/FiO2 ratio less than 200* is a criterion. PaO2 is 78 mm Hg; FiO2 is 0.6 (60%) 78/0.6 = 130

While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take? a. Suction the patient's oropharynx. b. Increase the prescribed O2 flow rate. c. Instruct the patient to cough and deep breathe. d. Help the patient to sit in a more upright position.

ANS: B Increasing O2 flow rate will usually improve O2 saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

A patient presents to the emergency department in acute respiratory failure secondary to community- acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation? a. Emergency tracheostomy and mechanical ventilation b. Mechanical ventilation via an endotracheal tube c. Noninvasive positive-pressure ventilation (NPPV) d. Oxygen at 100% via bag-valve-mask device

ANS: C Noninvasive measures are often recommended in the initial treatment of the patient with chronic obstructive pulmonary disease to prevent intubation and ventilator dependence. The history of chronic obstructive pulmonary disease increases the risk for ventilator dependence, so noninvasive options are a priority. Bag- valve ventilation with 100% oxygen is not required at this time and could depress the respiratory drive that exists. Emergency tracheostomy is not indicated, as there is an indication of an obstructed airway.

The basic underlying pathophysiology of acute respiratory distress syndrome results from: a decrease in the number of white blood cells available. b. damage to the right mainstem bronchus. c. damage to the type II pneumocytes, which produce surfactant. d. decreased capillary permeability.

ANS: C Acute respiratory distress syndrome results in damage to the pneumocytes, as well as: *increased capillary permeability*, and *noncardiogenic pulmonary edema*

During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first? a. Give the prescribed PRN sedative drug. b. Offer reassurance and reorient the patient. c. Use pulse oximetry to check the oxygen saturation. d. Notify the health care provider about the patient's status.

ANS: C Agitation may be an early indicator of hypoxemia. The other actions may also be appropriate, depending on the findings about O2 saturation.

Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: C Although the patient with a severe exacerbation of asthma (status asthmaticus) hyperventilates, bronchoconstriction and narrowing of the airways continue despite bronchodilator therapy, making it harder for patient to exhale CO2, which causes respiratory acidosis.

Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure? a. Chest x-ray b. O2 saturation c. Arterial blood gas analysis d. Central venous pressure monitoring

ANS: C Arterial blood gas (ABG) analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs provide information about the PaCO2 and pH. The other tests may also be done to help in assessing oxygenation or determining the cause of the patient's ventilatory failure.

The nurse notes that the patients arterial blood gas levels indicate hypoxemia. The patient is not intubated and has a respiratory rate of 22 breaths/min. The nurses first intervention to relieve hypoxemia is to: a. call the physician for an emergency intubation procedure. b. obtain an order for bilevel positive airway pressure (BiPAP). c. notify the provider of values and obtain order for oxygen. d. suction secretions from the oropharynx.

ANS: C Oxygen is administered to treat or prevent hypoxemia. Oxygen should be considered a first-line treatment in cases of hypoxemia. Emergency intubation is not warranted at this time. BiPAP may be considered if administration of supplemental oxygen does not correct the hypoxemia. There is no indication that the patient requires suctioning.

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next? a. Increase the tidal volume and respiratory rate. b. Decrease the fraction of inspired oxygen (FIO2). c. Perform endotracheal suctioning more frequently. d. Lower the positive end-expiratory pressure (PEEP).

ANS: D Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for another pneumothorax.

The nurse is caring for a patient whose ventilator settings include 15 cm H2O of positive end-expiratory pressure (PEEP). The nurse understands that although beneficial, PEEP may result in: a. fluid overload secondary to decreased venous return. b. high cardiac index secondary to more efficient ventricular function. c. hypoxemia secondary to prolonged positive pressure at expiration. d. low cardiac output secondary to increased intrathoracic pressure

ANS: D Positive end-expiratory pressure, especially at higher levels, can result in a *decreased cardiac output and index* secondary to increased intrathoracic pressure, which impedes venous return. Fluid overload is not an expected finding. The cardiac index would likely decrease, not increase, along with cardiac output. PEEP is used to treat hypoxemia; it does not cause it.

A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with a. obtaining a ventilation-perfusion scan. b. drawing blood for arterial blood gases. c. positioning the patient for a chest x-ray. d. insertion of a pulmonary artery catheter.

ANS: D Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema.

The nurse is caring for a patient with acute respiratory failure and identifies Risk for Ineffective Airway Clearance as a nursing diagnosis. A nursing intervention relevant to this diagnosis is: a. Elevate head of bed to 30 degrees. b. Obtain order for venous thromboembolism prophylaxis. c. Provide adequate sedation. d. Reposition patient every 2 hours.

ANS: D Repositioning the patient will facilitate mobilization of secretions. Elevating the head of bed is an intervention to prevent infection. Venous thromboembolism prophylaxis is ordered to prevent complications of immobility. Sedation is an intervention to manage anxiety, and administration of sedatives increases the risk for retained secretions.

Interpret the arterial blood gas levels: pH 7.31 PaCO2 48 mm Hg Bicarbonate 22 mEq/L PaO2 115 mm Hg O2 saturation 99% a. Normal arterial blood gas levels with a high oxygen level b. Partly compensated respiratory acidosis, normal oxygen c. Uncompensated metabolic acidosis with high oxygen levels d. Uncompensated respiratory acidosis; hyperoxygenated

ANS: D The high PaO2 level reflects hyperoxygenation; the PaCO2 and pH levels show respiratory acidosis. The respiratory acidosis is uncompensated as indicated by a pH of 7.31 (acidosis) and a normal bicarbonate level. No metabolic compensation has occurred.

A patient presents to the emergency department demonstrating agitation and complaining of numbness and tingling in his fingers. His arterial blood gas levels reveal the following: pH 7.51, PaCO2 25, HCO3 25. The nurse interprets these blood gas values as: a. compensated metabolic alkalosis. b. normal values. c. uncompensated respiratory acidosis. d. uncompensated respiratory alkalosis.

ANS: D The low PaCO2 and high pH values show respiratory alkalosis. The bicarbonate level is normal.

A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min. He receives a dose of morphine sulfate, and his respirations decrease to 4 breaths/min. What adjustments may need to be made to the patients ventilator settings? a. Add positive end-expiratory pressure (PEEP). b. Add pressure support. c. Change to assist/control ventilation at a rate of 4 breaths/min. d. Increase the synchronized intermittent mandatory ventilation respiratory rate.

ANS: D The morphine caused respiratory depression. As a result, the frequency and depth of respiration is compromised, which can lead to respiratory acidosis. The respiratory rate on the mechanical ventilator needs to be increased. The patient also may need to have naloxone administered to reverse the effects of the morphine. PEEP is added to improve oxygenation; it does not increase the rate or depth of respirations. Pressure support will not be effective in increasing the rate of spontaneous respiration. Changing to assist/control ventilation is an option; however, the rate needs to be set higher than 4 breaths/min.

The nurse is caring for a mechanically ventilated patient and notes the high pressure alarm sounding. The nurse cannot quickly identify the cause of the alarm and notes the patients oxygen saturation is decreasing and heart rate and respiratory rate are increasing. The nurses priority action is to: a. ask the respiratory therapist to get a new ventilator. b. call the rapid response team to assess the patient. c. continue to find the cause of the alarm and fix it. d. manually ventilate the patient while calling for a respiratory therapist.

ANS: D The nurse must quickly assess the patient and determine possible causes of the alarm (kinks in tubing, secretions in airway, coughing or talking). If the cause is not assessed within seconds, the nurse must manually ventilate the patient and secure assistance in troubleshooting the problem. The patient must be treated while the causes are being assessed by the nurse and respiratory therapist. Continuing to assess for the cause without manually ventilating the patient can result in patient compromise. The respiratory therapist, not the rapid response team, will assess and remedy the problem. A new ventilator may be needed, but that would be determined after the respiratory therapist has assessed the situation.

Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery? a. Aspirin b. Embolectomy c. Heparin d. Thrombolytics

ANS: D Thrombolytics are useful in the management of pulmonary embolus and are given to dissolve the clot. Heparin will prevent further clot formation, but it will not dissolve the clot. Aspirin is not a thrombolytic agent. An embolectomy is a surgical procedure to remove the clot. Heparin will prevent further clot formation, but it will not dissolve the clot.

11. The amount of effort needed to maintain a given level of ventilation is termed: a. compliance. b. resistance. c. tidal volume. d. work of breathing.

ANS: D Work of breathing is the amount of effort needed to maintain a given level of ventilation. Compliance is a measure of the distensibility, or stretchability, of the lung and chest wall. Resistance refers to the opposition to the flow of gases in the airways. Tidal volume is the volume of air in a typical breath.

Ventilator Complications

Aspiration (not very common) Barotrauma Pneumothorax Pneumonia (VAP) Decreased cardiac output (from high PEEP) Altered nutrition

mechanical ventilation indications

acute respiratory failure with inadequate gas exchange reflected in ABGs - PaO2 <60 mmHG on a FiO2 greater than 0.5 (oxygenation) - PaCO2 >50 mmHg, with a pH of 7.25 or less (ventilation)

Tidal Volume VT

amount of air delivered with each breath 500 mL (6-8mL/kg)

Tidal Volume (Vt)

amount of air delivered with each preset breath. dictated by patient's lung compliance and resistance starting point is 6-8 mL/kg monitor PIP and Pplat to remain below 40 and 30

Exhaled Tidal Volume EVt

assessed to determine if the patient is receiving the tidal volume that is prescribed, regardless of mode of ventilation; volume may be lost due to leaks in vent circuit, around cuff of airway, or via chest tube if there's a pleural air leak. *EVt should not deviate from the set Vt by more than 50 mL*

A patient at high risk for pulmonary embolism is receiving Lovenox. The nurse explains to the patient: a. Im going to contact the pharmacist to see if you can take this medication by mouth. b. This injection is being given to prevent blood clots from forming. c. This medication will dissolve any blood clots you might get. d. You should not be receiving this medication. I will contact the physician to get it stopped.

B. *Lovenox (LMWH) given SubQ* is recommended for patients at high risk for PE. The drug is an anticoagulant and *prevents clots from forming* but does not dissolve them (thrombolytics)

16. The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following? a. Antiseptic oral care b. Bed rest with head of bed elevated c. Coughing and deep breathing d. Mobility

D. Mobility helps to prevent deep vein thrombosis and pulmonary embolus. Oral care, head of bed elevation, and coughing and deep breathing assist in preventing pneumonia.

Positive end-expiratory pressure (PEEP) is a mode of ventilatory assistance that produces the following condition: a. Each time the patient initiates a breath, the ventilator delivers a full preset tidal volume. b. For each spontaneous breath taken by the patient, the tidal volume is determined by the patients ability to generate negative pressure. c. The patient must have a respiratory drive, or no breaths will be delivered. d. There is pressure remaining in the lungs at the end of expiration that is measured in cm H2O.

D. PEEP is the addition of positive pressure into the airways during expiration. PEEP is measured in centimeters of water. a) is volume-assist control b) intermittent mandatory c) is CPAP

Data regarding patient's response to ventilation (3)

Exhaled Tidal volume PIP Total RR monitored every 4 hours

Bundle care for prevention of Ventilator-associated Pneumonia

Oral care x4 hrs HOB up 30 degrees Daily awakening Ventilator care Oral intubation preferred Use orogastric tubes Antibiotics if necessary

A patients ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased from .60 to .70, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patients blood pressure drops from 120/76 mm Hg to 90/60 mm Hg. What is the most likely cause of this decrease in blood pressure? a. Decrease in cardiac output b. Hypovolemia c. Increase in venous return d. Oxygen toxicity

Positive end-expiratory pressure increases intrathoracic pressure and may result in decreased venous return. Cardiac output decreases as a result, and is reflected in the lower blood pressure. It is essential to assess the patient to identify optimal positive end-expiratory pressure - the highest amount that can be applied without compromising cardiac output. Although hypovolemia can result in a decrease in blood pressure, there is no indication that this patient has hypovolemia. As noted, higher levels of positive end-expiratory pressure may cause a decrease, not an increase, in venous return. Oxygen toxicity can occur in this case secondary to the high levels of oxygen needed to maintain gas exchange; however, oxygen toxicity is manifested in damage to the alveoli.

PPN (peripheral parenteral nutrition)

can go into a regular IV line

Pressure-Controlled Ventilation modes

driven by a set pressure. you don't set the volume; patient triggers breath and it gives gas until set pressure is reached vent allows airflow into lungs until a preset inspiratory pressure is reached; PIP is controlled, but tidal volume varies on lung compliance and resistance. *hypoventilation and respiratory acidosis may occur; monitor exhaled tidal volume closely*

TPN (total parenteral nutrition)

goes into a central line through a vein

Tube feeds/ ENteral feeds

goes into stomach through NG tube, NJ tube, or duodenal tube

Compliance

how easy it is for air to flow into the lungs compliance is decreased in pulmonary edema, infiltrate or ARDS)

A PaCO2 of 48 mm Hg is associated with:

hypoventilation

Ventilator settings

mode of ventilation FiO2 VT set RR rate PEEP

Synchronized intermittent mandatory ventilation (SIMV)

monitors pt and allows them to take their own tidal volume. can be set at 550, but if pt takes breath and only breathes in 330, it doesnt deliever 550 tidal volume of spontaneous/patient-triggered breaths is whatever the patient generates; pt assumes more WOB, reconditions weak resp muscles; good for weaning off vents; monitor exhaled tidal volume of both vent and patient-triggered breaths to ensure tidal volume is adequate Rising total RR indicates pt fatigue with more shallow and rapid breaths

Pulse oximetry (SpO2) measures:

oxygen saturation in peripheral tissue. estimate of PaO2 94-100%

Oxygen saturation (SaO2) represents:

oxygen that is chemically combined with hemoglobin....the oxygen saturation of hemoglobin 93-97%

PaO2 measures:

partial pressure of arterial oxygen 80-100 mmHg

pressure-support ventilation

pt controls each breath and positive pressure applied throughout inspiration to augment the tidal volume of pt's breath; *decreases pt WOB*; promotes resp muscle conditioning; good for weaning monitor exhaled tidal volume during PS, increase if it is inadequate.

Peak airway (inspiratory) pressure (PIP)

should be less than 40 amount of pressure needed to ventilate pt increases with airway resistance (secretions in airway, bronchospasm, biting the ETT) and decreased lung compliance (pulmonary edema, ARDS) Coughing, kinks, and mucus in the airway can cause the inspiratory pressure to increase

Trigger

the machine knows the pt is about to take a breath

Volume Assist-Control

tidal volume remains constant for both ventilator-initiated and patient-triggered breaths; vent performs bulk of WOB; for pt with normal resp drive but weak resp muscles (emerging from anasthesia; pneumonia); monitor exhaled tidal volume to ensure set tidal volume is delivered; *respiratory alkalosis* if pt hyperventilates (tx sedation or analgesia or changing to IMV); pt relies on vent and muscles get lazy

During rounds, the physician alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is: a. an optional treatment if the PaO2/FiO2 ratio is less 100. b. less of a risk for skin breakdown because the patient is face down. c. possible with minimal help from co-workers. d. used to provide continuous lateral rotational turning.

ANS: A Proning is considered if the PaO2/FiO2 ratio is low. The patient is not responding to treatment, and all options should be considered. The patient remains at risk for skin breakdown due to immobility; during proning, the risk is in the dependent areas such as the face. Proning is a labor-intensive procedure, and the nurse needs help from team members to ensure a safe turn, including protecting the airway. Continuous lateral rotation is a therapy done in the supine position with a specialized bed.

A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider? a. O2 saturation of 99% b. Heart rate 106 beats/minute c. Crackles audible at lung bases d. Respiratory rate 22 breaths/minute

ANS: A The FIO2 of 80% increases the risk for O2 toxicity *(anything over 60%!)* Because the patient's O2 saturation is 99% (normal SaO2 levels 93-97%) a decrease in FIO2 is indicated to avoid toxicity. The other patient data would be *typical for a patient with ARDS* and would not be the most important data to report to the health care provider.

The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? a. The patient's PaO2 is 45 mm Hg. b. The patient's PaCO2 is 33 mm Hg. c. The patient's respirations are shallow. d. The patient's respiratory rate is 32 breaths/min.

ANS: A The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient's poor oxygenation.

A patients endotracheal tube is not secured tightly. The respiratory care practitioner assists the nurse in taping the tube. After the tube is retaped, the nurse auscultates the patients lungs and notes that the breath sounds over the left lung fields are absent. The nurse suspects that: a. the endotracheal tube is in the right mainstem bronchus. b. the patient has a left pneumothorax. c. the patient has aspirated secretions during the procedure. d. the stethoscope earpiece is clogged with wax.

ANS: A The endotracheal tube can become dislodged during repositioning and is likely in the right mainstem bronchus. It is important to reassess breath sounds after the retaping procedure. A pneumothorax would also result in diminished or absent breath sounds; however, it is not associated with repositioning the endotracheal tube. Aspiration may occur during the procedure but would be manifested in changes in chest x-ray, hypoxemia, etc. The stethoscope is not a factor.

The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider? a. Red-brown drainage from nasogastric tube b. Blood urea nitrogen (BUN) level 32 mg/dL c. Scattered coarse crackles heard throughout lungs d. Arterial blood gases: pH of 7.31, PaCO2 of 50, and PaO2 of 68

ANS: A The nasogastric drainage indicates possible gastrointestinal bleeding or stress ulcer and should be reported. The pH and PaCO2 are slightly abnormal, but current guidelines advocating for permissive hypercapnia indicate that these would not indicate an immediate need for a change in therapy. The BUN is slightly elevated but does not indicate an immediate need for action. Adventitious breath sounds are commonly heard in patients with ARDS.

A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to improve gas exchange? a. On the left side c. In the tripod position b. On the right side d. In the high-Fowler's position

ANS: A The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions.

When prone positioning is used for a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. b. Endotracheal suctioning results in clear mucous return. c. Sputum and blood cultures show no growth after 48 hours. d. The skin on the patient's back is intact and without redness.

ANS: A The purpose of prone positioning is to improve the patient's oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective.

4. Which of the following are components of the Institute for Healthcare Improvements (IHIs) ventilator bundle? (Select all that apply.) a. Interrupt sedation each day to assess readiness to extubate. b. Maintain head of bed at least 30 degrees elevation. c. Provide deep vein thrombosis prophylaxis. d. Provide prophylaxis for peptic ulcer disease. e. Swab the mouth with foam swabs every 2 hours.

ANS: A, B, C, D Options A, B, C, and D are components of the IHI ventilator bundle. Providing oral care daily with chlorhexidine has recently been added to the IHI bundle. Swabbing alone provides comfort care.

Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.) a. Increase functional residual capacity b. Prevent collapse of unstable alveoli c. Improve arterial oxygenation d. Open collapsed alveoli

ANS: A, B, C, D Ventilatory support for ARDS typically includes PEEP to restore functional residual capacity, open collapsed alveoli, prevent collapse of unstable alveoli, and improve arterial oxygenation.

The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (Select all that apply.) a. Coughing or attempting to talk b. Disconnection from the ventilator c. Kinks in the ventilator tubing d. Need for suctioning

ANS: A, C, D Coughing, kinks, and mucus in the airway can cause the inspiratory pressure to increase; ventilator disconnects result in low-volume alarms. A disconnection from the ventilator would result in a low exhaled volume alarm, not a high-pressure alarm.

A patient is admitted to the ICU after cardiac surgery with stable vital signs and normal ABGs, and is placed on a T-piece for ventilatory weaning. 4 hours later, the patient is restless, heart rate has increased to 110 beats/min, respirations are 36 breaths/min, and blood pressure is 156/98. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretions. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. In communicating with the physician, *which statement indicates the nurse understands what is likely occurring with the patient?* a. May we have an order for cardiac enzymes? This patient is exhibiting signs of a myocardial infarction. b. My assessment indicates potential fluid overload. c. The patient is having frequent PVCs that are compromising the cardiac output. d. The patient is having a hypertensive crisis; what medications would you like to order?

ANS: B The *crackles, high pulmonary artery pressure, and pink, frothy sputum indicate fluid volume overload.* Normal PAP = 25/10 or MPAP 15. There are not any cues to suggest a myocardial infarction. The PVCs may be related to the surgery or hypoxemia; however, the *blood pressure indicates adequate perfusion*. The blood pressure is high secondary to fluid overload; treatment of the fluid overload will result in a decrease in blood pressure.

A 65-year-old patient is admitted to the progressive care unit with a diagnosis of community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease and diabetes. A set of arterial blood gases obtained on admission without supplemental oxygen shows pH 7.35; PaCO2 55 mm Hg; bicarbonate 30 mEq/L; PaO2 65 mm Hg. These blood gases reflect: a. hypoxemia and compensated metabolic alkalosis. b. hypoxemia and compensated respiratory acidosis. c. normal oxygenation and partly compensated metabolic alkalosis. d. normal oxygenation and uncompensated respiratory acidosis.

ANS: B The PaO2 of 65 mm Hg is lower than normal range (80-100 mm Hg), indicating hypoxemia. The high PaCO2 indicates respiratory acidosis. The elevated bicarbonate indicates metabolic alkalosis. Because the pH is normal, the underlying acid-base alteration is compensated. Given the patients history of chronic pulmonary disease and a pH that is at the lower end of normal range, it can be determined that this patient is hypoxemic with fully compensated respiratory acidosis.

A patient is having difficulty weaning from mechanical ventilation. The nurse assesses the patient for a potential cause of this difficult weaning, which includes: a. cardiac output of 6 L/min. b. hemoglobin of 8 g/dL. c. negative sputum culture and sensitivity. d. white blood cell count of 8000.

ANS: B The low hemoglobin level will decrease oxygen-carrying capacity and may make weaning difficult. (Hgb 12-16) A cardiac output of 6 L/min is normal (4-8). A negative sputum culture indicates absence of lower respiratory infection, which should promote rather than hinder weaning. A white blood cell count of 8000 is normal (4500-11000) and indicates absence of infection, which should promote rather than hinder weaning.

A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? a. Administration of 100% O2 by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of continuous positive pressure ventilation (CPAP)

ANS: B The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Giving high-flow O2 will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.

A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? a. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. b. The patient has subcutaneous emphysema on the upper thorax. c. The patient has bronchial breath sounds in both the lung fields. d. The patient has a first-degree atrioventricular heart block with a rate of 58 beats/min.

ANS: B The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not specific indications that PEEP should be reduced.

A patient is admitted to the ICU after cardiac surgery with stable vital signs and normal ABGs, and is placed on a T-piece for ventilatory weaning. 4 hours later, the patient is restless, heart rate has increased to 110 beats/min, respirations are 36 breaths/min, and blood pressure is 156/98. Pulmonary artery pressures are elevated. The nurse suctions the patient and obtains pink, frothy secretions. Loud crackles are audible throughout lung fields. The nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study. How does the nurse interpret the following blood gas levels? pH 7.28 PaCO2 46 mm Hg Bicarbonate 22 mEq/L PaO2 58 mm Hg O2 saturation 88% a. Hypoxemia and compensated respiratory alkalosis b. Hypoxemia and uncompensated respiratory acidosis c. Normal arterial blood gas levels d. Normal oxygen level and partially compensated metabolic acidosis

ANS: B These levels show respiratory acidosis. The bicarbonate is normal; therefore, no compensation has occurred. This patient is also hypoxemic.

Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)? a. Obtain arterial blood gases daily. b. Provide a "sedation holiday" daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30°. e. Provide oral care with chlorhexidine (0.12%) solution daily.

ANS: B, C, D, E All of these interventions are part of the ventilator bundle that is recommended to prevent VAP. Arterial blood gases may be done daily but are not always necessary and do not help prevent VAP.

A strategy for preventing thromboembolism in patients at risk who cannot take anticoagulants is: a. administration of two aspirin tablets every 4 hours. b. infusion of thrombolytics. c. insertion of a vena cava filter. d. subcutaneous heparin administration every 12 hours.

ANS: C A filter may be inserted as a prevention measure in patients who are at high risk for thromboembolism. Aspirin is not a preventive therapy for PE but it is for TIA. Thrombolytics are given to treat, not prevent, pulmonary embolism. Heparin is administered as a prophylaxis in acute care settings. Coumadin is given for long-term prevention in patients at high risk for VTE.

The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The physician orders a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the physician of this assessment and anticipates an order for: a. continuous lateral rotation therapy. b. guided imagery. c. neuromuscular blockade. d. prone positioning.

ANS: C Paralysis and additional sedation may be needed if the patient requires nontraditional ventilation. Guided imagery is an excellent non-pharmacological approach to manage anxiety; however, the non-traditional mode of ventilation usually requires that the patient receive neuromuscular blockade. Prone positioning is a treatment for refractory hypoxemia but not indicated until the neuromuscular blockade has been tried.

A mode of pressure-targeted ventilation that provides positive pressure to decrease the workload of spontaneous breathing through the endotracheal tube is: a. continuous positive airway pressure. b. positive end-expiratory pressure. c. pressure support ventilation. d. T-piece adapter.

ANS: C Pressure support (PS) is a mode of ventilation in which the patients spontaneous respiratory activity is augmented by the delivery of a preset amount of inspiratory positive pressure. Positive end-expiratory pressure provides positive pressure at end expiration during mechanical breaths, and continuous positive airway pressure provides positive pressure during spontaneous breaths. The T-piece adapter is used to provide oxygen with spontaneous, unassisted breaths.

Intrapulmonary shunting refers to: a. alveoli that are not perfused. b. blood that is shunted from the left side of the heart to the right and causes heart failure. c. blood that is shunted from the right side of the heart to the left without oxygenation. d. shunting of blood supply to only one lung.

ANS: C Shunting refers to blood that is not oxygenated in the lungs.

The nurse is assessing the exhaled tidal volume (EVT) in a mechanically ventilated patient. The rationale for this assessment is to: a. assess for tension pneumothorax. b. assess the level of positive end-expiratory pressure. c. compare the tidal volume delivered with the tidal volume prescribed. d. determine the patients work of breathing.

ANS: C The EVT is assessed to determine if the patient is receiving the tidal volume that is prescribed. Volume may be lost because of leaks in the ventilator circuit, around the endotracheal tube cuff, or around a chest tube. The assessment will not detect a pneumothorax and does not assess positive end-expiratory pressure or work of breathing

A definitive diagnosis of pulmonary embolism can be made by: a. arterial blood gas (ABG) analysis. b. chest x-ray examination. c. pulmonary angiogram. d. ventilation-perfusion scanning.

ANS: C The angiogram is the only test that can confirm pulmonary embolism. ABG would only indicate hypoxemia and/or acid-base abnormalities. A chest x-ray study is nonconclusive. A ventilation-perfusion scan is nonconclusive.

6. A patients status worsens and needs mechanical ventilation. The pulmonologist wants the patient to receive 10 breaths/min from the ventilator but wants to encourage the patient to breathe spontaneously in between the mechanical breaths at his own tidal volume. This mode of ventilation is called: a. assist/control ventilation b. controlled ventilation c. intermittent mandatory ventilation d. positive end-expiratory pressure

ANS: C The intermittent mandatory ventilation mode allows the patient to breathe spontaneously between breaths. The patient will receive a preset tidal volume at a preset rate. Any additional breaths that he initiates will be at his spontaneous tidal volume, which will likely be lower than the ventilator breaths. In assist/control ventilation, spontaneous effort results in a preset tidal volume delivered by the ventilator. Spontaneous effort during controlled ventilation results in patient/ventilator dyssynchrony. Positive end-expiratory pressure (PEEP) is application of positive pressure to breaths delivered by the ventilator. PEEP is an adjunct to both intermittent mandatory and assist/control ventilation.

A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min. He receives a dose of morphine sulfate, and his respirations decrease to 4 breaths/min. Which acid-base disturbance will likely occur? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: C The morphine caused respiratory depression. As a result, the frequency and depth of respiration is compromised, which can lead to respiratory acidosis.

The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider? a. Persistent cough of blood-tinged sputum. b. Scattered crackles in the posterior lung bases. c. Oxygen saturation 90% on 100% O2 by nonrebreather mask. d. Temperature 101.5° F (38.6° C) after 2 days of IV antibiotics.

ANS: C The patient's low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of *acute respiratory distress syndrome (ARDS)*. The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is *not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.*

The physician orders the following mechanical ventilation settings.. The patients spontaneous RR is 22 breaths/min. What arterial blood gas abnormality may occur if the patient continues to be tachypneic at these ventilator settings? Settings: Tidal volume: 600 mL (8 mL per kg) FiO2: 0.5 Respiratory rate: 14 breaths/min Mode: assist/control Positive end-expiratory pressure: 10 cm H2O a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: D Assist/control ventilation may result in respiratory alkalosis, especially when the patient is breathing at a high rate. Each time the patient initiates a spontaneous breathin this case 22 times per minutethe ventilator will deliver 600 mL of volume.

The physician orders the following mechanical ventilation settings for a patient who weighs 75 kg. The patients spontaneous respiratory rate is 22 breaths/min. What arterial blood gas abnormality may occur if the patient continues to be tachypneic at these ventilator settings? Tidal volume: 600 mL (8 mL per kg) FiO2: 0.5 Respiratory rate: 14 breaths/min Mode: assist/control PEEP: 10 cm H2O a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

ANS: D Assist/control ventilation may result in respiratory alkalosis, especially when the patient is breathing at a high rate. Each time the patient initiates a spontaneous breathin this case 22 times per minutethe ventilator will deliver 600 mL of volume.

Volume-controlled ventilation

Vent delivers a preset number of breaths of a preset tidal volume - allows airflow into lungs until a preset volume is reached delivered regardless of changes in lung compliance or resistance, but PIP varies on compliance and resistance monitor *PIP to remain below 40* and Pplat to remain below 30

Modes of ventilation

Volume-Controlled 1) Assist control (V-A/C) 2) Synchronized intermittent mandatory ventilation mode (SIMV) Pressure-controlled 1) Pressure-support 2) Continuous positive airway pressure (CPAP) 3) Pressure Assist/Control