ABG, R/F, ARDS, Mechanical Ventilation test prep
Care of the patient with ARDS include:
(1) O2 administration-to correct hypoxemia (2) mechanical ventilation- helps to keep the inspiratory and plateau pressures from becoming too high, preventing alveolar over distention and rupture. (3) low VT ventilation-prevents barotrauma (4) permissive hypercapnia-allows a slow increase in the positive pressure of carbon dioxide and is sometimes used when hypoxemia persists despite use of PEEP (5) PEEP-increases volume of air left in lungs at the end of expiration. PEEP always aids open up collapsed alveoli. (6) prone positioning-perfusion may be better matched to ventilation. (7) extracorporeal membrane oxygenation (ECMO)-O2 is delivered into the blood and CO2 removed. Oxygenated blood is returned back to the patient
What are the indications for mechanical ventilation?
-Apnea -Unprotected airway -ARDS -Hypoxemia -Absent breath sounds
What is the difference between CPAP and BiPAP?
-CPAP provides a continuous pressure and the same amount of pressure during inspiration and expiration and does not include oxygen. Pressures are in "cm of water". 10 cm of H20 means enough pressure to move a volume of water 10 cm. -BiPAP provides a different pressure during inspiration than expiration and includes oxygen. Inspiratory pressures are generally higher than expiratory pressures.
The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply. 1. Assess the client's level of consciousness. 2. Monitor urine output every shift. 3. Turn the client every two (2) hours. 4. Maintain intravenous fluids as ordered. 5. Place the client in the Fowler's positio
1. Assess the client's level of consciousness. 3. Turn the client every two (2) hours. 4. Maintain intravenous fluids as ordered. 5. Place the client in the Fowler's position Rationale: 1. Altered level of consciousness is the earliest sign of hypoxemia. 3. The client is at risk for complications of immobility; therefore, the nurse should turn the client at least every two (2) hours to prevent pressure ulcers. 4. The client is at risk for fluid volume overload, so the nurse should monitor and maintain the fluid intake. 5. Fowler's position facilitates lung expansion and reduces WOB
3 systems that keep pH in balance:
1. Chemical buffers (the bicarbonate/carbonic acid system in plasma and RBCs is the most important) 2. Lungs (respiratory system) 3. Kidneys (renal system)
What is an indication of hypercapnic respiratory failure? 1. PaCO2 >50 mmHg and pH <7.35 2. PaCO2 <50 and pH >7.35 3. PaO2 >60 mmHg and PaCO2 >50mmHg 4. PaO2 <60 mmHg and normal PaCO2
1. PaCO2 >50 mmHg and pH <7.35 slide 5 of ARDS ppt
What are the primary pathophysiologic changes that occur in the exudative phase of ARDS? select all that apply 1. Pulmonary hypertension 2. Refractory hypoxemia 3. Stiff ass lungs 4. interstitial & alveolar edema 5. Increased neutrophils 6. V/Q mismatch 7. Atelectasis
2. Refractory hypoxemia 4. Interstitial & alveolar edema 6. V/Q mismatch 7. Atelectasis
Pt admitted to ICU w/ hypercapnic respiratory failure . Which assessment findings should the nurse expect? (select all that apply) 1. cyanosis 2. metabolic acidosis 3. headache 4. respiratory acidosis 5. use of tripod position 6. rapid shallow respirations
3. headache 4. respiratory acidosis 5. use of tripod position 6. rapid shallow respirations Lewis MS workbook
The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube care? 1. Do not move or touch the ET tube. 2. Obtain a chest x-ray daily. 3. Determine if the ET cuff is deflated. 4. Ensure that the ET tube is secure.
4. Ensure that the ET tube is secure. Rationale: The ET tube should be secure to ensure it does not enter the right main bronchus. The ET tube should be one (1) inch above the bifurcation of the bronchi.
What is an indication of hypoxic respiratory failure? 1. PaCO2 >50 mmHg and pH <7.35 2. PaCO2 <50 and pH >7.35 3. PaO2 >60 mmHg and PaCO2 >50mmHg 4. PaO2 <60 mmHg and normal PaCO2
4. PaO2 <60 mmHg and normal PaCO2 slide 5 of ARDS ppt
2) A nurse must position the patient prone after his diagnosis of acute respiratory distress syndrome (ARDS). Which of the following is a benefit of using this position? Select all that apply. A)Decreased atelectasis B)Reduced need for endotracheal intubation c)Mobilization of secretions d)Decreased pleural pressure e)Increased response to corticosteroid therapy
A)Decreased atelectasis C)Mobilization of secretions D)Decreased pleural pressure Prone positioning, helps with pulmonary function in the patient with ARDS. In prone position, the heart and diaphragm are not pressing against the lungs, reducing pleural pressure in turn preventing atelectasis. Studies have shown that many patients in the prone position have increased lung secretions.
The nurse is caring for a client on a ventilator when the high-pressure alarm sounds. What actions are most appropriate? (Select all that apply.) a. Assess the tubing for kinks. b. Assess whether the tubing has become disconnected. c. Determine the need for suctioning. d. Call the health care provider. e. Call the Rapid Response Team. f. Auscultate the client's lungs.
A. Assess the tubing for kinks. C. Determine the need for suctioning. F. Auscultate the client's lungs. Reasons for a high-pressure alarm include water or a kink impeding airflow or mucus in the airway. The nurse first should assess the client and determine whether he or she needs to be suctioned; then the nurse should auscultate the lungs. The nurse also should assess the tubing for kinks.
The nurse is caring for a client who is receiving mechanical ventilation accompanied by positive end-expiratory pressure (PEEP). What assessment findings require immediate intervention? a. Blood pressure drop from 110/90 mm Hg to 80/50 mm/Hg b. Pulse oximetry value of 96% c. Arterial blood gas (ABG): pH, 7.40; PaO2, 80 mm Hg; PaCO2, 45 mm Hg; HCO3-, 26 mEq/L d. Urinary output of 30 mL/hr
A. Blood pressure drop from 110/90 mm Hg to 80/50 mm/Hg Increased intrathoracic pressure can inhibit blood return to the heart and cause decreased cardiac output. This manifests with a drop in blood pressure. The pulse oximetry reading, ABGs, and urinary output are all normal.
The nurse is caring for a client who is intubated with an endotracheal tube and on a mechanical ventilator. The client is able to make sounds. What is the nurse's first action? a. Check cuff inflation on the endotracheal tube. b. Listen carefully to the client. c. Call the health care provider. d. Auscultate the lungs
A. Check cuff inflation on the endotracheal tube. If client has the cuff on the endotracheal tube inflated, the cuff should prevent air from going around the cuff and through the vocal cords. If the client can talk with the cuff inflated, the cuff probably has a leak, causing it to become deflated and allowing air to pass through. The risk is that the client will not receive the prescribed tidal volume.
7) A nurse walks into a client who is in respiratory distress. The client has a tracheal deviation to the right side. The nurse knows to prepare for which of the following emergent procedures? a. Chest tube insertion on the left side. b. Chest tube insertion on the right side. c. Intubation d. Tracheostomy
A. Chest tube insertion on the left side. Tracheal deviation indicates a pneumothorax, the direction of the deviation indicates the side the pneumothorax is on. If the trachea is deviating to the right, then the pneumo is on the left. The treatment for this is a chest tube on the side of trhe deflated lung.
4) A patient who has recovered from ARDS in the ICU is now malnourished and has lost a significant amount of weight. The physician orders TPN to add nutrition for the patient, who then develops re-feeding syndrome. Which of the following signs or symptoms would the nurse expect to see with re-feeding syndrome? Select all that apply. a. Impaired mental status b. Insulin resistance c. Seizures d. Persistent weight loss e. Constipation
A. Impaired mental status B. Insulin resistance C. Seizures Re-feeding syndrome can occur as a response to nutrient reintroduction after a period of starvation. **this is why we prefer enteral feeding vs TPN** S/S of re-feeding syndrome: confusion and impaired mental status, insulin resistance, seizures, coma and death.
You are caring for a patient with acute respiratory distress syndrome. As the nurse, you know that prone positioning can be beneficial for some patients with this condition. Which findings below indicate this type of positioning was beneficial for your patient with ARDS? A. Improvement in lung sounds B. Development of a V/Q mismatch C. PaO2 increased from 59 mmHg to 82 mmHg D. PEEP needs to be titrated to 15 mmHg of water
A. Improvement in lung sounds C. PaO2 increased from 59 mmHg to 82 mmHg Prone positioning helps improve PaO2 without actually giving the patient high concentrations of oxygen. It helps improves perfusion and ventilation (hence correcting the V/Q mismatch).
The nurse is caring for a critically ill client with septic shock. The serum lactate level is 6.2. For which acid-base disturbance should the nurse assess? A.Metabolic acidosis B.Metabolic alkalosis C.Respiratory acidosis D.Respiratory alkalosis
A. Metabolic acidosis Rationale: Increased lactate levels are associated with hypoxia and metabolic acidosis secondary to anaerobic metabolism. -Metabolic alkalosis is related to bicarbonate therapy, diuretic use, vomiting, and nasogastric suction. -Respiratory acidosis is caused by CO2 retention and impaired pulmonary function, which is inconsistent with elevated lactate levels. -Respiratory alkalosis is caused by excessive loss of CO2 through hyperventilation, inconsistent with elevated lactate levels.
A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)? (Select all that apply.) a. Oxygen administered at 100%, PaO2 60 b. Increased dyspnea c. Anxiety d. Chest pain e. Pitting pedal edema f. Clubbing of fingertips
A. Oxygen administered at 100%, PaO2 60 B. Increased dyspnea C. Anxiety Pt w/ ARDS presents with a decrease in oxygen despite an increase in the fraction of inspired oxygen. Increased dyspnea goes along with the increased hypoxemia, as does anxiety.
1) A nurse is caring for a patient with ARDS. The nurse views the ABG. What value should the nurse report to the physician? pH: 7.35 PaCO2: 26mmhg PaO2:95 HCO3: 22 a) PaCO2 b)pH c)HCO3 d)PaO2
A. PaCO2 The normal range for PaCO2 is 35-45. This patient is experiencing a superimposed respiratory alkalosis likely due to hyperventilation. The nurse should report the PaCO2 to the physician.
A patient in acute respiratory failure is receiving assist-control mechanical ventilation with a peak end-expiration. A pressure (PEEP) of 10 cm H2O. A sign that alerts the nurse to undesirable effects of increased airway and thoracic pressure is? a. decreased BP. b. decreased PaO2. c. increased crackles. d. decreased spontaneous respirations.
A. decreased BP
The purpose of adding PEEP to positive-pressure ventilation is to? A. increase functional residual capacity and improve oxygenation. B. increase FIO2 in an attempt to wean the patient and avoid O2 toxicity. C. determine whether the patient is in synchrony with the ventilator or needs to be paralyzed. D. determine whether the patient is able to be weaned and avoid the risk of pneumomediastinum.
A. increase functional residual capacity and improve oxygenation. PEEP is a ventilatory maneuver in which positive pressure is applied to the airway during exhalation. This increases functional residual capacity (FRC) and often improves oxygenation, with the restoration of lung volume that normally remains at the end of passive exhalation.
A client has been admitted with chest trauma after a car crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds and notes that the client has absence breath sounds in the right upper lobe of the lung. the nurse immediately assess for other signs of which condition? a. right pneumothorax b. pulmonary embolism c. displaced endotracheal tube d. acute respiratory distress syndrome
A. right pneumothorax pneumothorax is characterized by restless, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side.
During the exudative phase of acute respiratory distress syndrome (ARDS), the patient's lung cells that produce surfactant have become damaged. As the nurse, you know this will lead to? A. bronchoconstriction B. atelectasis C. upper airway blockage D. pulmonary edema
B. Atelectasis Surfactant decreases surface tension in the lungs. Alveoli sacs will stay stable during exhalation.
A patient is on mechanical ventilation with PEEP (positive end-expiratory pressure). Which finding below indicates the patient is developing a complication related to their therapy and requires immediate treatment? A. HCO3 26 mmHg B. Blood pressure 70/45 C. PaO2 80 mmHg D. PaCO2 38 mmHg
B. Blood pressure 70/45 Mechanical ventilation with PEEP can cause issues with intrathoracic pressure and decrease the cardiac output
5) A nurse is caring for a patient with ARDS. Which of the following clinical indicators would signify that this client is in respiratory failure? Select all that apply. a. Pulse oximetry of 94% on room air b. A PaO2 level below 60 mmHg c. An ABG pH level of 7.35 d. A pCO2 level over 50 mmHg e. A respiratory rate of over 16/minute
B. PaO2 level below 60 mmHg D. pCO2 level over 50 mmHg Clinical indicators of respiratory failure include pulse oximetry of less than 91% on room air, PaO2 level less than 60 mmHg, and a pCO2 level of over 50 mmHg.
Which patient below is at MOST risk for developing ARDS and has the worst prognosis? A. A 52-year-old male patient with a pneumothorax. B. A 48-year-old male being treated for diabetic ketoacidosis. C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection. D. A 30-year-old female with cystic fibrosis.
C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection. Sepsis is the MOST common cause of ARDS bc of systemic inflammation experienced. This is also true if the cause of the sepsis is a gram-negative bacterium.
The nurse assesses a client admitted for chest trauma who reports dyspnea. The nurse finds tracheal deviation and a pulse oximetry reading of 86%. What is the nurse's priority intervention? a. Notify the health care provider and document the symptoms. b. Intubate the client and prepare for mechanical ventilation. c. Administer oxygen and prepare for chest tube insertion. d. Administer an intermittent positive-pressure breathing treatment.
C. Administer oxygen and prepare for chest tube insertion. Blunt chest trauma can cause an air leak into the thoracic cavity, collapsing the lung on the side with the air leak (pneumothorax). MEDICAL EMERGENCY!
The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation and positive end-expiratory pressure (PEEP). The alarm sounds, indicating decreased pressure in the system. What is the nurse's best action? a. Change the client's position. b. Suction the client. c. Assess lung sounds. d. Turn off the pressure alarm.
C. Assess lung sounds. One of the biggest risks in the client with ARDS on mechanical ventilation with PEEP is tension pneumothorax. The nurse needs to assess lung sounds hourly. The alarms on a ventilator should never be turned off. If the client needed to be suctioned, the high-pressure alarm would sound
The nurse auscultates the lungs of a client on mechanical ventilation and hears vesicular breath sounds throughout the right side but decreased sounds on the left side of the chest. What is the nurse's best action? a. Turn the client to the right side. b. Elevate the head of the bed. c. Assess placement of the endotracheal (ET) tube. d. Suction the client.
C. Assess placement of the endotracheal (ET) tube. The endotracheal tube is more likely to slip into the right mainstem bronchus, leading to the breath sounds described. Nurse should assess placement of the ET tube by assessing where the markings are, making sure it is taped, and confirming equal breath sounds bilaterally.
6) A nurse is caring for a patient who is in respiratory distress because of ARDS. Which of the following nursing diagnoses would most likely be associated with this condition? a. Ineffective thermoregulation b. Impaired urinary elimination c. Ineffective tissue perfusion d. Disturbed personal identity
C. Ineffective tissue perfusion (ARDS) is a life-threatening condition that affects the lungs and prevents the patient from getting enough oxygen. Decreased oxygen from lung disease prevents adequate oxygen from reaching the bloodstream and the peripheral tissues.
The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation. The client's oxygen saturation has dropped from 94% to 86%. What is the priority action by the nurse? a. Encourage the client to take deep, controlled breaths. b. Document findings and continue to monitor the client. c. Notify the health care provider and prepare for intubation. d. Stabilize the chest wall with rib binders.
C. Notify the health care provider and prepare for intubation. This client has a flail chest characterized by paradoxical chest wall motion. With the oxygen saturation dropping, the client is at high risk for respiratory failure and needs to be intubated.
The nurse is caring for several clients on the respiratory floor. Which client does the nurse assess most carefully for the development of acute respiratory distress syndrome (ARDS)? a. Older adult with COPD b. Middle-aged client receiving a blood transfusion c. Older adult who has aspirated his tube feeding d. Young adult with a broken leg from a motorcycle acciden
C. Older adult who has aspirated his tube feeding The older adult who has aspirated a tube feeding is at high risk and should be assessed closely for the possibility of ARDS. A client with COPD and a middle-aged client with no other risk factors are not at as high a risk for ARDS. The client who has a broken leg from an accident is not at high risk.
7. Select below all the INDIRECT causes of ARDS A. Drowning B. Aspiration C. Sepsis D. Blood transfusion E. Pneumonia F. Pancreatitis
C. Sepsis D. Blood transfusion F. Pancreatitis Indirect causes are processes that can cause inflammation OUTSIDE of the lungs....so the issue arises somewhere outside the lungs
You're providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the patient is developing acute respiratory distress syndrome (ARDS)? A. The patient is experiencing bradypnea. B. The patient is tired and confused. C. The patient's PaO2 remains at 45 mmHg. D. The patient's blood pressure is 180/96.
C. The patient's PaO2 remains at 45 mmHg. A hallmark sign and symptom found in ARDS is refractory hypoxemia. This is where that although the patient is receiving a high amount of oxygen the patient is STILL hypoxic
After interpreting ABGs as respiratory acidosis the nurse SBARs the surgeon with the results and with a recommendation to: A. keep the current ventilator settings. B. decrease the FiO2 C. increase the respiratory rate D. decrease the respiratory rate E. decrease the tidal volume
C. increase the respiratory rate
The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. which of the following interventions is appropriate? a. continue to suction b. notify the health care provider immediately c. stop the procedure and reoxygenate the client d. ensure that the suction is limited to 15 seconds
C. stop the procedure and reoxygenate the client If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.
The low-pressure alarm sounds on a ventilator. the nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? a. administer oxygen b. check the client's vital signs c. ventilate the client manually d. start cardiopulmonary resuscitation
C. ventilate the client manually If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected.
A patient has been hospitalized in the ICU for a near-drowning event. Respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS? A. infiltrates only on the upper lobes B. enlargement of the heart with bilateral lower lobe infiltrates C. white-out infiltrates bilaterally D. normal chest x-ray
C. white-out infiltrates bilaterally
pH 7.38, PaCO2 50 mm Hg, HCO3 30 mEq/L.
Compensated Respiratory Acidosis
You're discussing the topic of acute respiratory distress syndrome (ARDS). At the beginning of the lecture, you assess the new nurses understanding of this condition. Which statement by a new nurse demonstrates he understands the condition? A. "This condition develops because the exocrine glands start to work incorrectly leading to thick, copious mucous to collect in the alveoli sacs." B. "ARDS is a pulmonary disease that gradually causes chronic obstruction of airflow from the lungs." C. "Acute respiratory distress syndrome occurs due to the collapsing of a lung because air has accumulated in the pleural space." D. "This condition develops because alveolar-capillary membrane permeability has changed leading to fluid collecting in the alveoli sacs."
D. "This condition develops because alveolar-capillary membrane permeability has changed leading to fluid collecting in the alveoli sacs." ARDS is a type of respiratory failure that occurs when the capillary membrane that surrounds the alveoli sac becomes damaged, which causes fluid to leak into the alveoli sac
You're precepting a nursing student who is assisting you to care for a patient on mechanical ventilation with PEEP for treatment of ARDS. The student asks you why the PEEP setting is at 10 mmHg. Your response is: A. "This pressure setting assists the patient with breathing in and out and helps improve airflow." B. "This pressure setting will help prevent a decrease in cardiac output and hyperinflation of the lungs." C. "This pressure setting helps prevent fluid from filling the alveoli sacs." D. "This pressure setting helps open the alveoli sacs that are collapsed during exhalation."
D. "This pressure setting helps open the alveoli sacs that are collapsed during exhalation." This setting of PEEP (it can range between 10 to 20 mmHg of water) and it helps to open the alveoli sacs that are collapsed, especially during exhalation.
The nurse notes that each time the mechanical ventilator delivers a breath to a client with acute respiratory distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the nurse's best intervention? a. Suction the client. b. Perform chest physiotherapy. c. Administer an inhaler. d. Assess the airway.-
D. Assess the airway An increase in (PIP) in the ARDS client is indicative of decreased lung compliance, making it more difficult to ventilate diseased lungs. Nurse should first assess the airway to make sure no sputum is present in the airway and that no kinks are noted in the tubing. The nurse is not able to make changes in the ventilator settings, so an order is needed to increase inspiratory pressure to oxygenate the client.
The client receiving mechanical ventilation has become more restless over the course of the shift. Which is the nurse's first action? a. Sedate the client. b. Call the health care provider. c. Assess the client for pain. d. Assess the client's oxygenation.
D. Assess the client's oxygenation.
Which assessment finding of a client requires the nurse's immediate action? a. Being intubated for 4 days b. Uneven breath sounds c. Wheezing on auscultation d. Having the endotracheal (ET) tube taped to the lower jaw
D. Having the endotracheal (ET) tube taped to the lower jaw The endotracheal tube can be taped to the upper lip but should never be taped to the lower jaw because the lower jaw moves too much. The other clients need to be assessed by the nurse, but the one with the ET tube taped to the jaw requires immediate action.
Which nursing intervention takes priority for a client admitted with severe metabolic acidosis? A.Perform medication reconciliation B.Assess the client's strength in the extremities. C.Obtain a diet history for the past 3 days. D.Initiate cardiac monitoring.
D. Initiate cardiac monitoring. The nurse follows the ABG's and initiates cardiac monitoring to observe for signs of hyperkalemia or cardiac arrest
Which intervention will limit complications associated with open suctioning for an adult with a tracheostomy tube who is on a mechanical ventilator? A. Perform subglottal suctioning before suctioning the tracheostomy tube. B. Assure that the suction vacuum is set at 60 to 80 mm Hg before suctioning. C. Lightly coat the distal end of the suction catheter with water-soluble lubricant before suctioning. D. Limit each suctioning pass to 10 seconds or less.
D. Limit each suctioning pass to 10 seconds or less.
When planning care for a patient on a mechanical ventilator, you understand that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect? A. Increased FIO2 administration B. Increased inflation of the lungs C. Prevention of barotrauma to the lung tissue D. Prevention of alveolar collapse during expiration
D. Prevention of alveolar collapse during expiration
The nurse is performing an assessment on a client that is experiencing hyperreflexia. What condition should the nurse review the arterial blood gas results for? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis
D. Respiratory alkalosis -Respiratory alkalosis is manifested by hyperreflexia. Metabolic acidosis is manifested by abdominal pain and Kussmaul respirations. Tachycardia, anorexia, and muscle cramps are the manifestations of metabolic alkalosis. Headache, seizures, and hypotension are the manifestations of respiratory acidosis.
The nurse is caring for a patient that is in respiratory acidosis. What condition should the nurse closely monitor the patient for? a) Diarrhea b) Confusion c) Abdominal pain d) Ventricular fibrillation
D. Ventricular fibrillation Respiratory acidosis causes compensatory hyperkalemia, which leads to ventricular fibrillation. Diarrhea, confusion, and abdominal pain are manifestations of metabolic acidosis.
The nurse is assessing a client with multiple trauma who is at risk for developing ARDS. The nurse should assess for which of the earliest sign of acute respiratory distress syndrome? a. bilateral wheezing b. inspiratory crackles c. intercostal retractions d. increased respiratory rate
D. increased respiratory rate
The nursing management of a patient with an artificial airway includes A. maintaining endotracheal tube cuff pressure at 30 cm H2O. B. routine suctioning of the tube at least every 2 hours. C. preventing tube dislodgement by limiting mouth care to lubrication of the lips. D. observing for cardiac dysrhythmias during suctioning.
D. observing for cardiac dysrhythmias during suctioning.
The nurse is assessing arterial blood gases (ABGs). The client with which ABG reading requires the nurse's immediate attention? a. pH, 7.32; PaCO2, 55 mm Hg; PaO2, 70 mm Hg b. pH, 7.45; PaCO2, 42 mm Hg; PaO2, 70 mm Hg c. pH, 7.48; PaCO2, 38 mm Hg; PaO2, 60 mm Hg d. pH, 7.55; PaCO2, 30 mm Hg; PaO2, 50 mm Hg
D. pH, 7.55; PaCO2, 30 mm Hg; PaO2, 50 mm Hg This client has the most severe hypoxia and respiratory alkalosis, indicated by (PaCO2) values on ABG analysis.
What are Kussmaul respirations?
Deep, rapid breathing; usually the result of an accumulation of certain acids
If the pH is in a normal range and the metabolic/resp are not normal, is the ABG is compensated or not?
Fully compensated
What 2 acids accumulating could lead to metabolic acidosis?
Ketoacids or Lactic acids
Kussmaul respirations might be a compensation mechanism for:
Metabolic acidosis
Your patient has prolonged vomiting;--it has lasted for the last 36 hours! Acid Base imbalance ? What will the body do to compensate?
Metabolic alkalosis Hypoventilation by the lungs and excretion of bicarb by the kidneys while retaining H+
A 22 yr-old, comes to the clinic with severe vomiting over 24 hours. ABG: pH 7.46, PaCO2: 50, HCO3: 43 What is his acid base imbalance? Is it compensated?
Metabolic alkalosis partially compensated
The high-pressure alarm of a pt's mechanical ventilator goes off. What are the potential causes for this occurrence?
Mucus plus -Patient's fighting the ventilator -Bronchospasm -Patient is coughing
pH 7.30, PaCO2 60 mm Hg, HCO3 30 mEq/L
Partially compensated respiratory acidosis.
What are the clinical signs of hypoxemia?
RAT BED: (NCLEX Mnemonic) R-Restlessness A-Anxiety T-Tachycardia/Tachypnea (early) B-Bradycardia (late) E-Extreme Restlessness D-Dyspnea/Dysrythmias
What happens to K+ in alkalosis?
Shifts K+ into the cells in exchange for H+ which leads to hypokalemia in the ECF
pH 7.20, PaCO2 60 mm Hg, HCO3 24 mEq/L.
Uncompensated respiratory acidosis.
Synchronized Intermittent Mandatory Ventilation (SIMV)
Ventilator delivers a set number of specific volume breaths. the patient may breathe spontaneously between the SIMV breaths at volumes that differ from those on the machine. commonly used as a weaning tool.
Which actions should the nurse initiate 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. Elevate HOB 30-45 degrees d. H/H e. Provide oral care with CHG f. DVT/ Stress ulcer prophylaxis
b. Provide a "sedation holiday" daily c. Elevate HOB 30-45 degrees d. H/H e. Provide oral care with CHG f. DVT/ Stress ulcer prophylaxis
diarrhea, sepsis, and DKA leads to
metabolic acidosis b/c there is a bicarb deficit
A patient comes into clinic with 3 days of diarrhea. Acid Base imbalance? What will the body do to compensate?
metabolic acidosis hyperventilation by the lungs and retention of HCO3 by the kidneys and excretion of H+ by the kidneys
vomit leads to
metabolic alkalosis
Mechanical ventilation criteria
pH <7.35 PaO2 <50 PaCO2 >50 RR <8 or >40 absent breath sounds unprotected airway
Hypoventilation leads to
respiratory acidosis b/c the lungs are not able to eliminate carbon dioxide.
Hyperventilation leads to
respiratory alkalosis b/c there is a carbon dioxide deficit
